Assessment of the Health Management

Information Systems in Select Areas of

Aceh Province
Part of the GTZ Lead Initiative Post-Tsunami Reconstruction and Rehabilitation Programme
2005-2010

Table of Contents
Acknowledgements................................................................................................................................. 3
Executive Summary................................................................................................................................. 4
Key Findings ........................................................................................................................................ 4
Recommendations .............................................................................................................................. 5
Conclusion ........................................................................................................................................... 6
Background and Purpose ........................................................................................................................ 7
Methodology........................................................................................................................................... 8
Findings ................................................................................................................................................. 10
General.............................................................................................................................................. 10
Current Status ............................................................................................................................... 10
Implementation Methodology and Practices ................................................................................... 12
Strengths ........................................................................................................................................... 12
Project Management .................................................................................................................... 12
Project Documentation ................................................................................................................. 13
Evaluation and Readjustment ....................................................................................................... 13
System Selection ........................................................................................................................... 14
Opportunities and Challenges........................................................................................................... 15
Cultural Shift- Information Culture ............................................................................................... 15
Interfaces and Interoperability ..................................................................................................... 15
IT department ............................................................................................................................... 16
Next Steps ............................................................................................................................................. 17
Get a Clear Picture of What is Happening .................................................................................... 17
Ongoing Improvements ................................................................................................................ 17
Local Ownership ............................................................................................................................ 17
Recommendations ................................................................................................................................ 18
Overall ............................................................................................................................................... 18
Hospitals............................................................................................................................................ 18
Primary Health Care Centres ............................................................................................................ 19
Conclusion ............................................................................................................................................. 19

Acknowledgements
This evaluation was generously supported and funded by the Health Metrics Network.
We would also like to acknowledge the dedicated and knowledgeable staff of GTZ specifically Wolf
Wagner, Kelvin Hui, Paul Rueckert and Lieve Goeman who were excellent hosts and facilitated all
aspects of our visit. They provided quick and liberal access to all information, documentation and
resources, including accommodating several last minute schedule changes and impromptu visits.
We would also like to acknowledge the support and openness of the facilities, allowing us
unrestricted access to their staff, buildings and any relevant materials and documents.
Special thanks to the following organisations:
Zainoel Abidin Hospital (Provincial Hospital)
Provincial Health Office & Primary Healthcare centre Banda Aceh (Darussalam)
District health Office Lhokseumawe & Primary Healthcare centre (Mon Geudong & Blang Mangat)
District Hospital Lhokseumawe
District Hospital Langsa

This report was compiled by Liz Peloso from Deloitte, Canada. Christoph Bunge and Steven
Uggowitzer from HMN-WHO Geneva supported with contributions and editing.

Executive Summary
In 2004, a devastating earthquake and subsequent Tsunami struck Aceh province with a staggering
loss of life and property. Along with other international donors, the German government invested
money and resources to the stabilisation and rebuilding efforts. One of the projects they invested in
was the GTZ supported project Health Service Management Systems. This project implemented
two information systems (one for the hospitals and one for primary care) as a way to enable
improved business process and decision making. The project focused on 10 districts in Aceh
province, which included 10 hospitals and district health authorities, 130 primary care centers (called
Puskesmas), and 1 provincial hospital (in Banda Aceh).
As this project nears completion, a third party review was commissioned by the GTZ advisory team
to assess the progress and impact of the project.
This assessment was conducted over a 2 week period from May 3- 14 by two external reviewers
from Health Metrics Network and one from Deloitte. The assessment involved site visits, interviews,
direct observation and document reviews.

Key Findings
Overall, the project was very successful.
It is important to understand and fully appreciate the magnitude and scope of the project. The
business process and cultural changes that were required extended far beyond a technical
implementation. The post Tsunami stress/trauma experienced by virtually all of the staff of the
institutions involved, particularly in Banda Aceh, further complicated the project overall.
A well documented system selection process and resulting system that meets user needs
Two systems were selected, one for primary care and one for hospital use. The selection process
and rationale are well documented. The systems selected meet current and near term
requirements. The overwhelming feedback from the users revealed the system is easy to use.
When users encountered issues with the system, the provider was responsive and provided
satisfactory solutions. Although currently the systems lack the capability to interface with other
systems directly, there is confidence that the vendor will be able to modify the system accordingly, if
required. There are currently asynchronous data exchanges with other systems (such as the
provincial reporting system and EpiInfo).
Staff are able to use the system, but it was not always leveraged to improve processes.
Most staff were able to use the computer, although not always as familiar with the application.
When asked, most were able to find requested data in the system and demonstrate how to perform
specific tasks (such as entering data on a patient or looking up an order for stock). Most users had
been trained, although some had received on the job training, which varied significantly in
thoroughness. At the Puskesmas and in some hospital units (such as pharmacy) the users explored
the potential of the HIS and used several modules very effectively. Other units were less successful
4

with utilizing the system. This was typically a result of the managerial support when the manager
was promoting the use of the system- the area under their control typically used the system more
fully and with greater success.
We found many examples of staff who understood how to enter the information into the system,
but did not adopt the more efficient workflows that should have accompanied the process. This was
mostly evident in the number of dual entry processes completed by staff, either paper and
computer, or 2 different applications in the same computer. In most cases the end users did not
understand, or were not given permission to not use the old method, so they simply did both.
There were some notable exceptions, medication orders in the Puskesmas were entered in the
system and printed out in pharmacy for dispensing, supplies and stock. In the Provincial hospital,
staff predominately entered supply orders electronically, maintaining a real time, accurate
inventory. The most critical factor influencing success was managerial support when the manager
promoted the use of the system- the area under their control typically used the system more fully
and with greater success.
An information based culture is becoming established.
The most impressive finding in this assessment was the indications of a shift to a more information
based culture. This is particularly evident in the Primary Health Units and District Hospitals who have
maintained and even enhanced some of the changes in the 12-18 months since support for their
areas was concluded. They have successfully managed to budget for IT support staff, roll out to
additional areas and maintain more efficient business processes. This demonstrates both the
sustainability of the interventions, and the importance they now put on the systems. We found
many examples of managers using system data to make decisions (about hospital utilization, or
primary care delivery among others). In one of the districts, they even tried to improve the capacity
to interpret data by the front line staff to address activities, such as disease surveillance.

Recommendations
While the GTZ project did reach its objectives overall, and should be considered a success, there are
still some opportunities for improvement and reinforcement by the hospital / Provincial Health
Authorities / Puskesmas Management.
Budget for future hardware needs
As this initiative happened over a relatively short window of time, all hardware is new and operating
properly. This is not likely to be the case in the next few years, and as all the hardware is essentially
the same age, it will require replacement in the same time frame. This will represent a major
expense and will need to be budgeted for early.
Look for low hanging fruit
There were several opportunities to make relatively straightforward, high impact improvements in
business processes. These opportunities include:

improving the patient and information flow between registration and insurance (this was
evident in some hospitals, particularly the provincial hospital)
5

stop the double entry of data- reassess the need to maintain previous, now redundant,
processes (such as entering the OR schedule in excel and then into the system, or retyping
the radiology exam list)

ensure adequate hardware to support new processes- for example in one Puskesmas, the
volume of prescriptions printing often jammed the only printer, an additional dot matrix
printer is inexpensive and would encourage their innovation and system use.

Streamline reporting - if the data resides in the system, reports should be generated from
the system. This may involve the entry of additional data, such as the LB3-4 data collected at
the community level, which if entered into the system would allow provincial reports to be
generated.

Improve the capacity of front line staff to use the data

Encouraging and fostering appropriate and sufficient data literacy among front line staff will
increase the value of accurate and timely data (as it will be used by those very close to
collection) and will improve the ability to respond to some issues (such as outbreaks) in a more
timely manner.

Conclusion
Overall GTZ and its partner institutions and organisations were very successful and met all of their
stated project objectives. The complexity of the situation particularly in the areas most significantly
impacted by the Tsunami meant that some of the more significant behavioural and cultural shifts will
still require more nurturing and support (which should now be done by the hospital and district
managers). The approach, tools and processes used throughout the project, coupled with the
dedication, skill and knowledge of the project team were responsible for the success.

Background and Purpose

GTZ was commissioned by the German Ministry of Cooperation (BMZ) to contribute to the
reconstruction of the Aceh Province after the tsunami in the year 2004. The support of the German
Government to the provincials post-Tsunami health sector recovery efforts was twofold. The
financial cooperation (KFW) assisted in the rehabilitation or reconstruction of damaged health
infrastructure and in the provision or the replacement of missing or damaged medical equipment.
The technical cooperation agency GTZ complemented these efforts with a project aimed at
improving the overall management system in the public health sector.
The GTZ supported project Health Service Management Systems is one of five GTZ supported
Technical Assistance projects under the umbrella of the Aceh Rehabilitation and Reconstruction
Program.
This included initiatives such as strategic planning; quality, financial, and human resource
management and process improvement through implementation of two information systems. Since
2005 the project has been engaged in supporting management reforms and organizational changes
in the following partner institutions:
a)
b)
c)
d)

Provincial Hospital Zainoel Abidin in Banda Aceh (ZAH)

10 District hospitals
130 primary health care centres or PUSKESMAS.
Provincial and 10 District Health Authorities in the Aceh Province

In preparation for the project completion (June 30, 2010) the GTZ Health Advisory Team engaged
HMN as an external /3rd party, independent evaluator to review the progress and impacts. The GTZ
advisors special interest (and the focus of the evaluation) was on the two information systems
installed: the Hospital Management Information System (HMIS-Aceh) and the information system
for primary Health Care Centres (SIMPUS-Aceh, collaboration between GTZ and Malteser
International).

Methodology
At the onset of the project GTZ had stated a number of objectives they planned to meet over the
course of the project. These stated objectives were used as a guideline in developing the interview
and focus group questions, as well as identifying specific quantitative measures.

Specific Goal

Activities to achieve
goal

Hospital Staff Able to use

electronic information
systems

Measurement Strategy
Number of users trained
Training program
Direct observation and spot
checks

Non- clinical hospitals

business processes reengineered; efficiency
increased
Hospital staff able to
produce accurate and timely
information to support
decision making
Hospital managers adopt the
culture of information
based decision making
Improved care delivery

Revise SOPs
Automated manual
processes
Improved timely
reports

Processes automated
Current SOPs
Direct observations and interview
questions
Report delay for data (days)
-use of data (interviews)

Automation lead to
improved reporting

Evidence of data being used for

decisions (i.e. targets)

QA methodology

Quality Circles monitored- trends

in data
Success indicators
Staff know about quality
Managers can clearly articulate
goals and their areas strategic
objectives
DHO and PHO gather data in
automated way
Turnaround times on reports
Evidence of use for decision
making
Evidence of use of performance
indicators (performance reviews
completed)
Clear and appropriate job
descriptions
Evidence of application of
incentive system (interviews)
Managers and staff understand
evaluation criteria
Accounting reports produced and
verifiable
Evidence of use of accounting

Improve surveillance
capability through faster
data collection and
increased data accuracy

Convert manual data to

automated data

Improved service delivery

Human resource
restructuring

Improve the transparency

and accountability of the
health system

Reorganise and
implementation of
computerised billing

system

Improve equipment
maintenance

Training
Adequately equipped
repair shops

software (user logins, general

departmental understanding
-income
Budget line items for maintenance
Evidence of regular maintenance
program for computers
(scheduled)

The methods used to evaluate the systems included interviews of a variety of staff- both managers
and individual users, focus groups, document reviews, direct observation and independent system
review.

Findings
Quick Facts:

General
The scope and difficult circumstances surrounding this
Population in target area: 2,4 million
project cannot be overstated. The Tsunami claimed
165,000 lives, with the overwhelming majority of them
Number of Hospitals: 5 (4 District and 1
Provincial)
from the capital of Banda Aceh where 150,000 of the
population of 450,000 perished (one third of the
Number of users trained (hospital):2158+
population). It is impossible to find someone in the area
who was not directly impacted. Much of the
Number of Primary Health Units: 120
infrastructure was destroyed or became very unstable. In
addition, there was significant increase on the demands of
the health system as a result of the injuries and issues in
Primary Health users trained: 1200
the short term post tsunami. Although much of the
emergency care was delivered with the support of
Total implementation team: less than 30
external international organisations, daily life was disrupted most significantly.
Amidst this almost unimaginable human tragedy, the rebuilding and reorganisation of the hospitals
began. Despite the obvious and urgent need to re-establish health services delivery, the
reorganisation and improvement opportunities were more opportunistic than the result of a long
standing recognition for the need for change. Since major changes (new hospital building, new
equipment) were underway, the opportunity to improve medical services quality and delivery was
also seized. Although this was not formally part of any long term plan prior to the Tsunami, there
was general buy in from management.
Current Status
A new hospital building was constructed for the Provincial Hospital by the partner organisation KfW
(the German Development Bank) and was supplied with medical equipment and furniture. Two years
after construction, the hospital remains meticulously clean and well kept. GTZ assisted the
Provincial Hospital in management changes and improvements GTZ was continuing to support the
provincial hospital even at the time of the evaluation. KfW will continue to support the hospital
until 2011.
The Provincial Hospital has a (wired) network throughout and most areas (although not all) have
access to a network port- even if there is not yet a computer. There are 169 networked computers in
the hospital that are for HMIS use, and 280 computers in total. Most clinical and administrative
areas had networked computers and they were functioning. In two days of walking around the
hospital, we did not see any issues with restricted access to computers based on high demand and
sharing between users. In fact it was uncommon to find someone actually using the computer at the
moment we arrived- although in most cases the computer was on and the application was open or
at least available.

10

Size of hospital (beds), Number of Users Trained and Number of Computers

Hospital

Size of Hospital
(beds)
Provincial
ZAH (RSU dr. Zainoel Abidin)
320
District
District Hospital Lhokseumawe
107
District Hospital Langsa
146
District Hospital Biruen
139
District Hospital of Aceh Tamiang
60

Number of Users
Trained

Number of
Computers

980

169

unavailable
400
392
386

39
48
36
32

Total
Source: GTZ project team

In the District Hospitals the situation was somewhat similar, although they were no longer supported
by GTZ and had been maintaining the system and processes on their own for over a year. They also
had challenges with electricity (experiencing power failures almost daily). When doing spot checks
on data in the system- it appeared to be up to date in most areas, specifically the information that
was related to billing (procedure codes). The hospitals were supporting the IT departments from
their own budget, and (in the 2 we visited) had in fact increased the IT staff. There were some other
notable advances and successes;

The hospital in Langsa entered all inpatient and outpatient lab results into the system so it
was available online.

Registration process typically took less than 30 seconds per person.

Some outpatient clinics were entering their orders online, and the physicians in those clinics
reported being happy with the system and wishing it was more widely used.

External auditors (who were there verifying data at the time of our visit) reported they
found few discrepancies or errors in the insurance submissions (done using information
from the system).

In the Primary Health Care Centres (PHC Centres, Puskesmas) it was a similar finding. Most areas had
computers and they were obviously in productive use. It is important to note that GTZ support of
the areas outside of Banda Aceh was completed approximately 18 months ago. As with the district
hospitals an additional challenge for several of the more remote areas was consistent electricity, the
electricity was often out multiple times every day. Interestingly the staff had developed a workable
way to not lose data in the event of power outages by putting data into a suspend mode until all
information was entered into the system. This was something they discovered and were using on
their own- and it worked very well! In general the uptake and use of the information system was
generally better and more widely spread (meaning more staff could and did interact with the

11

system) in the areas outside of Banda Aceh. Overall the implementation and related changes in the
Puskesmas would be considered a resounding success.

Implementation Methodology and Practices

One of the overall strengths of this project was in the use of a systematic approach based on several
industry best practices.
Overall the timeline for implementation

Dec 2006
Tsunami hits
Banda Aceh

2005

Oct- Nov
National
Tender

2006

June
Move in to
New Hospital

Construction of
New Hospital
Begins
Sept- Nov
System in
Productive Use
in District
Hospitals

2007

June July
Preliminary
assessment
Dec
Begin
Implementation

2008

April- May
System in
Productive Use
in Provincial
Hospital

2009

2010

Nov
Handed over
responsibility to
PHO and NAD

Throughout the implementation the GTZ team worked closely with other partners and the software
provider. The implementation team made regular scheduled visits to each of the sites to support and
troubleshoot. They had developed a governance and project oversight model that afforded both
local presence and central coordination. This allowed for waves of concurrent activities within each
district and with the hospitals.

Strengths
Project Management
Activities were planned in advance and monitored throughout the project according to industry best
practices. Regular status updates were done to keep all parties up to date on the process and
progress.
There was a project plan which was followed and updated regularly. Due to the close working
relationship with the software provider and other stakeholders, risks were identified and dealt with
quickly.

12

Project Documentation
All major decisions about the project (such as selection of approach and solutions) was well
documented along with the justification. This documentation was also made widely available to
others in the project. Not only does this provide a great deal of transparency to the process- it also
provides an excellent resource for other stakeholders who will be responsible for ongoing
sustainability activities.
Decisions were made after a thorough evaluation of the options and an understanding of the
supporting evidence and extenuating circumstances and context.
In addition to the documentation of project decisions a number of supporting documents in the
form of guidelines and tools have been produced. These documents will also serve to inform future
implementations and are closer to producing a replicable methodology. These guidelines/tools
include

Health Information Systems

Quality Management

Rapid Assessment of Hospital Management

Health Market Analysis

Physical Assets Management (Maintenance)

Health Care Waste Management

Impact Monitoring in Health Services

These tools will be very valuable on future projects and could be considered for use more widely.
Evaluation and Readjustment
The change management was by far the most difficult and challenging aspect to the implementation.
Throughout the implementation the GTZ Advisory Team
constantly re-evaluated their approach and made
Throughout the implementation the
necessary adjustments. Often interventions were aimed
GTZ Advisory Team constantly reat adding additional resources or techniques to those
evaluated their approach and made
already employed. In some cases the approach and
necessary adjustments.
interventions were changed completely. The insight for
the need for change, as well as the ability to be
responsive enough to make the necessary changes, were significant advantages and strengths of the
project.
Part way through the project it became evident that the provincial hospital was going to require
further support to be successful. The GTZ Advisory Team realigned resources to provide more
coaching support to make some of the behavioural changes stick. The importance of this
additional coaching support was a major learning from the project. The ability to recognise this

13

need, coupled with the nimbleness and flexibility to be able to redirect funds and resources should
be commended.
System Selection
The system in use in the Provincial and District Hospitals is appropriate and largely meets the needs
of the users. There are some minor software deficiencies that we encountered, as well as some
features that would be beneficial to include, but overall it was stable and easy to use. If reported
appropriately- many of the bugs and enhancement requests could be addressed- and none of them
were significant enough to prevent the productive use of the system.
One of the best features of the system is that it is easy
to use. Most users are only required to perform a very
The system selection process was
limited set of activities on the system, and they are
rigorous and well documented. The
constantly repeating the same set of tasks- which
resulting systems meet the needs of
makes them very proficient in a short amount of time.
the hospitals as well as the primary
For those who actually used the system- they found it
care centers.
easier and more efficient. Despite this- we came across
many potential users who did NOT really understand
how to use the system although when asked they
could often figure out how to complete a task. We refer to them as potential users as they had a
login and password, had usually been trained (either on the job or in class) yet they largely did not
use the system. When asked why- the overwhelming response was that entering the information
into the computer was not their job. Most units had 1 person essentially appointed to enter all
the data into the computer- if that person was not there- the data entry waited. Interestingly- these
units did keep parallel paper log books- that data was entered in by many of those people who felt
computer entry was not their job. In essence, they accepted responsibility for collecting the datajust not for entering it into the computer. Base on our observations- the issue was not necessarily
that they were computer illiterate- since when asked to try and show us- they were able to use both
a mouse and keyboard well, although they did not really know how to use the application to its
fullest (since they never really used it).
The situation in the District Hospitals and PCH Centres outside of Banda Aceh was very different.
Most employees of a Puskesmas were able to use the system- and often did to cover busy times and
for when the primary data entry person was away. They not only understood how to use the
application, they had also developed a number of tricks and short cuts- such as suspending a
record until the patient left- allowing them to have a temporary saved version that allowed them to
make changes to the record (if there were any) as well as to recover the record in the event of a
power disruption. The users were very competent and easily able to answer questions and
demonstrate competencies on the spot. This was assessed by asking them to perform certain
activities such as show me a list of patients seen in your clinic yesterday or show me the
prescription history for any patient you have seen today. In every case they were able to perform
these activities quickly and correctly.

14

Opportunities and Challenges

Cultural Shift- Information Culture
By far the most difficult aspect of this project was promoting the cultural shift required to embrace
the use of health data and information as a critical component for decision making. We found this to
be well done in the primary health units and at the district level in both Lhokseumawe and Langsa.
Directors and staff used the data produced by the
system for continuous improvement effort, as well
as for planning. In Lhokseumawe the District Officer
had used the information gathered from the local
Puskesmas in order to justify and plan services for a
new district hospital. Most managers saw value in
the information and demonstrated this in very
visible ways. For example, in one of the
Puskesmass we visited the manager displayed
some of the major indicators created form the
system
data prominently in the health center.
Clinic manager in front of prominently displayed
data from the system
These charts and graphs were kept current and
were referred to giving a powerful message about
the importance he attached to the data.
In the Provincial Hospital this shift was still in the early stages, there were definitely pockets of
success (for example in the supply and pharmacy areas). Upon reflection, this shift is really an issue
of change management, and getting the users to embrace that change. There was no overt rejection
of the system or changes, just a slower and less convincing adoption rate. Given the extremely
difficult circumstances experienced by the people of Banda Aceh, it is no surprise that they changes
that faced them (personally and professionally) exceeded their ability to absorb those changes. They
changed buildings, changed staff and changed processes all while coping with massive personal
losses and changes. It is only recently that there is enough stability for them to really participate in
this cultural shift. The Advisory and Implementation team at GTZ has armed them with the tools and
understanding on how to do this- the managers and directors must now be the ones who champion
the cause.

Interfaces and Interoperability

Although the systems selected (SIMPUS for primary care and the HMIS for hospitals) meet the
current need they are at this time not capable of interfacing with other systems to allow them to
share data in real time. Data sharing does occur between systems- of particular note from the
district reporting system to the provincial reporting system- but this is achieved with an import and
data migration protocol.
Although this is not necessary at this time, it does factor heavily in the future capabilities for the
system. The software provider is also aware of this. In discussion with implementation staff and
resources, it was felt that they have been very responsive to other needs, and would likely be able to
15

develop interfaces and become compliant with specific standards (such as HL7) if the need were to
arise. Although this confidence may well be warranted, the fact that these features do not exist at
this time needs to be taken into consideration.
IT department
The District Hospitals in Lhokseumawe and Langsa both maintained IT departments which were
supported by the hospital budget. Largely the IT departments met the needs of the hospitals. It also
appeared that the service level expectations of the user community were fairly low and they did not
utilise the IT services to the fullest. Some hospital IT departments conducted regular walk about
rounds- where they would proactively look for issues. This is an excellent approach. This approach
was also done by some members of the IT department in the provincial hospital, but only looking for
issues with hardware. This is unfortunate, and a very significant missed opportunity as most of the
users in the provincial hospital would have benefitted for additional support to optimise the use of
the application. (the other hospitals offered application support as well on these walk abouts).
All hospitals had an established process for end users to report issues. Most users we asked knew
how to access help if they needed it. Despite this, the provincial hospital logged only 5-6 calls a day
for assistance. During our assessment we called the IT department several times one afternoon to
report an issue, but no one answered the phone. Hardware and network connection issues were
typically corrected very quickly and very successfully. Issues involving improvements to the
application (both minor software fixes as well as enhancement requests- such as a new report) were
not handled as effectively.
In order to improve the uptake and success in the provincial hospital- it is critical that the IT
department take an active role in supporting not only the application but the workflow surrounding
it. One of the key resources that will be able to make this successful is the formal appointment of
the public health nurse in the provincial hospital who has a deep and thorough understanding of the
issues and how to correct them. More resources with similar skills and understanding would make a
significant impact on the hospitals success.

16

Next Steps
Get a Clear Picture of What is Happening
It should be fairly simple to perform some general chart audits to determine where the pockets of
success are, and what areas or units may need some additional support or encouragement. Although
this was done at a high level with the spot checks performed during the assessment, it was at best
a high level impression. Understanding where the issues are will help to target valuable resources to
produce the biggest impact. If, for example, a clinic was consistently not entering the diagnosis
online as well as other areas, perhaps an on unit training session with the staff and manager would
be of benefit.
Another potential option for getting more insight into issues (particularly in an area such as the
hospital) would be a roving expert team, who could visit a number of units and observe workflow
and processes- this would help to identify issues such as duplicate entry of data that could be
addressed (ideally very quickly).
Ongoing Improvements
There are always opportunities for improving both the information systems as well as the workflow
and data use. Once it is clear where the major issues are, a plan can be made to address them. It is
important not to ignore the areas that have been very successful, as they will often be strong
supporters for further enhancements- they should be empowered to actively seek out ways to
improve on current processes, and have support from their organisation (IT or management
support) to do so.
Local Ownership
Probably the greatest testament to the success of the GTZ assisted project was in the continued use,
improvements and ownership exhibited by the Districts Hospitals and PHC Centres. It has been 18
months since GTZ had completed their projects in those areas. Not only have they continued, they
have also improved on the initial implementation. They have lobbied (successfully) to increase their
IT budgets, they have implemented quality checks on the data and addressed issues (and continue to
do so), they have achieved widespread adoption and use and most importantly, they see this as their
own initiative. The district officer in Lhokseumawe was explaining the next steps for the SIMPUS
system in his area- which included rolling it out to other areas. He had already budgeted for the
computers out of the operating budget. When asked how they would go about this, and who was
going to do it- he replied they were confident they could do it on their own, and had made
arrangements with a vendor for ad hoc support if needed. This was their system and part of their
operations. With so many projects failing once donor or development agencies withdraw- there can
be no greater testament to success than this.

17

Recommendations
Overall
Success in the long run will require ongoing support from managers and leaders at all levels of the
health system. All interview participants credited manager support for their success- in fact they all
identified it as the most critical factor. GTZ did an excellent job with providing the supportive
environment to enable these managers and directors to make this a success. Many units and areas
have already risen to this challenge and have been undeniably successful. Others are still on the
journey.
As the implementation is relatively new, and essentially was done in a relatively short time frame, all
equipment is new and in good working order. The disadvantage is that all equipment will also start
reaching the end of its life expectancy at the same time. It is critical that the health centers are
aware of this and budget accordingly. A system wide replacement for hardware in a single budget
year (or 2) will likely be unmanageable. It may be wise to consider lease arrangements (if possible)
or at a minimum begin to reserve capital funds for hardware replacement.

Hospitals
In the Provincial Hospital there were several opportunities to take advantage of workflow
efficiencies now afforded by the systems in place. Some of these will require cooperation across
areas and some workflow and process redesign, but will be well worth it for both the hospital and
patients. One such example which should be considered high priority, is to improve the flow of
information (and patients) between the registration and insurance. If these issues (particularly the
bottle neck created as the patient goes between registration and insurance verification) can be
corrected, it will have a significant impact almost immediately. It is wins such as that which will
further bolster the system use and quality improvement activities.
Understanding that this is not an IT project, the skill mix of the IT department in some hospitals may
need to change. Most hospitals (and particularly the Provincial Hospital) would benefit from the
addition of a clinical and business analyst. These resources can help support the workflow changes,
and will understand how the software can be used to improve processes, reduce workload and
improve service delivery.
The most critical success factor, particularly for hospitals, is management support for the changes
that are taking place. This visible support and leading by example will help to foster the culture of
information use. When the data is used for monitoring and decision making at all levels (but
particularly at the top levels) its importance and usefulness becomes respected and realised
throughout the organisation.

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Primary Health Care Centres

Overall, the primary health centers were doing well. Although they did not always get the most out
of the software, they had made significant improvements in some areas of data collection. There
were several opportunities to take some of these changes further, and hopefully make more
significant improvements. The following are recommendations for doing that:
1) Improve the capacity of the front line staff to use data- while their ability to collect and
enter accurate timely data is improved, if they were empowered and equipped to actually
use that data for decision making, this would allow changes to be made much more quickly.
Using the data to improve disease surveillance is an obvious and important place to start. It
is already possible to link the data to EpiInfo, and that should be further supported.
2) Make reporting easier- not all reports can be generated from the system and some still
require entry into another system. The ideal state would have a single source of truth that
is also capable of producing all necessary reports. There were also situations we came across
when duplicate reports were done because the data entry people were not given permission
to stop doing things the old way as well.
3) Support and encourage the use of the system for improving clinical care- the primary
health units did make great strides in using the system for clinical care. We observed the
medication orders being entered in real time- and then being printed at the pharmacy for
filling. In some clinics the volume of pharmacy orders needing printing often exceeded the
capacity of the printer- causing paper jams and other issues. Addressing these issues is
inexpensive and shows support for these practices.

Conclusion
Overall GTZ and its partner institutions and organisations were very successful and met all of their
stated project objectives. The complexity of the situation particularly in the areas most significantly
impacted by the Tsunami meant that some of the more significant behavioural and cultural shifts will
still require more nurturing and support (which should now be done by the hospital and district
managers). The approach, tools and processes used throughout the project, coupled with the
dedication, skill and knowledge of the project team were responsible for the success.
Although there is still a great deal more to be completed, significant progress has been made. This is
a cultural change on multiple levels and will take a number of years to complete.

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