Health informatics course unit 1.0a introduction and overview_final_vf (4)

Introduction to Health
Informatics:
Introduction and Overview
Health Informatics in Low- and Middle-Income Countries
Short Course for Health Information System Professionals
1

I will begin with a brief introduction to GEMNet-Health – the Global Evaluation and Monitoring Network for Health. GEMNet-Health is a global consortium of 9 regional training institutions that have
come together to collaborate on activities related to Monitoring and Evaluation.
The Global Evaluation and Monitoring Network for Health (GEMNet-Health) was launched in 2012 by MEASURE Evaluation.
Currently there are nine member institutions as shown on the map above:
1. Addis Ababa University (AAU), Ethiopia
2. Addis Continental Institute of Public Health (ACIPH), Ethiopia
3. Centre Africain d’Etudes Supérieures en Gestion (CESAG), Senegal
4. Instituto Nacional de Salud Pública (INSP), Mexico
5. Kenyatta University, School of Public Health
6. Mahidol University’s Institute for Population and Social Research (IPSR), Thailand
7. Public Health Foundation of India (PHFI), India
8. University of Ghana (UG), Ghana
9. University of Pretoria (UP), South Africa
MEASURE Evaluation serves as the Secretariat for GEMNet-Health. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) to monitor and evaluate a wide range of
activities to improve human health and well-being. MEASURE Evaluation has a long history of establishing capacity building partnerships with regional training institutions to develop and conduct joint
training programs on M&E of health programs. MEASURE Evaluation launched GEMNet-Health in 2012 as a consortium of its current and former regional training partner institutions.
By investing in consolidating the Network’s infrastructure while simultaneously building technical capacity of member institutions in rigorous evaluation and health information systems, GEMNet-
Health will be well-positioned as a key resource and instrument for providing M&E services at the local, regional and global levels, while also providing a platform for information sharing and
collaboration among member institutions.
Details about the scope of GEMNet-Health’s activities are described in the briefing document that’s available. (copies of the briefing document will be available for distribution)
2
Global Evaluation and Monitoring Network for Health
(GEMNet-Health)
2

The purpose of GEMNet-Health is to foster organizational growth, collaboration, and peer-
to-peer support for monitoring and evaluation (M&E) of health programs globally through
ongoing and future institutional linkages among members, beginning with a core of
MEASURE Evaluation's current and former training partners. The aim is for GEMNet-Health
to serve as a stable, sustainable, and independent global network for M&E training,
technical assistance, and research.
GEMNet-Health’s Steering Committee provides strategic guidance and monitoring of the
implementation of its strategic plan. There is also a standing committee for overseeing
coordination and collaboration activities among member institutions such as faculty
exchange, collaborative research, webinars, and engaging with external stakeholders.
The platform of GEMNet-Health facilitates interaction among member institutions,
promoting sharing of information, collaborative research and conducting joint training
programs. The member institutions that make up the network have well-established
programs in the M&E of health programs. GEMNet-Health’s current strategic plan
identifies evaluation as the primary area of focus for the network’s activities.
GEMNet-Health’s Purpose
To foster organizational growth, collaboration,
and mutual support for monitoring and
evaluation (M&E) of health programs globally
through institutional linkages among members
3

GEMNet-Health is involved in a range of activities , all of which work toward achieving the
network mission
- (Read through the list on the slide)
• I will talk briefly about the first three activity areas and then focus more on the
curriculum harmonization activities which is the focus of our session today.
GEMNet-Health Activities
•Impact evaluation
workshop
•Qualitative evaluation ToT
Joint Training
•CLEAR
•3ie
Links with
External
Stakeholders
•Formal
•Informal
Coordination
and
Collaboration
•Competency
development
•Mapping existing curricula
Curriculum
Harmonization
To foster
organizational
growth,
collaboration,and
mutualsupport for
monitoringand
evaluation(M&E)
ofhealthprograms
globallythrough
institutionallinkages
amongmembers
4

• Growing interest for health informatics in low- and middle-
income countries (LMICs)
o Reduce inefficiencies, improve access, reduce costs,
increase quality
• Need for skilled workforce
o Technology spreading faster than skills
• Sustainability of digital health investments is in doubt
Rationale
Health Informatics Course
5

Image source: MEASURE Evaluation
Outcomes of a Strong Health
Information System
6

Better Health Outcomes
Better
health
outcomes
Improved
health
system
Strong
health
information
system
7

8
2018 World Health Assembly Resolution
on Digital Health
8

2018 World Health Assembly Resolution
on Digital Health
• Digital health:
o Has a role in advancing the Sustainable Development
Goals
o Complements integrated, people-centered health
services
o Helps contribute to improved population health and
health equity, including gender equality
9

10
Role of Member States on Digital Health
• Use digital technologies in health delivery
• Prioritize development, evaluation, implementation,
scale-up, and greater use of digital technologies
• Work toward and support the interoperability of digital
technologies using international and open standards
• Build capacity for human resources for digital health
• Build public trust and support for digital health solutions
and applications
10

Course Development Process
• Rapid assessment:
o Understand distribution of institutions offering health
informatics in LMICs
o Review the content in the health informatics programs
o Understand modes of delivery
o Assess skills gaps
11

General Findings
• Analytics and statistics
• Data management, information, and information system
governance
• Health information systems applications
• Data ethics and health law, regulation, accreditation, and
certification
• Human resource management, training
• Strategic planning, organization, management, and
leadership
Seven Common Courses
12

Findings—Africa
governance
• Data ethics, regulation, accreditation, and certification
• Human resource management, training, and
development
leadership
• Health informatics standards
13

Findings—India
governance
• Data ethics and health law, regulation, accreditation, and
certification
• Human resource management training
leadership
• Health informatics standards
14

15
Course Contributors
• Developed in 2017
• Adapted existing material
• Collaboration among:
o MEASURE Evaluation
o Public Health Foundation India
o University of Pretoria, South Africa
o Kenyatta University, Kenya
o University of Ghana
15

16
• Health informatics overview
• Clinical decision support
• Telehealth
• Privacy, security, and
confidentiality
• Workflow process
improvement
• Technology, people, and
processes
• Process engineering
• Quality process
improvement and health
information technology
Course Content
16
• Computer hardware
• Software
• Databases
• Data warehousing
• Information networks
• Information systems
• Information exchange
• Data analytics
• Usability methods

19
Introduction to Health Informatics
19
What is health
informatics?

The Objectives for this lecture are to:
• Define information management, information system (technology) and informatics;
• Explain the basic theoretical concept that underlies informatics practice;
• Define the meaning of health informatics as a field of study;
• Describe the informatics areas of applications; and
• Summarize the informatics drivers and trends.
20
Health Informatics
• Define information management, information system
(technology), and informatics
• Explain the basic theoretical concept that underlies
informatics practice
• Define the meaning of health informatics as a field of
study and practice
• Describe the health informatics areas of applications
• Summarize the informatics drivers and trends
Learning Objectives
20

This introductory lecture will define information management, information system (technology), and informatics,
describe the fundamental theorem of informatics, explain the meaning of biomedical and health informatics as a field of
study, offer definitions of the major biomedical informatics areas of applications, and provide an overview of informatics
drivers and trends.
Let’s begin with defining information management, information system (technology), and informatics.
According to the American Health Information Management Association (AHIMA), information management is “The
generation, collection, organization, validation, analysis, storage, and integration of data as well as the dissemination,
communication, presentation, utilization, transmission, and safeguarding of the information” (AHIMA, 2012, p. 181).
If the type of information were health, then health information management would entail acquisition, organization,
storage, retrieval, and dissemination of health information from a multitude of places. The purpose is ensuring
availability, accuracy, and protection of health information that is needed by a variety of individuals in the delivery of
health care services and to support decision-making activities.
21
Information Management
• Data
o Generate
o Collect
o Organize
o Validate
o Analyze
o Store
o Integrate
21
• Information
o Disseminate
o Communicate
o Present
o Use
o Transmit
o Safeguard

An example of information management would be deploying a content or document management system.
21

The next definition in the series of terms closely related to information management and informatics is information
system or technology. AHIMA defines information system as “An automated system that uses computer hardware and
software to record, manipulate, store, recover, and disseminate data (that is, a system that receives and processes input
and provides output); often used interchangeably with information technology (IT)” (AHIMA, 2012).
When you think of information technology, some things that should come to mind are computer networks, database and
systems administration, security, and programming.
Therefore, information technology could be used in the management of information.
Connecting information technology to health, consider the following definition by the Office of the National Coordinator
for Health Information:
“Health Information Technology (HIT) – The application of information processing involving both computer hardware and
software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for
22
Information System (Technology)
• Interchangeable terms
o Information system
o Information technology
• Automated system
o Computer hardware and software
- Receives and stores data
- Processes data
- Outputs data
22

communication and decision making” (U.S. Department of Health and Human Services, 2009, para. 8).
An example of health information technology would be administrative and financial systems that facilitate billing, accounting, and
other administrative tasks.
22

The final definition in this “information” series comes from authors Elmer Bernstam, Jack Smith, and Todd Johnson in
their article, What is Biomedical Informatics? Based on their research they determined data, information, and knowledge
were central to informatics. Their literature review and subsequent analysis concluded in the following definition of
informatics: “Informatics is the science of information, where information is defined as data with meaning” (Bernstam,
Smith, & Johnson, 2009, p. 106).
Thus, the similarity between all three terms is that all involve information in some way. However a critical difference
between information management, information technology, and informatics is in the object of study where information
management focuses on the organization and dissemination of information, information technology on the tools and
machines, and informatics on the optimal use of meaningful data.
23
Informatics
• The science of information
o Information = data with meaning
• Definition based on:
o Data
o Information
o Knowledge
“Informatics is the science of information, where
information is defined as data with meaning” (Bernstam,
Smith, & Johnson, 2009, p. 106).
23

In order to gain a better understanding of informatics, one needs to learn the differences between data, information, knowledge, and wisdom.
As explained on the previous slide, the research performed by Bernstam, Smith, & Johnson (2009) showed that data, information, and
knowledge were central to informatics. In their article, they referenced Ackoff’s Data, Information, Knowledge, and Wisdom (DIKW) hierarchy.
Jennifer Rowley, explored further the DIKW hierarchy. Rowley states, “The hierarchy is used to contextualize data, information, knowledge,
and sometimes wisdom, with respect to one another and to identify and describe the processes involved in the transformation of an entity at
a lower level in the hierarchy…to an entity at a higher level in the hierarchy (e.g. information). The implicit assumption is that data can be used
to create information; information can be used to create knowledge, and knowledge can be used to create wisdom” (Rowley, 2007, p. 164).
Data are simple symbols, isolated facts, and measurements. When such data are processed, put into a context, and combined within a
structure, information emerges. Information provides the answers to “who, what, when and where.” When information is given meaning by
interpreting it, that is there is an application of data, information becomes knowledge. Knowledge answers the “how” questions. Finally,
wisdom is evaluated understanding and answers the “why” questions.
Central to informatics is the processing of data so it becomes meaningful.
24
Data, Information, Knowledge, Wisdom
Hierarchy
• Data
o Symbols, facts, measurements
• Information
o Data processed to be useful
o Provides the “who, what, when, where”
• Knowledge
o Application of data and information
o Provides the “how”
• Wisdom
o Evaluated understanding
o Provides the “why”
24

Clinical Informatics is concerned with information use in health care by clinicians.
Biomedical informatics (BMI) : interdisciplinary field that studies and pursues the effective uses of biomedical data,
information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve
human health.
Medical informatics: This field deals with the resources, devices, and methods required to optimize the acquisition,
storage, retrieval, and use of information in health and biomedicine
Categories of Health Informatics
• Medical informatics
• Clinical informatics
• Biomedical informatics
• Nursing informatics
• Imaging informatics
• Public health informatics
• And many more ….
25

Building on what has been learned so far, Dr. Friedman’s proposed fundamental theorem of informatics will be reviewed next. Other theories, such as Bayes’
Theorem, also apply to informatics but will not be addressed in this unit.
Merriam-Webster’s Online Dictionary defines a theorem as “an idea accepted or proposed as a demonstrable truth often as a part of a general theory” (Merriam-
Webster, 2011).
Dr. Friedman utilized Figure 1.1 to represent the theorem. The picture is that of parentheses, picture of a head of a person, a plus sign, picture of a computer,
parentheses, greater than symbol, picture of a head of a person.
According to Dr. Friedman, this figure is to be interpreted to mean “A person working in partnership with an information resource is ‘better’ than that same person
unassisted” (Friedman, 2009, p. 169).
He further explains, “the metaphoric ‘person’ depicted in the theorem can be a clinician, a scientist, a student, a patient or an administrator. The “person” can also
be a team or group, or even an organization. The ‘information resource’ is any mechanism capable of providing information or knowledge or advice to support the
person's completion of a task. Information resources are usually, but do not have to be, computer-based. The ‘plus’ in the figure is intended to convey interaction
between the person and the resource, the outcome of which is determined by what the information resource is capable of, as well as how the person elects to use
26
Fundamental Theorem of Informatics
26
A “Fundamental Theorem” of Informatics (Friedman, 2009)

it. The ‘plus’ symbol is employed because of its universal recognition, but is not to be read literally in the sense of mathematical addition. The
parentheses further connote a bonding between the person and resource, and suggest that the person-resource interaction is shaped by its
environment or organizational context. ‘Better’ and the ‘greater than’ inequality are used loosely by intention, so as not to convey specific
requirements for testing the theorem” (Friedman, 2009, p. 169).
26

Now that you have a better understanding of informatics, let’s look at where one would find this science applied.
As one would expect there is not just one segment or domain for informatics. Any domain where there is a need for
analysis of data and dissemination of information through the use of computer applications is a possible application
domain. These include a wide range of industries including entertainment, hotel management, law and law enforcement,
health care, and many other fields where computer technology interfaces with people.
As the focus of this unit is “What is Health Informatics?,” informatics and its application to health care will be explored
further.
27
Application Domains for Informatics
• Any area of human endeavor that can be supported by
information technology, such as:
o Entertainment
o Law and law enforcement
o Healthcare
o Other fields in which computer technology interfaces
with people
27

While various perspectives of informatics and its application to health care have been published, two have been chosen for review and discussion because of
their significance within the field.
The first definition comes from the American Medical Informatics Association or AMIA. AMIA is a non-profit organization dedicated to the development and
application of medical informatics in the support of patient care, teaching, research, and health administration. This organization is seen as the prominent
informatics organization in the US. According to their web site, “AMIA is the professional home of leading informaticians: clinicians, scientists, researchers,
educators, students, and other informatics professionals who rely on data to connect people, information, and technology” (AMIA, 2011, para. 2).
AMIA’s definition, therefore, is essential to understand. Accordingly, “Biomedical informatics (BMI) is the interdisciplinary field that studies and pursues the
effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve
human health” (AMIA's Academic Forum, n.d., para. 3).
The second definition comes from another highly respected source for biomedical informatics material, the textbook Biomedical Informatics: Computer
Applications in Health Care and Biomedicine.
Shortliffe and Blois define biomedical informatics as “the scientific field that deals with biomedical information, data, and knowledge – their storage,
28
Health Informatics
• Centers for Disease Control and Prevention
o Public health informatics is “defined as the systematic
application of information and computer science and
technology to public health practice, research, and
learning.”
• Modified for health informatics
o “… the systematic application of information and
computer science and technology to health care
practice, research, and learning.”
28

retrieval, and optimal use for problem solving and decision making” (Shortliffe & Blois, 2001, p. 24). As a field of study, Shortliffe and Blois
state biomedical informatics is “concerned with the broad range of issues in the management and use of biomedical information, including
biomedical computing and the study and nature of biomedical information itself” (Shortliffe & Blois, 2001, p. 920).
28

Another term you may come across is health informatics. It has various interpretations but each one connects
information science to health care in some fashion.
For example, AMIA’s perspective is “The informatics community typically uses the term health informatics to refer to
applied research and practice of informatics across the clinical and public health domain” (AMIA, 2011, para. 3). While
AHIMA defines health care informatics as “The field of information science concerned with the management of all
aspects of health data and information through the application of computers and computer technologies” (AHIMA, 2012,
pp. 154-155).
As you can imagine, applying information science to health care requires health informatics standards to define
acceptable methods for collecting, organizing, maintaining, and exchanging data among health management information
systems.
29
Health Informatics
• Informatics applied to healthcare and population health
• Includes
o Management and use of data and information in
healthcare
• Involves
o Information technology
• Requires
o Standards
29

30
Drivers of Health Informatics
30

Why else are informatics applications a growing need?
Trends which are stimulating the need for health informatics applications include: the focus on eHealth, the adoption and
implementation of electronic medical records or EMRs, and electronic health records or EHRs, and the growing desire to
be able to electronically exchange health information across organizations within a region, community or hospital system.
The application of information technology to health care is a critical tool in achieving the benefits of eHealth, EMRs,
EHRs, and health information exchange.
As you will learn later in this unit, practitioners of informatics known as informaticians use information technology to
advance cost-effective care, high-quality care, and patient safety.
But first, let’s review the connection informatics has to eHealth, electronic medical records, electronic health records,
and health information exchange.
31
Current Trends in Health Informatics
• eHealth
• mHealth
• Electronic client-level systems
• Health administration information systems (e.g., logistics,
human resources, aggregate-level information systems)
• Health information exchange
• Interoperability
31

32
Digital Health Categories
32
Source: Broadband Commission, 2017

A general direction with regards to health IT relates to the global environment. The World Health Organization or WHO, a United
Nations agency responsible for directing and coordinating international health activities, recognized a trend involving the use of
information and communication technologies and its impact on health care delivery, public health, research and health-related
activities.
With this recognition, WHO set about defining eHealth and developing a WHO eHealth strategy to help direct WHO’s activities on
eHealth. As defined by the WHO, “eHealth is the use of information and communication technologies (ICT) for health to, for
example, treat patients, pursue research, educate students, track diseases and monitor public health” (WHO, 2011).
The HIMSS definition is “The application of Internet and other related technologies in the healthcare industry to improve the access,
efficiency, effectiveness, and quality of clinical and business processes utilized by healthcare organizations, practitioners, patients,
and consumers to improve the health status of patients” (HIMSS, 2003, p.4).
Thus, there is a very close connection between eHealth and informatics as it is the combined use of electronic communication and
information technology in the health segment. Some in the industry see eHealth as a sub-discipline of health informatics. Certainly,
the application of information and communication technology to health care is a critical tool in achieving the benefits of eHealth,
33
eHealth
• World Health Organization definition:
o Use of information and communication technologies for
health for different purposes
• Healthcare Information and Management Systems
Society definition:
o Application of the Internet and other technologies to
healthcare for various goals and objectives
33

such as improving health care delivery.
An example of eHealth is telemedicine which is delivery of health care at a distance most often via the Internet.
33

34
Digital health and eHealth: Umbrella terms to encompass all concepts and
activities at the intersection of health and information and
communications technologies (ICTs), including mHealth, health
information technology, electronic health records, and telehealth, and
encompassing three main functions:
• Delivery of health information, for health professionals and health
consumers, through the Internet and telecommunications media
• Use of ICTs to improve public health services (e.g., through the
education and training of health workers)
• Use of health information systems to capture, store, manage, or
transmit information on patient health or health facility activities
Digital Health
34
Broadband Commission report:
Digital Health: A Call for Government Leadership and Cooperation between ICT and Health

The final trend is the utilization of health IT, in order to achieve widespread adoption of health IT and enable electronic
exchange of health information. Included in the report, Defining Key Health Information Technology Terms, is the
following definition for health information exchange (HIE):
“The electronic movement of health-related information among organizations according to nationally recognized
standards” (NAHIT, 2008, p. 6).
HIE involves networks that give providers the ability to electronically transmit in a secure manner an individual’s health
records.
Through the utilization of EHRs, HIE supports the sharing of health-related information to facilitate coordinated care.
EHRs draw information from many sources through health information exchange. Thus, the process of health information
exchange is another piece of the health information technology infrastructure and informatics. There are many local,
state, and national HIE initiatives going on throughout the U.S.
35
Health Information Exchange
• Electronic movement of health-related information
among organizations
• Involves networks
• Local, state, and national health information initiatives
• Through the utilization of electronic health records, Health
Information Exchange supports the sharing of health-
related information to facilitate coordinated care
35

The final trend is the utilization of health IT, in order to achieve widespread adoption of health IT and enable electronic
exchange of health information. Included in the report, Defining Key Health Information Technology Terms, is the
following definition for health information exchange (HIE):
“The electronic movement of health-related information among organizations according to nationally recognized
standards” (NAHIT, 2008, p. 6).
HIE involves networks that give providers the ability to electronically transmit in a secure manner an individual’s health
records.
Through the utilization of EHRs, HIE supports the sharing of health-related information to facilitate coordinated care.
EHRs draw information from many sources through health information exchange. Thus, the process of health information
exchange is another piece of the health information technology infrastructure and informatics. There are many local,
state, and national HIE initiatives going on throughout the U.S.
36
Interoperability
• In healthcare, interoperability is the ability of different
information technology systems and software applications
to communicate, exchange data, and use the
information that has been exchanged.
• Data exchange schema and standards should permit
data to be shared across clinician, lab, hospital,
pharmacy, and patient regardless of the application or
application vendor.
36

37
Principles for Digital Development
The foundation on which this course is built
37

This concludes Lecture A of What is Health Informatics?.
This lecture defined information management, information technology, and informatics, described the fundamental
theorem of informatics. It also provided an overview of informatics drivers and trends in the health care field.
38
What is Health Informatics?
• Defined terms
• Described theorem
• Explained field of study related to biomedical and health
informatics
• Provided an overview of drivers and trends
Summary
38

No audio
39
Altman, R. B. , & Mooney, S. D. (2001). Bioinformatics. In Shortliffe. E., & Cimino, J. J. (Eds.),
Biomedical informatics: Computer applications in health care and biomedicine (3rd edition)
(p. 763). New York, NY: Springer Science + Business Media.
American Health Information Management Association. (2012). Pocket glossary for health
information management and technology (3rd edition). Chicago, IL: American Health
Information Management Association.
American Medical Informatics Association. (2016). About AMIA. Retrieved from
http://www.amia.org/about-amia
American Medical Informatics Association’s Academic Forum. (n.d.). Definition of biomedical
informatics. Retrieved from http://www.amia.org/biomedical-informatics-core-competencies
Bernstam E., Smith J., & Johnson T. (2009). What is biomedical Informatics. Journal of
Biomedical Informatics, 43(1). doi: 10.1016/j.jbi.2009.08.006
Friedman, C. (2009). A "fundamental theorem" of biomedical informatics. Journal of the
American Medical Informatics Association, 16(2), 169-170. doi: 10.1197/jamia.M3092
Healthcare Information and Management Systems Society. (2003). HIMSS e-health SIG white
paper. Retrieved from http://www.longwoods.com/content/20034
Merriam-Webster. (2011). Theorem. Retrieved from http://www.merriam-
webster.com/dictionary/theorem
References
39

No audio
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Rowley, J. (2007). The wisdom hierarchy: Representations of the DIKW hierarchy. Journal of
Information Science, 44. doi: 10.1177/0165551506070706
Shortliffe, E., & Blois, M. (2006). The computer meets medicine and biology: Emergence of a
discipline. In Shortliffe. E., & Cimino, J.J. (Eds.), Biomedical informatics: Computer
applications in health care and biomedicine (3rd edition) (pp. 3-45). New York, NY: Springer
Science + Business Media.
The National Alliance for Health Information Technology. (2008). Defining key health
information technology terms. Retrieved from http://www.hitechanswers.net/wp-
content/uploads/2013/05/NAHIT-Definitions2008.pdf
UMDNJ-Robert Wood Johnson Medical School, UMDNJ-School of Health Related Professions
Department of Health Informatics & New Jersey Institute of Technology. (n.d.). MD/MS in
Biomedical Informatics. [Brochure]. Retrieved from
http://rwjms.rutgers.edu/Education/current_students/academics/dual_degree_programs/d
ocuments//mdms_biomedicalinformatics.pdf
U.S. Department of Health and Human Services, The Office of the National Coordinator for
Health Information Technology. (2016, September 8). Health IT terms.
World Health Organization. (n.d.). eHealth. Retrieved from
http://www.who.int/topics/ehealth/en/
References
40

No audio
41
This material was developed by Duke University, funded by the Department of Health and Human Services, Office
of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material
was updated by Normandale Community College, funded under Award Number 90WT0003.
This presentation was produced with the support of the United
States Agency for International Development (USAID) under the
terms of MEASURE Evaluation cooperative agreement AID-OAA-L-
14-00004. MEASURE Evaluation is implemented by the Carolina
Population Center, University of North Carolina at Chapel Hill in
partnership with ICF International; John Snow, Inc.; Management
Sciences for Health; Palladium; and Tulane University. Views
expressed are not necessarily those of USAID or the United States
government.
www.measureevaluation.org

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