Health Management Information Systems lack holistic, integrated, and pandemic resilient character

Being a part of the United Nations’ system, the World Health Organization (WHO) deserves its share of rebuke for its alleged failure issue COVID-19 health emergency alerts on appropriate time. However, the pandemic has also exposed loopholes in health management information system (HMIS) of several international health organizations that claim to extend speedy health services or quality management of health information in an independent and impartial manner across continents.

As most of the international public health organizations have their origin in developed countries, it gives a perception that the developed world and such organizations would be the largest funder for public healthcare in developing countries. But you may be surprised to know that the developing countries bear over 95 percent cost of public healthcare on their own. According to an estimate, the financial contribution of developed countries is ‘less than 5% of the total healthcare costs in the developing world’.

We sincerely recognize the noble works being done by various international health organizations throughout the world. Some of those organizations predate the World Health Organization (WHO) and are almost at par with WHO in terms of territorial coverage. As the UNEP and other forums have also warned about more COVID-19 like pandemics in the future, it becomes imperative for these organizations to have a robust pandemic resilience health management information system in place. In a previous blog, we have presented a critical review of WHO's health management information system. 

The present critical investigation aims to catalyze the rebooting of the Health Management Information System (HMIS) in these international health organizations to make them resilient to the unforeseen pandemics and natural disasters in the future. In the present analysis, we have taken up multilateral agencies and NGOs working primarily in the public healthcare sector in multiple countries across continents.

Pan American Health Organization (PAHO)

Established on 2 December 1902, Pan American Health Organization (PAHO) is the oldest multilateral international health organization in the world. Pan American Sanitary Bureau (PAB) in Washington D.C. is the secretariat of PAHO.

Besides acting as a regional office of the WHO for the Americas, PAHO also retains its previous autonomous position of international health organization for the Americas (North America and Latin America & Caribbean). While WHO was constituted after World War II, PAHO was formed in the background of the yellow fever epidemic of 1870 in Brazil, Paraguay, Uruguay, and Argentina that spread to the United States through marine transport where it killed about 20,000 people.

PAHO claims to have its designated scientific and technical experts in its Washington D.C. headquarters, 28 country offices, and four scientific centers that serve its 35 member countries. In addition to the member countries, it also has four Associate Members (Puerto Rico, Aruba, Curaçao, and Sint Maarten), three Participating States (France, Netherlands, and the United Kingdom), and two Observer States (Portugal and Spain). The policy decisions of PAHO are taken in its annual meetings of Governing Body and PAHO Directing Council. PAHO has mandates to provide technical cooperation in epidemic alert and response, disaster preparedness, health services organization and financing, immunization, nutrition, environmental health, mental health, road safety, health legislation, access to medicines and technologies, regulatory capacity, and other areas. PAHO’s Executive Committee, which constitutes elected representatives of nine elected member countries, meets twice in a year and acts as the executive body of PAHO.

Besides, it also partners with nearly 200 PAHO/WHO Collaborating Centers in 15 countries of the Americas. In comparison to WHO, PAHO has a broader mandate in its region as it also covers humanitarian issues such as human rights and non-discrimination, multi-culturalism, gender equality, and social participation in protection and promotion of health. While WHO primarily works with health ministries of the member countries, PAHO also ‘works with other government agencies as well as professional associations, academic institutions, and faith-based, community, and civil society organizations’. Thus as for as any health emergency/ event is confined to the Americas, PAHO exercises autonomy but for emergencies of a global scale, it coordinates with WHO.

HMIS of PAHO

PAHO’s cooperation with the countries is dependent on the ‘technical cooperation strategy’ agreed upon with its member countries. Though the portal displays links of the websites of its country offices and health ministries of member states, the data is not synchronized with the HMIS of the member countries on a real-time basis but the information is disseminated after following a process of verification and approval. PAHO assists the countries in managing health events/ emergencies in pursuance to the requirements/ demand of its member nations. 

It disseminates the health data and healthcare information through various publications and web pages such as PLISA Healthcare Information Platform, Institutional Repository for Information Sharing, Communication Material, Health Library for Disasters, knowledge center on public health and disasters and interactive maps. PAHO has recently launched a geospatial map of COVID in Americas and also a dashboard on COVID-19 Guidance and Latest Research in the Americas.

Health Surveillance and Health Emergencies

Theoretically, PAHO seems to have a better health event/ emergency surveillance system as ‘in addition to directly receiving information from member countries, the Detection, Verification and Risk Assessment (DVA) team of PAHO’ claims to continuously screen information of unofficial information forces. However, in practice, the link to DVA was not accessible. PAHO follows IHR’s process for verification of health events before disseminating ‘health emergency alerts’. 

It has a dedicated page - health emergencies - for disseminating information related to health emergencies under three categories – COVID-19 Outbreak, Natural Disasters Monitoring, and Epidemiological Alerts and Updates. However, the available information is in the form of letters and periodic updates not on a real-time basis. The PAHO/WHO Emergency News Letters provide more detailed information on health emergencies and health-related information.

The portal lacks integrated updates as during the visit on June 19 at one page the latest update on COVID-19 was from May 20 while at another place periodic situation report was available till June 18.

WHO’s initiative Global Outbreak Alert and Response Network (GOARN), started in 2000, for coordination among member countries on disease outbreak reportedly played a crucial role in the 2009 H1N1 pandemic in the Americas. However, WHO has moved on geospatial and interactive Public Health Emergency Dashboard, PAHO is still using GOARN and prominently displays it on its portal.  

PAHO seems to have launched an initiative ‘Unique Patient Identifier’ to identify patients at the national, regional, and institutional level but sufficient details are not available about this project. 

Most recently, the loopholes in the HMIS of PAHO were revealed during the Zika crisis in 2017 when it allegedly failed to detect and issue alerts on the disease outbreak. According to reports, Cuba reported 1384 Zika cases but PAHO could not take cognizance due to a technical glitch – ‘the information was held in a database, but not visible on the website’. Meanwhile, Cuba witnessed an unprecedented rise of 16 percent in its tourism sector. PAHO came to knew of the outbreak when it reached the USA. In the outbreak, about 98 percent of cases in Florida reported a travel history to Cuba.

This negligence came on the heels of a previous Zika outbreak in 2016 to which PAHO had declared Public Health Emergency of International Concern  (PHEIC) without consulting WHO. However, then WHO Director-General Margaret Chan completed the process and approved the PHEIC declaration. But this alertness was missing during the COVID-19 outbreak. The first confirmed case of local transmission of COVID-19 was reported in the US on January 20 and also in Canada on January 27 but this time no specific response was seen from PAHO.

Doctors without Borders (Médecins Sans Frontières)

Médecins Sans Frontières (MSF) founded on December 22, 1971, is an international health organization of French origin that describes itself as ‘an international, independent, and medical humanitarian organization that delivers emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from a healthcare’. It was awarded Noble Peace Prize in 1999 and presently serves in more than 70 countries out of which 32 are in the African continent. MSF works in close association with the government agencies/ UN bodies to provide healthcare to the people in health emergencies such as catastrophes, including armed conflicts, disasters such as floods and earthquakes, epidemics of disease, and malnutrition crises. MSF is an NGO funded by donors – states, private and Individuals.  

MSF is primarily dependent on inputs of government agencies, UN bodies, and its local members for its HMIS. It earned appreciations for playing a key role in getting Ebola Outbreak in Congo declared a PHEIC on July 18, 2019, which was rejected by the WHO for three times.

On its portal, MSF has not included China in the list of countries where it is responding to health events/emergencies. However, a statement issued by MSN on 18 November 2019 to clarify allegations of not providing medical help to the protestors injured during the Hong Kong protest, is sufficient to prove its presence in China and nearby countries. In the statement, MSF has proudly accepted working with the government system to improve the healthcare of protestors. However, it was apparently silent on the COVID-19 issue until the declaration of PHEIC by the WHO on January 30, 2020. In comparison to the Ebola Outbreak in Congo in 2019, MSF is not seen active enough on COVID-19. However, it is now reportedly responding to the COVID-19 pandemic in the countries/ territories of work. 

International Red Cross and Red Crescent Movement

The International Red Cross and Red Crescent Movement, constitute several legally independent NGOs throughout the world united with common objectives. It describes itself ‘a global humanitarian network of 80 million people that helps those facing disaster, conflict, health, and social problems’. It consists of the International Committee of the Red Cross (ICRC), founded in 1863, the International Federation of Red Cross and Red Crescent Societies (IFRC) (1919), and the National Red Cross and Red Crescent Societies comprising of national-level organizations in 191 countries. The group has three Noble Prizes to its credit.

Thus in terms of coverage, IFRC is almost equal to the WHO which has 194 member countries. The group also works on health, humanitarian crisis, and other issues with a focus on conflict areas and war zones throughout the world. In its quadrennial Red Cross Red Crescent Conference 2019 in Geneva which concluded on 12 December, the representatives from 168 countries had participated.

Despite such a huge network, the first response of IFRC to COVID-19 came on 26 March. It is pertinent to mention that the WHO had declared COVID-19 a PHEIC on January 30 and Pandemic on March 11.  Furthermore, Wuhan, the epicenter of COVID-19, had come under strict lockdown on January 23. IFRC has a presence in China and neighboring countries but no significant response was visible in this period.

Global Health Security Index (GHS Index)

Global Health Security (GHS) Index is an assessment and grading of health security capabilities in 195 countries jointly by Johns Hopkins Center for Health Security, the Nuclear Threat Initiative (NTI), and the Economist Intelligence Unit (EIU). GHS Index claims to be moved by the ‘2014 Ebola Epidemic’ in Western Africa and seeks to ‘illuminate preparedness and capacity gaps to increase both political will and financial to fill them at the national and international level’.

The Index is primarily based on the International Health Regulation (IHR) 2005 of the World Health Organization. It assesses the healthcare preparations of countries on the basis of six categories – prevention, detection, response, health, norms, and risk; 34 indicators, and 85 sub-indicators. GHS Index is based on secondary data collected through 140 questions across the categories. The first GHS Index was released in October 2019. Though it recommends for reforms in all the countries, the index identified the top ten countries most prepared for the pandemic and other health crises with the USA ranked first with 83.5 out of 100 points while Finland at 10^th with 68.7 ranks. The other countries in the top ten ranks are – the UK, Netherlands, Australia, Canada, Thailand, Sweden, Denmark, South Korea, and Finland. As per the recent COVID-19 outbreak data of WHO, we know that all the high ranked countries were hit hard except South Korea which significantly controlled the pandemic. In the initial days of the COVID-19 outbreak, US President Donald Trump used the data and maps of GHS Index to convince his fellow countrymen that the USA was the most prepared to handle the pandemic. Till June 22, the USA had reported maximum cases and deaths due to COVID-19.

After criticism, it came out with a report on the vulnerability of COVID-19 in 195 countries on March 13, over one month after the outbreak was declared a PHEIC by the WHO. In its vulnerability assessment, it classified the countries into two categories – most vulnerable and more vulnerable. However, even this report had not included the US and Brazil under any of the two categories which are the two most hard-hit countries by COVID-19 pandemic. Besides, several countries such as UAE, Israel, and Saudi Arab, etc., that were ranked poorly have performed better.

United Nations Development Program (UNDP)

UNDP works in about 170 countries and territories of the world. It’s the nodal agency of the UN for monitoring and ensuring implementation of the Sustainable Development Goals (SDGs) adopted by the UN in 2015 for the year 2030.

UNDP, on the basis of the Human Development Index (HDI), launched two dashboards on the vulnerability and preparedness of its member countries for the COVID-19 pandemic. The preparedness index is primarily based on the number of hospital beds, physicians, and nurses per 10,000 population. It also includes internet connection and mobile phone subscriptions as these tools have become very crucial in implementing social distancing and disseminating healthcare information to the people including combating infodemic.

The vulnerability has been assessed primarily on the grounds of poverty, social protection, labor reforms, and economic vulnerability caused by possible lockdowns. However, these dashboards are also not very helpful on the ground as they rank the developing countries in Europe and the Americas on higher grades but they have suffered the most in the COVID-19 pandemic.

Conclusion and Agenda for Discussion

Public health and well-being is a broad area. There are several humanitarian, development and healthcare organizations such as World Bank Group, United Nations Development Program (UNDP), United States Agency for International Development (USAID), World Food Program (WFP), UN High Commissioner for Refugees (UNHCR), Food and Agricultural Organization (FAO), UN Environmental Program (UNEP), Project Hope, Oxfam, CRY, CARE, etc., which contribute in public healthcare across communities throughout the world.

Therefore, there seems no dearth in terms of a global network for surveillance on public healthcare. What seems lacking is - a holistic, integrated, and pandemic resilient HMIS. There is a need for a robust HMIS at the level of every organization (but connected with HMIS of other organizations as well) working in public healthcare or associated problems. These organizations could have real-time information sharing agreements (MoUs) to develop an integrated health management information system at the global level for a speedy, efficient, and effective global response to health events/emergencies and also for unforeseen pandemics and disasters in future.

Furthermore, WHO should own up the responsibility to convince all the 194 member nations to synchronize all needed information on a real-time basis for a better global response to health events and health emergencies. Alleging partiality, the USA is reportedly searching for a new partner to replace the WHO but any such effort will be futile unless a robust health management information system is in place. Therefore, the health management information system should be the focus of reforms in public healthcare systems both at the national and international levels. 

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.