How the roll-out of electronic reporting to health posts improves local planning and budgeting
As Nepal transitions to a federal system of government, local municipalities need good quality data to plan for and monitor the delivery of health services. The introduction of e-reporting to all 73 health facilities in Nuwakot District is one part of a national strategy to transform the collection and use of routine health information in the country.
A new beginning for the Kalyanpur Health Post
The devastating earthquake which shook Nepal in April 2015 completely levelled the Kalyanpur Health Post, a one-room stone structure just west of the town of Bidur, the headquarter of Nuwakot District and, under Nepal’s new federal system, the seat of Bidur Municipality. Only a table, a chair and two benches could be salvaged from the rubble. For the next two years, staff at the health post provided health services to local residents out of a temporary structure made of galvanised iron sheets.
Post-earthquake recovery in Nepal has been guided by the principle of ‘Build Back Better’ and the new Kalyanpur Health Post, which opened its doors to the public in July 2017, shows what this can look like in practice. Constructed with German support, the new prefabricated structure is larger, cleaner and brighter, with windows that allow in plenty of light. It has a waiting room, two consultation rooms, a delivery room and a storage room. It has running water, toilets and a stable electricity supply.
Although less visible at first, something else important has changed: for the first time, the Kalyanpur Health Post has a laptop computer and access to the internet.
Thanks to a project implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, in partnership with the Korea International Cooperation Agency (KOICA), Kalyanpur is one of the first health posts in Nepal to report directly into the country’s health management information system (HMIS), which runs on the open source software DHIS2. Since the new health post opened, staff at Kalyanpur have been submitting monthly service statistics electronically, rather than delivering paper copies to the District Public Health Office (DPHO) in Bidur, a 30-minute drive away. They can now access and work with their own data in digital form, thereby allowing them to better understand changes in the local health profile and in the coverage of key programmes in their catchment area.
‘Build Back Better’ has provided an opportunity to improve not only the physical infrastructure in the Nepal’s health sector, but also the way facilities function.
Transforming the collection and use of routine health information
By June 2018, with support from GIZ and KOICA, e-reporting will be rolled out to all 73 health facilities in Nuwakot District – part of a larger effort by the Ministry of Health to transform the way routine health information is collected, processed and used for decision-making in Nepal. The same strategy is being extended to more than 400 facilities in 10 more districts with support from GIZ, the Global Fund, the UK Department for International Development and the World Health Organization, and to another 500 facilities with resources mobilized by the Ministry of Health.
These developments are coming at a critical time. As Nepal transitions to a federal system of government, and responsibility for health services is devolved to municipalities, the ability to work with health data at the local level is essential for evidence-based planning and budgeting, and for tracking health service delivery at facility level. Good quality data is also needed to monitor progress towards the Sustainable Development Goals. The roll-out of e-reporting which is currently underway will make it more likely that Nepal achieves its targets.
An inflexible and antiquated health information system
Until recently, it was difficult to access, analyse and share data from the country’s HMIS. Routine health information was collected and compiled by hand at the facility level, passed to the DPHO in paper reports on a monthly basis, and then re-captured electronically into the HMIS. The data were published in the annual report of the Department of Health Services, but were otherwise not fed back to facilities. Statisticians at the DPHO could see old data in the HMIS, but there was no way to work with them in electronic form. The software on which HMIS formerly ran had limited analytical capabilities and did not allow users to generate reports automatically. Analysing routine health information at the local level could therefore only be done by manually working through towering stacks of old paper reports.
This situation has now completely changed. Recent advances in information technology, including the emergence of open source digital solutions which are embedded in global user communities, have presented opportunities to radically rethink earlier approaches.
DHIS2 shows how it can be done differently
DHIS2 is an open source software with powerful data analysis and visualisation capabilities that is used in over 60 countries around the world to collect, manage and analyse data. Its simple web-based interface makes it easy for health workers to enter aggregate data right at facility level, where they are generated, rather than passing information on paper to the next level of the health system for capture. This saves time and reduces the paperwork burden by eliminating duplication of effort. DHIS2 also ensures the completeness of reported data, as required fields cannot be left blank, and helps to improve accuracy through built-in verification functions. For example, the software alerts the user to potential mistakes (e.g. large deviations from the value entered the previous month or year) and invalid entries (e.g. discrepancies between the number of children immunised and vaccine doses consumed).
DHIS2 also acts as a data repository. DPHOs and health facilities can access and analyse their own data using pivot tables, charts and GIS functions. The user-friendly design makes it possible for even those with little or no computer experience to learn it fairly quickly. The introduction of DHIS2 therefore holds the potential to re-vitalise the routine reporting of health information by putting the power of data into the hands of service providers and decision-makers at the local level.
Bringing e-reporting to Nuwakot
In 2016 the Ministry of Health decided to upgrade the software which powers HMIS from a locally-developed product to DHIS2 – first at the national and district level, and then by extending e-reporting to health posts and primary care facilities in a handful of districts on a pilot basis. Nuwakot is the first of these.
While migrating the HMIS to DHIS2 at national and district level was no small task, bringing it to health facilities in remote areas presents a very different set of challenges. Health facilities in Nuwakot District are spread across 1,120 square kilometers of hilly terrain; some can only be reached by foot. There are only two internet service providers, and connections in some areas are weak or unreliable. Many of the health personnel working at these facilities have never used computers before.
In 2016 project advisors started laying the groundwork for the transition. They undertook data quality assessments with staff at selected facilities and began sensitising health workers to the benefits of e-reporting. They visited each health facility in the district and tested out various Internet devices to determine what type of connection would work where.
On the basis of these assessments, facilities were then divided into three groups according to their readiness to adopt e-reporting. Laptops, Internet devices and power back-ups were procured and installed in the first group of facilities. Beginning in July 2017, master trainers led five-day training courses on basic computer skills and DHIS2 for two health workers from each facility. With project support, an IT-consultant was hired at the DPHO to provide technical backstopping, including everything from troubleshooting connectivity problems to configuring dashboards in DHIS2.
The first 27 facilities, including Kalyanpur, are now e-reporting, with the remaining two groups scheduled to come on line by June 2018. The roll-out has not been without bumps – poor network coverage in hilly areas continues to cause difficulty for some health facilities – but on the whole, it has been well-received and some important changes have already taken place.
Saving time, reducing unnecessary paperwork, improving accuracy
The time savings generated by e-reporting are clear to see at the DPHO in Bidur. Narayan Rijal, the statistical officer, can log into DHIS2 and see at a glance exactly which of the 27 facilities have already reported for the previous month. Mukunda Bhatta, the IT consultant, knows which facilities he needs to follow-up with. Santosh Bogati, the computer operator, now enters data from only 46 health facilities each month, rather than 73. In March 2018, when the next batch of facilities comes online, this number will be cut in half; in June 2018 it will drop to zero.
Because the system for recording information at point of service is still fully paper-based, the time savings introduced by e-reporting at health post level are less dramatic. Amber Tamang, the Health In-Charge at the Kalyanpur Health Post, and his colleagues still manually collate service statistics from multiple paper registers each month in order to complete HMIS Form 9.3. But now, rather than physically taking Form 9.3 to the DPHO in Bidur, Tamang spends about 10 minutes entering the information into DHIS2. Bigger time savings are to be found in the preparation of presentations. Before annual review meetings, it used to take Tamang two to three days to work his way through old reports, copy down data for specific indicators, and then construct graphs or tables by hand. Now, in DHIS2, these charts can be generated automatically and printed out or shared electronically.
Beyond the convenience, Tamang believes that e-reporting via DHIS2 is improving the quality of the data the health post reports. One month, for example, the software’s validation programme caught a discrepancy between the number of vaccine doses received from the DPHO and the number of patients vaccinated at the health post. Tamang was able to trace the discrepancy back to a transcription error and immediately corrected it in the report for the immunisation programme.
Setting priorities at the local level
What Tamang likes best about the new system is the fact that he can access and analyse facility data on a regular basis. He logs into DHIS2 at least once a week and particularly enjoys working with the pivot tables. The arrival of DHIS2 has made it much easier for staff at the Kalyanpur Health Post to monitor changes in service coverage – and as a result they are much more motivated to do so. In the past, Tamang and his colleagues would manually calculate key indicators, such as the contraceptive prevalence rate. Now, the software does this automatically, allowing them to track changes continuously over time. DHIS2 makes it easy for the team at the health post to see which indicators are progressing and which aren’t. This helps them to know where they need to focus their efforts and to take action.
This type of insight is increasingly needed for health facilities to be able to do their work. Since the adoption of the 2015 constitution, Nepal has been transitioning to a federal state and previously-centralised functions are being devolved to the sub-national level. Nuwakot, which used to be comprised of one municipality and 61 Village Development Committees, has been reorganised into one municipality and 10 village councils which are now responsible for planning, budgeting and overseeing health service delivery, alongside a wide range of other activities.
The district hospital, four urban health clinics and five health posts, including Kalyanpur, now fall under the authority of Bidur Municipality. Eventually, once the transfer of functions required for federalism is complete, health sector planning and budgeting across Nepal will take place at local municipal offices, such as this one. Tamang and the other facility heads who are already working with DHIS2 can support the municipality to fulfil these tasks. The introduction of DHIS2 is positioning health workers to be much more directly involved in planning and decision-making processes, something which holds the potential to greatly strengthen health sector governance and to improve the quality of health service delivery.
Karen Birdsall, February 2018