The Health Management Information System (HMIS) needs to be unpacked and viewed with the perspective of multi layer approach
Japan International Cooperation Agency (JICA) Reproductive Health Project has been active in five districts of the Sagar division of Madhya Pradesh since September 2005. Through implementation in these districts, JICA has been contributing to the State Department of Health & Family Welfare (DoH&FW) on improvement of the quality of services for maternal health. JICA has kept the stance of technical cooperation with the DoH&FW, and has conducted operations within the framework of NRHM/RCH-II. Strategically working in small scale, JICA has accumulated operational knowledge on several maternal health activities for safe motherhood. The project has four major components, namely, human resource management (HRM), total quality management (TQM), HMIS and IEC/BCC and activities are addressed to various layers of the health system, including state, division, district, block, sector, SHC and village.
In contrast to the usual approach, JICA/MP Reproductive Health Project adopted a bottom up approach (focused on data recording, inputting and upward flow), concentrated on the human element of the HMIS and started working towards generation of authentic data with validation mechanism.
A situation analysis was done and the findings of the situation analysis presented a plethora of issues which bore reflections on each level. Each level had a different set of problems, which could be identified as factors weakening the HMIS as a whole.
At the SHC level, it was found that there is a high information overload. On an average, there are about 30 registers, 4 records, 7 lists and some other reports being maintained by the ANMs. The anatomy of source of information for the various parameters being reported was also not clear. Proper orientation and guidelines for any format were conspicuous in their absence. Non-uniformity and ambiguity about the mandated set of recording and reporting formats was found to be a unanimous feature for all levels. Interestingly, new formats kept on being introduced without the older formats being withdrawn. This had led to the same data element being reported in different formats and at times with different values. Form 6 seemed to be the most accepted reporting format and the ANMs were very comfortable using it. However, since the forms were out of print, the MPW were making manual forms which led to non-standardised reporting format.
Activities undertaken during the Transition phase
A Time Use Analysis was done in Hatta block of Damoh district. The findings of the time use analysis revealed that on an average, one day per week is given in filling the record books (rough to fair); for each service delivery day, around half to two hours is given in filling the rough records. This depends on the efficiency of the worker in filling records and the target load; on an average, two days are given in preparing the monthly report. Therefore, total time allotted monthly is around six days which is around 25 percent of the time allotted for service delivery per month (taking that 24 days in a month are days of service delivery). Taking the average of 75 minutes for rough recording, out of the remaining 18 days of service delivery, around one full day (approx. 23 hrs) equivalent to percent of the available time (18 days) is lost in rough record keeping. Therefore total time lost in reporting is seven days out of 24 working days which amounts to 29 percent.
At the block level, there was no uniformity in the formats being sent from the block to the district level. The number of formats being sent vary in number from anywhere from 15-25. The numbers vary within blocks. Computerisation of information was almost absent. NRHM provided the opportunity to recruit DEOs who had no clarity about their roles. Proper orientation (each entry) on the MIES (NRHM) format was required for the block level data managers. There was no clarity on the source of information for each data element leading to compromise in data quality.
At the district level, the situation analysis revealed too many loop holes. For example, the NRHM MIES was a new format and required caste disaggregation of data which was not being generated at the lower levels. The reporting format for block and district were not in similar formats for many parameters. Therefore compilation at district level became a very time taking process since it required data transfer and compilation from one format to another. Several reports were being sent from the district to the state and by different people. There was no data standardisation and the same data elements had different values quoted in different reports.
The findings from the situation analysis clearly revealed that it was essential to first streamline the reporting system at all levels and standardise it. However, it was also clear that not much could be done for standardisation of reporting formats as the formats are sent from either the national or state level. The strategy therefore adopted was to create systems for coping up with the transition period- till the reporting formats were finalised from national level. Another key input area was capacity building of data managers of all levels, familiarising the newly recruited computer operators with programmatic issues.
National level advocacy during the designing of the NRHM reporting formats
The field level scenario revealed that there is a limitation up to which a meaningful dent can be made to reduce the information overload at the district level. It was therefore strategically decided to start advocacy at the state and national level to reduce the reporting and recording burden of the frontline workers. Field implementation had enabled to gain an in-depth understanding about the prerequisites for a functional HMIS at the field level. Some basic design principals for reporting formats always need to be borne in mind. The design principals were that the data elements should be such that they feed into national indicators, have usability by the worker herself, feasibility of data collection and avoiding data duplication.
Meetings at national level for advocating the need to streamline the hardware (reporting and recording formats) were periodically held. The HMIS Consultant was invited by NHSRC in for a national workshop on finalising the data elements for reporting format at each level. The main inputs at the national level were to fine tune the reporting data elements according to the capacity of the ANMs. The formats were field tested in Pathariya block of Damoh district. Later the NHSRC HMIS team came to JICA/MP RHP Project Office to have a detailed discussion on each data element from the point of feasibility of data collection by the front line health workers. The new NRHM reporting formats were finally rolled out to the states from Ministry of Health and Family Welfare (MoHFW).
Rolling out the new NRHM reporting formats in Madhya Pradesh
At the state level, MP had taken the initiative to take these reporting formats to the district level and JICA/MP RHP has been constantly providing Technical Assistance for this purpose. JICA/MP RHP team was invited by the state to take the session on orientation on the new NRHM reporting formats in March 2009. This training was done for all the 50 districts and the participants included the DPM / ASO and DDA from each district. The participants were oriented on each data element. During the orientation, many issues came up which required state specific decisions.
At the state level, the Project team also facilitated to initiate a discussion and come to a consensus amongst the various program heads on the new reporting formats. JICA team met the Joint Director (RCH) to chalk out the plan for rolling out the NRHM formats at all levels in the state. The main decisions reached, with the Technical Assistance of JICA, were to allow the districts to print the formats at their level for the first three months since large scale printing from state would have some procedural delays. Considering that this was a transition phase for HMIS reforms, the state also decided to retain the old reporting formats till the new system is perfect. Meanwhile, divisional level trainings started rolling out in the state. A level wise capacity building plan for the new NRHM reporting formats was devised by the JICA/MP RHP and is now being followed in the state.
HMIS implementation in Bundelkhand
Apart from the advocacy efforts at state level to roll out the NRHM reporting formats, district and block level orientations on the reporting formats are presently going on in Sagar division of the state. There are several challenges like changing the mindset of workers on the main design principal of the formats. For years the frontline workers have been used to filling reports on area basis and not service basis. This mammoth change is the main message delivered during the block level orientation. Building new systems for information flow have been devised so that manual compilation (one of the main reasons for bad quality data) gets minimal. Computerisation from SHC level onwards has already been initiated and roles and responsibilities of various levels of data managers been clearly demarcated.
One of the new interventions in the project area has been the usage of GIS for evidence-based planning and management at the district level. The Project has also constantly been providing assistance to plot state level indicators on GIS and is in the process of encouraging the usage of GIS as a planning tool by policy makers at the state level.
With the new system in place, operationalising it involves hand holding and constant support in the initial months. This might not be possible for the Project team alone to take it forward. There are scalar implications and mechanisms for ensuring data quality and streamlining information flow needs to be created for the whole state.
Much as it may seem, but reforming HMIS has to have a bottom up approach and not limited to software. Capacity building, data standardisation, building linkage between program and data and computerisation are the bigger challenges facing our country.