Gender and Intersectional Stratifiers in Health Information System of Nepal: a study of HIS policies and practices

Our context – HIS and federalization

Health Information System (HIS), one of the building blocks as identified by WHO is a priority for strengthening health systems in Nepal. Health Management Information System (HMIS) is the only HIS platform used across the country for recording and reporting routine data generated in public health facilities, whereas private institutions have their own HIS that varies within the private health sector and are not mainstreamed into national HMIS, hence less is known about data generation, quality, and its use. Besides, poor quality of HMIS characterized by lack of completeness, accuracy and timeliness, lack of generation and analysis of disaggregated data by various intersectional stratifiers (such as age, gender, ethnicity, education, geographical location, marital status and parity, occupation or economic status, disability etc) and use of such disaggregated data in health sector decision-making are the prevailing gaps in HMIS in Nepal.  Gender equality and social inclusion (GESI) has emerged as a critical area to be addressed in every sectors, including HIS, however implementation status of such policies has been less known.

Nepal is a newly federalized state with three tiers of government – one federal, seven provincial and 753 local governments, and the health system functions at all three tiers. The Federal MoHP provides stewardship to implement the national health policy, and to develop national standards and regulatory frameworks. The Provincial Ministry of Social Development (in 7 provinces) with its extended offices such as Health Directorate, functions similarly, including formulation of provincial level health policies and plans, management of provincial hospitals and coordination across sectors. And, delivery of basic health services and other public health programmes, in-line with federal policy and programmes, falls under the exclusive functions of a local (municipal) government. Health is one among the different sectors managed by municipal offices and health section is overseen by a designated Health Coordinator supported by a dedicated team, while the municipal council comprising of elected representatives (Mayor, Deputy Mayor, ward chair and ward members) is responsible for the overall decision making. The Health Facility Operation and Management Committee (HFOMC) manages the public health facility, led by the ward chair along with representatives from different sectors including community and service users.

In this context where non-technical locally elected representatives are not aware of the technicalities of HIS and its use in decision making, and where health facilities lack basic infrastructure, technical capacity and technical backstopping, health facilities and local health coordinators in the municipalities are in dire need for capacity improvement support for managing and strengthening local health system. Therefore, in order to build resilient health system that is inclusive of and responsive to gender and equity, one of the crucial steps to move forward is by strengthening HIS pillar for promoting evidence informed planning and decision making. Against this background, it is therefore imperative to understand what different social stratifiers are generated in routine data through HIS, how generated evidence are being analyzed and whether or how health facilities (public and private) and local governments are using these stratified data in gendered and equitable health system planning and decision making.

Our aim to explore

Evidence suggests that more than half of health care is sought primarily through private facilities including poor and excluded groups, resulting in considerable disparities in service utilization between public and private providers. It is less known whether, how and to what extent these HIS in public and private sectors provide intersectional data (ie stratified as gender, age, geography, ethnicity, education, occupation, disability, etc) and how they inform health sector planning and decisions. With this view and importance, this study assesses intersectional stratifiers in public (HMIS) and sample of two private sectors HIS to explore stratified data generated through HIS, understand the perceived importance of stratified data at local level and explore current practices of analysis and use of such data in local decision making processes that will enable us to design an evidence-informed framework that promotes gender and intersectional lens in health services planning and delivery.

Our approaches of evidence generation

We are conducting a cross-sectional exploratory study where we are first undertaking desk-based review of HIS related national policies and guiding documents, forms and formats to explore what level of social stratifiers have been generated through HIS. Based on the findings from documents review, we will carry out qualitative research to further explore what is being done in practice and what are the gaps in terms of generation and use of stratified data at health facilities and municipalities level. We are undertaking 12-15 key informant interviews (KIIs) at federal, provincial and local levels to understand informants’ perspectives on the availability, need and use of intersectional stratifiers in routine HIS. Likewise, we will generate case studies of four sampled health facilities (two public and two private) in two municipalities, capturing observations from HMIS review, perceptions of facilities staff, their responses etc recorded through formal interviews and informal discussions. Policy documents and qualitative data will be analyzed using thematic framework analysis approach.

Another important approach we are adopting is engaging stakeholders from the inception throughout the study to achieve maximum buy-in and ownership of study results. We plan to utilize existing Technical Working Group (TWG) at the HMIS section of the Management Division, Department of Health Services (DoHS) of Ministry of Health and Populations (MOHP) to present identified gaps and jointly explore and co-design approaches that can be adopted at local municipalities. Moreover, we will also invite the views of local and provincial representatives in the TWG. Then the study team in coordination with TWG will engage with HFOMC of the selected health facilities of two sampled municipalities. We will take opportunity of this existing presumably gender and inclusive group (HFOMC) and try to explore community voices by hearing from HFOMC members who represent their community, in the process of informing our results and thus generation of the framework.

Use of evidence to inform decision-making

The findings from the project will identify gaps in existing HIS documents and practices (information generation, reporting and use). In the next stage, in consultations with federal and local governments, health facilities staff and HFOMC, a framework will be developed focusing on gender and equity aspects that to be considered in service planning and delivery that leaves no one behind. Learnings from the project will be shared at study sites and where possible at other municipalities, which will provide evidence to inform local planning processes and also larger research projects that aim to strengthen delivery of routine health services targeting marginalized and vulnerable populations.