Achieving Data Excellence for Stronger Health Systems

Quality health data is crucial for informed, responsive decision making and resource allocation for improved health outcomes. But how do we ensure data is of a high quality and is used effectively by those making the decisions?

There have been evident gaps in the capacity of healthcare professionals in understanding the District Health Information Software-2 (DHIS-2) interface, and how to use the platform to generate inferences and indicators. This capacity is important not only for the healthcare professionals to interpret the information in relation to their own patients, but also for them to share such information with wider stakeholders, including local representatives, to use for decision making and resource allocation.

A needs assessment was conducted by the Pokhara Metropolitan City and HERD International in Nepal as part of the CHORUS project on understanding the approaches needed to strengthen service delivery of non-communicable diseases programmes for the urban poor. The extensive needs assessment included data from all 45 public health facilities across 33 wards and interviews with selected stakeholders at the system and institute level. The assessment identified a significant need to strengthen the health management information system, and healthcare professionals’ understanding of DHIS-2.

What is DHIS-2?

The Nepali government uses the DHIS-2 as a comprehensive information management system for health data. This platform allows for the collection, analysis, and visualisation of various health indicators at different levels of the healthcare system, from national to local. This system provides real time access to health data that helps healthcare professionals and policymakers to make informed decisions. The data includes disease prevalence, immunization coverage, healthcare service utilization, and demographic information.

The DHIS-2 system is expected to contribute to improving public health outcomes by enabling evidence-based planning, resource allocation, and intervention strategies. However, this is not happening on the ground, particularly in the federalized context where local government has the mandate to fulfil these expectations.

Figure 1: Information cycle (source: https://hmis.gov.np/overview/)

The [above] figure presents the information cycle. It shows how data can be used by various individuals or teams to inform their decision-making. At each stage of the cycle, however, there is potential for data and information to be misused or misinterpreted, which impacts later stages of data and information use. This can ultimately impact plans and decisions. The needs assessment identified the importance of the capacity of the health workers in Pokhara to understand and increase usage of the DHIS-2 data, to inform decision-making.

CHORUS collaboration with Pokhara Metropolitan City Health Division

As part of the CHORUS study, we conducted an extensive needs assessment on health system readiness to respond to the rising NCDs within urban areas. The needs assessment involved actors from the local health system and health facility level, and assessed their capacity to deliver basic health care services. The assessment highlighted that the data quality and data use were key areas to address through the system. HERDi and the Pokhara Metropolitan City Health Division held several rounds of consultative meetings and workshops with public health care providers to co-design an intervention which could address this identified need.

We designed a series of capacity strengthening initiatives, to be embedded within the intervention. These included an intensive two-day training for all the public health facilities within the metropolitan city, in collaboration with the health division and Gandaki Provincial health directorate. The training was organized in two phases, with 58 health care providers, health facility in-charges and health division officials participating (24 female, 34 male). The sessions included:

• Introduction to DHIS2: This included development of the software, overview of the interface, server management, and how the system can ensure data quality.
• Data entry, pivot table & data visualizer: Elements of data entry, exporting data in excel, web-based pivot table that analyzes data along all data dimensions.
• GIS & dashboard: GIS features for mapping of areas, view facilities based on classifications, and visualize catchment areas.
• Standard Report: Customization of the report as per the need.

 Was the training useful?

We carried out assessments to measure the effectiveness of the training. Of the 58 participants, 18 participants (31%) could answer all the questions correctly in pretest, which increased to 22 participants (38%) in the post-test.  Based on the assessment, we held a further round of discussions with the participants to clarify the issues, and it was clear that the pre-post assessment did not tell the complete story. During follow up discussions, participants shared useful perspectives on the longevity of the knowledge and skills obtained, the mechanisms available for troubleshooting on a real time basis, and the framework to translate the use of the data into the decision-making process.

“There is frequent discussion around the informed decision making, but nobody talks about how that can be translated into the practice when we have the data in hand, it is an important gap.” (Participant-Health Post)

Recommendations

The training and follow up discussion provided a very valuable opportunity for participants to share their issues and learnings from using DHIS-2. It was clear that these experiences were relevant to most of the participants, and highlighted a real need for a platform for shared learning, with expert input, to be available to participants.

“When I was at the training, it felt like everything was working well, but when we try to execute it at our workplace, we encounter issues and don’t know where to seek support. If there had been a helpline, such as a contact number, it would help sustain our learning in case of any confusion,” (Participant -Urban Health Center)

Such a platform need not always be intensive face to face training, but could be shorter events, or virtual engagement. Not all the health care professionals were confident or proficient with technology; there is a need for ongoing support, through virtual engagement or onsite-coaching, to encourage frequent use of DHIS-2. With the technology and social media platforms now available, health system actors, mentors and health care providers can be connected with each other, and with data experts, to allow health care professionals to share their experiences and difficulties on real-time basis, and allow experts or mentors to share troubleshooting ideas, updates and advice.