Redressing Health Disparities with Information. Jon E. Rohde, MD Director (former) EQUITY Project South Africa

Transcription

1 Redressing Health Disparities with Information Jon E. Rohde, MD Director (former) EQUITY Project South Africa

2 Redressing Health Disparities with Information Introduce the South African health system the setting and the workload for nurses Describe the development of the HMIS Illustrate the usefulness of the information to redressing inequity Community involvement in seeking equity Principles of developing an appropriate HMIS Examples from other countries

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12 South African Health System 270 District Hospitals; 267 Health Centers; 3670 Nurse-run Clinics serving 40 million Eastern Cape 7 million poorest province 92 small hospitals; 55 Health centers; 750 Clinics 250 doctors (all in hospitals); 15,000 nurses 15 million clinic OPD visits/year Routine FP, EPI, STI, TB, Antenatal care Diarrhea (cholera), malnutrition, hypertension and obesity, violence and motor accidents and then HIV

13 ECape Contrasts Housing

14 ECape Contrasts Density of Population

15 ECape Contrasts Health Facilities

16 Information System 9 different competing and non-comparable systems just for routine stats!! Independent systems for each vertical program: EPI, FP, STIs, TB, Genetics, malaria, environment and more Some 2500 essential drugs and supplies No forms, no registers, no feedback and no know use of the information

17 A Divided Province - Inequities within the EC Population Density & Poverty in the Eastern Cape Population Poverty Distribution

18 MORTALITY RATES IN THE EASTERN CAPE Deaths per 1, A B C Infant Mortality Rate D Under 5 Mortality Rate E

19 Estimated Adult HIV Positive Rate 1999 (15 to 44 age group) Adult Positive Rate <5% % % % >19.5%

20 Health Expenditure Per Capita 1996/1997 to 1998/ Region A Region B Region C 96/97 98/99 Region D Region E

21 EQUITY Project Improve management of resources Improve Equity Measure disparities in order to redress Baseline sample surveys Annual resurvey to see progress Routine information system to enable managers to visualise the problems and to see the effects of their actions

22 Minimum Essential Data Workload and staff under and over 5 years Essential services new and old FP, new and repeat ANC, Complete immunisation, All STIs, TB case load, HIV tests positive Patients referred to hospital Drugs out of stock 10 key items only Supervision visit received All recorded on a single page monthly form

23 Tally Sheet NAME OF ec Empilweni CHC MONTH: YEAR: TOTAL First antenatal visit Oral pill cycle Nuristerate injection Depo-provera/Petogen injection IUCD inserted Condoms distributed Case treated as STI - new Male urethral discharge - new STI contact slip issued STI contact treated - new Violence against woman HIV counseled - male HIV counseled test done - male HIV positive test - female HIV positive test - male

24 FAMILY PLANNING REGISTER NAME Theresa Brown Jill Hill Thembi Mafoka Xoliswa Jones ADDRESS CLINIC YEAR #LIVING METHOD Starting JAN FEB MAR ARP MAY JUN JUL AUG SEP OCT NOV DEC CONTINUE date CHILDREN NEXT YEAR 3 IUD 1 Depo 01-Sep 0 1 6/00 X Condom 02-Jan X pill 02-Feb X

25 Key indicators for Action Work load patients/nurse/day Coverage: immunisation, FP, Drug stock outs - % that ran out in month Disease outbreaks: diarrhea, flu Quality of care: standard treatment for STI Continuity of care: TB, hypertension Severity of cases: referral rates

26 Immunisation report Previously had 40 plus data items Now, % of infants fully immunised this month Possible problems: Vaccine stock out Refrigerator not working Nursing absence Lack of community motivation No outreach services Call, or go find out how to help!

27 M Da bas lin he Um dye LS zim bo A Um vub LSA zim u L Am kulu SA a L Ny hlat SA an i L S M deni A hlo L S M ntlo A nq L En uma SA Int gc L sik ob SA a Ye o LS Ing thu A Em qu LSA ala za L Ca hle S md ni A eb LS o A Se o LS n A N Elu qu L M nd S an in A de i L S l Lu a LS A Bu kh A ffa anj C lo i M Ci LSA N alet ty L M sw SA an a Sa dela i LS kh LS A isi A z M we B ak LS Inx an A ub a K a L o Ye ug SA the a L Nk mb SA N onk a L M o SA an be de L la SA Gr LS an A A d To ta l Ki ng % of infants Immunisation Coverage Imm coverage yy

28 adu Lot a N qab Kw a-m e kho n i lo z a Ms Su endo nd wa na Ba d Nq i a Bo du Idu mv ty w ana an qab ara Mq he Nq le aba ra Ta le Xo ra n i Cli n Mp ic ozo l Nk o an ya Bo So lotw ga a Idu (B tyw utt) av il Fo age rt M ala n Jin gq Me i lita fa Gw Immunisation % by clinic - MBASHE fully immunised under age one

29 Gw ad u Lo t Nq a Kw ab amk en i ho lo z M a se n Su do nd wa na Ba di Id Nq ut yw ad a u Nq ab a Bo ra m va na M W qh ill o el wv ale e CH Ny C hw ar a Ta le Nq n i ab ar a So ga Nk a Xo nya ra Cl in M ic po Bo zo lot wa lo Id (B ut yw utt ) a Vi lla Xo ge ra Fo Mob rt M ala n J in gq i M eli ta fa % immunised Mbashe - Measles vs fully immunised Imm coverage yy Measles 1st covr yy

30 Mq he l Ms e W en illo d wv ale o Bo lot CHC wa (B Fo utt) rt Ma lan Gw Idu tyw ad u av illa ge Jin gq Nk i an Xo y a ra Mo Mp b oz ol Nq o ab ar a S Xo oga ra Cl in i Me c lita Bo fa mv an a Nq ad Nq u Idu ab tyw en an i qa ba Su ra nd wa na Kw Ta len amk i ho lo z Ny a hw ara Ba di Lo ta % months out of Stock % months DTP_Hib vacc Out of stock % DTP_Hib vacc Out

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34 WHO mandated TB Info strdatafieldpatients not transferred inpatients from TB clinic in other health districtpatients from TB clinic in same health districtpatients from HospitalPatients from ElsewherePulmonary tuberculosis (011)Primary tuberculosis (010)Other tuberculosis ( )All PTB - Smear+ (irrespective of culture)all PTB - Smear-/culture+All PTB - Smear-/culture-All PTB - Culture not done/results not inall PTB - Bacteriology not donenew PTB - Smear+ (irrespective of culture)new PTB - Smear-/culture+New PTB - Smear-/culture-New PTB - Culture not done/results not innew PTB - Bacteriology not donenew Smear+ PTB - White males yearsnew Smear+ PTB - White males yearsnew Smear+ PTB - White males yearsnew Smear+ PTB - White males yearsnew Smear+ PTB - White males 60+ yearsnew Smear+ PTB - White females yearsnew Smear+ PTB - White females yearsnew Smear+ PTB - White females yearsnew Smear+ PTB - White females yearsnew Smear+ PTB - White females 60+ yearsnew Smear+ PTB - Coloured males yearsnew Smear+ PTB - Coloured males yearsnew Smear+ PTB - Coloured males yearsnew Smear+ PTB - Coloured males yearsnew Smear+ PTB - Coloured males 60+ yearsnew Smear+ PTB - Coloured females yearsnew Smear+ PTB - Coloured females yearsnew Smear+ PTB - Coloured females yearsnew Smear+ PTB - Coloured females yearsnew Smear+ PTB - Coloured females 60+ yearsnew Smear+ PTB - Asian males yearsnew Smear+ PTB - Asian males yearsnew Smear+ PTB - Asian males yearsnew Smear+ PTB - Asian males yearsnew Smear+ PTB - Asian males 60+ yearsnew Smear+ PTB - Asian females yearsnew Smear+ PTB - Asian females yearsnew Smear+ PTB - Asian females yearsnew Smear+ PTB - Asian females 4059 yearsnew Smear+ PTB - Asian females 60+ yearsnew Smear+ PTB - Black males yearsnew Smear+ PTB - Black males yearsnew Smear+ PTB - Black males yearsnew Smear+ PTB - Black males yearsnew Smear+ PTB - Black males 60+ yearsnew Smear+ PTB - Black females yearsnew Smear+ PTB - Black females yearsnew Smear+ PTB - Black females yearsnew Smear+ PTB - Black females 4059 yearsnew Smear+ PTB - Black females 60+ yearsdot New adults intensive phase - communitydot New adults intensive phase - clinicdot New adults intensive phase - workplacedot New adults intensive phase - otherdot New adults intensive phase - no supportdot New adults intensive phase - total registereddot New adults continuation phase - communitydot New adults continuation phase - clinicdot New adults continuation phase workplacedot New adults continuation phase - otherdot New adults continuation phase - no supportdot New adults continuation phase - total registereddot Retr adults intensive phase - communitydot Retr adults intensive phase - clinicdot Retr adults intensive phase - workplacedot Retr adults intensive phase - otherdot Retr adults intensive phase - no supportdot Retr adults intensive phase - total registereddot Retr adults continuation phase - communitydot Retr adults continuation phase - clinicdot Retr adults continuation phase - workplacedot Retr adults continuation phase otherdot Retr adults continuation phase - no supportdot Retr adults continuation phase - total registerednew - Pre-treatmentNew - Smear not done at 2-3 monthsnew - Still positive at 3 monthsnew - Converted at 2 monthsnew - Converted at 3 monthsrelapse - Pre-treatmentRelapse - Smear not done at 2-3 monthsrelapse - Still positive at 3 monthsrelapse - Converted at 3 monthsother retr - Pre-treatmentOther retr - Smear not done at 2-3 monthsother retr - Still positive at 3 monthsother retr - Converted at 3 monthsnew No smear at 2-3 months - DiedRetr No smear at 2-3 months - DiedNew No smear at 2-3 months - Transferred outretr No smear at 2-3 months - Transferred outnew No smear at 2-3 months - InterruptedRetr No smear at 2-3 months InterruptedOutcome - Pulmonary tuberculosis (011)Outcome - Primary tuberculosis (010)Outcome - Other tuberculosis ( )Outcome - New Smear+ CuredOutcome - New Smear+ CompletedOutcome - New Smear+ FailureOutcome - New Smear+ InterruptedOutcome - New Smear+ Died of TBOutcome - New Smear+ Died of non-tboutcome - New Smear+ Transferred outoutcome - New Smear+ Not TBOutcome - Retr Smear+ CuredOutcome - Retr Smear+ CompletedOutcome - Retr Smear+ FailureOutcome - Retr Smear+ InterruptedOutcome - Retr Smear+ Died of TBOutcome - Retr Smear+ Died of non-tboutcome - Retr Smear+ Transferred outoutcome - Retr Smear+ Not TBOutcome - New Smear-/Culture+ CuredOutcome New Smear-/Culture+ CompletedOutcome - New Smear-/Culture+ FailureOutcome - New Smear-/Culture+ InterruptedOutcome - New Smear-/Culture+ Died of TBOutcome - New Smear-/Culture+ Died of non-tboutcome - New Smear-/Culture+ Transferred outoutcome - New Smear-/Culture+ Not TBOutcome - Retr Smear-/Culture+ CuredOutcome - Retr Smear-/Culture+ CompletedOutcome - Retr Smear-/Culture+ FailureOutcome - Retr Smear/Culture+ InterruptedOutcome - Retr Smear-/Culture+ Died of TBOutcome - Retr Smear-/Culture+ Died of non-tboutcome - Retr Smear-/Culture+ Transferred outoutcome - Retr Smear-/Culture+ Not TBOutcome - New w/o Bacteriological OK CompletedOutcome - New w/o Bacteriological OK FailureOutcome - New w/o Bacteriological OK InterruptedOutcome - New w/o Bacteriological OK Died of TBOutcome - New w/o Bacteriological OK Died of non-tboutcome - New w/o Bacteriological OK Transferred outoutcome - New w/o Bacteriological OK Not TBOutcome - Retr w/o Bacteriological OK CompletedOutcome - Retr w/o Bacteriological OK FailureOutcome - Retr w/o Bacteriological OK InterruptedOutcome - Retr w/o Bacteriological OK Died of TBOutcome - Retr w/o Bacteriological OK Died of non-tboutcome - Retr w/o Bacteriological OK Transferred outoutcome - Retr w/o Bacteriological OK Not TBTB case load (all cases)retr PTB - Smear+ (irrespective of culture)retr PTB - Smear-/culture+Retr PTB - Smear-/culture-Retr PTB - Culture not done/results not inretr PTB - Bacteriology not donetb lab costtb drug costtb treatment costdemography 0-14 yearsdemography yearsdemography yearsdemography yearsdemography 60 years and olderdemography AsianDemography BlackDemography ColouredDemography WhiteDemography FemaleDemography MaleDOT cases - communitydot cases - facilitydot cases - workplacedot cases otherdot cases - no supportdot cases - total registeredall retr cases - pre-treatment

35 Streamlined Monthly TB Information Data type Monthly TB Data Fields Data Source Case finding Suspected TB case TB case diagnosed - new TB patient under treatment MDR patient on outpatient treatment TB patient on DOTS - Facility TB patient on DOTS - Community 2/3 month sputum due 2/3 month sputum sent 2/3 month sputum positive TB suspend - new TB suspend - restarted Child under 5 years - TB contact Child under 5 years - TB treatment Outcome - PTB Cured Outcome - PTB Completed Outcome - PTB Failure Outcome - PTB Interrupted Outcome - PTB Died Outcome - PTB Transferred out Patient register Lab register TB register TB register TB register TB register Desk Calender Lab register Lab register Suspender Register Suspender Register Blue cards Blue cards Blue cards Blue cards Blue cards Blue cards Blue cards Blue cards Case prevalence Sputum Conversion Potential Interrupters Child contacts Monthly outcomes

36 TB suspenders restarted on Rx % of susp restarted on Rx Jun-01 Jul-01 Aug-01 TB suspend restart Sep-01 Oct-01 Linear (TB suspend restart) Nov-01 Dec-01

37 Interrupted as % Outcomes % of outcomes Oct-00 Nov-00 Dec-00 Jan-01 Feb-01 Mar-01 Apr-01 Interrupted PTB May-01 Jun-01 Jul-01 Linear (Interrupted PTB) Aug-01 Sep-01 Oct-01 Nov-01 Dec-01

38 Locally relevant data items Bilharzia cases (school age) Malaria (only a few districts in So Africa) Rape and HIV response Industrial accidents New toilets installed in schools

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40 Areas without toilets

41 Sa kh isi zw Am e L ah SA la Ma t i L S A k Ma ana L l N etsw SA Ma a nd i L S ela Em L A ala SA hle B ni Ko LSA ug Inx a ub Se L S ay n A e th qu L SA e Ca mba md LS e A Nk boo on L S Int k sik obe A a Y LS eth A Mh u L l S N Ma ontlo A n L N dela SA Ma nd LSA ela C Mb LSA as A En he L gc S ob A o Lu kh LSA Um a n zim ji LS A ku El lu LS un d A Mn ini L S q Um u m A Ki z im a L ng S Da vubu A li n dy L SA e Ny bo an LS Bu d en A ffa i lo LSA Ci t Ing y LS qu A za LS A cases of diarrhea <5 Diarrhoea under 5 years - new ,000 35,000 30,000 25,000 20,000 Areas without toilets 15,000 10,000 5,000 0 Diarrhoea under 5 years - new

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44 Improved Management Decisions Personnel Deployment Drug ordering to avoid stock-outs Better Supervision more supportive Reallocated finances

45 Int ala h sik len a Y i LS eth A Mh u L lon SA t Lu lo L kh SA Um a n zim ji LS A ku lu Se LSA n En qu L gc SA o Ny bo an LS A d Nk eni on LS ko A Mn be L q S Um u m A a Ki ng zimv LSA Da ub u lin d y L SA e Inx Am b o L ub S a Y ahla A t il e th SA em Sa b kh a L isi SA zw Ing e LS Bu quz A al ffa lo SA Ci t y Mb LS N a Ma she A nd L ela SA Ma LSA k Ca ana C md L eb SA o El o L un SA Ma dini L l N etsw SA Ma a nd i LS ela A LS Ko A N Ma uga A nd L ela SA LS A B Em Patients Nurse clin workload - patients/nurse/day Nurse clin workload

46 ta Va alb a nk rth ur Cl in ic Nd on L Fr ga er e Mo Bo b 2 om pla L as Fr er e Ng Mo on b ya 3 m a CH L Fr C er e Mo b 1 Xo nx a M aq as Hl hu a la Up Ph hil ila il e ni Ga te wa y M k ap Do us rd i re ch tm o Qo b qo da l In dw a Do em rd ob re ch t No Clin ic mp um ele lo M be yi Gu ba at er hla ng a 20.0 Ts em M Sw ar tw patients/day/nurse 60.0 Nurse clinical workload/day Emalahleni District 50.0 Heavy patient load Very light patient loads Nurse clin workload

47 Facility level Indicators Availability of 10 Key Indicator Drugs % clinics

48 Improving Supervision activities Review PHC Reports CHC Drug stock cards Train staff 2003 Observe consultations

49 Health Expenditure Per Capita 1996/1997 to 1998/ Region A Region B Region C 96/97 98/99 Region D Region E

50 Per capita Allocation for PHC Rands/capita Region A Region B Region C Region D Per Capita for PHC Region E Province

51 Percent The EQUITY Index 1997 to Year

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53 Principles for EQUITY Start small, limit the requests for data One page rule: reports fit on ONE PAGE Paper based do it by hand till all understand where the numbers come from Users identify priorities for info they need

54 Principles for EQUITY Data collected only if it makes an indicator Action linked to each indicator (up or down inspires some action) Indicators are exactly that they INDICATE what needs attention, not what to do Indicators MUST be interpreted to make information which is used for ACTION to give results that can be measured Managers act on low performers figure out why and redress the needs ACT!

55 Principles for EQUITY Chose only data period likely to show a change: monthly, quarterly, annually collect and report only as often as needed to see a change Feedback and action is the strategy for sustainability

56 Principles for EQUITY One-page rule of data forms Tick registers and tally sheets simple and easy to use and sum at end of month Registers for continuity the real measure of quality is continuity of care Let computers come later and with a flexible program that can accommodate local variations as well as do the donkey work of statistics

57 Principles for EQUITY Don t let the higher authorities dictate the routine system force their info requests to clearly define their needs - where these legitimately exceed the routine report, make a part of annual or biannual surveys or audits. Don t overwhelm the workers. Establish a national clearing house to approve any and all info requests from higher up. Let the Committee withstand the pressure from higher up and donors

58 Information for Equity examples: Community nutrition programs in Indonesia, India, Honduras and Bangladesh % kids gaining weight single indicator of progress Tanzania nutrition assessment helped focus government efforts to poorest communities Bangladesh districts are now ranked annually based on measured progress for children Progress of Indian States ranked states best practises highlighted and recognised Progress of Nations UNICEF ranked countries on World Summit for Children goals

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60 Conclusions Keep it simple! A little accurate and timely information is worth far more than a lot of late and inaccurate figures. Donors and experts PLEASE do NOT overwhelm the system help strengthen it accept more limited data and see performance improve and disparity reduced Consult with the front line workers and meet their needs Redress Disparity to bring results and Equity

61 Obrigado e Boa Sorte!!! Jon Rohde, MD Management Sciences for Health Cape Town South Africa