Health Information Systems—Routine, and Not Sexy - 2001
Moderated By: Dr. Julia Hussein (Dugald Baird Centre for Research on Women's Health at the University of Aberdeen)
In 1998, an effort commenced in Malawi as part of the Malawi Safe Motherhood Project Southern Region, to adopt the use of the UNICEF/WHO/UNFPA "Guidelines for Monitoring the Availability and Use of Obstetric Services. The UN guidelines describe methods to collect maternity data using survey methodology, but adaptations were made to the data collection instruments so that the same indicators could be collected as part of the routine health information system. Maternity registers, data collection sheets and data reporting systems were upgraded as part of this exercise. The endeavour covered a population of 5 million people, with 193 government and mission health facilities. It took a year to set up at a cost of $100 000. The aim of setting up this system was primarily to collect data to monitor the progress of the project over six years.
The experience of establishing the system over three years provided several insights into the process of institutionalising change in routine systems. Many difficulties were encountered during the course of implementation. Technical issues like determining catchment sizes, double counting and case definitions were identified and largely overcome through wide consultation and discussion, and subsequently by establishing agreed conventions.
Without purposely seeking information relating to motivation and attitudes towards routine health information systems, project staff involved in the training and provision of support for establishment of the system noted that health workers commonly raised such concerns of their own accord. Over the three years, 803 health service providers were trained. They included doctors (and other para-medical grades), nurse-midwives and data or ward clerks from regional centres, district hospitals and health centres or clinics. As expected, the lack of practical based training, feedback and supportive supervision were highlighted as problems in routine health information systems. Other, more unexpected complaints were also noted. Health workers commonly expressed feelings that collecting and analysing data for routine health systems were a chore; unattractive and uninteresting compared to their clinical tasks. Others remarked that calculating indicators was very much within the domain of men, "who are naturally better at these calculations." Health workers also indicated that specific responsibility was not given to individuals for collection of routine data and therefore there was no chance of specific commendation being given for a job well done.
We concluded that a "personal touch" was missing from data compilation activities. Advocacy tools were used to try to increase the profile of health information systems amongst policy makers as well as in front-line service providers. The project conducted six monthly supervision visits to a selection of facilities and advocated amongst high level supervisors to ensure that their visits to facilities included asking questions and finding out more about the registers and data collection forms. Yearly formal re-training sessions were put into place and feedback on results provided directly to health workers using the health information system as well as the yearly meetings. To make those working in this area feel valued, competitions and prize giving sessions were integrated into re-training activities. Comparisons were made between districts and rewards were given for good data quality, promptness in returning data and improving health indicators. T-shirts, carrier bags and other promotional materials were given to individual health workers for simple achievements like keeping neat registers and returning monthly data on time. Individuals were identified to act as trouble-shooters, whom health workers could contact in the case of difficulties in compiling data or calculating figures. Within a district, several people were trained in the system, to allow a support system to be built up between colleagues.
The above introduction is put forward as a case study to stimulate discussion on how the profile of health information systems can be raised, along with motivational levels of health workers involved in routine data collection. Contributions to the discussion should focus on one main question:
"Taking into consideration the constraints of competing priorities, to what degree should programme managers devote time and resources towards addressing motivational issues when establishing routine monitoring systems—and why?"