In accordance with the 2015 Measurement and Accountability for Results in Health summit, Germany supports Nepal in reforming its health information system, and Malawi, where better data has already yielded convincing results.
When a major measurement conference in Washington DC agreed a roadmap to better health data, it addressed a long-standing development problem: how to really know what’s happening on the ground and plan and tailor interventions around that knowledge. We look at Nepal, which has started reforming its health information system, and at Malawi, where better data has already yielded convincing results.
Lack of good health data is a constant problem in many low- and lower-middle income countries, so recent international efforts to harmonize health information systems are fueling excitement amongst development practitioners and healthcare planners at country level. Released at the Measurement and Accountability for Results in Health, a high-level summit in Washington DC in June 2015, the Roadmap for Health Measurement and Accountability and the 5-Point Call to Action seek to make it easier for countries to collect and use health data – without which they are working in the dark, unable to develop appropriate policies, make sound decisions, or plan and provide the necessary health services.
The summit, co-organized by USAID, the World Bank and the World Health Organization (WHO), gathered experts from around the world – including from several German-supported health programmes – to share experiences and learn how colleagues from other countries had tackled this challenge. The roadmap lays out a common strategic approach with milestones to help countries build their health monitoring systems, whereas the call to action – dealing with investments, institutional capacity, effective data use, collaboration and accountability – provides concrete targets and actions to help countries implement the roadmap.
Towards country-led M&E platforms for national and global reporting
“The measurement conference and the Call to Action that was endorsed there define the priority needs in countries’ measurement and accountability systems and set the scene for a post-2015 agenda,” said Kathryn O’Neill, Coordinator for Results Monitoring and Evaluation in WHO’s Department of Health Statistics and Information Systems. “There are many partners and despite efforts to harmonize there is still huge fragmentation at country level, with many reporting systems and indicators.” “Every national health strategic plan needs to be monitored for performance. If the monitoring system is good and robust it will generate the data the government, donors and global partners need and it will render obsolete the many parallel reporting streams and data collection initiatives which currently still exist. With the roadmap and call to action we want to make country-led M&E plans the basis for both national and global reporting,” she added.
The German Federal Ministry for Economic Cooperation and Development (BMZ), through its implementing agency GIZ, is promoting the use of the roadmap and call to action in various partner countries, including Nepal and Malawi, which have highly diverse health information systems.
Nepal: in need of numbers
When a devastating earthquake struck Nepal and killed more than 8000 people in April 2015, the fragility of its health structure and information systems was painfully exposed. Not only were health facilities damaged or destroyed, but the simplest health information was at times unobtainable. Something as basic as a reporting form could be hard to find, and even service registers went missing, making it difficult to follow up patients with communicable diseases, such as tuberculosis.
The earthquake brought home what Nepal’s health experts have known for some time: that the country’s existing data collection systems are inefficient and in need of an upgrade. More than a dozen fragmented systems, all partially paper-based, cannot speak to one another; manual collection and aggregation means data is unreliable and of little use in helping policy makers and frontline workers react in a timely manner.
A common complaint is that data is merely reported upwards to be further aggregated at each level of the hierarchy, mutating on the way and eventually providing an inaccurate picture of conditions on the ground. The results of analyses taking place at higher levels are not reported back to the frontline health workers who originally collected the data, making the task even more tedious for them.
“At present, the routine health information system is structured from the perspective of different vertical programmes and their respective reporting needs. It can neither generate the kind of information required for decision making at health facilities on the ground, nor for policy development at the central level,” said Franziska Fürst, Senior Technical Advisor with GIZ in Nepal. As a consequence, development partners commission costly additional surveys, baseline and endline studies whenever they need reliable data to plan, manage or evaluate interventions.
All this may soon change: in implementing the roadmap and its call to action, Nepal is set to switch this year to a web-based open-source system known as DHIS2, already in use in more than 40 low- and lower-middle income countries (see e.g. A Quiet Revolution: Strengthening the routine health information system in Bangladesh).
Ms Fürst and her colleagues at the Ministry of Health believe that the switch to DHIS2 stands to benefit Nepal in a number of ways. Accessing up-to-date, reliable and disaggregated data will allow health system managers to provide services when and where they are needed, and health system planners to monitor whether particular health policies are having the intended effect. At facility level, it will enable health district authorities and health workers to respond immediately when they recognize data trends, such as an increase or a reduction in the uptake of particular services or in the incidence of specific diseases. Also, a responsive information system could alert community health workers if a woman misses an antenatal or postnatal visit or a child is due for immunization.
Still, changes will not happen instantly and the shift to DHIS2 will not solve all problems. Nepal needs to engage in a longer-term process of specifying its data needs and of gradually rebuilding the architecture of its health information system. Ideally, this should generate the information needed by staff at all levels of the health system, from policy makers at ministry level to female community health workers in local communities. Also, data collection will need to be integrated into the daily work processes of each group of staff to minimize the administrative burden in a time- and human resource- constrained work environment.
Despite these challenges the launch of the Third Nepal Health Sector Strategic Plan has filled experts within both the government and the development community with optimism. Implementing the roadmap may be in its early stages but Nepal stands to make major gains.
Malawi, building momentum
If Nepal wants a vision of what an upgraded health information system can do, it might look to Malawi’s more robust monitoring and evaluation.
Malawi had understood the benefits of shared and centralized data before the roadmap was agreed, for example by starting discussions with development partners to define a new and streamlined list of national indicators to monitor the country’s Health System Strategic Plan, and by implementing DHIS2.
“DHIS2 is already running and we have been able to track progress on various Millennium Development Goals,” said Rhino Mchenga, Head of the Central Monitoring and Evaluation Division of Malawi’s Ministry of Health. “For example we know Malawi achieved MDG4 because we use DHIS2 to capture data. We have also identified areas where we are having problems achieving our goals and where we need more effort.”
To many, this is only the beginning.
According to Dr Simon Ndira, Senior Health Information Systems Advisor to the Ministry of Health under the GIZ-supported Malawi German Health Programme, the next step is implementation. “With the number of health indicators now manageable (cut from 190 to 100) and a Health Information Systems Policy approved, we now need to implement, to operationalize, and that means working with different departments and partners to harmonize data collection tools so we won’t have double reporting,” Dr. Ndira said.
Despite the advances, Malawi still faces challenges that are often similar to those in other countries. For example, not everyone is on board with DHIS2 and parallel systems still exist among the many vertical health programmes, leading to duplication. There are also gaps in data, especially in civil registration and vital statistics on births and deaths, which Malawi has no systematic process to record; not everyone is willing to share data with other groups; and employees are overburdened and lack equipment, while technology advances faster than they can keep up.
To give it greater autonomy and authority, some experts believe the Central Monitoring and Evaluation Division should be promoted to the level of Department. This elevation would ensure it an adequate budget and highlight the cross-cutting role of health data. Implementing the roadmap and call to action may help resolve some of these problems by promoting the use of a single national data reporting system and finally convincing partners and donors of the need to eliminate duplication and focus on strengthening the single platform. In a promising development, the Ministry of Health senior management at the end of August endorsed the new Health Information Systems Policy that will be critical in identifying data gaps and helping end such practices as vertical reporting.
In the roadmap’s footsteps
Improvements in data collection and analysis will take time, even with the release of the roadmap and call to action. Resistance to change will not be vanquished overnight, trust will not magically materialize, and governance challenges will not melt away simply because another framework has been adopted. Yet lives will inevitably be saved. Not only will strong data systems help health personnel spend less time on paperwork and more time on health, but gaps in health services will be caught early, populations and their needs will be better understood, and health systems strengthened.
Malawi has already experienced what harmonization and the implementation of DHIS2 can do, and Nepal is keen to reap similar benefits. As the world moves from the MDGs to the SDGs, the time is right to shape the way development data is gathered and used for the benefit of global health.
by Leyla Alyanak