Strengthening Routine HealthInformation System

2012-2014

January 13, 2015January 13, 2015

MIS Auditorium, DGHS

Summary of RHIS InitiativesUndertaken

Strengthening RHIS of DGHS and DGFP by USAID-supportedpartners (MEASURE Evaluation, icddr,b, MaMoni/HSS,MSH/SIAPS) has been directed to• support to M&E functions of HPNSDP with particular focus on 6 OPs

(MNC&AH, NNS, CBHC, MCR&AH, CCSDP, and FSDP)

• streamline MIS tools to minimize information gaps and duplication, andreduce the burden of data collection and compilation

• design and use a supply chain management portal for efficient and effectivelogistics management of RMNCH commodities

• improve capacity of MIS Units of DGHS and DGFP to generate reliableinformation on time.

• improve use of information at the local level and promote evidence-baseddecision

SUPPORT TO M&E FUNCTIONS OF

HPNSDPHPNSDP

Support to M&E functions of HPNSDP

Streamlining of OP indicators by MEASURE/icddr,bincludes• Review of 342 indicators across 32 OPs and development

of PMP• Developing indicator reference sheets for 342 indicators• Developing indicator reference sheets for 342 indicators

with detailed information:– Definition, Calculation, Unit of measurement, Frequency, Source

of information, Level of data generation

• Categorized 342 indicators by types (i.e training, service,facility readiness, drug/logistic, infrastructure,workshop/meeting etc.)

STREAMLINING MIS TOOLS

A Key Focus ofA Key Focus ofMaMoni/HSS

&MEASURE Evaluation/icddr,b

Review of OP indicators andassessment of MIS tools

6 priority OPs were reviewed where routine MISs coveredonly 50% of original OP-level service indicators

Service providers and field-workers overburdened withrecording and reporting requirements, e.g.,

14 registers for FWVs• 14 registers for FWVs

• 11 key sections in FWA register

• 5 in-patient monthly reports manually aggregated

• 5 (at least) monthly reports by HA

Inadequate data accessibility as computer-based databasenot fully functional

Inadequate use of RHIS data for local-level decision making

DGHS/MISDGHS/MIS

MIS tools streamlined

Old systemOld system

- No structured HAregister

- No structured CSBAregister

Revised systemRevised system

- Structured HA & CSBAregisters

- Revised monthly reportsonline

Revision and development of tools/systems from community to hospital level

CommunityCommunity

register online

DGFP/MISDGFP/MIS

- Paper-based FWA registerhas separate pregnantwomen and birth list andmissing a number of OPindicators (i.e ANC, PNC,delivery)

- No structured CSBAregister

- Review of FWA register (inprocess) adding missinginformation + pregnant andbirth list replaced by piloted‘pregnancy registrationhandbook’

- Online pregnancy registration- Review of MIS 1 & 2 forms

are in process- Structured CSBA registers

DGHS/MISDGHS/MIS

MIS tools streamlined

Old systemOld system

Paper-based CC serviceregister

Revised systemRevised system

- Revised paper-basedregisters included NNSindicators

- Online reporting formats

Revision and development of tools/systems from community to hospital level

Community ClinicsCommunity Clinics

register - Online reporting formats

- PW & U5 childrenregistration system

DGHS/MISDGHS/MIS

MIS tools streamlined

Old systemOld system

- Unstructured generaloutpatient register

- Paper-based diseaseprofile report

Revised systemRevised system

- Structured register

- Simplified monthly report+ online reporting atupazila level

Revision and development of tools/systems from community to hospital level

UnionUnion

profile report upazila level

MIS tools streamlined

Old systemOld system Revised systemRevised system

Revision and development of tools/systems from community to hospital level

UnionUnion

DGFP/MISDGFP/MIS

Separate FWV registers forevery service, viz. delivery,ANC, PNC, birth, pill,condom, IUD and IUD followup

-Reduced FWV registers(MNH, OCP/Pill, IUD) bymerging relevant registers

-MIS 3 reporting form is underrevisionup revision

Single register for FWV for MNH services (MNH register)

DGHS/MISDGHS/MIS

MIS tools streamlined

Old systemOld system

- Paper-based in-patientreports

Revised systemRevised system

Online in-patient MIS withICD-10 classification

Revision and development of tools/systems from community to hospital level

Upazila & DistrictUpazila & District

DGFP/MISDGFP/MIS Existing MIS 4MIS 4 reporting form is

under revision

Implementation of tools/systemsTools/Systems Nationwide by

DGHS-MISWith support fromicddr,b and MaMoni

Otherpartners

Directorate General of Health Services (DGHS)

District and sub-districtlevel:Online hospital in-patient system

Provided ToT tostatisticians andinstructed to give in-patient data entry,Developed manual inc.

All UHCs and DH of Tangailand Chunarughat UHC andDH of Habiganj (logistics,training and onsite support)+ central level monitoring

UNICEF:SCANU part ofthe system in16 DH

Developed manual inc.ICD 10

+ central level monitoringby M&E staff

Union level: Generalpatient register forSACMO and Monthlyprogress report(aggregated) in DHIS2

DGHS-MIS developeddata entry guideline.Currently, 60 districtsreporting in DHIS2

Paper-based register andreporting format, trainingswere provided in entireTangail district andChunarughat (Habiganj)upazila

CC: Online monthlyreporting (aggregated)format in DHIS 2

Provided laptops withconnectivity, training toCHCP, developedmanual~8,000 CCs reporting

Entire Tangail andChunarughat (Habiganj)upazila (onsite support),central level monitoring byM&E staff

Implementation of tools/systemsTools/Systems Nationwide by

DGHS-MISWith support fromicddr,b and MaMoni

Otherpartners

Directorate General of Health Services (DGHS)

CC: Pregnant womenand U5 registrationsystem (as part of COIAinitiative)

Provided ToT,developed manual,Intensive monitoringfrom central level andworkshop at divisional

Training and onsite supportin 3 upazilas of tangail + ToTto UNICEF + central levelmonitoring by M&E staff

UNICEF: in 3districtsJICA: inSatkhiraPlan: inworkshop at divisional

levelPlan: inDinajpur ++

Household level:a. HA register andreporting tool + onlinereporting format inDHIS2

DGHS-MIS developeddata entry guideline.PHC circulated GOCurrently, 62 districtsare reporting in DHIS2

Paper-based register andreporting format, trainingswere provided in entireTangail district andChunarughat (Habiganj)upazila

b. CSBA register andreporting tool (both FPand Health) + onlinereporting format inDHIS2 (health)

DGHS-MIS developeddata entry guideline.PHC circulated GOCurrently, 62 districtsare reporting in DHIS2

CARE: inSunamganj++SNL: Kushtia

Implementation of tools/systemsTools/Systems Nationwide by

DGFP-MISWith support fromicddr,b and MaMoni

Otherpartners

Directorate General of Family Planning (DGFP)

Sub-district level:Aggregated nationalreporting form-MIS 4

Revision of MIS4 isdone and awaiting forapproval

Technical assistance in thereview process

Union level (for FWV):- Single register for MNHservices- OCP, Condom and ECPregister- IUD register- Facility reportingformat-MIS 3

-Review Committee hasrevised and finalizedreduced MNH and FPregisters for FWV.These registers werepiloted in icddr,b andMaMoni areas- Revision of MIS 3 isdone and awaiting forapproval

Paper-based register andtrainings were provided inentire Tangail andChunarughat (Habiganj)upazila

Technical assistance in thereview process of MIS 3

SNL: MNHregister inKushtia

Implementation of tools/systemsTools/Systems Nationwide by DGFP-MIS With support

from icddr,b andMaMoni

Otherpartners

Directorate General of Family Planning (DGFP)

Community level:a. PregnancyRegistrationHandbook + online

MCH-Services initiated onlineregistration format has beenaccepted and DGFP-MIS hascirculated GO to do online

Paper-basedhandbook, training ,onsite support inentire Tangail and

SNL: Kushtia

Handbook + onlineregistration format

circulated GO to do onlinepregnant women registration

entire Tangail andChunarughat(Habiganj) upazila

b. FWA register 8th

edition and monthlyreporting form - MIS 1

Review committee has revisedand finalized 8th edition ofFWA register and MIS forms 1and 2.(Piloted pregnancy registrationhandbook has been added in8th edition of FWA register)

icddr,b providedtechnical assistance inthe review process

Icddr,b in collaboration with GIZ providing technical support to DGFP-MIS to transfer their servicestatistics (monthly report) into DHIS 2 platform. Initially, new system will be piloted in two districtsbefore national scale up.

Quality of reporting improving

100

120

100

120

Community micro-planning in MaMoni areas: HA-FWA-CVnetwork to share MNH/FP information, update registersand reduce inconsistencies in reporting

0

20

40

60

80

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Nu

mb

er

FWA report HA report

0

20

40

60

80

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Nu

mb

er

FWA report HA report

16Neonatal deaths, Habiganj, 2012 Neonatal deaths, Habiganj, 2013

Real time population level estimategenerated through MHN register

70

45 45

64

51 51

17

17

45 45

17

At least 1 ANC visit 4 ANC visits SBA delivery PNC within 48 hours

Poil MIS 2012 Poil MIS 2013

Data source: Poil Union MNH Register, Habiganj

Issues and Challenges

System, connectivity related issueso Absence of individual client-based tracking system

and not synchronized with community database

o Dual systems (both old and revised) are in place

o No provision for offline entry (both DHIS 2 andpregnancy registration system of DGFP)

o Report generation or data sorting is limited; scopeof improving dashboard for different users level

o Frequent power cut and slow internet connectioncause delay in online data recording and reporting

Issues and Challenges

Administrative issueso Perceived high workload of nurses and senior nurses

are reluctant to use computer

o Several admission registers make it difficult to checkwhether all patient in a day have been registeredwhether all patient in a day have been registered

o Perceived inadequate encouragement from local levelmanager to use the new system

o Although registration coverage is good, updatinginformation is poor

o Security of computers and accessories is a majorconcern

DESIGN AND USE A SUPPLY CHAIN

MANAGEMENT PORTALMANAGEMENT PORTAL

Why LMIS is important?

An effective logistics management informationsystem is necessary to ensure consistent availabilityof medicines :

• Provide real-time information

• Allow managers to react quickly and efficiently• Allow managers to react quickly and efficientlyto avoid stock-outs and over-stocks

• Help plan for proper distribution

• Assist in forecasting & supply planning

DGFP Logistics Information Management Systems Flow

National Stock Status of Contraceptives

indicates < 4 monthsindicates 4-7.9 monthsindicates >=8 months

Fewer stock-outs (<5%) of IUDs while nearly no stock-outs (<1%) of injectables for last two years.

Reference: M G Kibria et.al, 2013, Impact of a Computerized InventoryManagement System in Ensuring Commodity Security of Contraceptivesin Bangladesh (Presented in the International FP conference, AddisAbaba, Nov 2013))

DGFP SDP Dashboard Module• Service Delivery Points

(SDP) include FamilyWelfare Assistants (FWA),Family Welfare Visitors(FWV), NGO etc

• SDP Stock Status isavailable in UIMS (whichavailable in UIMS (whichis running in 488 sub-districts)

• UIMS data upload to web(SCMP/ SCIP)

• Dashboard indicate stockstatus of individual SDP

DGFP SDP Dashboard Module

Salient experience:

• Contributed to identifying the root causes of stock-outs

• Helped to assess the quality of SDP reports and assist

Pilot phase: March-September 2014Pilot area: 20 Upazilas in Sylhet, Lakshmipur, Gazipur and Bogra

• Helped to assess the quality of SDP reports and assistin designing supervision plans for low-performingsites

• Reduced the stock-out rate significantly

• Improved decentralized decision making

• Promoted governance and accountability

Next Steps

• Update the DGFP LMIS tools (UIMS, WIMS andeLMIS) and expand the product list (n=304items)

• Roll-out national implementation of the SDP• Roll-out national implementation of the SDPdashboard module to all Service DeliveryPoints (~30,000) by July 2015

• Handing-over the tools to the DGFP formanagement and maintenance

Challenges

• Prompt actions taken based on information

• Retention of trained staff

• Improving the ICT infrastructure

• Ensuring feedback mechanism from upperEnsuring feedback mechanism from uppertier/supportive supervision visit

• Thoroughly discussing FP program’s performancein the district/Upazila monthly meeting

• Staff motivation

Replicating Best Practices (LMIS) inDGHS and NTP

• Formation of Technical Working Group- Done

• Selected a list of Items to tracked on [26 itemsincluding UN commissioned life-saving commodities] inconsultation with the TWG

• Map-out and design the Logistics recording and• Map-out and design the Logistics recording andreporting systems in collaboration with MaMoni/HSS-in progress [Piloted in Lakshmipur]

• Technological assessment of MOHFW Supply ChainManagement Portal (SCMP) and DHiS2 to integrate theeLMIS- To be started soon

• Work with DGHS/TWG to introduce the DGHS LMIS

IMPROVING CAPACITY

Technical personnel support

M&E manager: Supervision of development team,coordination among stakeholders, developingguidelines, ToT etc.

M&E Officers: Monitoring and reporting of MIS activitiesfrom the central level. Assisting development offrom the central level. Assisting development oftools/guidelines and providing ToT

Programmers: Designing online tools, maintenance ,troubleshooting of the systems and providing ToT

Technical support in development ofRHIS materials

1. Training manual for CHCP on computer andonline reporting

2. Training manual for HA on Tablet PC use2. Training manual for HA on Tablet PC use3. Training Manual on ICD-104. Indicator book5. Local health bulletin6. Instruction manual on monthly reporting

Technical support to MIS relatedMeetings/Workshops/Trainings

1. Meeting and workshop on COIA2. ToT on ICD-102. ToT on ICD-103. ToT on Community clinic reporting4. Workshop on CRVS5. Meeting on nutrition related indicators6. Meeting on SCANU reporting system7. Meeting on HIV/AIDS reporting system

IMPROVING USE OF INFORMATION

AT THE LOCAL LEVEL FOR

EVIDENCE-BASED DECISION

MAKINGMAKING

Improve data availability andaccessibility

• Online reporting makes datamore easily available atdifferent levels.

• Online entry at/close to• Online entry at/close tosource reduced chance ofcompilation errors

• Report generation usingroutine data at the local leveland presentation at annualMIS conference

Thanks