Development of the Health Management Information System in Malawi Overview of Achievements and the Way Forward

Transcription

1 Development of the Health Management Information System in Malawi Overview of Achievements and the Way Forward Ministry of Health and Population In collaboration with the Netherlands support Malawi Health Population and Nutrition Programme December 2003

2 Executive Summary 1 Lack of reliable data and grossly inadequate appreciation and use of available information in planning and management of health services were two main issues with regard to health information systems in Malawi. In 1999, Malawi began strengthening health management information system with analysis of strengths and weaknesses of existing information systems and sharing findings with all stakeholders. The systems had all the weaknesses an information system could posses. All stakeholders agreed on the need for reformation of various vertical programme specific information systems into a comprehensive, integrated, decentralised, and action oriented simple system. As the first step towards conceptualisation and designing of the system, a minimum set of indicators was identified and an agreeable strategy was formulated for establishing a system in the country. The design solely focussed on the use of information in planning, management, and improvement of quality and coverage of services. All health and support personnel were trained employing training of trainers cascade approach. Information management and use was included in pre service training curriculum and in the job description of all health workers and support personnel. Quarterly feedback, supportive supervision visits and annual reviews were institutionalised. Civil societies were involved in monitoring coverage of health services at local levels. A mid-term review of the system carried out in 2002 stated this achievement as one of the best in the continent. For the first time in Malawi, the health sector has information by facility by month. Yet very little improvement has been noted in use of information in rationalising decisions. The practice of managing and using information before and after launching the system has been found not much different. Changes in some management practices have been seen as the straight way forward. Baseline Situation in 1999 The systems that were gathering information for management of health services were too many and uncoordinated. Most of them were not able to produce the information required for management decision-making (MOHP, 1999a). Data were of poor quality and rarely used in planning and management of health services. Collection of data for performance monitoring and evaluation was not a priority in the districts (MOHP, 1999a). Information related to disease surveillance; vital statistics; maternal and child and reproductive health indicators; and tracking of financial resource allocations was neither systematized nor easily accessible for proactive analysis or planning purposes (MOHP, 1999 a). Various national vertical programmes imposed their unilateral data requirements upon frontline staff, resulting in duplication and wastage of time and resources (MOHP. 1999a; MOHP. 1999b). Backlog of health facilities raw data directly reported to headquarters not yet captured or analysed was enormous (MOHP. 1999a; MOHP. 1999b). 1 Prepared by Chet Chaulagai, Chris Moyo, Humphrey Moyo, Thokozani Sambakunsi, Patrick Naphini, and Ferdinand Khunga. December 2003 Overview of Achievements and the Way Forward Page 2 of 16

3 The purpose of this paper is to elaborate on how a comprehensive health information system has been designed and implemented in Malawi taking into account the complex design of health service delivery systems, health status of the people, economic status of the country, major health problems and immediate and long-term plans and programmes of the health sector. A number of innovative elements were included in the design. This paper attempts to discuss the essence of each innovation and mirrors on the results with regard to its success in resolving the issues highlighted in the national policy and plans. System design and establishment process The process of restructuring the health information systems in Malawi began in September 1999 with an analysis of strengths and weaknesses of the existing information systems. The findings were presented in a workshop attended by all stakeholders. Stakeholders agreed on the need for the establishment of a comprehensive system that is capable of feeding information to the users at community, health facility, district and national levels. The design process started with identification of minimum indicators, datasets and a 5-year strategy for strengthening routine HMIS. Consensus on indicators led to revision of data collection, processing and reporting tools and a procedures manual which was tested over 18 months in phases starting from 3 health facilities to an entire district and a tertiary care facility. The tests focused not only on data collection and processing but also on the use of information at local and district levels. Soon after the consensus on indicators, while waiting for newly devised comprehensive tools and guidelines, DHMT members from all districts were provided with tools and skills to utilise existing data in calculating indicators and making their use in planning and management of health services at district and periphery. In this way, the revision and testing of tools and maximisation of use of available information began simultaneously. All health workers were oriented on information management and use. The orientation was completed within 6 months using cascade-training approach in which a group of trainers were prepared for each district and central hospitals who in turn trained other health personnel within their jurisdiction. The system was put into effect in the entire country from January 1, The newly devised HMIS tools and procedures were included in the curricula of all pre-service health training programmes. Information management and use functions were added in the job description of all health and support personnel. Monthly meeting at health facility, quarterly reporting to district and from district to headquarters, quarterly feedback from headquarters to district and district to facility, quarterly management meeting and annual performance review meeting at facility, district and national level were instituted. Health information policy, indicators handbook, routine monitoring and annual health sector joint review guidelines were developed. The steps undertaken in the process of designing, testing, launching and sustaining HMIS in Malawi can be summarised as follows: 1. Inventory and analysis of existing 3. Consensus on minimum indicators information systems. and data elements. 2. Dissemination of findings to key 4. Consensus on five-year strategy for stakeholders and decision on the strengthening HMIS. way forward. 5. Orientation of DHMT on minimum set of national routine indicators December 2003 Overview of Achievements and the Way Forward Page 3 of 16

4 and provision of tools and technique for optimising the use of existing information. 6. Design of data collection, processing, dissemination, and routine monitoring tools and procedures manual. 7. Testing of tools and guidelines in three phases: starting from three health facilities covering an entire district and a tertiary care facility over 18 months. 8. Training of master trainers, district trainers, and all health and support personnel in the entire country including NGO and private. 9. Printing and supply of data collection, processing, dissemination, and routine monitoring tools and guidelines to all health facilities. 10. Training of central HMIS team in rotation. 11. Revision of pre-service training curriculum and job description of health and support personnel. 12. Demarcation of catchment area of each public health facility for basic essential health care services and digitisation of map for use at health facility, district and national levels. 13. Computerisation of data processing at district and above after 6 months of manual processing. 14. Several rounds of supportive supervision, follow-up and feedback visit from headquarters to district health offices. 15. Basic and refresher training of HMIS focal person and data processing clerks. 16. Electronic data transfer by and dissemination of information through printed materials, intranet and website. 17. Introduction of electronic inpatient register in tertiary care facilities. 18. Endorsement of health information policy, health sector indicators, routine monitoring and review guidelines that have been evolved over 4 years of interactions and exercises. Figure 1: The process through which HMIS evolved in Malawi Follow-up and support the system until... Launch the system nation wide Start analysing and using available data Select minimum indicators Conceptualisation / system design / strategy development Culture of evidence based decision making established Finalise design and instruments Test the design and instruments Revise instruments, guidelines and training material Assessment of current systems The steps and the process followed in designing and implementing the system have been summarised in figure 1. It should be noted that the process of implementing the information system does not end just by putting the system in place. It seeks to follow-up and support until the collection, analysis and use of information becomes a culture in the entire health sector. The information reformation process started simultaneously with several health sector reform initiatives: decentralisation of management of health services to local government, hospital autonomy and sector wide approach. The overall health sector December 2003 Overview of Achievements and the Way Forward Page 4 of 16

5 reform process has been much slower than the development in the establishment of the new information system. Thus the environment expected to be created for optimum utilisation of information in planning and management of health services has not come yet into existence. Tools devised in order to improve management and use of information Tools were designed aiming at optimising the quality of individual s care, attaining of universal coverage of health services in the communities, and improving health status of the people in the catchment areas. Tools that have been devised can be grouped into four categories as shown in table 1. Client health booklets Three client health booklets (child, woman and general) were introduced to improve the quality of individual s health care. All booklets contain records of individual s updated history, assessment of current problems and Table 1: Tools devised for effective management and fostering usage of information 1. Client health booklets 2. Facility based registers 3. Data aggregation and monitoring workbook 4. Annual planning and review tools types of care given. The child health booklet is issued at birth. It contains specific information on immunisation, vitamin A and growth monitoring. A male child can use the same booklet for his entire life. The general health booklet can be annexed to child health booklet for continuous recording of assessment and care. The girl child, however, has to use a woman health booklet when she reaches puberty. The woman health booklet contains specific information on tetanus toxoide injection, family planning services, antenatal check-ups, obstetric history and postnatal services as well as her general history. These booklets are sold at a cost price to ensure re-supply of booklets without adding burden to the already stretched government s financial resources. Facility based registers Registers are designed to collect data on predefined minimum datasets and indicators. Additionally, each record includes data on four dimensions: age, sex, time and place. At the end of each day data are aggregated on key elements to identify emerging issues and proper and adequate preparations for interventions. Data aggregation and monitoring workbook A simple poster-sized wall chart has been introduced at facility level to aggregate monthly data and monitor indicators. Monthly-disaggregated quarterly report is prepared transcribing data from wall chart. The workbook contains data on current status, year-end targets, monthly or quarterly targets and achievements. Annual planning and review tools Districts prepare their annual district implementation plan (DIP). The DIP process follows the steps of situation analysis, prioritisation, resource allocation, and target setting. Standard forms have been introduced to fill baseline values, year end and monthly targets so that the performance level is timely detected and necessary actions are taken on time in order to ensure achievement of end targets. December 2003 Overview of Achievements and the Way Forward Page 5 of 16

6 Analysis of Achievements A comprehensive but simple and manageable health information system has been introduced in the country in For the first time the country has continuous monthly data (see fig. 2) on all agreed indicators for each facility, district (see fig.3) and the nation. It is also for the first time that each public health facility and district health office knows its catchment area and population to be served. Welldefined catchment area and population has enabled each facility to monitor coverage, organise outreach clinics, and plan community health development activities together with respective communities. By defining Figure 2: OPD attendance by month, Malaw i Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun catchment area, the accountability of each facility towards the communities it serves has become clearer. Quality of care is much better when a client health booklet is consistently used. Duly completed wall Figure 3:OPD visits percapita by district Malawi Balaka Blantyre Chikwawa Chiradzulu Chitipa Dedza Dowa Karonga Kasungu Lilongwe Machinga Mangochi Mchinji Mulanje Mwanza Mzimba Nkhata Bay Nkhotakot Nsanje Ntcheu Ntchisi Phalom be Rumphi Salim a Thyolo Zom ba Malawi charts enable health workers and other users to understand the magnitude of health problems, health services utilisation rates and their subsequent results. Wall charts and health passport booklets are contributing to enhance the understanding of health by individual and society. The comparative figures provided in quarterly reports generated at district and national levels provide a basis for self-evaluation by facilities and district health offices. Each district or facility can rank its performance by making comparisons with other districts or facilities. The mid-term evaluation report qualify the achievement of a newly implemented system as unprecedented in other countries (Bijlmakers et al. 2002). However, it does not mean that everything has been done perfectly. The results are mixed with some successes and some failures. The highlights on various achievements and a critical reflection on each of them are discussed below. Consensus on minimum indicators: The first step in the design process was to assess the need and agree on minimum indicators and datasets. Despite the fact that no programme was making adequate use of available information, each wanted to include all possible pieces of information in the routine data collection system. Most vertical programmes reluctantly agreed to give up their own vertical data collection system and join the integrated HMIS. Through concerted efforts, eventually, consensus was achieved and necessary data December 2003 Overview of Achievements and the Way Forward Page 6 of 16

7 collection tools and procedures manuals were developed, tested and introduced in the entire health system. Several vertical programmes did not extend their cooperation required for effective functioning of an integrated system. Vertical programme could not easily accept the fact that the integrated system was designed to fulfil their information requirements. In addition, the moment leadership gets changed in a vertical programme; the hard earned consensus becomes invalid. New people come with new non-negotiable ideas. Even small donors keep on bringing new demands to meet their headquarters interest rather than supporting MOHP to implement its agreed strategy. It is true that the system should be dynamic so that it is capable to address emerging issues. However, frequent change in design and process does not help build a system. It is realised that consensus is very important. It must be achieved on minimum indicators before embarking on designing and implementing a HMIS. Once a consensus is achieved, no change should be allowed until the next formal review of the system is undertaken. In this matter, the leadership has to be strong enough; otherwise, the newly emerged system can be uprooted anytime. Integration of different information systems Health management information systems can never be fully integrated into a single entity. Some small entity can be grouped and several grouped entity work in collaboration to meet the national broader interests. Logically grouped, a number of sub-systems have been identified as collaborated component of national health management information system. They are: a) financial management information system, b) human resource management information system, c) logistic and supply management information system, d) physical assets management information system, e) diseases surveillance system and f) health service management information system. The health service management information system is at core and derives information from all other sub-systems besides directly managing the service related information. Malawi has fully integrated all service related information systems and disease surveillance system into a single entity of routine health management information system. The programme specific logistics and supply components have been integrated into a broader LMIS. Besides those routine in-house collaborated systems, the national health management information system obtains information from census, survey and research studies and collect additional less frequently required data on adhoc basis through rapid assessment. The national HMIS is ultimately responsible for coordinating all data collection functions, compiling data from all sources, storing them in appropriate format and disseminating in different ready to use format to meet different users predefined requirements. Only strong leadership can keep all the subcomponents functionally interlinked and grow to meet national interests. Decentralisation of the national health management information system National information system cannot be fully decentralised. Designing the system, developing tools and defining minimum datasets are centrally controlled in order to have nationally comparable data. Nonetheless, local analysis and local use is the primary purpose of collecting information. Health passport, registers, data aggregation and monitoring tools are designed for immediate use of information at the point of collection. Despite emphasis on maximising the use at local levels, the traditional thinking of collecting data for reporting purpose is still deeply rooted in the system. December 2003 Overview of Achievements and the Way Forward Page 7 of 16

8 Facilities still consider the submission of reports as completion of information cycle. Efforts are being made to encourage participation of civil societies in planning and monitoring of health services at local and district level. Routine community surveillance findings are shared with village health committees, quarterly performance report of health facility and district are shared with heath facility committees and district assemblies. Health facilities continue to be reluctant to report their performance to the people s representatives. Generally, government servants do not think that they are servants of the people they serve. Without national effort to change such thinking communities cannot be truly empowered. New Institutional set-up The same people who manage and deliver services collect the routine data related to their own work performance. Accountants compile financial information; personnel administrators compile human resource information, service providers compile services and disease related information. The philosophy behind the design of the current system is that the people who compile information are its first users. However, storage, interpretation, and dissemination to different users in different ready to use format is done from a single point at each level. To provide comprehensive information from one point at district and national levels, where data is managed for each its underneath unit, was not possible without having a separate set-up. A statistical position was created for each district health office and central hospital to assist with computerised data processing at that level. To take up the revised role of the information system, a unit was established in the ministry headquarters with a number Figure 4: Framework of routine data collection, storage and of senior positions who Report to higher Level are trained in public health and epidemiology. This unit is Component specific data Data warehouse Data Bank Comprehensive report(s) Component specific responsible person charged with Feedback to lower level the responsibility of coordinating information collection functions; compiling complete health information from internal, external, primary and secondary sources; analysing, interpreting and storing information in appropriate format; generating reports in different ready to use format and disseminating to all relevant stakeholders. At the time of writing this paper, this unit is located in the planning department. Different departments have expressed their desire to split the functions of this unit and place in their respective departments. This reflects the desire of expanding the empire of departments rather than finding a viable effective solution for the national cause. A viable proposal has been under discussion to move the unit under health information management technical committee in which directors of all departments will be members. Efforts were made to fill HMIS positions from the people with health background. Due to severe shortage of health workforce in the market, people from outside the December 2003 Overview of Achievements and the Way Forward Page 8 of 16

9 health market were recruited and trained for the intended job. But this semi-health workforce still belongs to common service, which means they can be transferred to any Ministry. There is no clear career prospect for them within the health sector. Out of 32 trained Assistant Statisticians 3 have already been transferred out from the Ministry of Health and Population without consent from the health management information unit. Investment in their training cannot be productive if they are not retained within health sector. Efforts are underway to convert those positions to departmental positions and establish a career structure. Positive development in this endeavour is important for sustaining and further strengthening of the system. The vacated positions of Assistant Statisticians have not been filled even in two years time. Data entry and reporting in the three districts are done by non-statistical personnel who also have other fulltime duties. Consequently the deadlines for data processing and dissemination are never met. Foundation for the establishment of an information culture Revision of academic training curriculum and job descriptions were the main efforts towards creating a foundation for information culture among health personnel from outset of their career in the health sector. Under the leadership of nursing and midwives and medical councils all training institutions participated in curriculum revision exercises and subsequent training of trainers programme. This exercise itself was a remarkable achievement. However, as of now, no report has been received with regard to actual inclusion of HMIS in respective training. Job descriptions of all health and support personnel were revised in the light of newly envisaged functions of information collection and use. One year has elapsed since the document was submitted for official endorsement. Interface between paper and computer The overall design of the system is paper based. Each provider records, compiles, analyses and make use of information in day-to-day functions. Managing and using information related to its job is the function of every health and support personnel. When the system was first started, programme specific coordinators were made responsible for compiling data specific to their department and carry out routine monitoring functions. This was an advantage of the system as the concerned people get informed about the performance of a facility as the report arrives at his her desk. The only disadvantage was the time it consumes to get the same report at all desks within a certain period. Sometime it was difficult to trace the whereabouts of a report. Furthermore, manually transcribing data was unnecessarily time consuming task and manual compilation was error prone. A computer programme developed in South Africa for such data transaction was adapted for Malawi. Computer expedited data processing at the cost of participation of programme coordinators in the process. The introduction of computerised data processing system made district programme coordinators passive consumers of information. The software has versatile functionalities, which have evolved over a long period. It intra/extrapolates data for a missing month, calculates reporting coverage of population, generates report on raw data or indicators and presents data on maps linking to GIS. The introduction of computer for routine data processing was a trade off between participation in data processing and timely availability of more reliable data. December 2003 Overview of Achievements and the Way Forward Page 9 of 16

10 Further to computerised data processing system as described above 2 electronic registers for general inpatient and maternity services have been introduced in tertiary care hospitals. Almost 200,000 cases are annually admitted in four tertiary care hospitals. Manually compiling those cases by disease category, age, sex, length of stay etc. has been found cumbersome and error prone tasks. Those tasks have been made simple by introducing maternity and general inpatient electronic registers. Data on each record is entered two times, at the time of admission and discharge. Diagnosis is recorded according to local disease classification and ICD9. Treatments are recorded using generic drug name. It has predefined reporting template to generate report on indicators. It has also template for user defined reporting. Electronic register is expected to enhance the quality of data and timeliness of reporting. Since the programme is used in stand-alone computer, the cost is minimum and it can be expanded to any hospital. One step further to the electronic inpatient and maternity register, a touch screen patient management information system has been introduced in a central hospital. The real time data available from this system enables clinicians to make more accurate diagnosis and provide better treatment. The network is on expansion to cover pharmacy, pathology, radiography and other support services. Use of health passports Having been positively impressed from a health passport system introduced in some hospitals that are managed by the Christian Health Association of Malawi, the MOHP decided to introduce a similar health passport system in the entire health sector. The booklets were designed separate for women, children and men. There had been long debate on the content of booklets. Finally, it was agreed to have a simple profile rather than having an ideal content. Booklets have been instrumental in improving quality of individual s care. This system made individual responsible for keeping their personal health records which also provided them freedom to go anywhere with their complete past records to seek better services. As the cost of booklet was directly recovered from people and many people see the value of having their personal health profile with them, the booklets were rarely lost from negligence. The personal profile of the person has to be recorded on the booklet at the time of issue. The records require updating at every visit. Due to incompliance of some providers, some profiles are not up to date. Introduction of three booklets was, in fact, unnecessary. Male and female booklet can precisely serve the purpose by adding child health components in both of them. Managing revolving funds for health passports An initial supply of 2.5 million booklets was distributed to DHOs and central hospitals to sell at a cost price (with a nominal margin to make up the inflation) and manage re-supply through revolving the same money. This was the first attempt that the government was selling commodities or services to the people. Surprisingly, the booklets were on great demand. People felt worth spending on it, except for certain politicians who tried to make political gains out of this issue. Otherwise, it was well accepted by both the providers and recipients. Districts were instructed to operate a special health passport revolving funds account to manage this scheme. Misappropriation of money was discovered in some districts and therefore the Ministry intervened with the provision of centrally controlled health passport December 2003 Overview of Achievements and the Way Forward Page 10 of 16

11 revolving funds deposit and operating accounts. Under this measure, a district must deposit the proceeds and get them released through established procedures. Districts followed the instructions but failed to access the money in order to replenish the booklet. The initial supply and re-supply covered about one third of Malawi population. Two thirds of the population do not yet have a booklet. This interruption in supply negatively affected the quality of data collected. In the defined standard data collection procedure, the provider records assessment, diagnosis and prescription in the booklet from which selected information is transcribed into facility-based register. The absence of booklet resulted in interruption of the process. This issue had been raised time and again in high forums but could not produce any solution for a long time. Finally, the issue was resolved after rigorous follow-up with treasury and accountant general s office by an individual from HMIS unit. Thanks for the dedication of this unnamed person. With this money, if sincerely handled, the system will run in the district and central hospitals for ages. Defining catchment areas and deriving catchment populations For local monitoring of utilisation of health services each facility must know the population that it is responsible for. The process of demarcating the catchment area of each public health facility started at the time when nationwide HMIS training was started in For practical reason a catchment area was defined as the population living within certain geographical boundaries that would be served by a health facility. The steps followed in defining catchment area are: Identify the addresses of users in the service registers from where people are attending services Find an appropriate map and shade the area in map covering the areas listed above. Discard unusual visits from far away villages. Have a meeting with all adjoining health facilities to agree on the catchment boundaries to be responsibly served by respective facility. No village remains uncovered. Each village comes under the catchment area of a facility. Catchment areas for secondary and tertiary care facilities are also defined in the same way. Demarcating the catchment area for all public health facilities for the first level care has been found a tiresome exercise. This exercise was supposed to be completed before starting HMIS in January It has however taken ten fold more time than expected. Difficulties were encountered where there was more than one facility in the proximity, people from the same small village were visiting two different facilities and when several facilities had to meet to make agreement. If there were two or more than two facilities in the same area, the same catchment area was used by both facilities with division of responsibilities and targets. A new facility has to be operated for some time to have sufficient users data in order to precisely define its catchment area. The task of determining catchment population was equally difficult especially when the figures from headcounts and national census appear away apart. When the census figures are used, no growth rate was available for sub-district and local level to project current population. Without systematically defined catchment area, information cannot be optimally used at local levels. Now the 94,276 square kilometres land area of Malawi has been divided into 550 health facility catchment areas, ranging the area of a facility from 25 to 650 square kilometres and catchment population from 1,000 to 175,000 with some exceptions in national parks and game December 2003 Overview of Achievements and the Way Forward Page 11 of 16

12 reserve areas. Maps have now been produced showing location of health facilities, catchment boundary and total population. The maps are prepared for use at local, district and national levels for planning, comparative monitoring of service coverage, distribution of disease in question etc. Cascade approach training: Pros and cons The training for nationwide roll out of HMIS was initially planned in such a way that national trainers would conduct all the training in batches from district to district. Due to the lack of sufficient cooperation from national vertical programme in allocating qualified person for nationwide training, a cascade training of trainers approach was employed. Four central hospitals and 26 districts training team were prepared to train everybody in their respective district and central hospital. Nationwide training was completed within a period of 6 months. Supportive supervision visits were organised from headquarters during the initial batches of training. Follow-up visits were made to maximum number of facilities during the initial stage of implementation. Despite heavy inputs on training, not much difference was observed in performance of trained and untrained persons. In some facilities, the performance of newly recruited person was even better than the person who had a 5 day training in HMIS. Comparative analysis of quality of collected data, quality of analysis and format used in dissemination showed that people could perform much better with half-day practice based training than their colleagues with 5 days training in classroom setting. Practice based training was found effective in bringing immediate changes in the practice. Participants often think that classroom learning is not for immediate practice. They need several follow-ups and reminders to put into practice what they learned in the classroom training. A training intended to bring immediate changes in the system should always be practice based: learning at work by doing under supervision. Partnership and collaboration The Government initiated the health information reformation process with the financial and technical support from the Netherlands Government. Other development partners especially DFID, UNFPA, UNICEF USAID, and WHO gradually expanded their support while The Netherlands started gradually phasing out. This reveals the commitment of key stakeholders to sustain the current achievement and further strengthen the system. Data quality Routinely collected facility based data has known limitations. It does not capture all the cases that exist in the communities. Nevertheless, it can precisely tell about the people who have visited health facilities. However, completeness of facility based routine data is still a big problem. Data are incomplete in several ways. There are a number of facilities not sending a report at all. There are some other facilities not sending report regularly. The facilities regularly sending report are also not reporting data on each element every month. The facilities that are sending report regularly on each data element are also failing to capture all the records. Thus, an indicator value generated from routine data is always lower than actual and therefore each report needs adjustment for under reporting. Definition of cases and each data element are available at each desk nationwide but not used consistently. Consequently, incorrect diagnosis, wrong coding and entry on December 2003 Overview of Achievements and the Way Forward Page 12 of 16

13 wrong fields are commonly observed problems. Those problems were gradually minimised through systematic data verification. Once the data is compiled, facilities generally do not revisit the figures. Criteria for making diagnosis at primary and tertiary levels are not the same. Lay case definitions and syndromic approach are used where there is no diagnostic facility. This is absolutely necessary arrangement where services are organised in tires of primary, secondary and tertiary levels. To come up with more clearer and precise picture on major diseases, cases diagnosed at primary, secondary and tertiary care facilities should be disaggregated. As an example, HMIS reported 16,000 new TB cases whereas there were only 8,000 confirmed sputum positive cases. By disaggregating the data by level of care, the true picture could be revealed. Timeliness of compilation, analysis and dissemination of information Most routine data are collected for immediate actions. In order to achieve 100% coverage over 12 months, one must achieve around 8.3% coverage every month. If achievement of 100% is important, the achievement of monthly target is necessary. Under achievements have to be recovered immediately in the following month with extra interventions so as not to fail to achieve 100% in the end. The changes in communicable and infectious disease trends should be comprehended immediately so as to prevent spread of disease and provide treatment to affected people. If such information is not available on time it bears no value. The routine information system requires daily compilation of data on key elements and immediate reporting of notifiable cases. Despite consistent follow-ups and reminders, such practice has been established as a discipline hardly in 50% facilities. Health facilities require updating monthly wall chart and constantly reviewing disease and service coverage trends. A facility is also required to submit monthly data to district on quarterly basis, by mid of the fourth month. Most facilities do not pay attention to deadlines. Consequently, deadlines for dissemination of information at any level Figure 5: Information flow within the health sector is not met. Information use Use is the only reason for generating a piece of information and was therefore the main focus from the outset of conceptualisation and designing of the system. The design of client health booklets, data collection registers, data compilation workbooks demand immediate interpretation of information and immediate actions on each viable issue. This has resulted in some improvements in the Donors Non-Routine Information CHIP HIMTC HIMS/ Data Bank DHO s Hospital s Health Centre s HSA s Policy Maker s Directors Programme Managers Central Hospital s Private Facilities VHC s TBA s CBDA s December 2003 Overview of Achievements and the Way Forward Page 13 of 16

14 understanding of value of information. However, very little influence of information has been noted on routine management decisions. Despite the availability of much needed information right on the table, either its existence is not recognised or it is ignored entirely while making important management decisions. An example is that the management know about a poorly performing facility and underlying causes. It also knows remedies, which are viable to undertake from internal resources, but does not act because the management does not think that acting on it is its responsibility. With establishment of HMIS in the country, there has been shift on DIP preparation process and the content of the plan. The planning exercise begins with review of previous year performance and establishing baseline value for current year. Resources are allocated using a number of criteria including some performance indicators. Recently a couple of donors have started directly topping up district quarterly ORT budget in order to optimise quality of services. The submission of routine HMIS report to headquarters has been set as a single condition in order to get the top up quarterly budget by the district. The person at the Ministry headquarters, who is responsible for recommending release of funds to the districts, is not bothering to abide by this self-set rule. Information flows throughout the health system network as shown in figure 5. It is exactly like the circulation of blood in a body. Feedback on each report has been considered as essential as submitting a report. The quality and coverage of services is expected to improve through timely feedback and follow-up. Except between HMIS/ Data Bank and DHO and central hospitals there is grossly inadequate communication between sender and recipient. The recipients will have to be given critically analysed information and consistently reminded for actions until the use of information in rationalising decisions become a national norm and professional ethic. Summary of main outputs A nationwide fully functioning health management information system is the main outcome of the efforts of the past 5 years. The overall outcome can be better explained by the following outputs: 1. National health information policy and strategy 2. Health sector indicators handbook. 3. Health information activities and budget for the next 6 years within the Programme of Work 4. Defined catchment areas and populations to be served by each public health facility. Digitised boundary maps linked to HMIS indicators database for production of thematic maps. Provision of a GPS in each district for updating of geo-referenced data. A plotter in HMIU for printing of big poster sized maps. 5. Electronic inpatient and maternity registers (in a test phase). 6. Touch screen patient management information system in Paediatric department of LCH in collaboration with Baobab partnership. 7. Fully adapted software for data entry, processing, report generation, transfer and archival purpose in use in all districts, central hospitals and the ministry headquarters. 8. HMIS training and reference manual. December 2003 Overview of Achievements and the Way Forward Page 14 of 16

15 9. HMIS tools reference manual. 10. Revised job description of all health and support personnel. (Though not yet officially endorsed) 11. Revised pre-service training curriculum for nursing, clinical and medical cadre (though not yet used). 12. Health information website Health passports 14. HMIS registers 15. Relocation of the national health information unit closer to the top management at the Ministry headquarters, as an indication of the importance attached to information in planning and management of health services. 16. Poster size wall charts for data aggregation and monitoring at health facilities. 17. Intranet connection to all directors and above in the Ministry headquarters. 18. HMIS training in College of Medicine credited towards Master of Public Health in the Universities of SADC region. 19. Skilled personnel: 1 MPH, 1 Master of Information Management, 32 Assistant Statisticians and 1 Chief Statistician trained in health information management. All health and support personnel oriented in HMIS. 20. Several routine monitoring/feedback and annual performance reports. 21. A good understanding and support of development partners in strengthening the information system. Besides the Netherlands Government, UNICEF, USAID, DFID, NORAD, UNFPA, ADB provided financial support while EC and WHO have been providing advocacy support. The way forward A good foundation that is required for the full growth of the health management information system in the country has been laid down. The government has endorsed a health information policy 2003 to sustain the past development and put all the future course of actions regarding management and use of information on proper track. The basic concerns of health information component have been fully addressed in the 6 years ( ) programme of work of the Ministry of Health and Population. The system has taken direction but it is still far from perfection. The way forward is suggested below: 1. Now that the health information policy has been endorsed, it has to be strictly implemented to bring the desired improvements in the system. 2. Monitoring and evaluation is the core function of the information system. The person responsible for M&E should be at higher level than directors and programme managers. 3. As the management of health information requires public health knowledge, all the positions that have been created for managing health information should be departmentalised and a clear career path should be developed. 4. The current planning and management practices should be gradually shifted towards evidence based planning and management of health services. Resources (human, financial, and material) need to be allocated in the light of population to be served, poverty level, level of care, specific problems of the area, and performance status. 5. Quarterly self-monitoring and annual performance review has been introduced but has not yet become routine activity of the system. Without them to planning at facility, district and national levels use of information cannot be improved. December 2003 Overview of Achievements and the Way Forward Page 15 of 16

16 6. The revised curricula and job descriptions need to be endorsed immediately. 7. Health passport should be made compulsory with a provision of free or subsidised booklets to the people unable to afford it. The profit from the small margin between purchase and sale of booklets is sufficient to subsidise or provide a limited number of free books. The printing of child health passport should be discontinued. The child health components should be integrated into the other two passports. Reference Bijlmakers L, Kegels G, and Vander Plaetse B Mid-Term Review Report: Malawi Health Population and Nutrition Programme. Chaulagai C, Moyo C, Pendame R Health Management Information System in Malawi: Issues and Innovations. Accessed on October 30, 2003 at Church M and Moyo C Health Management Information System in Malawi. GOM (1998) Local Government Act GOM (1998) Guidelines for Sector Devolution Plans GOM Malawi Poverty Strategy Paper MOHP. 1999a. Malawi National Health Plan, MOHP. 1999b. To The Year 2020: A Vision for the Health Sector in Malawi. MOHP Annual Performance Review Report MOHP HMIS Strategy MOHP Annual report 2002 MOHP Annual report MOHP Malawi Essential Health Care Package MOHP Mid-Term Review Report. Part II: Health Management Information Systems. Editors: C. Moyo, Deputy Director, HMIU; C. Chaulagai, Technical Assistant HMIS; T. Rashid, Programme Officer RHU; J. Koot, Consultant ETC/PHC consortium. April. MOHP a. National Health Information Policy and Strategies MOHP b. Health Indicators Handbook NAC Monitoring and Evaluation Plan United Nations Development Group Reporting on the Millennium Development Goals at the Country Level December 2003 Overview of Achievements and the Way Forward Page 16 of 16