Data-Informed Platform for Health (DIPH)
Phase: NA
Conditions: Behavior
Sponsor: London School of Hygiene and Tropical Medicine

 
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Data-Informed for Health (DIPH)  
 
 
 
Study protocol including plan of analysis  
 
 
 
Date:01/07/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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ETHIOPIAN PUBLIC HEALTH INSTITUTE 
INSTITUTIONAL REVIEW BOARD (EPHI-IRB) 
RESEARCH PROPOSAL FORM 
 
 
 
 
Project No.___________________  (To be given by EPHI-IRB) 
 
Data-Informed Platform for Health (DIPH) – health system strengthening innovation in North 
Shewa Amhara region, Ethiopia 
 
Person(s) undertaking the project in order of contribution 
                        Name 
     Qualification 
((Area of study & 
Degree) 
Institution/Company 
Country 
From London School of Hygiene and Tropical Medicine 
 
Bilal Avan  
MD PhD 
London School of Hygiene and Tropical Medicine  
U.K. 
Joanna Schellenberg 
PhD 
London School of Hygiene and Tropical Medicine  
U.K. 
Mehret Dubale 
MSc 
London School of Hygiene and Tropical Medicine  
Ethiopia 
Della Berhanu 
PhD  
London School of Hygiene and Tropical Medicine  
Ethiopia 
Lars Åke Persson 
MD, PhD 
London School of Hygiene and Tropical Medicine 
Ethiopia 
From Ethiopian Public Health Institute 
 
Girum Taye 
MSc 
Ethiopian Public Health Institute (EPHI) 
Ethiopia  
Abebe Bekele 
MSc 
Ethiopian Public Health Institute (EPHI) 
Ethiopia  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source of budget:  Bill and Melinda Gates Foundation through the 
London School of Hygiene and Tropical Medicine 
Total budget required: ETB 10,528,180.01 
(USD 396,028.) 
Contact address of the PI: Tel. Address +442079272317       Email:  Bilal.Avan@lshtm.ac.uk 
Contact address of first co-investigator: Tel. Address +251932223164      Email: girumt2000@yahoo.com 
Study period:  30 months 
Date of commencement: August 2019 
Date of completion: July 2021 
Institution at which study to be conducted:  Ethiopian Public Health Institute 

 
 
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Table of contents 
Abbreviations and acronyms ........................................................................................................................................ 4 
List of appendices ......................................................................................................................................................... 5 
Summary ....................................................................................................................................................................... 6 
Background and justification ........................................................................................................................................ 8 
Objectives of DIPH project ...................................................................................................................................... 14 
Materials and methods ............................................................................................................................................... 15 
Data Analysis Plan ....................................................................................................................................................... 18 
Strengths and limitations of the DIPH project ............................................................................................................ 20 
Communication and dissemination of study findings ................................................................................................. 20 
Ethical considerations and review process ................................................................................................................. 20 
Implementation of DIPH project ................................................................................................................................. 21 
Benefits of the Study’s Results ................................................................................................................................... 21 
Research Collaborators ............................................................................................................................................... 22 
Assumptions, risks and mitigations ............................................................................................................................ 22 
Facilities available for the study ................................................................................................................................. 23 
Authorship right .......................................................................................................................................................... 23 
Declaration of conflict of interest ............................................................................................................................... 23 
References .................................................................................................................................................................. 24 
Assurance of the Principal Investigator: ..................................................................................................................... 25 
Appendices ................................................................................................................................................................. 27 
Annex I:  Map of North Shewa within broader Amahara region.    (and if possible map of woredas within north 
Shoa zone) .............................................................................................................................................................. 27 
Annex II:  List woreda by type: and population size in North Shoa zone ............................................................. 28 
Annex III:    Health Profile of North Shewa zone on selected Maternal and Child Health indicators .................. 29 
Annex IV: informed consent and Information sheet ............................................................................................ 30 
Annex V: DIPH Study Instruments ......................................................................................................................... 32 
 
 
 

 
 
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Abbreviations and acronyms 
DIPH: Data-Informed Platform for Health 
EPHI: Ethiopian Public Health Institute  
LSHTM: London School of Hygiene and Tropical Medicine  
IDEAS: Informed Decisions for Actions in Maternal and Newborn Health 
FMoH: Federal Ministry of Health 
HMIS: Health Management Information System 
DHIS2: District Health Information System 2 
PI: Principal Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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List of appendices 
Annex I:  Map of North Shewa within broader Amahara region.    (and if possible map of woredas within north 
Shoa zone) 
Annex II:  List woreda by type: and population size in North Shoa zone 
Annex III:    Health Profile of North Shewa zone on selected Maternal and Child Health indicators 
Annex IV: information about the study 
Annex V: DIPH Study Instruments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Summary 
 
Appraisal and use of local data for health system planning and decision-making are often limited, despite advances 
in data-gathering operations in lower- and middle-income countries. A data-sharing culture and opportunities for 
collaborative action-planning among health-stakeholders are lacking. Local health administrators in such settings 
often have limited capacity to analyze and use data for decision-making.   
  
The overall aim of the Data-Informed Platform for Health (DIPH) is to improve Maternal, New-born and Child Health 
(MNCH) programmes and services at the Woreda level. The DIPH strategy does this by bringing together data on 
inputs and processes in order to promote the use of local data for decision-making, priority-setting and planning 
through the introduction of a structured decision-making process at the Woreda level. This resonates closely with 
the Ethiopian Health Sector Transformation Plan in 2015 [ref], which identifies the information revolution as part of 
the transformation agenda. Promoting a culture of information-use at, or close to, the point of collection is central 
to the information revolution. 
  
The transition of the DIPH from a concept to a health-systems initiative is based on a series of implementation-
research activities, including a background assessment and the development and testing of the intervention. Our 
formative research showed that there is only a limited structured district decision-making process, with limited 
interactions between departments and little formal Woreda-level data-sharing. The DIPH is embedded in existing 
Woreda decision-making approaches - e.g. Performance Review Teams at Woreda level - adding a structured process 
of coordination between different departments, and formal data-sharing for evidence-based decision-making, 
planning and resource allocation according to local health priorities. 
   
Conceptually, the DIPH strategy uses a structured set of processes involving five pre-defined steps, and standardized 
job-aids corresponding to each step, to facilitate linking data from health and associated departments and 
stakeholders. A typical DIPH cycle has five steps around a health theme, which take about three to four months to 
complete. Technical assistance is provided by the induction, orientation and handholding of the Woreda 
stakeholders during the implementation of the initial cycles.  
  
The DIPH job-aids – a set of standardized job-aids (paper forms or web-based interface) corresponding to each of 
the five steps – are designed to help in the organization and interpretation of data from multiple sectors involved in 
the delivery of services around the chosen theme using a common data-sharing platform. They areaimedat Woreda 
leadership and management teams using, inputting and processing data systematically for decision-making, planning 
and progress-monitoring of the theme.   
  
In Ethiopia, action-research will be employed to adapt, implement and evaluate the DIPH approach in a series of 
overlapping phases. 
 
1. 
Developmental phase (August 2018 – May 2019):  Engage with Ethiopian Federal Ministry of Health and 
synchronize with similar projects, Adapt DIPH tools and strategies for the local context, and Finalize the 
selection study area.  This phase has been successfully completed, and we anticipate that the study will be 
implemented in North Shewa zone of Amhara region (12 DIPH, 12 Non-DIPH Woredas).  
 

 
 
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2. 
Implementation phase (August 2019 - July 2021): Implementation for 24 months (two fiscal years: first 
year for embedding, and second year to establish effectiveness), up to six four-monthly cycles conducted in 
each of 12 Woredas.  
 
3. 
Evaluation phase (2019 - 2021):  Process evaluation to understand and improve on-going implementation 
issues. Before-and-after comparison of intermediate outcomes in intervention and comparison areas via 
health facility and Woreda surveys.   
  
Budget: The estimated cost of DIPH implementation and evaluation will be will be 10,528,180.01 Ethiopian birr. 
 
This study is a collaboration between the Ethiopian Public Health Institute (EPHI) and the London School of Hygiene 
and Tropical Medicine (LSHTM) under the remit of the IDEAS (Informed Decisions for Actions in Maternal and 
Newborn Health) project. In Ethiopia, we anticipate federal government interest in the findings of the DIPH 
approach, given its potential to strengthen district level health systems by enabling data-driven decision-making, 
which could be instrumental in operationalizing the Ethiopian Health Sector Transformation Plan. 
 
 

 
 
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Background and justification 
 
In low-resource settings, the use of local health data for planning is usually limited. It is typical for diverse health-
providers – relevant local government departments, NGOs, private providers – to work in parallel with no formal 
mechanism to share their data or plan their services collaboratively. If mechanisms for data-sharing were improved, 
there would be opportunities to reduce duplication, make better use of resources and meet community health needs 
more fully.   
  
In Ethiopia, multiple sources of data exist at the district level: the Health Management Information System (HMIS) 
reflects health facility utilisation and performance; programme staff report on human and physical resources; 
relevant government departments (e.g. agriculture) have information on nutrition, social welfare and food security; 
and non-governmental organisations report on community-based activities. Access to shared data could empower 
local decision-makers to make better decisions, derived from a broader base of evidence, and deliver health services 
on the basis of available resources. 
 
 The initial phase was started with the DIPH co-creation workshop in Addis Ababa, held on 25 April 2018 and chaired 
by the Federal Ministry of Health’s (FMOH) Policy and Planning Department (PPD).  Participants included 
representatives from: the Ethiopian Public Health Institute, Ethiopia Data Use Partnership - DUP, Last 10 Kilometres, 
and the Bill and Melinda Gates Foundation. The objective of the workshop was to collaboratively develop a plan to: 
a) adapt DIPH and its implementation through research activities relevant for Ethiopian health systems; and b) 
identify and establish linkages with complementary initiatives supporting the use of local data. 
 
Based on the recommendations of the workshop, the objectives of the developmental phase were formulated: 
1.       To understand how routine data (DHIS, LMIS, PFSA and any other data collected on an ongoing basis) are used 
at present at Woreda level for problem-solving. 
2.       To understand what are the existing decision-making and/or data-review forums in Woredas. 
3.       To determine the short-term needs (if any) of Woreda health-system managers in terms of being able to move 
towards a more structured approach to problem-solving such as DIPH. 
4.       To introduce respondents to DIPH’s process-steps and interviews, and record their views on its feasibility. 
In order to operationalize these objectives, a series of exploratory activities was carried out, including consultation 
with federal, regional and Woreda-level health managers, direct observation of key problem-solving 
forums/meetings, and workshops with district-health management staff (Appendix: information-collection 
instruments). 
 
Guided by the findings of the development phase,  
1.       We adapted DIPH tools and strategies from West Bengal to the Ethiopian context, and 
2.       A DIPH training curriculum was developed.  The overall aim of this curriculum, which is the basis of a training 
handbook, is to provide tools and knowledge for improved decision-making at the district level, utilizing available 
data.  Its target audience are district health officers, in both administrative and managerial roles within health 
systems. The first half of the course will cover the four core skills of decision-making, stakeholder-engagement, data-
use, and monitoring health-system performance. Next, participants will be provided with an overview of district-
level organizational structure, followed by an introduction to DIPH, steps in the DIPH cycle, primary and 
supplementary forms, roles and responsibilities, DIPH meetings, and, finally, how to use the DIPH interface. 

 
 
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Core Concept 
The overall aim of the Data-Informed Platform for Health - or DIPH - is to improve MNCH programmes and services 
through data-driven decision-making at the district level.  It is a strategy for strengthening health systems.  The DIPH 
does this by bringing together a variety of stakeholders into a single platform, and facilitating their understanding 
and use of key district-level data. 
 
Our focus is MNCH, although the DIPH concept has broad applicability. The primary objectives of the DIPH are to 
promote the use of local data from programmatic activities for: 1) decision-making, priority-setting and planning at 
the district health administration level; and 2) appraisal of health services and programmes. 
  
A district is considered to be the operating unit for the DIPH based on the assumption that this is the lowest effective 
administrative level of decision-making in a health system in Ethiopia.   The DIPH concept has its roots in the ‘District 
Evaluation Platform approach1, 2, 3. 
  
The DIPH approach will bring governmental and non-governmental service providers to a common forum on a 
regular basis, in order to share data according to an agreed plan and to use the resulting information as a tool in 
priority-setting for resource allocation and needs-assessment for the further acquisition of funds. 
  
The DIPH does not try to reinvent the wheel - it is embedded in decision-making procedures that already exist at the 
district level. What DIPH adds is a structured process of coordination between government and private stakeholders 
of formal data-sharing for evidence-based decision-making, planning and resource allocation.  Moreover, the DIPH 
is conducted in accordance with local health priorities. 
  
Problem statement 
Decision-making within a health system requires stakeholders to reach consensus on a particular health theme – e.g. 
antenatal care - in order to address challenges in the management and delivery of health services. 
  
When making decisions about issues of a health theme at the local level, using data is instrumental in setting 
priorities, allocating resources, effectively monitoring services and making realistic plans.  However, a) data captured 
by different stakeholders – health and non-health departments, non-governmental organizations, or the private 
sector – need to be brought to a common platform to enable evidence-based decision-making,  b) in countries and 
regions of limited resources and expertise, the possibilities of using local data for health system planning and 
decision-making are often limited,  c)  the data that is available may be of poor quality, and a culture of data-sharing 
may not have developed,  and d) when decisions are made about health service management, those making the 
decision often have a limited capacity to understand  and use the data available to them. 
  
The DIPH brings together key data from the district level and promotes the use of local data for decision-making, 
priority-setting, planning and course-correction at the district level.   This is done through the introduction of a 
structured and collaborative decision-making process.  Further details of the underlying core principles of the DIPH 
strategy are described in figure 1. As such, while the DIPH approach has been applied primarily to Maternal, Newborn 
and Child Health, it can be applied to any area of healthcare. 
  

 
 
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How does the DIPH work? 
The DIPH is delivered as a package of job aids and guidelines. Structurally, the package is made up of three 
main elements:   Firstly, the package involves the grouping of stakeholders who are brought together to deliberate 
on issues in a virtual platform facilitated by regular meetings.   The membership of this virtual platform is flexible 
and responds to the needs of the issues in focus.   Secondly, the DIPH package facilitates these stakeholder meetings 
in five steps:  Assessment, Engagement, Definition, Planning and Follow-up.  These five steps together make up one 
whole cycle of the DIPH and, in practice, take 3-4 months to complete.   Each cycle looks at a specific health theme, 
identified in the early stages of the cycle itself.  Thirdly, the DIPH package also includes a digital interface where 
everyone involved in the process can regularly review data and check on progress. 
 

 
 
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Fig 1:  Core Principles of the DIPH strategy  
 
1 
Integrated support of health systems 
  
The primary focus is on strengthening health systems through effective decision-making and 
collaboration by converging across health and social sectors. 
2 
Data driven  
 
Locally-generated data is central to decision-making and management at the Woreda level.     
3 
Health systems performance 
  
Problem-solving is by employing the WHO health system blocks framework, for health system 
management and monitoring performance at the district level. 
4 
Embeddedness 
  
The Embeddedness of the DIPH into existing decision-making at the district and above levels with 
respect to  
1. 
Participatory decision-making 
2. 
Government-specified priorities  
5 
Responsiveness  
  
Identification of a thematic focus   in response to local needs at the district level, and execution of the 
implementation plan to strengthen health systems. 
6 
Implementation support 
  
Providing assistance to district administration staff in terms of training and capacity-building:    
 
1. 
Inter-sectoral collaboration  
2. 
structured decision-making   
3. 
Data use and 
4. 
Monitoring health systems performance 
7 
Outcome focused  
  
Improving health data-management, data-use and effective decision-making culture at the district 
level. 
 
Development of DIPH 
 Until now, the DIPH development has been led by the IDEAS project.   In working to transform the DIPH from a 
concept to a health systems initiative, we undertook a series of implementation research activities. 
This included conceptualization, feasibility assessment, and the development and testing of the DIPH strategy. The 
feasibility of establishing the DIPH was assessed in the context of district health systems in various countries.   The 
feasibility of the DIPH was assessed in five dimensions: technology and systems, economics, law and politics, 
operations, and schedule feasibility. Through this assessment the primary structure and content of the DIPH 
evolved. In the Health Policy and Planning Journal we reported on the feasibility of establishing the DIPH in the 
context of district health systems in India, Nigeria and Ethiopia, taking into consideration five dimensions: technology 
and systems, economics, law and politics, operations, and schedule feasibility4, 5, 6, 7, 8. Our papers describe the 
potential of health data from multiple sources. If utilised regularly and in a more structured way, they would greatly 
enhance evidence-based decision-making. 
   
Operationalization of the DIPH concept 
Figure 2 represents the sequence and links between the 5 steps of DIPH.  Usually, steps 1, 2 and 3 comprise a core 
team of district-level officials, including District Programme-Managers, Heads of Department, and Statistical and 
Research Officers of health and non-health departments.    However, more stakeholders can be included - according 

 
 
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to the nature of the steps and the health challenge in focus during the cycle.   This includes health and non-health 
departments in the public sector along with private service-providers and NGOs. 
 
Figure 2:  Five-step DIPH cycle 
 
 
 
Step 1 – ‘Assessing’ the current situation of the district 
The first step of structured decision-making requires understanding the existing situation in the area of interest, e.g. 
Maternal, Newborn and Child Health. Understanding the situation requires a systematic review of existing of data, 
district health policies and plans - as well as other contextual information – in order to identify the specific health 
theme that needs to be addressed.   This step is also marked by the selection, by group consensus, of the theme 
leader, who is responsible for coordinating the progress of the DIPH cycle.    This process establishes a detailed and 
realistic picture of the coverage of services, and what human, material and financial resources are available in a 
particular district. 
  
Step 2 is about engaging other departments and key people to understand how collective action can help, and how 
to coordinate it.  Engaging stakeholders generates ownership of actions on specific health themes.  The process will 
enhance engagement of, and collaboration among, stakeholders. It involves the same members as in step 1. 
  
Step 3 involves ‘Defining’ the areas to be improved in a cycle. Usually in this third step, the core team are joined by 
a wider group of stakeholders relevant to the selected theme.   Everyone involved in the DIPH further defines the 
challenges related to the selected theme in line with the World Health Organization’s health system 6 building 
blocks*.  This then helps identify an area where implementing a full cycle of the DIPH can potentially help improve 
outcomes.   Steps one, two and three can potentially be conducted in one day. 
  

 
 
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In step 4, which can be actioned immediately after step three, stakeholders are joined by a senior representative of 
the district administration.  The stakeholders discuss actionable solutions proposed in step 3, and define indicators 
to measure their progress against the action-points.  They allocate the responsibilities of each action point to the 
concerned stakeholders and define a timeline for it to be completed. 
  
The fifth and final step involves “Following up” on the implementation of the plan set out in step 4.  The DIPH cycle 
theme leader monitors the implementation of the plan by all the stakeholders over a period of three to four months 
and provides support wherever needed. 
  
In step 5 all DIPH stakeholders from step 4 meet again, three to four months later.  The group evaluate the action 
plan based on the target and timeline developed, and this enables them to track progress. If the action point is not 
on track, they can review and redefine the responsibilities and timeline.   During the follow-up period, the theme 
leader of the cycle receives monthly progress reports from the sub-district level.  This completes a full cycle of the 
Data-Informed Platform for Health for a specific theme-related challenge in Maternal and Newborn health, or any 
other health theme. 
  
During all five phases of the Data-Informed Platform for Health, stakeholders use a variety of resources developed 
to support all the steps of the cycle. These resources bring structure to the discussions, and help capture data and 
feed it efficiently into the next step of the cycle. 
 
A guide to all the resources available in the DIPH package - including the DIPH web interface - can be found 
at ideas.lshtm.ac.uk 
 
DIPH was developed and successfully tested in West Bengal over the course of two years.  External evaluation 
suggested the DIPH prototype phase was successful in achieving its goals. It also facilitated further development of 
the DIPH Programme Theory which has been outlined in figure 3, i.e.  mechanisms, context, and determinants of 
data-sharing and data-use for decision-making, planning, progress-monitoring and follow-up among inter-sectoral 
stakeholders using DIPH9  . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 3:  DIPH Programme Theory  

 
 
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Objectives of DIPH project  
Overall aim: 

 
 
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We propose a project of implementation research with the aim  to enhance interaction among district-level health 
personnel and linkage of databases to improve coordinated decision-making and planning by strengthening health 
systems through capacity-building and effective use of data for decision-making. 
 
Specific research objectives:  
1. 
To systematically strengthen the Woreda health system using the DIPH strategy by developing a coordinated 
decision-making and planning through the Data-Informed Platformfor Health strategy 
2. 
To evaluate the effectiveness of embedding the Data-Informed Platform for Health within the Woreda 
health system with respect to improvement in Woreda health performance in terms of data management 
and data-driven decision-making as compared to Non-DIPH woredas. 
 
Materials and methods 
We propose an action-research approach to adapt, implement and evaluate the DIPH approach in Ethiopia. We aim 
to work in close collaboration with national and local institutions, and engage key government stakeholders. This 
will provide essential information for policy-makers and decision-makers about the usefulness of DIPH. 
  
The total duration of this work will be three years which is going to be implemented in phases. 
  
Study Design 
A quasi-experimental study with pre and post comparisons will be applied. Study woredas will be considered as 
clusters and equal number will be allocated for presence and absence of intervention arm. The study will be 
conducted in all Woredas of North Shewa Zone by allocating 12 of them in intervention and 12 in non-intervention 
arms. A matched peer random allocation will be employed. To reduce subjective allocation, matching will be done 
based on Woredas’ performance level and distance. 
 
Study area: based on the criteria of a) receptiveness of the zonal health office, B) manageable distance from Addis 
Ababa, the Amhara region was shortlisted for the implementation phase of DIPH.   
 
Amhara regional state consists of 10 administrative zones, one special zone, 105 Woredas, and 75 urban centres. 
Amharic is the working language of the state. The capital of the region is Bahir Dar, where Ethiopia’s largest inland 
body of water, Lake Tana, is located. The state of Amhara covers an estimated area of 170,752 square kilometres, 
and its projected population for 2019 G.C. is 21,844,000. 
 
The study will be implemented in North Shewa, one of the administrative zones in the Amhara region. 
Geographically, it is bordered in the south and west by the Oromia region, in the north by South Wollo, in the north-
east by the Oromia Zone, and in the east by the Afar Region. The total area is 15,936.13 square km, with a population 
density of 115.30. According to the 2007 census conducted by the Central Statistical Agency of Ethiopia (CSA), this 
zone has a total population of 1,837,490. 11.66% are urban dwellers. Towns and cities in North Shewa include 
Ankober, Debre Berhan and Shewa Robit. Amharic is the first language of 92.97% of the population, followed by 
Oromiffa (6.32%). 94.71% of the population are Ethiopian Orthodox Christians. Details of selected maternal and 
child-health indictors and health-system infrastructure in the proposed administrative zone are given in Annex I, II 
and III. 
 

 
 
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This development phase has been successfully completed, and we anticipate the study will be implemented in all 24 
Woredas of the North Shewa zone (i.e. 12 DIPH, 12 non-DIPH). 
   
Implementation phase (August 2019-July 2021): up to six four-monthly cycles of DIPH each will be conducted in the 
12 woredas of North Shewa zone over 24 months (i.e. two fiscal years: the first year to complete the embedding of 
the strategy within the system, and the second year to establish effectiveness). 
  
The Data-Informed Platform for Health will be implemented in the North Shewa administrative zone of the Amhara 
region. Its Woredas will be stratified by urban and rural, and 12 intervention and 12 comparison Woredas will be 
randomly selected in collaboration with the zonal health department. 
  
Embedding: The Performance Review Team meetings of the district health administration, which is entrusted with 
integrating planning and facilitating data-driven and collaborative decision-making, will be used as a platform to 
introduce the DIPH.  Activities will focus primarily on: 
1.       Strengthening the Performance Review Team forum for the engagement of all government and non-
governmental stakeholders in order to identify challenges and solutions, and to assess resource allocation and 
responsibilities.  These meetings will be convened with the aim of consensus-building and collective decision-making 
to improve health systems and services in their areas. 
2.       Promoting the critical review and regular use of local data to understand health-system progress at the Woreda 
level. 
  
Training:  Prior to the initiation of the first DIPH cycle, district health management staff of DIPH Woredas will be 
provided with three days’ intensive residential training based on the specifically-designed curriculum (described 
above) in their zonal city. On average, six staff members per Woreda will be trained by the research team.   Along 
with the Woreda’s health department head, programme officers and an HMIS focal person, experts from the zonal 
health department will be included in the training.  The three-day residential training will be conducted by the DIPH 
research investigators team 
  
Field research team:  Overall, the field team will comprise one DIPH regional coordinator, four DIPH support 
supervisors and one data manager. The positions of DIPH support supervisor will be filled by applicants who have 
completed their MPH with a minimum of two years’ experience in the Ethiopian health system, while the regional 
coordinator will have at least 10 years’ experience of research coordination. The data manager should have an MSc. 
in computer programming. Recruitment will be carried out through EPHI in collaboration with IDEAS-LSHTM. 
  
Each support supervisor will be assigned three Woredas where they will provide overall technical support in 
implementing the DIPH strategy. This will consist of inducting, orientating and handholding Woreda stakeholders 
during the implementation of the initial cycles, participating in Woredas’ monthly performance-review meetings, 
and monitoring collected data. Data-collection will be performed on tablets using appropriate software for electronic 
data collection. Data collected from the field will be sent to EPHI’s server on a daily basis through the Internet File 
Streaming System, a technology for transferring data already installed at EPHI. 
  
Evaluation phase (2019-2021): This will have three aspects: 
I.            Process evaluation – to understand and address on-going implementation issues. The monitoring of DIPH 
in-progress will address the following questions: 

 
 
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1.       To what extent is health data used for problem-solving and delivering health services in each DIPH cycle? 
2.       What is the level of engagement of various health stakeholders? 
3.       What are the key mechanisms for data-sharing and consensus-building among the range of health-service 
stakeholders at the Woreda level? 
4.       What are the facilitators of, and barriers to, sustaining the DIPH strategy?  
  
Data will be collected on structured forms by DIPH support supervisors for each cycle throughout the 
implementation of DIPH.  (Appendix:  DIPH Study Instruments, Section B: monitoring framework, definition and 
indicators).  Synthesised findings will be presented periodically to respective Woreda staff so that learning can used 
to improve the next cycle. 
  
II.            Before-and-after comparison of health-system outcomes in intervention- and comparison-district 
(Woreda) surveys to assess changes resulting from DIPH implementation for at least two fiscal years, in terms of 
1. 
Health Information System performance at the district level (the summary measure will be created based on 
the constructs of 1) essential infrastructure for data management, 2) data diversity, 3)reporting timelines, 4) 
data-quality assessment mechanisms, and 5) data use. 
2. 
Governance of data-driven decision-making at the district level (the summary measurewill be created based on 
the constructs of 1) evidence-based decision-making,  2) participatory   decision-making,  3) understanding 
value of  data,  4) health system support for data-use/data-driven decision-making,  and 5) accountability). 
The summary measures/indices will be calculated for each of the 24 Woredas at baseline and at endline, and will 
range from 0-100%.  They will also be categorized to create indicators to determine proportion change for before 
and after comparison.   
Inclusion criteria 
• 
All Woredas in North Shewa zone will be included in the study.  
• 
All managerial and administrative Woreda staff.  
 
Exclusion criteria 
Study participants who do not consent will be excluded.  
  
Timing:  the baseline study will be conducted in early August 2019, prior to the DIPH-training of Woreda staff, while 
the end-line survey will be conducted in late July 2021, after the end of the sixth DIPH cycle.  
  
Study participants:  The survey respondents will be the head of the health department, all programme officers and 
data managers at the district level. All eligible district staff will be interviewed, except those working in their 
respective districts for less than six months. We anticipate on average 6 -7 eligible staff would be available in each 
Woreda and we aim to include all of them in the study.  
 
Table 1. Sample size for before-vs.-after comparison  
 

 
 
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Indicator 
Expected 
level at 
baseline 
Expected Minimum 
percentage point 
increase 
Health management 
staff  assessed/ 
Woreda 
No. of Woredas 
/study arm 
Health Information System 
performance at the district level 
50% 
25% 
6 
12 
 
The sample size estimations for the required number of Woredas required per study arm is based on the statistical 
formula recommended by Hayes et al10.   i.e.  
 
𝑐= 1 + (𝑧! "
⁄ + 𝑧$)" %!('(%!)/+,%"('(%")/+,(-!#%!#,-"#%"#)
(%!(%")#
 
 
Based on the calculations reported in Table above, a minimum sample size of 72 health management staff per 
study arm (144 in total) would have 80% power to detect a difference of at least 25 percentage points as 
statistically significant. 
 
Where:- 
C is number of clusters required (Woredas) 
Zα/2 is confidence level (95%) 
Zβ is required power (80%) 
π0 is true proportion in the absence of intervention (50%) 
π1 is true proportion in the presence of intervention (75%) 
m is individuals sampled in each cluster/woreda (72)  
k0 is coefficient of variation of true proportion in the absence of intervention (0.096942) 
k1 is coefficient of variation of true proportion in the presence of intervention (0.096942) 
 
 
 
Based on the calculations reported in Table above, a minimum sample size of 72 health management staff per 
study arm (144 in total) would have 80% power to detect a difference of at least 25 percentage points as 
statistically significant. 
 
Data-collection:  After a detailed pilot testing (Appendix: DIPH Study Instruments, section B) , baseline survey data-
collection will be carried out by DIPH field teams.  For end-line survey data-collection, an independent team of four 
data-collectors and one supervisor will be recruited from the zone for one month. Data-collectors will be recruited 
by EPHI and will, as a minimum, have a Master’s degree.  Their classroom training on the survey instruments will be 
followed by a written assessment on the survey contents.  Data-collectors will be provided with a field manual for 
reference during fieldwork. Job descriptions – with the roles and responsibilities of each team member, and 
expected day-to-day deliverables - will be provided. The survey will be piloted to test survey procedures and tools, 
and a detailed standard operating-procedures document for the survey will be provided to the data-collection team. 
   
Data Analysis Plan  
 
The  Primary outcomes of the study includes  
a) Change in 'Health Information System performance' at the district level over as compared to non-DIPH 
districts   

 
 
19 
It refers to changes in the a) Behavioural (the knowledge, skills, attitudes, values, and motivation of the people 
who collect and use data)  and b) Technical (data collection forms, processes, systems, and methods)  aspects of 
the district health system  
Key constructs:   
1) essential infrastructure for data management,  
2) data diversity,  
3)reporting timelines,  
4) data-quality assessment mechanisms, and  
5) data use.  
 
b) Change in Governance of data-driven decision-making at the district level level as compared to non-DIPH 
districts .  
It refers to changes in the organizational aspects of district health system   (information culture, structure, 
resources, and roles and responsibilities of key contributors at each level of the health system. )  
Key constructs:   
1) evidence-based decision-making,   
2) participatory   decision-making,   
3) understanding value of  data,   
4) health system support for data-use/data-driven decision-making,  and  
5) accountability). 
The primary outcomes are the  survey-based assessment indices developed by Performance of Routine Information 
System 
Management 
(PRISM) 
Toolkit 
( https://www.measureevaluation.org/resources/publications/tl-18-
13/index.html).  They will be created by summating the survey item's responses and converting scores to fall on a 
standardized scale of 0-100. 
 
Study data will analysed using descriptive, inferential and regression statistics. Chi-square and t-test will be used to 
compare sample characteristics between DIPH and non- DIPH study aims to assess the differences in categorical and 
continuous variables, respectively.   
We are using difference-in-differences estimates because the change may inherently happen over time. Therefore, 
a control group will capture this intrinsic temporal change without DIPH intervention and subtract it from the change 
brought by the DIPH  intervention to assess  the net effect on key study outcomes  i.e Health Information System 
performance  and Governance of data-driven decision-making at the district level. First, we will calculate absolute 
differences in percentages from the baseline and the endline, then calculate the net-effect by subtracting the 
absolute DIPH- intervention difference from the control. We will use multilevel random regression to test the 

 
 
20 
intervention's impact (net-effect), accounting for observed and unobserved time-invariant and the time-variant 
factor between intervention and control sites.  
We will include districts as level two variables with multilevel modelling to control intra-class correlation. The 
analysis will be adjusted for personal and professional  characteristics of respondents and contextual factors of 
districts 
 
Strengths and limitations of the DIPH project 
 The overall strength of this study is that it enables the intervention Woredas to use their locally generated data for 
decision making.  
Since the effectiveness of the intervention will be conducted in 12 Woredas in one zone in Amhara region, if the 
intervention is effective, the study findings will be further scaled-up in a wider setting. 
Communication and dissemination of study findings 
After the conduct of the study, study results will be disseminated through dissemination workshop by inviting the 
Federal Ministry of Health, North Shewa Zonal health office, Amhara Regional health bureau and other relevant 
stake holders.  
From the final study findings, manuscript will be prepared and submitted to relevant peer reviewed scientific 
journals for publication.  
Ethical considerations and review process 
Timely ethical clearance will be sought at the Ethical Review Board of the Ethiopian Public Health Institute, 
and at the corresponding board at the London School of Hygiene and Tropical Medicine. 
 
The study does not involve data-collection from community members or health records.  The study 
participants are health-system officials, and the template of a consent form for their interviewees with a 
standard introduction to, and explanation of, the project is attached (Annex IV). 
 
Voluntary participation 
Participation in this study is completely voluntary and the participants are free to withdraw at any time without 
giving any reason and without any negative consequences. 
Confidentiality 
The researchers will not identify study participants by name in any reports and confidentiality as a participant in 
this study will remain secure. Subsequent use of data will be subject to standard data use policies that protect 
anonymity of study participants. 
Privacy 
During data collection from study participants; privacy will be secured, no one will be around. Field staff are 
committed to collect personal information responsibly.    

 
 
21 
Implementation of DIPH project 
 
No 
Activities 
 
 
Year  
19 
19 
19 
19/20 
20 
20 
20/21 
21 
21 
21 
21 
 
 
Months  
May  
June  
Jul- 
Oct 
Nov-Feb Mar-
Jun 
Jul- 
Oct 
Nov-Feb Mar-Jun July 
Aug- 
Nov 
Nov- 
Dec  
 
Developmental  
phase 
 
 
 
 
 
 
 
 
 
 
 
1 
Ethics/IRB submission 
 
 
  
 
 
 
 
 
 
 
 
 
2 
Baseline survey 
 
 
 
 
 
 
 
 
 
 
 
 
 
Implementation  
phase 
 
 
 
 
 
 
 
 
 
 
 
3 
DIPH training  
 
 
 
 
 
 
 
 
 
 
 
 
4 
DIPH cycles  
 
 
C1 
C2 
C3 
C4 
C5 
C6 
 
 
 
 
Evaluation 
phase 
 
 
 
 
 
 
 
 
 
 
 
 
DIPH cycle Monitoring  
 
 
 
 
 
 
 
 
 
 
 
5 
End-line survey 
 
 
 
 
 
 
 
 
 
 
 
6 
Data cleaning, Analysis & 
reporting 
 
 
 
 
 
 
 
 
 
 
 
7 
Dissemination   
 
 
 
 
 
 
 
 
 
 
 
 
Benefits of the Study’s Results 
 
The overall aim of the Data-Informed Platform for Health (DIPH) is to improve health programmes and 
services at the Woreda level. As an innovation to strengthen health systems, the DIPH promotes the sharing 
and use of local data for health-decision-making, particularly problem-solving.  Key health-data on inputs 
and processes from multiple programmatic activities at the district-health administration level are brought 
together.  This data then informs the collaborative action-plan and follow-up of different government 
departments and private sector agencies through a structured process that uses existing platforms at the 
district level.   This resonates closely with the Ethiopian Health Sector Transformation Plan in 2015 [6], which 
identifies the information revolution as part of its transformation agenda. Promoting a culture of 
information-use at, or close to, the point of collection is central to the information revolution. 
 
Importance of DIPH in Health System Strengthening 

 
 
22 
1. 
Inter-sectoral convergence, through effective coordination with key departments to address health 
determinants, including water, sanitation, hygiene, nutrition; education; gender and women-
empowerment; and integrated Child health and Development services etc.; 
2. 
Multi-sectoral data-sharing;   
3. 
Strengthening data-quality, aiming to rationalize regular use of local HMIS indicators; and reliable health-
data/data-triangulation mechanisms; and 
4. 
Accountability and planning, through regular meetings of Performance Review Team dedicated to 
periodic review progress and a re-calibrated future road map, such meetings having a clear agenda and 
follow-up action with regular, focused reviews at different levels. 
 
Research Collaborators 
This study is a collaboration between the Ethiopian Public Health Institute (EPHI) and the London School of Hygiene 
and Tropical Medicine (LSHTM) under the remit of the IDEAS (Informed Decisions for Action in Maternal and 
Newborn Health) project. Overall, the IDEAS-EPHI team will take responsibility for the DIPH development, and for 
monitoring and evaluating its implementation, in active collaboration with the Health Bureau of Amhara region. 
  
London School of Hygiene and Tropical Medicine (LSHTM) 
The primary role of LSHTM is to lead the overall DIPH project coordination, provide technical support and participate 
in report development. This will include providing training for DIPH support supervisors, data analysis, report writing 
and manuscript preparation. 
  
Ethiopian Public Health Institute 
EPHI will lead the overall DIPH project implementation in terms of recruiting field staff, training, and DIPH 
implementation.   It will also take a lead role in liaising between the DIPH project and the FMoH, Amahra regional 
health bureau, and similar on-going projects in the region. EPHI will be responsible for the quality of the DIPH 
implementation and data management. Dissemination of DIPH’s findings for national and regional stakeholders will 
also be one of its main roles. EPHI will also participate in providing training for support supervisors about DIPH 
strategy and steps.   EPHI will participate in data analysis, report writing and manuscript preparation. 
  
Amhara Health Bureau 
The leading role of the Amhara Health Bureau in the DIPH project will be facilitating the project’s implementation 
through selecting Woredas; and, from time to time, participating in field supervision during the project’s 
implementation, enabling them to provide their views and feedback by the end of each cycle. 
 
Assumptions, risks and mitigations 
 
The law and order of study site, safety and security of the research staff and protection of study participants are 
assumed to be secured and stable. If circumstances change, research site/ location will be reconsidered. By 
participating in this study and answering the questions, study participants will not receive any direct benefit. 
However, they will help to increase the understanding of health system operations in Ethiopia. The result of this 
study will contribute in generating evidence and knowledge to inform policy and practice at national and global 

 
 
23 
levels. This study involves provision of information through pre-developed questionnaires and the organization will 
keep the data in a safe place which can only be accessed by the study team.  Therefore, participation in this study 
has minimal risk. 
 
Facilities available for the study  
The study will be conducted in EPHI where there is internet connection and a server space. The project’s field 
office is located in Debrebirhan town where the zonal health office is located. The project will have an office based 
in Debrebirhan with six field staff.  
 
Authorship right  
The PI of the DIPH project and all the research team will take public responsibility for the content, concept, design, 
analysis, writing or revision of the study findings.  
 
Declaration of conflict of interest 
The principal investigator declared that there is no conflict of interest among co-investigators for this project. 
 
 
 
 
 
 
 
 
 

 
 
24 
References 
1. 1. Victora CG1, Black RE, Boerma JT, Bryce J.  Measuring impact in the Millennium Development Goal era 
and beyond: a new approach to large-scale effectiveness evaluations. Lancet. 2011 Jan 1;377(9759):85-95. 
doi: 10.1016/S0140-6736(10)60810-0. Epub 2010 Jul 9. 
2. Heidkamp R; NEP Working Group. The National Evaluation Platform for Maternal, Newborn, and Child 
Health, and Nutrition: From idea to implementation. J Glob Health. 2017 Dec;7(2):020305. doi: 
10.7189/jogh.07.020305. 
3. Sawadogo-Lewis T. Vignola, Aung T, Heidkamp R. Developing data use capacity in the maternal, newborn, 
child health and nutrition sector in Malawi, Mali, Mozambique and Tanzania: an evolving strategy.  J Glob 
Health.   June 2019 • Vol. 9 No. 1 • 010310.  doi: 10.7189/jogh.09.010309 
3. Hanson K, Schellenberg J . Commentary- District decision 
making to strengthen maternal, newborn and child health servicesin low-income settings. Health Policy 
Plan. 2016 Sep;31 Suppl 2:ii1-ii2.  
4. Wickremasinghe D, Hashmi IE, Schellenberg J, Avan BI. District decision-making for health in low-
income settings: a systematic literature review. Health Policy Plan. 2016 Sep;31 Suppl 2:ii12-ii24 
5. 1Bhattacharyya S, Berhanu D, Taddesse N, Srivastava A, Wickremasinghe D, Schellenberg J, Iqbal Avan 
B.District decision-making for health in low-income settings:a case study of 
the   potential of publicand private sector data in India and Ethiopia. Health Policy Plan. 2016 Sep;31 Suppl 
2:ii25-ii34 
6. Avan BI, Berhanu D, Umar N, Wickremasinghe D, Schellenberg J. .District decision-making for health in low-
income settings: a feasibility study of a data-informed platform for health in India, Nigeria and Ethiopia. 
Health Policy Plan. 2016 Sep;31 Suppl 2:ii3-ii11 
7. Gautham M, Spicer N, Subharwal M, Gupta S, Srivastava A, Bhattacharyya S, Avan BI, Schellenberg J. 
District decision-making for health in low-income settings: a qualitative study in Uttar Pradesh, India, 
on engaging the private health sector in sharing health-related data. Health Policy Plan. 2016 Sep;31 Suppl 
2:ii35-ii46 
8. IDEAS-LSHTM (2018). Data Informed Platform for Health. Structured decision-making using local data. 
Prototype Phase, West Bengal, India. External Evaluation Report. London, UK, London School of Hygiene & 
Tropical Medicine. 
9. Hayes RJ, Bennett S.  Simple sample size calculation for cluster-randomized trials. Int J Epidemiol. 1999 
Apr;28(2):319-26. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
25 
Assurance of the Principal Investigator: 
 
I the undersigned agree to accept responsibilities for: 
1. 
The scientific, ethical and technical conduct of the research project, 
2. 
Requesting amendment for ANY change on the protocol that might need to happen during execution of the 
project, and obtain written approval for the request from EPHI-IRB, 
3. 
Submitting progress report every year and technical report within two months after completion of the 
project, 
4. 
Reporting any adverse event that might happen to the study participants, data collectors, supervisors and 
coordinators during investigation,  
5. 
Submitting scientific publications that emanate from the project within two months of publication, and  
6. 
Reporting any unprecedented protocol violation within seven days of event. if the project is approved as a 
result of this application. 
7. 
Submitting your raw cleaned data to EPHI data management Center after writing the final report  
Name: Bilal Avan 
 
 
Signature: 
 
 
 
 
 
 
 
Date:  23th July 2019 
 
Commitment for and signatures of Co-Investigators 
 
 
Name 
 
 
Specific Responsibility/ Signature 
 
From London School of Hygiene and Tropical Medicine 
 
1. Joanna Schellenberg:  Co-PI /     
2.  Mehret Dubale :  Co investigator/  
 
 
3.   Della Berhanu: Co investigator /      
 
4. Lars Åke Persson:  Co investigator / 
 
 
From Ethiopian Public Health Institute 
1. Girum Taye:    
Co-PI             /        
 
 
2.  Abebe Bekele    Co investigator 
 
 
 
 

 
 
26 
Comment and concurrence of the responsible head for principal investigator 
 
___________________________________________________________________ 
 
___________________________________________________________________ 
 
 
 
 
Name__________________________Signature______________Date___________ 
 
 
 

 
 
27 
Appendices 
Annex I:  Map of North Shewa within broader Amahara region.    (and if possible map of woredas 
within north Shoa zone) 
 
 
 
 
 
 
 
 
 

 
 
28 
Annex II:  List woreda by type: and population size in North Shoa zone 
 
  
Woreda Name  
Population 
Type 
1 Minjar Shenkora 
128,879 
RURAL 
2 Merhabete 
126,501 
RURAL 
3 Basona Werana 
120,930 
RURAL 
4 Menz Gera Midir 
120,469 
RURAL 
5 Kewet 
118,381 
RURAL 
6 Efrata Gidim 
110,493 
RURAL 
7 Mida Woremo 
93,729 
RURAL 
8 Moretna Jiru 
92,937 
RURAL 
9 Menz Mama Midir 
85,129 
RURAL 
10 Tarma Ber 
84,481 
RURAL 
11 Angolala Tera 
82,349 
RURAL 
12 Antsokiya Gemza 
79,091 
RURAL 
13 Ankober 
76,510 
RURAL 
14 Mojana Waderea 
69,667 
RURAL 
15 Debre Berhan 
65,231 
URBAN 
16 Gishe 
61,521 
RURAL 
17 Saya Debirna Wayu 
61,046 
RURAL 
18 Ensaro 
58,203 
RURAL 
19 Hagere Mariam Kesem 
55,235 
RURAL 
20 Asagirt 
48,371 
RURAL 
21 Menz Keya Gebreal 
46,219 
RURAL 
22 Berehet 
34,810 
RURAL 
23 Shewa Robit 
17,575 
URBAN 
24 Menz Lalo Midir 
17,308 
RURAL 
Source: The 2007 Population and Housing Census of Ethiopia 
 
 
 
 
 
 
 
 

 
 
29 
Annex III:    Health Profile of North Shewa zone on selected Maternal and Child Health indicators 
Indicators 
Amhara 
Ethiopia 
Total population1 
 21,844,000  98,665,000 
Antenatal care2 
Mothers who had at least 3 ANC check-ups (to total ANC registered) (%) 
  
 62% 
Institutional deliveries2 
Total institutional deliveries (as % of total reported deliveries) 
 27.1% 
 26.2% 
Deliveries at public facilities (as % of total reported institutional facilities) 
 26.4% 
 24.8% 
Postnatal care2 
Post-partum check-up within 48 hrs of delivery (as % of total reported 
deliveries) 
 12.6% 
 13% 
Immunization coverage2 
% of infants fully immunized to total reported live births (BCG, 3 doses 
each of DPT, Polio & Measles) 
 46% 
 39% 
Mortality details 
Infant mortality rate 
 67 per 
1000 
 48 per 1000  
Source: 1Central Statistical Agency population projection for Ethiopia in 2019 
2The 2016 Ethiopia Demographic and Health Survey  
 
  
 
 
 

 
 
30 
Annex IV: informed consent and Information sheet 
 
 
                                                                                                       
                                                                    
Data-Informed for Health (DIPH) Information Sheet and Consent form 
 
Good day. My name is ------------------- I am working in the research team organized by the Ethiopian Public Health 
Institute (EPHI), in collaboration with the London School of Hygiene & Tropical Medicine (LSHTM). I am a member of 
DIPH research team. I would like to ask you some questions about health data use for decision making in your 
Woreda in North Shewa zone, Amhara region, Ethiopia. Before the questions, I will provide you full information of 
the study so that you can decide whether or not you choose to take part. 
 
To improve the health system of Ethiopia, the MoH has initiated the Health Sector Transformation Plan (HSTP) which 
has Information Revolution as one of the main components. The aim of DIPH intervention. research is to support 
the decision making, planning and priority setting process of Woreda health offices and health administrators using 
routinely collected data in Ethiopia.  
Project title 
Study on the health of mothers, babies and children under five years of age. 
Duration of the study 
It will take up to two hours for each questionnaire to be fully completed.  
Purpose of the Study 
The overall purpose of this study is to strengthen health system at the Woreda level 
With this information we will be able to give advice health ministry how to improve operations and work 
environment within health system at the district level.   
Confidentiality 
Your responses will be kept confidential by the research team and will not be linked to your identifying information. 
You will not be able to be identified in any ensuing reports or publications. The data collected in this study will be 
securely stored by EPHI and LSHTM. 
Procedures 
Specifically, I am going to ask you information about processes and work culture . You were selected to participate 
in this study because you are believed to have significant knowledge and experience in health system administration. 
Risk and Benefits of the Study  
By participating in this study and answering our questions you will not receive any direct benefit. However, you will 
help to increase our understanding health system operations  in Ethiopia. The result of this study will contribute in 
generating evidence and knowledge to inform policy and practice at national and global levels. This study involves 
your provision of information through pre-developed questionnaires and the organization will keep your data in a 
safe place which can only be accessed by the study team.  Therefore I want to assure you that your participation in 
this study will not involve any risks to you. 
Rights 
Your participation in this study is voluntary and you have the right to refuse to participate or to not answer any 
questions that you feel uncomfortable. If you change your mind about participating during the course of the study, 
you have the right to withdraw at any time. The decision not to participate or to withdraw will not affect any aspect 
of your social life, and future medical care you should require or any other benefits to which you are entitled. If there 
is anything unclear or you need further information about, I am happy to provide it. 
 

 
 
31 
Further information: 
If you would like any further information, or would like to raise any concerns regarding this research project, please 
contact: 
Girum Taye (Co-PI) EPHI 
Phone: +251 932  223164,  Email: (girumt2000@yahoo.com ). P.O. Box 1242, Addis Ababa Ethiopia 
 
Declaration of the Volunteer Study Participant/ Interview Consent Form 
Please complete this form after you have read the Information Sheet and/or listened to an explanation about the 
research. 
Thank you for considering taking part in this research.  The person organising the research must explain the project 
to you before you agree to take part.  If you have any questions, please ask the researcher before you decide whether 
to take part.  You will be given a copy of this Consent Form to keep and refer to at any time. 
I confirm that: 
• 
I understand that by ticking each box below that I am agreeing to this part of the study.   
• 
I understand that not ticking a box means that I DO NOT agree to that part of the study.   
• 
I understand that by not agreeing to all parts of the study, I may not be eligible for the study. 
 
Tick Box 
I confirm that I have understood the Study Information given to me.  I have had an opportunity to 
consider the information and what will be expected of me.  I have also had the opportunity to ask 
questions which have been answered to my satisfaction.  
  
 
I understand that my participation is voluntary and that I am free to withdraw at any time, 
without giving a reason.  
 
I consent to the processing of any personal information I provide for the purposes explained to 
me.  I understand that this information will be handled in accordance with all applicable data 
protection legislation. 
 
I understand that all personal information will remain confidential and that all efforts will be 
made to ensure I cannot be identified. I understand that my data gathered in this study will be 
stored anonymously and securely.  It will not be possible to identify me in any publications.  
 
I understand that my information may be subject to review by responsible individuals from EPHI, 
and LSHTM for monitoring and audit purposes. 
 
I agree that my anonymized research data may be used by others for future research. (No one will 
be able to identify you when this data is shared.)  
 
I consent to this interview being audio recorded and understand that the recordings will be kept 
confidential    
 
I voluntarily agree to take part in this study.  
 
 
________________________ 
________________ 
___________________ 
Name of Informant 
            Date 
             Signature 
 
________________________ 
________________ 
______________ 
 
 

 
 
32 
Annex V: DIPH Study Instruments 
SECTION A:   DIPH Monitoring Framework Indicators with Definitions 
Module I:  Utilization of data at Woreda level 
Whether the DIPH study led to the utilization of the health system data or policy directive at Woreda level 
for decision-making? 
Theme 
Indicators with Definitions 
Sources of 
information 
A. Selection of the 
primary theme for 
the current DIPH 
cycle  
1. Whether the DIPH cycle theme selection was based on HMIS 
data? (1:Yes 2:No) 
 
Health system data: statistical information collected either routinely 
or periodically by government institutions on public health issues. This 
includes information related to provision and management of health 
services. This data can be from the health department and/or non-
health departments 
In the Ethiopian context, the main data sources will include HMIS and  
may be non-HMIS parallel reports XXX 
Form 1B: 
Health system 
capacity 
assessments 
 
2. Whether the DIPH cycle theme selection used any data from non-
health offices? (1:Yes 2:No) 
 
Non-health offices: government offices, other than the health office, 
which directly or indirectly contributes to public health service 
provision 
In the Ethiopian context, this includes AgricultureXXX  and XXX 
Form 1B: 
Health system 
capacity 
assessments 
 
3. Whether the DIPH cycle theme selection was based on health 
policy and programme directives?(1:Yes 2:No) 
Health policy: refers to decisions that are undertaken by the 
state/national/Woreda to achieve specific health care plans and goals. 
It defines a vision for the future which in turn helps to establish 
targets and points of reference for the short- and medium-term 
health programmes 
 
Health programme: focused health interventions for a specific time 
period to create improvements in a very specific health domain 
In the Ethiopian  context: any health-related 
directives/guidelines/government orders in the form of an official 
letter or circular issued by the woreda /state government 
Form 1A: 
Database and 
document 
checklist 
B. Data-based 
monitoring of the 
action points for the 
primary theme of the 
DIPH 
4. (Number of action points on which progress is being monitored by 
data) / (total number of action points for the primary theme of 
DIPH) 
 
Action points: a specific task taken to achieve a specific objective 
In DIPH context: a specific action, arisen from the stakeholder 
discussions during Steps 3 and 4, to achieve the target of the given 
DIPH cycle 
Form 5: 
Follow-up 
 
 

 
 
33 
C. Revision of 
Woreda programme 
data elements for the 
primary theme of the 
DIPH 
5. Whether stakeholders suggested a revision/addition to health 
system data in the given DIPH cycle? (1:Yes 2:No) 
Form 4: Plan 
 
 
6. (Number of data elements added in the health database as per 
the prepared action plan) / (total number of additional data 
elements requested for the primary theme of the DIPH) 
 
Data elements: operationally, refers to any specific information 
collected in the health system data forms, pertaining to all six WHO 
health system building blocks (demographic, human resources, 
finance, service delivery, health outcome, governance) 
Form 5: 
Follow-up 
 
 
D. Improvement in 
the availability of 
health system data 
 
 
7. Whether the health system data required on the specified theme 
as per the given DIPH cycle was made available to the assigned 
person in the given DIPH cycle? (Y/N) 
 
Assigned person: as per the cycle-specific DIPH action plan; this can 
be the theme leader, Data Manager or any other stakeholder who is 
assigned with the responsibility of compiling/reporting of specified 
data 
Form 1B: 
Health system 
capacity 
assessments 
 
8. Whether the health system data on the specified theme area is 
up-to-date as per the given DIPH cycle? (Y/N) 
Up-to-date data 
 
1. If monthly data, then the previous complete month at the time of 
Step 1 of the DIPH cycle 
2. If annual data, then the complete last year at the time of Step 1 of 
the DIPH cycle 
Form 1B: 
Health system 
capacity 
assessments 
 
 
 
 
 

 
 
34 
Module II:  Interactions among stakeholders: co-operation in decision-making, planning and implementation 
Whether the DIPH study ensured involvement of stakeholders from different sectors (health, non-health 
and NGO/private for-profit organizations) 
Theme 
Indicators with Definitions 
Sources of 
information 
E. Extent of 
stakeholder 
participation  
1. (Number of DIPH stakeholders present in the planning actions 
meeting) / (total number of DIPH stakeholders officially invited in 
the planning actions meeting) 
 
Participants in Steps 4 and 5 
DIPH stakeholders: public and private sector departments, 
organizations and bodies relevant for the specific cycle of the DIPH 
Officially invited: stakeholders formally being invited to participate 
for the specific DIPH cycle 
In the Ethiopian context, for example: 
1. XXX 
2. YYY 
3. ZZZ 
Form A.2: 
Record of 
Proceedings – 
Summary 
Tables 
2. (Number of representatives from the health department present 
in the planning actions meeting) / (total number of DIPH 
participants present in the planning actions meeting) 
 
Participants in Steps 4 and 5  
Form A.2: 
Record of 
Proceedings – 
Summary 
Tables 
3. (Number of representatives from non-health departments 
present in the planning actions meeting) / (total number of DIPH 
participants present in the planning actions meeting) 
 
Participants in Steps 4 and 5  
Form A.2: 
Record of 
Proceedings – 
Summary 
Tables 
4. (Number of representatives from NGOs present in the planning 
actions meeting) / (total number of DIPH participants present in the 
planning actions meeting) 
 
Participants in Steps 4 and 5  
Form A.2: 
Record of 
Proceedings – 
Summary 
Tables 
5. (Number of representatives from private for-profit organizations 
present in the planning actions meeting) / (total number of DIPH 
participants present in the planning actions meeting) 
 
Participants in Steps 4 and 5  
Form A.2: 
Record of 
Proceedings – 
Summary 
Tables 
F. Responsibilities 
assigned to 
stakeholders 
 
6. (Number of action points with responsibilities of the health 
department) / (total number of action points for the primary theme 
of the DIPH) 
Form 4: Plan 
7. (Number of action points with responsibilities of non-health 
departments) / (total number of action points for the primary theme 
of the DIPH) 
 
Form 4: Plan 
 

 
 
35 
8. (Number of action points with responsibilities of NGOs) / (total 
number of action points for the primary theme of the DIPH) 
 
Form 4: Plan 
9. (Number of action points with responsibilities of private for-profit 
organizations) / (total number of action points for the primary 
theme of the DIPH) 
 
Form 4: Plan 
G. Factors influencing 
co-operation among 
health, non-health 
and NGO/private for-
profit organizations 
to achieve the 
specific action points 
in the given DIPH 
cycle 
10. List of facilitating factors 
1. 
2. 
3 
In-Depth 
Interviews 
with 
Stakeholders 
11. List of challenging factors 
1. 
2. 
3 
In-Depth 
Interviews 
with 
Stakeholders 
H. Action points 
initiated  
1. (Number of primary theme-specific action points initiated within 
the planned date) / (total number of primary theme-specific action 
points planned within the specific DIPH cycle) 
Form 5: 
Follow-up 
I. Action points 
achieved  
2. (Number of primary theme-specific action points completed 
within the planned date) / (total number of primary theme-specific 
action points planned within the specific DIPH cycle) 
Form 5: 
Follow-up 
3. (Number of written directives/letters issued by the Woreda/state 
health authority as per action plan) / (total number of written 
directives/letters by the Woreda/state health authority planned as 
per action points of the DIPH primary theme) 
 
Form 
5: 
Follow-up 
4. (Amount of finance sanctioned for the primary theme-specific 
action points) / (total amount of finance requested as per action 
points of the DIPH primary theme) 
 
Form 
5: 
Follow-up 
5. (Units of specific medicine or supplies  provided for the primary 
theme-specific action points) / (total units of specific medicine  or 
supplies requested as per action points of the DIPH primary theme) 
 
Form 
5: 
Follow-up 
6. (Units of specific equipment provided for the primary theme-
specific action points) / (total units of specific equipment requested 
as per action points of the DIPH primary theme) 
 
Equipment: technical instruments, vehicles, etc. provided to achieve 
the DIPH action points 
Form 
5: 
Follow-up 
 
7. (Units of specific IEC materials provided for the primary theme-
specific action points) / (total units of specific IEC materials 
requested as per action points of the DIPH primary theme) 
 
Form 4: Plan 
 
Form 
5: 
Follow-up 

 
 
36 
8. (Number of human resources recruited for the primary theme-
specific action points) / (total human resources recruitment needed 
as per action points of the DIPH primary theme) 
 
Form 4: Plan 
 
Form 
5: 
Follow-up 
9. (Number of human resources trained for the primary theme-
specific action points) / (total human resources training requested 
as per action points of the DIPH primary theme) 
 
Form 4: Plan 
Form 
5: 
Follow-up 
J. Factors influencing 
the achievements as 
per action points of 
the DIPH primary 
theme  
10. List of facilitating factors 
1. 
2. 
3 
In-Depth 
Interviews 
with 
Stakeholders 
11. List of challenging factors 
1. 
2 
3. . 
In-Depth 
Interviews 
with 
Stakeholders 
 
 
 
 
 
 
 
 
 

 
 
37 
SECTION B:  DIPH Survey Instruments 
Module I:  General Identifications 
Facilitator ID 
1.1 
Survey datedate (DD, MM, YYYY) 
 
1.2 
Survey start time 
(24-hour clock system, e.g., 14:30) 
 
                                                           : 
1.3 
Facilitator name 
 
1.4 
Facilitator code 
Enter your 2-character identifier. 
 
1. 
Unit ID 
1.5 
Type of health Administration unit  
1. 
Woreda health office 
2. 
Zonal health Department 
3. 
Regional health Bureau 
1.6 
List of the offices visited with in the admin 
Unit 
1. 
2.  
3. 
4. 
 
1.7 
Regional ID 
 
 
1.8 
Zonal ID 
 
 
1.9 
Woreda ID 
 
 
1.10 
Respondent Designation 
1= Woreda health office  Head 
2= MNCH Head/Focal Person 
3= Data Manager  
4= Other s, specify  
1.11 
Respondent Age  (years)  
 
1.12 
Gender  
 
1.13 
Academic qualification  
 

 
 
38 
1.14 
Professional experience in the health 
department (Years) 
 
1.1 
Duration of experience in the index  Woreda 
office (months)  
 
Module II: Woreda profile - Resources and Potential Profiling for DIPH 
 
1. 
Staff 
2.1 
Please describe the total number of people under each category below.  
(need further additions ..) 
Title/ post 
 
Number by sex 
(If none, enter 0; if post not applicable, 
write 99) 
Male 
Female 
1. Head of Woreda health office 
 
 
2. Program officer 
 
 
3. Disease surveillance officer 
 
 
4. M&E/HMIS officer 
 
 
5. Data clerk 
 
 
96. Other (specify)___________________ 
 
 
 
2. 
Infrastructure and Equipment Inventory 
2.2 
Please verify if the following equipment 
or type of service is available in the 
facility or office. 
 A. Total quantity 
 
(If none, enter 0) 
B. Total quantity that are in 
working condition 
(If none, enter 0) 
1. 
Laptop computer 
 
 
2. 
Desktop computer 
 
 
3. 
Printers 
 
 
4. 
Modems 
 
 
5. 
Uninterruptible power supply 
(UPS) 
 
 
6. 
Circuit breaker 
 
 

 
 
39 
7. 
Generators/grid/solar 
 
 
8. 
Calculator 
 
 
 
checklist to assess whether or not the office has the following inventory: 
2.3 
Data back-up unit  
 
 
 
 
1. Server 
1. Yes 
2. No 
 
2. USB key 
1. Yes 
2. No 
 
3. CD (compact disc) 
1. Yes 
2. No 
 
4. External hard drive 
1. Yes 
2. No 
 
5. Zip drive 
1. Yes 
2. No 
2.4 
If yes then primary Back-up unit(s) is/are kept on site 
1. Yes 
2. No 
2.5 
1. 
Facility/office official mobile phone with access 
to telephone network 
1. Yes 
2. No 
 
2. 
Personal mobile phone with access to telephone 
network 
1. Yes 
2. No 
2.6 
1. 
Is there access to an Internet network? 
1. Yes 
2. No 
 
2. 
If yes, on average, how many days in a month do 
you have Internet access? 
1. 20 days or more 
2. 10-19 days 
3. Less than 10 days 
 
3. 
If yes ,  when was the last disruption of access (days)  
 
4. 
Wi-Fi  
1. Yes 
2. No 
2.7 
1. 
Is there a continuous electricity supply? 
1. Yes 
2. No 
 
2. 
If no, on average, how many days in a month is the 
electricity supply interrupted?   
1. 20 days or more 
2. 10-19 days 
3. Less than 10 days 
 
Data sources 
 
2.8 
 
Data collection forms used  
Source: Data collection 
introduced by codes:  
0. no form exist  
1.  Standard HIS- FMoH 
Data collection 
format Codes: 
0.  no data 
collection  
Onward 
Reporting  
format Codes 
0.  no reporting  

 
 
40 
Module III: Data Management 
1. 
Resources for Data Assessment 
2. Programme specific-
FMoH 
3. Regional health Bureau 
4.  Zonal Health 
Department 
5.  Woreda Health office 
6. NGO/WHO 
7. Others: 
1. paper based 
2. electronic 
1. paper based 
2. electronic 
 
1. 
Maternal health services 
 
 
 
 
2. 
Family planning (FP) services 
 
 
 
 
3. 
Child health services 
 
 
 
 
4. 
Immunization services 
 
 
 
 
5. 
General outpatient department 
(OPD) 
 
 
 
 
6. 
Inpatient services 
 
 
 
 
7. 
Tuberculosis 
 
 
 
 
8. 
HIV/AIDS 
 
 
 
 
9. 
Malaria 
 
 
 
 
10. 
Other specific disease(s) 
 
 
 
 
11. 
Nutrition services 
 
 
 
 
12. 
Notifiable diseases/ integrated 
disease surveillance and response 
(IDSR) 
 
 
 
 
13. 
Financial information 
 
 
 
 
14. 
Medicines and supplies stock 
 
 
 
 
15. 
Human resources (HR) 
 
 
 
 
16. 
Equipment 
 
 
 
 
17. 
Capital assets 
 
 
 
 
18. 
Vital events 
 
 
 
 
19. 
Other (specify) 
 
 
 

 
 
41 
3.1 
Does the Woredahealth officehave a designated person 
responsible for entering data/compiling reports from 
health facilities? 
1. Yes 
2. No 
3.3 
If yes , Are designated staff trained on Data 
entry/compilation 
1. Yes (all staff have received training in the 
past two years) 
2. Mostly (all staff have received training but  
not in the past two years) 
3. Partly (some staff have received training) 
4. Not at all 
3.4 
Does the Woredahealth officehave written guidelines for 
Data entry/compilation?  
 
1. Yes,  observed  
2.  Yes,  not found  
3. No 
3.5 
Does the Woredahealth officehave a designated person to 
review the quality of compiled data prior to submission to 
the next level, e.g., to Zonal/regional offices, to the central 
health management information system (HMIS)? 
1. Yes 
2. Partly (the data are reviewed but no one is 
designated with the responsibility) 
3. Not at all 
3.6 
If yes, Are designated staff trained on Data review and 
quality control 
1. Yes (staff have received training in the past 
two years) 
2. Mostly (all staff have received training but  
not in the past two years) 
3. Partly (some staff have received training) 
4. Not at all 
3.7 
Does the Woredahealth officehave written guidelines for 
Data review and quality control?  
 
1. Yes,  observed  
2.  Yes,  not found  
3. No 
 
2. 
Completeness of Health Facilities Reporting To Woreda For Last Three Months 
3.8 
Does the Woreda keep copies of monthly data reports 
sent by the health facilities? 
 
(Check the reports from month 1 to month 3) 
 
1. Yes, paper-based copies only 
2. Yes, electronic copies only 
3. Yes, both paper-based and electronic copies  
(all health facilities submit both types of  
reports) 
4. Yes, mixed (some health facilities submit paper-based 
reports; others submit electronic reports) 
5. No 
3.9 
How many Primary care health facilities in the 
Woreda? 
a.  Health center  
b.  Health Posts  
 
 
 
 

 
 
42 
3.  Private Clinics  
 
 
3.10 
Format of  monthly report to the Woredahealth 
officeduring last 3 months ? 
Data submission format Codes: 
paper based 
electronic 
Both  
Data submission in last 
3 months : 1:Yes,  2:NO  
M-1 
M-2 
M-3 
 
a. Health centers 
  1. 
  2.  
  3.  
 
 
 
 
 
b. Health posts 
  1. 
  2.  
  3. 
 
 
 
 
 
c. Private clinics 
  1. 
  2.  
  3. 
 
 
 
 
 
3.11 
If health facilities are not submitting monthly data 
reports, in your opinion what are the possible reasons 
for this? 
1. Storage or archiving problems 
2. Staffing issues 
3. Absence of reporting forms 
4. Transportation issues 
5. Internet connectivity issues 
6. Presence of other vertical reporting  
requirements 
96. Other (specify) 
 
_____________________________________________
__ 
 
 
 
 
4. 
Report Timeliness 
3.12 
 Is there a deadline for submission of the monthly report by the health 
facilities? 
1. Yes 
2. No  
 If yes, what is the Reporting deadline? :                  ____________________________________________ 

 
 
43 
3.13 
If yes, Does the Woredahealth officeoffice maintain a  record of dates of 
receiving monthly reports?  
 
1. Yes 
2. No  
3.14 
If yes, how many reports were received on time (before or on the 
deadline)? 
(Check the recorded receiving dates for the three review months) 
 
Data submission in last 3 months 
on time : 1:Yes,  2:NO  
M-1 
M-2 
M-3 
Health centers 
  1. 
  2.  
  3. 
 
 
 
Health posts 
  1. 
  2.  
  3. 
 
 
 
Private clinics 
  1. 
  2.  
  3. 
 
 
 
 
5. 
Data Quality Assessment Mechanisms 
3.15 
Does the Woredahealth officehave written guidelines on routine health data quality 
assessment/assurance?  
  (Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
3.16 
Does the Woreda health office conduct data quality assessments at health facilities?  
1. Yes 
2. No  
3.17 
If yes, does the Woredahealth officeuse data quality assessment tools (e.g., lot quality 
assurance sampling [LQAS], routine data quality assessment [RDQA], in-built electronic 
data quality validation rules/system)?   
(Ob
)
1. Yes, observed 
2. Yes, not found 
3. No 
3.18 
Does the Woredahealth officemaintain a record of health facility data quality 
assessments conducted in the past 12 months?   (Observe) 
21. Yes, observed 
2. Yes, not found 
3. No 
3.19 
Does the Woredahealth officemaintain a record of feedback to health facilities on data 
quality assessment findings?    
 (Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
 
6. 
Data Processing and Analysis 
3.20 
Does the Woredahealth officeuse an electronic database/system to 
enter and analyze routine health data? 
1. Yes 
2. No 
3.21 
If yes, indicate the type of electronic system used for routine data entry 
and analysis  
For Data entry 
1: yes, 2: No 
For Data analysis  
1: yes, 2: No 
1. 
HMIS_ National proprietary software 
 
 
2. 
Excel-based spreadsheet 
 
 

 
 
44 
3. 
National open-source data processing system (e.g., DHIS 2) 
 
 
4. 
Other (specify) 
 
 
3.22 
Check the up-to-date reports, documents, and/or displays that contain the following information.   
 
1. 
Aggregated/summary HMIS report within the past three months. 
(Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
 
2. 
Demographic data on the catchment population of the Woreda for 
calculating coverages.    
(Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
 
3. 
Comparisons among facilities in the Woreda for key HMIS indicators.   
(Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
 
4. 
Comparisons of annual Woreda/national targets.    
(Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 
 
5. 
Comparisons of data over time (monitoring trends) for key HMIS 
indicators.   
6
(Observe)
1. Yes, observed 
2. Yes, not found 
3 No
 
7. 
Comparisons of service coverage along continuum of care  (e.g. ANC, 
tetanus-toxoid [TT] immunization, facility birth etc.).   
(Observe) 
1. Yes, observed 
2. Yes, not found 
3. No 

 
45 
 
Module IV:   Data Use Assessment Form 
1. 
Information Use:  Guidelines Documentation 
4.1 
Are there any written guidelines on Data/HMIS 
information display, use, and feedback?  
 (Observe) 
1. Yes, copy available at the Woredahealth office 
2. Yes, but copy not available at the Woredahealth 
office 
3. No 
4.2 
Does the Woredahealth officehave copies of the 
national HMIS strategic plans, Woreda annual plans, 
and/or Woreda performance targets? 
 (Observe) 
1. Yes, copy available at the Woredahealth office 
2. Yes, but copy not available at the Woredahealth 
office 
3. No 
 
2. 
Data Presentations  & Visualization 
4.3 
Does the Woredahealth office prepare infographics 
(graphs, tables, maps, etc.) showing achievements 
toward targets (indicators, geographic and/or temporal 
trends, and situation data)?(Observe) 
1. Yes,  
2. No  
4.4 
If yes, what type of information is captured in the data visuals? 
1. Maternal health care    
(Observe) 
1. Yes 
2. No 
2. The Expanded Program on Immunization [EPI])  
 (Observe) 
1. Yes 
2. No 
2. Neonate and child health care (other than the Expanded Program on 
Immunization [EPI])  
 (Observe) 
1. Yes 
2. No 
3. Top causes of morbidity and mortality  
 (Observe) 
1. Yes 
2. No 
96. Other 
(specify)______________________________________________________ 
1. Yes 
2. No 
 
3. 
HMIS:   Analysis  documentation 
4.5 
Does the Woredahealth office have access to analyzed 
HMIS data (e.g., summary tables, charts, maps)? 
(Observe) 
1. Yes, observed paper-based 
2. Yes, observed electronic 
3. No 
4.6 
Does the Woredahealthoffice produce any report (annual, 
quarterly or monthly summary/aggregate reports 
submitted to the higher level, etc.) based on an analysis of 
RHIS data?   
(Observe) 
1. Yes, observed 
2. No 
 
 
4.6 
If yes, list the reports and indicate the frequency of the reports and number of times the reports were 
actually issued in the past 12 months. 
A. Title of the report 
B. Number of times 
this report is supposed 
to be issued per year 
C. Number of times 
this report was 
actually issued in the 
past 12 months 
D. Target audience of the 
report (e.g., MOH, civil 
administration, parliament, 

 
46 
 
community forums, general 
population) 
 
1. 
 
 
 
 
2. 
 
 
 
 
3. 
 
 
 
 
4. 
Feedback to Health Facilities 
4.7 
Did the Woredahealthoffice send feedback reports using Health data to 
health facilities in the past three months?  
(Observe the report and check the date) 
1. Yes, observed 
2. No 
4.9 
If yes, indicate the types of feedback reports:  
1. Feedback on data quality (including data accuracy, reporting 
timeliness, and/or report completeness)   
(Observe) 
1. Yes, observed 
2. No 
2. Feedback on service performance based on reported health data (e.g., 
appreciation/acknowledgement of good performance; resource 
allocation/mobilization) 
(Observe) 
1. Yes, observed 
2. No 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
47 
 
Module V: Routine Decision-Making Forums at the Woreda Office 
A. Performance Monitoring Team Meeting 
5.1 
Does the Woredahealthoffice have a Performance monitoring team 
(PMT) ?   
1. Yes 
2. No 
5.2 
If yes, how often are the PMT meetings supposed to take place? 
1. Weekly 
2. Monthly        
3. Quarterly 
4. Biannually 
5. Annually  
6. No schedule 
5.3  
When the most recent PMT was conducted?  (months)  
 
 
5.4 
How many times did PMT meetings take place during the past three 
months? 
1. More than four times 
2. Four times 
3. Three times 
4. Two times 
5. One time 
6. Not once 
5.5 
Were minutes of the last performance monitoring/management 
meetingmaintained?(Observe) 
1. Yes 
2. No 
 
If yes, please check the PMT meetings record for the review months and see if the following topics were 
discussed. 
5.6 Did they have any discussions on Health Data  , such as data quality, 
completeness, or timeliness of reporting? 
 (Observe) 
1. Yes 
2. No 
5.7 If yes, have they made any decisions based on the discussions of 
health data -related issues (including no interventions required at 
this time)? 
1. Yes 
2. No  
5.8 If yes, has any follow-up action taken place on the decisions made 
during the previous meetings on health data -related issues (e.g., 
referring Health data related issues/problems for solution to the 
higher level)? 
1. Yes 
2. No 
5.9 Were discussions held to review key performance targets (tracking progress against targets) based on health 
data? Such as: 
Coverage of service like ANC, delivery, EPI, or TB 
(Observe) 
1. Yes 
2. No 
 
Hospital/health center performance indicators 
(Observe)
1. Yes 
2. No
Disease data, e.g., top ten diseases 
(Observe) 
1. Yes 
2. No 
Identification of emerging issues/epidemics  
(Observe) 
1. Yes 
2. No 
Medicine stockouts 
(Observe)                                                
1. Yes 
2. No 
Human resource management 
(Observe) 
1. Yes 
2. No 
Sex-disaggregated data 
(Observe)                           
1. Yes 
2. No 

 
48 
 
5.10 Were any decisions made based on the discussion of the Woredahealthoffice and/or health facility’s 
performance? Such as: 
Formulation of plans 
1. Yes 
2. No 
Budget preparation 
1. Yes 
2. No 
Budget reallocation 
1. Yes 
2. No 
Medicine supply and drug management 
1. Yes 
2. No 
Human resource management (training, reallocation, etc.) 
1. Yes 
2. No 
Advocacy for policy, programmatic, or strategic decisions from 
the higher level 
1. Yes 
2. No 
Health services (preventive, promotive, clinical, rehabilitative) 
planning 
1. Yes 
2. No 
Promotion of service quality/improvement 
1. Yes 
2. No 
Reducing the gender gap in the provision of health services 
1. Yes 
2. No 
Involvement of the community and local government 
1. Yes 
2. No 
No action required at this time 
1. Yes 
2. No 
5.11 Were the PMT meeting minutes circulated to all members? 
1. Yes 
2. No 
5.12 Did the head of the Woreda health office attend any of the 
performance review/management meetings during last 6months ? 
1. Yes 
2. No 
 
B. Other routine health management team (HMT)  meetings 
5.13 Does the Woredahealthoffice have health management team (HMT)  
meetings to discuss performance monitoring and management? 
1. Yes 
2. No 
5.14 If yes, how often are the HMT meetings supposed to take place? 
1. Weekly 
2. Monthly        
3. Quarterly 
4. Biannually 
5. Annually  
6. No schedule 
5.15 How many times did HMT meetings take place during the past three 
months? 
1. More than four times 
2. Four times 
3. Three times 
4. Two times 
5. One time 
6. Not once 
5.16 Were minutes of the last health management team 
meetingperformancemaintained?(Observe) 
1. Yes 
2. No 
 
If yes, please check the HMT meetings for the review months and see if the following topics were discussed. 

 
49 
 
5.17 Did they have any discussions on Health Data  , such as data quality, 
completeness, or timeliness of reporting? 
 (Observe) 
1. Yes 
2. No 
5.18 If yes, have they made any decisions based on the discussions of 
health data -related issues (including no interventions required at 
this time)? 
1. Yes 
2. No  
5.19 If yes, has any follow-up action taken place on the decisions made 
during the previous meetings on health data -related issues (e.g., 
referring Health data related issues/problems for solution to the 
higher level)?
1. Yes 
2. No 
5.20 Were discussions held to review key performance targets (tracking progress against targets) based on health 
data? Such as: 
Coverage of service like ANC, delivery, EPI, or TB 
(Observe) 
1. Yes 
2. No 
 
Hospital/health center performance indicators 
(Observe) 
1. Yes 
2. No 
Disease data, e.g., top ten diseases 
(Observe) 
1. Yes 
2. No 
Identification of emerging issues/epidemics  
(Observe) 
1. Yes 
2. No 
Medicine stockouts 
(Observe) 
1. Yes 
2. No 
Human resource management 
(Observe) 
1. Yes 
2. No 
Sex-disaggregated data 
(Observe)                           
1. Yes 
2. No 
5.21 Were any decisions made based on the discussion of the Woredahealth office and/or health facility’s 
performance? Such as: 
Formulation of plans 
1. Yes 
2. No 
Budget preparation 
1. Yes 
2. No 
Budget reallocation 
1. Yes 
2. No 
Medicine supply and drug management 
1. Yes 
2. No 
Human resource management (training, reallocation, etc.) 
1. Yes 
2. No 
Advocacy for policy, programmatic, or strategic decisions from 
the higher level 
1. Yes 
2. No 
Health services (preventive, promotive, clinical, rehabilitative) 
planning 
1. Yes 
2. No 
Promotion of service quality/improvement 
1. Yes 
2. No 
Reducing the gender gap in the provision of health services 
1. Yes 
2. No 
 
Involvement of the community and local government 
1. Yes 
2. No 

 
50 
 
 
No action required at this time 
1. Yes 
2. No 
5.22 Were the HMT meeting minutes circulated to all members? 
1. Yes 
2. No 
5.33 Did the head of the Woreda health office attend the last health 
management team? 
1. Yes 
2. No 
 
12. 
Annual Planning 
5.34 
Does the Woredahealthoffice have an annual plan for the 
current year?   
1. Yes 
2. No  
5.33 
If yes, does that annual plan use data from the RHIS for 
problem identification and/or target setting? 
1. Yes 
2. No  
5.34 
If yes, does the annual plan contain activities and/or targets related to improving or addressing any of the 
following? 
1. Coverage of service like ANC, delivery, EPI, or TB 
1. Yes 
2. No 
2. Hospital/health center performance 
1. Yes 
2. No 
3. Diseases, e.g., top ten diseases 
1. Yes 
2. No 
4. Emerging issues/epidemics 
1. Yes 
2. No 
5. Medicine stockouts 
1. Yes 
2. No 
6. Human resource management 
1. Yes 
2. No 
7. Gender disparity in health services coverage 
1. Yes 
2. No 
 
Data sharing with the non- Health Sector 
5.35 
Does the Woredahealthoffice have to submit/present 
health sector performance reports to the Woreda Cabinet?   
1. Yes 
2. No 
5.36 
If yes, did the Woreda submit/present health sector 
performance reports the Woreda Cabinet in the past one 
year?   
1. Yes 
2. No 
5.37 
Do those reports/presentations use data from the HMIS to 
assess the health sector’s progress? 
1. Yes 
2. No 
 
 
 
 
 

 
51 
 
Module VI: Decision making Culture 
 
We would like to know your opinion (regarding certain aspects of the Health system decision making i.e how  strongly you 
agree or disagree with the given option. The scale assesses the intensity of your belief and ranges from “strongly 
disagree”(score of 1)to “strongly agree”(score of 5).There is no right or wrong answer, only an expression of your opinion 
based on a scale 
 
6.1 
In the woreda health office , decisions are based on: 
Strongly 
disagree 
Disagree 
Neither 
disagree nor 
agree 
Agree 
Strongly 
agree 
 
Personal preference of decision makers 
1 
2 
3 
4 
5 
 
Superiors’ directives 
1 
2 
3 
4 
5 
 
Evidence/facts/data 
1 
2 
3 
4 
5 
 
History (e.g., what was done last year) 
1 
2 
3 
4 
5 
 
Funding directives from higher levels 
1 
2 
3 
4 
5 
 
Political considerations 
1 
2 
3 
4 
5 
 
Official health sector strategic objectives 
1 
2 
3 
4 
5 
 
Locally identified health needs of the population 
1 
2 
3 
4 
5 
 
The relative cost of interventions 
1 
2 
3 
4 
5 
 
 
Participatory decision making, by obtaining input 
from relevant staff 
1 
2 
3 
4 
5 
 
 
6.2 
In the health department, superiors (managers or 
higher-level supervisors): 
Strongly 
disagree 
Disagree 
Neither 
disagree nor 
agree 
Agree 
Strongly 
agree 
 
Seek input from the relevant woreda health office 
staff 
1 
2 
3 
4 
5 
 
Emphasize that data quality procedures be followed 
in the compilation and submission of periodic reports 
(e.g., monthly reports) 
1 
2 
3 
4 
5 
 
Promote multidirectional feedback mechanisms to 
share/present information within the team, and to 
lower and upper levels of the health system 
1 
2 
3 
4 
5 
 
Use RHIS data for service performance monitoring 
and target setting 
1 
2 
3 
4 
5 
 
Emphasize the need to use RHIS data to identify 
potential gender-related disparities in service delivery 
or use 
1 
2 
3 
4 
5 
 
Conduct routine data quality checks at points where 
data are captured, processed, or aggregated 
1 
2 
3 
4 
5 
 
Ensure that regular meetings are held where data 
and information are discussed, performance reports 
are presented and reviewed, decisions are made, 
follow-up actions are identified, and their 
implementation is monitored 
1 
2 
3 
4 
5 
 
Provide regular feedback on reported data quality 
(e.g., accuracy of data compilation/reporting) to the 
staff responsible for compiling and reporting the data 
1 
2 
3 
4 
5 
 
Recognize or reward staff for good work performance 
1 
2 
3 
4 
5 

 
52 
 
 
 
 
6.3  
In the health department staff: 
Strongly 
disagree 
Disagree 
Neither 
disagree nor 
agree 
Agree 
Strongly 
agree 
 
Complete RHIS tasks (reporting, 
processing/aggregation, and/or analysis) in a timely 
manner (i.e., meet appropriate deadlines) 
1 
2 
3 
4 
5 
 
Display commitment to the RHIS mission (i.e., to 
generate and use good-quality—accurate, complete, 
and timely—data for evidence-based decision making) 
1 
2 
3 
4 
5 
 
Pursue national targets and set feasible local targets 
for essential service performance 
1 
2 
3 
4 
5 
 
Feel “personal responsibility” for failing to reach 
performance targets 
1 
2 
3 
4 
5 
 
Use RHIS data for day-to-day management of the 
facility and Woreda (e.g., service delivery, financial, 
commodities, and human resource management) 
1 
2 
3 
4 
5 
 
Use RHIS data to solve common problems in service 
delivery 
1 
2 
3 
4 
5 
 
Use sex-disaggregated or gender-sensitive RHIS data 
to identify and/or solve gender-related problems in 
service delivery 
1 
2 
3 
4 
5 
 
Prepare data visuals (graphs, tables, maps, etc.) 
showing progress toward targets (indicators, 
geographic and/or temporal trends, or situation data) 
1 
2 
3 
4 
5 
 
Can evaluate whether an intervention achieved the 
target(s) or goal(s) 
1 
2 
3 
4 
5 
 
Are able to make decisions appropriate to their job 
descriptions in response to the findings of data 
analysis (e.g., changes in service delivery or 
management practices)  
1 
2 
3 
4 
5 
 
Are held accountable for poor performance (e.g., 
failure to meet reporting deadlines) 
1 
2 
3 
4 
5 
 
Admit mistakes if/when they occur and take corrective 
action 
1 
2 
3 
4 
5 
 
 
 
 
 
 
 
 
 
 

 
53 
 
6.4 
Personal feelings: 
Strongly 
disagree 
Disagree 
Neither 
disagree nor 
agree 
Agree 
Strongly 
agree 
 
I feel discouraged when the data that I 
collect/record are not used for taking action 
(either for monitoring or decision making) 
1 
2 
3 
4 
5 
 
I find collecting/recording data to be tedious (i.e., 
repetitive or duplicative) 
1 
2 
3 
4 
5 
 
I find that the data that I collect burdens my 
workload, making it difficult for me to complete 
my other duties 
1 
2 
3 
4 
5 
 
Collecting data is meaningful/useful for me  
1 
2 
3 
4 
5 
 
I feel that the data I collect are important for 
monitoring the performance of the health 
services provided at my facility/unit 
1 
2 
3 
4 
5 
 
My work of collecting data is appreciated and 
valued by supervisors 
1 
2 
3 
4 
5 
 
I feel that data collection/recording is not the 
responsibility of healthcare providers 
1 
2 
3 
4 
5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
54 
 
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