January 2009

NRHM gets the IT edge – eHEALTH Bureau (Dipanjan Banerjee & Susan Thomas)

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National Rural Health Mission (NRHM) the flagship program under Ministry of Health & Family Welfare, Government of India, recently launched its ‘Health Statistics Information Portal’ – a web-based health management information system that will facilitate quick and efficient flow of information starting from the Facility-level, up to the District, State and finally the Centre. On top of all this, the system will provide an array of intelligent tools for advanced data analysis, reporting, monitoring, evaluation and overall program management.

eHEALTH provides an insight into this novel initiative and finds out how it will impact efficiency and effectiveness towards improving rural health in India.

Improving health conditions in rural areas has always been the biggest challenge in India! With an enormous land area spread across a staggering 3.28 million sq. km. and having nearly 70% of its teeming billion living in rural areas, providing equitable and efficient health services is surely a herculean task by any scale of measure.

Not only does it require a huge funding base, it also involves massive operations in terms of mobilising materials, medicines, human resources and physical infrastructure, required to deliver and administer health services.

At the centre of all these lies an essential element – ‘information’.

Flow of information and management of resources is critical for the success of any program. Understandably, this is even more pronounced, when it entails the issue of public health. Starting right from policy makers, to program managers, to implementers and even for field health workers, information is a critical resource in understanding challenges, identifying gap areas and ensuring efficient implementation of the program.

Even up till recently, health data collected at village level took some few months to reach authorities at the Centre. With manual and semi-automated systems in place, it was almost impossible to receive information in a short time. This resulted in delayed response time for authorities and a high rate of data redundancy in the system. In turn, this led to create lacunae in public health planning by way of creating difficulty in forecasting the accurate need for service provisioning, emergency preparedness and even resource mobilisation.

In a project as crucial as the National Rural Health Mission, inefficiency of any form, not only escalates costs but often proves critical in terms of human life and health conditions. Since public health has a direct bearing on national productivity and consumption, it makes sense to plug all holes to bring efficiency in a project which will invest as much as INR 12,050 crores/INR 120.5 billion in the current fiscal, with scope for higher allocation in successive years till 2012.

Keeping this in mind, The Ministry of Health and Family Welfare, Government of India in technical collaboration with iBilt Technologies (a SEI CMMI Level 5, ISO 9001:2000 and ISO 27001:2005 IT solutions company headquartered in New Delhi) recently launched the NRHM health statistics information portal – www.nrhm-mis.nic.in

Built to serve as a one-stop-site for the entire NRHM program, the portal combines an array of cutting edge technologies that render superior data analytics, robust data warehousing and sharp business intelligence tools, which can allow decision makers to generate more frequent periodic reports and closely monitor the status of the health sector.

Commenting on this initiative, Sri Pravin Srivastava, Director-NRHM, Ministry of Health and Family Welfare, Government of India said, “The NRHM portal is essentially meant to create a standardised single-point entry route for all field data and develop a centralised repository of all physical and financial information of the program, which can be easily-accessed and analysed online using a range of sophisticated software tools.”

In addition to all this, the NRHM portal also aims to harness the power of information to bring quickest and fastest corrective action on ground for fighting any challenge in rural public health. The idea is that, in the long-run, data collected at ground level can be made readily available for quick and immediate decision making at the local level. Reflecting on this issue, Srivastava says, “Traditionally, data collected at the local level bear no ownership among local people. Typically, the time lag for data to reach decision makers at higher levels; their subsequent aggregation and analysis into meaningful interpretations; and finally, execution of corrective action on ground is often too long, cumbersome and in many instances, not effective.  On the contrary, if local people are empowered to recognise the ownership of their data and are made capable of taking immediate action for potential threats, the benefits will be much better. This will lead to actual realisation of objectives of data-for-action. However, it’ll be a considerable time before we are able to create requisite capacities at local level and realise the true potential. The efforts have just begun.”

The NRHM portal is also going to bring a paradigm shift in terms of overall program management and administration. Commenting on this, Ashok Tiwari, Chairman & Managing Director, iBilt Technologies said, “The NRHM portal is going to bring a substantial change in the management and operation of the entire program. It’ll provide health administrators with immense power to analyse field data like never before; monitor progress at every step of the work; and improve success levels and outcomes of program implementation.”

On a mission to empower


Praveen Srivastava
Director
Ministry of Health and Family Welfare, Govt. of India

Q. What are the basic challenges that are meant to be addressed through the NRHM-HMIS portal?
A. When NRHM was launched in April 2005, there were a number of separate programs for different areas such as TB, malaria, maternal and child health etc. Under the NRHM, we tried to bring it all together as an integrated program for facilitating coordination among all of them. The reason for that was, whether one is suffering from TB, malaria or any other health problem, the person will go to the same institution or facility for his/her treatment.

We had a similar problem regarding management of information across different programs. Each program had its own reporting channels built up over the years. Some programs had very elaborate reporting systems (such as in TB, where they monitor up to the most micro level) and for some the reporting systems were weak, which resulted in acute scarcity of data. This situation made it immensely difficult for understanding exact problems at the district and sub-district levels, and magnified at the State and the Central level.

We realised that if NRHM is itself integrated as a program, we need to integrate various monitoring and evaluation systems as well. Even our fund flow mechanism started to get integrated. We no longer send funds through separate programs, but rather through one single society in each state. In turn, state societies sign off funds to district societies and so on. To support all these activities, the medical officers were supposed to provide healthcare to people, which they were unable to. To address this problem, we established ‘programme management units’ in each state and district headquarters, where professionally qualified people were recruited for handling finance, program management and MIS. However, inspite of having people and equipment in place, data was not coming in on time. This was the actual genesis of the NRHM-HMIS portal.

Q. How did you go about in developing the conceptual framework of the HMIS portal?
A. About two years ago we created a task force on health management information system, under the Chairmanship of the Director General of Health Services (DGHS). The task force developed a blueprint for the system and defined various technical and functional aspects required for the portal. Once the blueprint was ready we went ahead for the tendering process. Criteria were laid in such a manner that it fit only those agencies with a certain level of calibre and credibility, and not any fly-by-night operator. We built in a 5-year maintenance contract, so that the vendor stays with us even beyond the development period – share the pains and gains of the project, help us build stronger processes and see through its entire evolution.

To begin with, we were thinking to have a state level reporting system. But soon we felt the need to make it more pervasive and decided to have it as district level. However, when we actually set out to develop the system, we found that the real need is to make it facility-level. Based on this realisation we developed the system with all requisite capability and scalability features to make it work even for facility-level reporting. However, we will roll out the facility-level system only after the districts start showing certain degree of stability in their processes. The biggest strength of this system lies in its ability to bring apparently disparate data sets and spatially distributed resources on one single platform. This has been achieved to the extent of even integrating the financial reporting system within the health information system. Getting both physical and financial information on the same portal is in itself quite unique and remarkable.

Q. How much time do you think it will be before you can actually start realising the benefits of this system?

A. Ideally, we should have started drawing the benefits yesterday!

NRHM started in the year 2005 and is scheduled to terminate in 2012. We have crossed mid-way through the program and hence I think we’re already late. We need to put this on a fast track and ensure that we get data on a regular basis. However, it will take some time for the system to stabilise, as people need to be trained and sensitised. We have roped in ‘National Health Systems Resource Centre’ for training and capacity building at the district level. Considering that there are more than 600 districts across India, this is not an easy task at all. In addition, there is wide variation in technical and functional competence levels among district MIS teams, which can cause substantial difference in training outcomes in different places.

Over last two months since the system started running, we’ve had a maximum of 329 districts entering data (out of 600+ districts) for a particular month. This squarely points to the huge amount of capacity building that is still required. Efforts are going on all around and even iBilt is helping us in some places.

But for a huge number of people it’s something novel, requiring an entire change of mindset. This requires us to not only explain how and what to report but also generate a sense of accountability and ownership about their reported data. We need to make them realise that what they report today will bear profound impact on decisions about tomorrow.

In the long run, our purpose is to make them capable of taking decisions based on their own data and information. The society system of public health management is trying to empower people so they can take decisions based on their requirements. For example, at each facility levels, we now have something called ‘Rogi Kalyan Committee’ (patient welfare committee), which comprises of members from medical fraternity, public health, civil engineering, irrigation, water and sanitation departments, along with local elected representatives, who decide how funds can be best utilised to improve health services. The HMIS will play a vital role in all such local level planning and at the same time empower Central authorities with substantive evidence and data to rationalise fund allocation.

Q. What is the strategy being followed with respect to data that is already available in paper format?

A. We have migrated most of the data prior to April 2008 in the consolidated form. While those before April ’08 will be available only state-wise, we are trying to get those after April ’08 district-wise. Once we have one full year of time-series data, we start can doing district-level trend analysis.

Q. Even with the HMIS system in place, the quality of field data might still be questionable in some cases. How do you plan to address this challenge?

A. The HMIS portal is equipped to handle data from multiple sources such as National Family Health Survey (NFHS), District Level Household Survey (DLHS), National Census etc. In addition, we will also get data from independent agencies, which will start flowing in from March-April ’09 onwards. When all of these come together, we’ll have huge data sets � much more than what is humanly possible to analyse or disseminate. This will help in cross-checking and validating primary data, and finding possible discrepancies in reporting. The aim is to aggregate data from different sources within a common indicator framework and seeing how we can map it through data triangulation.

Q. What is the ultimate outcome of this project? How do you foresee changes in the way public health is managed and delivered?

A. The ultimate goal of this project is to put data for action at the local level. However, to make this happen, firstly we need data, secondly we need analytical capabilities, and thirdly we need the authority to use this analysis for action on ground. This calls for a huge amount of mindset change that has to go in for making people capable of making their own decisions.

However, it is not at all easy to put this in practice – primarily because we have never thought in that direction. We are used to filling forms, collecting data and then forgetting all about it. But we need to stop forgetting and start using the data. The cutting-edge analytical tools of this HMIS portal will help consolidate data from different sources and facilitate timely action. It also requires talking to institutions, creating capacity by training and sensitising people who have never before thought about using data in such a way.

The portal has been designed through an exhaustive consultation process with health officials, which brought out vital needs of administrators in terms of their MIS requirements, and also facilitated in making the portal more user-friendly, analytical and intuitive.

Running on a SAS business intelligent platform, the portal is equipped with rich reporting tools that can take care of almost any and every reporting need of officers and administrators. In order to make the process more flexible, the system has been endowed with custom reporting capabilities, which can match new data requirements of officials.

A dashboard format of data representation gives complete control for officials to keep tab on key performance indicators (KPIs) and take immediate corrective action for any deviance and variation. If need be, the dashboard also provides for inclusion of new KPIs and custom analysis tools, which might be of relevance in future. Keeping in mind the pattern of information flow and existing organisational reporting mechanisms, the system has been structured to take care of hierarchical protocols with appropriate checks and validations at appropriate levels.

In addition, keeping in consideration low-bandwidth availability in non-metro and semi-rural areas, the portal has been built to run efficiently even on narrowband, dial-up connections. Furthermore, the portal allows for offline working mode, which gives users the liberty to carry out data entry jobs in spreadsheet files even in offline mode. Once connected, they can simply upload the spreadsheet file and the system will accept it as valid submission by automatically converting it into the relevant format. Moreover, in case of sudden connection breakdown, while working online, the system will revive all work stored till that point and resume from the same point where it left.

Over next few years, the NRHM-HMIS portal promises to bring a whole new paradigm in the way public health information is reported, analysed and understood. With the power of web technologies and cutting-edge IT tools delivered right into the hands of health officials, we can hope for a much better future for rural health in India.

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