How Health Data Are Managed in Mozambique

. Data is the basis for designing information. In the healthcare, the management of data can improve patients’ treatment and contribute to better provide healthcare services. This study aims to explore how health data are treated in the national health system in Mozambique. The methodological strategy was based on a qualitative analysis, through a semi-structured interview made to the manager of the health information department, supported by a bibliographic search based on PRISMA. The keywords used weredata,value,andhealthcare,withalimitationofthearticlesresearched.Forthe work,onlyarticlesreferringtothesetermsandwithaccesswereincluded.After screeningthearticles,consideringthecriteriaused,49articleswereanalyzed.17 articleswerethenincludedinthisstudy. Theresultsofthisarticleareimportant,astheyofferinformationaboutthe treatmentofhealthdata.Throughthestudyitwaspossibletoverifyhowessential thetreatmentofhealthdatais,asithelpsindecisionmaking.Itwasalsopossible toconcludethatitisnecessarytocomputerizedataandinformationonhealth,in Mozambique.Theuseofthehealthinformationsystemservesasamechanism forthecollection,processing,analysis,andtransmissionofinformationtoplan, organize,operationalize,andevaluatehealthservices. Inthisway,healthdata,whenincomputerizedsystems,assistindecision support,decreasingthehypothesisoferrorsandacceleratingthedecision-making processbyhealthprofessionals.


Introduction
The data is one of the most important elements of the health information systems, and the information is composed of data with meaning for those who see it [1]. The data alone do not speak, they are as raw material and need to be worked on to produce information that translates into knowledge, an interpretation and a judgment about a given situation. Data collection and sharing through the healthcare system is needed and has several benefits: it can help to identify patients' profiles and improve care; can help to identify geographical trends and groups of individuals and; can help to better allocate resources and improve healthcare service provision [2,3].
In Mozambique, with a population of over 30 million people [4], the paper information system continues to be used in all health units. This constitutes an obstacle for the correct management of health data through a global approach in the country. The government has been trying to fit the electronic system, through the development of systems that allow the collected data to flow until reaching the level of the Department of Health Information such as SIS-MA.
In this way, the present article intends to analyse how health data are treated in the national health system of Mozambique to find flaws and/or improvements. The treatment of health data is extremely important, as it is through them that the information that the Ministry of Health (MISAU) uses to design strategic actions is obtained, thus supporting decision making. The information obtained helps MISAU to take measures to resolve certain cases in the health units.
Considering the above, this article is structured as follows: first, we present the introduction followed by the theoretical foundation. Third, the methodology for this study is presented, followed by main results and discussion about the findings, the limitations of the study and the paths for future research. Finally, the conclusion is presented with final considerations around the practical/theoretical implications and limitations of the study.

The Case of Mozambique
With an increase of the average life expectancy (63 years for women and 57 years for men), the way the health service in Mozambique is being improved over the years is an important topic for analysis [6].
The National Health System (NHS) in Mozambique comprises the public sector, the private sector for profit, the private sector for non-profit and the community. Of these, the public sector, that is, the NHS, is the main provider of health services at the national level. As for the for-profit private sector, it is gradually developing, especially in large cities. However, the growth of these providers is conditioned by the increase in household income.
The NHS is organized into four levels. Levels I and II are the most peripheral, with the mission of providing primary care and referring patients with more serious clinical conditions -complications in childbirth, trauma, medical and surgical emergencies, among others -to the next levels. Levels III and IV are basically aimed at providing specialized curative health care. In general, primary care continues to be the dominant strategy in health intervention, aiming to reduce the high mortality rates (e.g. the child mortality rate in 2020 is 67,4%) imposed by communicable diseases such as HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases [4,7]. Health problems associated with high maternal mortality rates, around 490 deaths for 100.000 inhabitants in 2015, are also priority areas for intervention [6,8].
In Mozambique, the Ministry of Health (MISAU) is the central body of the NHS. This is responsible for defining the policies, guidelines and standards that must be followed by each Health Unit (HU). Each region has a MISAU representation that is called the Provincial Health Directorate (PHD). Still in each district there is a representation of the NHS which is the District Service for Health, Women and Social Action (SDAMAS). The Health System Diagram is represented in Fig. 1: . This is responsible for coordinating the general health information process from validity, treatment and processing until the data are used not only at MISAU level, but also at other levels. Also, MISAU is responsible for making strategic decisions, as there are some decisions that are taken at each level, and by the HU.

Management of Health Data in Mozambique
This study is based on the theoretical assumption that health data are important for obtaining information [9,10]. In the healthcare sector, information is a fundamental source for improving processes and to help improve the decision-making process.
To have information of quality, data must reflect the reality found. Data collection methodologies need to take into account the socio-cultural context and investigate in detail how perceptions and practices can facilitate or prevent data collection, to improve the quality of data [11].
Also, there is the need for continuous training on data recording procedures at all levels. To maintain data quality, health care data must be appropriate, organized, timely, available, accurate and complete [12].
Regarding healthcare services, there is a relation between a proper health system and the provision of better health services, because with this practice, patients and the hospital can gain [13,14]. The use of electronic health records is fundamental for improving patient care [2].
Health Information Systems are composed of a structure capable of guaranteeing the collection and transformation of data into information. In this way, information systems (IS) are systems or processes that transform data into information that assist decision-making processes, efficiently, objectively and quickly, which is why they are increasingly implemented [15]. For the results to be successful, collaborative interaction between people, technologies and procedures is necessary.
Also, IS are increasingly necessary in organizations and this reality is also inserted in health services [16]. IS are a strategic resource, regarding actions in decision making, both by health professionals and government officials involved in public health policies.
Considering the importance of data in health, as mentioned above, data alone does not constitute information [17]. They must be treated to be conceived as information that will assist in the decision-making process of MISAU.
Information systems must be simple, allowing an easy and quick access to data. They must be well organized so that they can process relevant, useful information that will facilitate decision making. It is in this sense that the strategies of using tools that assist in the work of health professionals must seek to improve the quality of care provided to the patient [16].
As an example, the SIS-MA is a flexible, open-source, web-based monitoring and evaluation platform that collects, validates, analyses, and presents aggregated statistical data, adapted to integrated health information management activities. It works as an online system and intermittent with the following features. The data is stored on a centralized server that allows access from any device in any region. Also, it allows the collection of data through aggregated data forms, which results from the combination of various items such as sex and age. At the same time, it allows the capture of the various events that occur during the patient care process based on their individual processes. This system provides the list of health units in the NHS, interactively. Through it, several reports related to the proportion and types of units can be made. Lastly, the Public Data Portal allows reporting of data collected and processed by SIS-MA without having to log in. This presentation is made using graphs, tables and maps [5].
However, some obstacles still emerge. Namely, SIS-MA is used by hospitals from the NHS even though majority of the hospitals are from the private sector. Therefore, it remains the doubt about to what extent the healthcare institutions from the public and private sectors share data.
The use of health data shared among participants of the healthcare ecosystem (e.g., hospital, universities, AIDS) is useful to identify geographic trends. So, data sharing is increasingly important, especially in developing countries, such as Mozambique [2]. This sharing of data, turned in information, helps in the various spheres of MISAU. To make decisions and outline strategies at the MISAU level, data sharing is necessary. However, data must be of quality and reliable, since MISAU will take decisions based on this information.
At the same time, the reduced capacity of the Mozambican health system, both in terms of human resources (0.7 clinicians per 10000 people between 2010 and 2018) and quality infrastructure, reduces access to health care by the population, especially in rural areas, which leads to an unknown reality of data [6,8].
In the analysis of how Mozambique is evolving there is the need to considerer that the country remains among the poorest countries in the world. While in 2011 it was ranked in the 184th position out of 187 countries, according to the UNDP Human Development Report, after eight years, in 2019 it remains in the 180th position [6].

Methodology
For the theoretical basis of this article, an online search was made using Scopus and ISI Web of Knowledge. The keywords "data", "value" and "healthcare" were used to identify all articles published on this topic. From this search, 49 articles were found. There were no duplicates of the selected articles. Then, the records were sorted by keywords and the summary with a total of 17 articles included in this study. The screening also included the keyword "Mozambique" considering the context of the research.
In this screening, the PRISMA method was used, as shown in Fig. 2. PRISMA is useful for the critical evaluation of published systematic reviews to reduce the risk of bias [18]. After, a pilot sheet was also developed in Excel for data extraction to gather all the information necessary to produce this article. It allows to systematize the information found, dividing it by year, title, authors, journal, keywords, summary, research questions, variables, hypotheses, methods, application context, results, future research and DOI.
From the research of the databases, we can conclude that in Mozambique there are few studies regarding the treatment of health data. Of the researched articles, it was difficult to find one that addressed the topic. Information on the matter was found on the MISAU website. Another important fact observed was that, although there are few articles addressing the theme in the Mozambican case, it was possible to support the study using some articles, as example [19,20].
After, the methodological strategy was based on a qualitative analysis, with the aid of a semi-structured interview. The manager of the health information department was interviewed to understand how data processing works in the health sector, supported by what was found in the literature.

Results and Discussion
From the interview, it was possible to verify that data are important in health. They should be worked on for the design of information, and this information, in turn, will assist in decision making.
It should be noted that MISAU, although using IS, has not yet released the paper in its entirety, having tried to computerize some procedures. The use of paper is still very present. This occurs in many locations, where there are books of records in the HU for several programs, because there are no conditions for the use of information and communication technologies.
The periodicity of the information depends on the programs, but most of the forms are monthly. Those that are weekly, refer to epidemiological bulletins of diseases of mandatory notification (e.g., cases of malaria, cholera), which must be reported weekly. Some cards are still of a quarterly nature. After the registration of all events, a monthly summary is produced at the end of each month. The person responsible for the program, at the local HU is responsible for producing this summary, referring to the 30 past days.
Regarding the treatment of data, after obtaining information, MISAU will assist in the decision-making process. The goal is to be able to outline some intervention strategies for the HU, thus supporting decision making.
Note that great care must be taken at all levels when analyzing and verifying data to avoid disparities. However, there are flaws while making decisions and there is a risk of allocating a program in a location that does not need it. This means that one can make a wrong decision if the data is not checked effectively and efficiently.
So, data from computerized systems help support decision making in health, reducing the chance of errors, and speeding up decision making by professionals.
In summary, there is still the need to improve the health system in Mozambique in relation to the treatment of health data. However, the government has tried to overcome this situation. The study made it possible to verify that the use of paper is still frequent, and it should be eliminated. In the literature, several authors speak of the importance of using computerized systems [21,22] and the need to computerize the entire system, from the bottom to the top. By computerizing data and information, it is expected that the processes are well organized and allow to assist effectively and efficiently in decision making. Having the computerized system, it is possible to have a structured database that will support health professionals.
The lack of studies carried out in this area of study is also a flaw, which needs to be improved to be able to share information worldwide.
In the Strategic Social Health Plan, one of the established principles and which must be obeyed is that of "Transparency and Accountability". It appears that in Mozambique the healthcare sector seeks to be transparent and understandable. While analyzing statistics on the country, statistics on performance are out of date and there is not a clear definition the role of each person who works in the sector. Also, it seeks to provide information on the progress of the population's health and on the efficiency, effectiveness and impact of the actions developed by the NHS. The disclosure of the sector's statistical data is done at any level of health care provision or health system management, aggregated or not according to the level that disseminates them (district, provincial or central).

Conclusions
From the research, it was found that information systems in health are necessary and indispensable. However, it is dependent on data, information, and knowledge. In addition, health information systems are composed of a structure capable of guaranteeing the collection and transformation of data into information. Information is power, and competitive organizations today are those that have information.
Also, in health it is necessary that the information is there and that it is computerized, increasing its quality to facilitate the decision-making process.

Practical and Theoretical Implications
Considering that in some cases the data processing is still done based on the use of paper, it is suggested that the government find alternative ways of transform the entire process to the computerized system. This is a practical application that was found in the literature and corroborates the idea that computerized information systems are better than paper [23,24]. In turn, information systems play a vital role in assessing quality, as they allow timely access to records collected, processed, and documented in health.
Regarding the implications, after conducting the study, there is a need to conduct more case studies in different regions, in terms of data processing, to analyse what the real situation is. With this study it was found that, in terms of literature, there is little information regarding the management of data in the healthcare sector in Mozambique. Also, there is a lack of articles regarding the treatment of data in health.

Limitations and Future Research Avenues
Like any study, this investigation has some limitations. Only one interview was made. It is suggested that future studies may include interviews with various representatives of the different levels of the system to enrich the study. This would allow to assess other perceptions in relation to the treatment of health data.
It is also suggested that in future investigations, interviews can be conducted with people from different entities that collaborate in the system. The involvement of different stakeholders can help to understand the network of contacts and how it can be operationalized to improve data sharing.