FINAL Maksph Fellowship Report Doc 26.11.2013Doc

STRENGTHENING DATA MANAGEMENT AND USE AT HOIMA REGIONAL REFERRAL HOSPITAL

SIMON NDIZEYE – (MASTER OF SCIENCE IN POPULATION AND REPRODUCTIVE HEALTH) MEDIUM TERM FELLOW

AND

LUCY ASABA (REGISTERED NURSE / MIDWIFE; BACHELOR OF ARTS IN COMMUNITY BASED DEVELOPMENT) MEDIUM TERM FELLOW

MAKERERE UNIVERSITY SCHOOL OF PUBLIC HEALTH-CDC MEDIUM TERM FELLOWSHIP PROGRAM REPORT

NOVEMBER 2013

TABLE OF CONTENTS DECLARATION ...... iii LIST OF ACRONYMS ...... vi OPERATIONAL DEFINITIONS ...... vii EXECUTIVE SUMMARY ...... ix 1.0 INTRODUCTION AND BACKGROUND ...... 1 2.0 LITERATURE REVIEW ...... 2 2.1 Utilization of Health Data for Decision Making...... 3 2.2 Improving Data Quality and Availability ...... 4 2.3 Capacity Building in Data Management and Use ...... 5 3.0 STATEMENT OF THE PROBLEM & PROJECT JUSTIFICATION ...... 6 3.1 Statement of the Problem ...... 6 3.2 Justification for the project ...... 7 4.0 GENERAL & SPECIFIC OBJECTIVES ...... 7 4.1 General objective ...... 7 4.2 Specific Objectives ...... 7 5.0 METHODOLOGY ...... 8 6.0 PROJECT OUTCOMES ...... 11 7.0 LESSONS LEARNT ...... 15 8.0 CHALLENGES FACED ...... 16 9.0 SUMMARY AND CONCLUSIONS ...... 16 10. RECOMMENDATIONS ...... 17 11. SCALE-UP/SUSTAINABILITY AND DISSEMINATION PLAN ...... 17

REFERENCES ...... 19

LIST OF TABLES

Table 1: DHIS2 Timeliness of Reporting Summary for January to September 2013…………...14

APPENDICES

Appendix 1: Terms of Reference for the Data Review Committee ...... 21 Appendix 2: Sample of the Agenda for a Data Review Meeting ...... 23 Appendix 3: Members of the Data Review Committee ...... 24

DECLARATION

I, Simon Ndizeye and Lucy Asaba do hereby declare that this end of project report entitled “Strengthening data management and use at Hoima Regional Referral Hospital” was prepared and submitted in fulfillment of the requirements of the Medium-term Fellowship Program at Makerere University School of Public Health and has not been submitted for any academic or non-academic qualifications.

Signed ………………………………… Date………………………………….. Simon Ndizeye, Medium-term Fellow

Signed ………………………………… Date……………………………………. Lucy Asaba, Medium-term Fellow

Signed ………………………………… Date………………………………….. Dr. Rose Mukisa Bisoborwa - Institutional Mentor

Signed ………………………………… Date………………………………….. Assoc Prof. Rhoda Wanyenze - Academic Mentor

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ACKNOWLEDGEMENTS

We would like to acknowledge the concerted efforts and invaluable contributions of various individuals towards the successful implementation of the Fellowship Project. We extend our gratitude to EngenderHealth management especially Ms Karen Beattie, the Fistula Care Program Director and Dr. Rose Mukisa Bisoborwa, the Country Program Manager for accepting us to participate in the MakSPH Fellowship program and providing funds to cover our travels, accommodation, meals and other incidentals during project implementation in Hoima district. Dr. Rose also acted as our institutional mentor and was able to provide ongoing technical guidance in the course of implementing the project. EngenderHealth Uganda staff especially the Finance and Administration team played a key role in coordinating procurement, transport and other logistics needed in the field as well as ensuring our compliance with the organization’s financial SOPs and systems.

Special thanks go to our academic mentor Associate Professor Rhoda Wanyenze for reviewing our initial concept paper that we later used to develop a project proposal. She was also very instrumental in ensuring that the project proposal detailed how the identified problem of poor data management and use was going to be addressed at Hoima Hospital using the limited resources at hand.

Furthermore we would like to acknowledge with much appreciation the crucial role played by Hoima Hospital top management especially the Hospital Director, Dr. Francis Mulwanyi and the Senior Principal Nursing Officer Sr. Florence Acheng in providing overall onsite leadership and creating an enabling environment for project implementation. We also thank the data review committee, medical records personnel and all staff of Hoima Hospital for spearheading the setting up of systems to strengthen data management and use.

We cannot forget to commend the excellent work done by MakSPH-CDC Fellowship Staff especially Mr. Joseph Matovu, Ms. Stella Ongorok, Ms. Susan Mawemuko and Ms. Faridah Mbambu. They provided us with ongoing administrative, financial and technical/academic guidance from day one thereby enabling us to successfully complete the Fellowship Program.

Last but not least we are grateful to the Hoima District Biostatician, Mr. David Kabagambe for providing technical support in conducting data review meetings and training health workers on how to use health facility data for decision making.

LIST OF ACRONYMS

ANC - Antenatal Care DHIS2 - District Health Information System DHO - District Health Officer FC - Fistula Care HC - Health Centre HIV/AIDS - Human Immuno Virus/Acquired Immune Deficiency Syndrome HMIS - Health Management Information System M&E - Monitoring and Evaluation MCH - Maternal and Child Health MOH - Ministry of Health NGO - Non-government organization OPD - Outpatients Department PMTCT - Prevention of Mother to Child Transmission of HIV RRH - Regional Referral Hospital RVF - Rectal-Vaginal Fistula SUSTAIN - Strengthening Uganda's Systems for Treating AIDS Nationally SOPs - Standard Operation Procedures TOR - Terms of Reference VHTs - Village Health Teams VVF - Vesico-Vaginal Fistula

OPERATIONAL DEFINITIONS

• A project: An intervention that consists of a set of planned, interrelated activities designed to achieve defined objectives within a given budget and a specified period of time.

• Obstetric Fistula: This is a medical complication normally caused by prolonged and/or obstructed labor where the presenting part, usually the head presses against the vagina or bladder causing death of tissues. This results in an opening/hole commonly between the bladder and the vagina (vesico vaginal fistula-VVF) or between the rectum and the vagina (recto-vaginal fistula -RVF). A woman with VVF passes urine uncontrollably through the vagina while one with RVF passes feaces through the vagina or both in extreme cases.

• Mentoring: Mentoring is the long term passing on of support, guidance and advice. In the workplace it is intended to describe a relationship in which a more experienced colleague uses their greater knowledge and understanding of the work or workplace to support the development of a more junior or inexperienced member of staff in a bid to strengthen competences.

• Coaching: This is defined as ‘developing a person’s skills and knowledge so that their job performance improves, hopefully leading to the achievement of organizational objectives. It targets high performance and improvement at work, although it may also have an impact on an individual’s private life. It usually lasts for a short period and focuses on specific skills and goals.

• Sustainability : This is the likelihood that the positive effects of a project (such as assets, skills, facilities or improved services) will persist for an extended period after the external assistance ends.

• Data management: This is the process of putting in place mechanisms and actions to track data flow, storage and reduce the probability of errors being introduced into the data at any stage.

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• Data quality refers to accurate, timely, complete, precise and reliable information collected through a monitoring and evaluation system.

• Data Use refers to the process of applying available information to make decisions, changes, or to take other specific actions designed to improve desired outcomes. This process is key in planning, policy making, program administration/ management and delivery of services.

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EXECUTIVE SUMMARY

Hoima Regional Referral Hospital herein referred to as “Hoima Hospital” is one of the health facilities being supported by EngenderHealth Fistula Care project to provide fistula prevention and repair services. In August 2012, an assessment was carried out to determine its capacity to collect, store and utilize health data for decision making. Findings showed that all HMIS registers for the different services except family planning were available. Data for family planning was being captured in a counter book but it was not complete and accurate. Monthly summaries in the HMIS maternity, outpatient and antenatal care registers were not regularly compiled as expected. Maternity and family planning data captured in the monthly HMIS 105 report did not tally with what was in the respective registers. DHIS timeliness of all HMIS reports was low at 27% whereas poor storage of data in the medical records room was evident with many files heaped on the floor and not properly arranged. Data issues were rarely discussed in meetings and there was no functional data review committee in place. Only a few staff at the hospital were trained in using health facility data for decision making.

A project herein referred to as the “M&E project” to strengthen data management and use at the hospital was implemented between April and September 2013 with support from the MakSPH- CDC medium term Fellowship Program. The specific objectives of the project were to improve data management, promote the collection of good quality data at the health facility specifically focusing on completeness, accuracy and timeliness and to build the capacity of health workers in using data in decision making.

Overall the M&E project achieved all its objectives and the main goal of strengthening data management and use at Hoima Hospital. Data management and storage was improved through shifting the data room to a more spacious environment, installation of shelves, sorting and filing data according to the reporting period and services provided. A desktop computer and internet modem were also purchased to aid electronic data entry into the DHIS2, storage, analysis and presentation. The capacity of health workers to use data for decision making was enhanced through training, mentoring and coaching them on site and holding quarterly data review meetings. Three meetings were held in which key decisions were made based on the data

ix analyzed and presented. To foster more detailed and focused data discussions, the HIV/ART unit started holding monthly data review meetings to assess performance of selected indicators with technical support from the SUSTAIN Project whereas the OPD, paediatric, maternity and MCH departments integrated discussion of data issues into their monthly meetings. There was a marked improvement in the completeness of patient data, accuracy of monthly summaries for all HMIS registers and timeliness of reporting into the DHIS2 increased from 27% at baseline to 81% by the end of the project.

Strengthening data management and use at a regional referral hospital is a viable venture that is bound to succeed once the hospital management appreciates it, is committed and willing to put in place necessary structures. Hoima hospital management committed itself to sustain the project interventions through convening quarterly data review meetings, always recharging the internet modem in order to ensure timely DHIS2 reporting and included box files on the budget for stationary to ensure steady supply. The District HMIS Office has recognized the importance of data review committees and intends to work with Hoima Hospital to support Kikube and Kigorobya HC IVs to properly file their data and start holding data review meetings. EngenderHealth will continue supporting efforts aimed at strengthening data management and use at Hoima hospital and will scale up similar interventions to four other hospitals it supports including Masaka Regional Referral Hospital, Bwera District Hospital, Kagando and Kitovu Mission Hospitals.

1.0 INTRODUCTION AND BACKGROUND

EngenderHealth is an international NGO working in more than 20 countries in Asia, Africa and Latin America. It aims at improving the lives of men, women, families and providing quality health care in the world’s poorest communities through its work in advancing family planning, maternal health, HIV/AIDS prevention and care and gender equity. It also focuses on improving the quality of clinical services. In Uganda, EngenderHealth has been implementing a 5 year USAID funded Fistula Care Project (FC Project) whose goal is to strengthen the capacity of selected health facilities to provide quality fistula prevention and repair services.

The FC Project aims at: • Strengthening the capacity of hospitals to provide quality services to repair and care for women with obstetric and traumatic gynecologic fistula • Enhancing community and facility understanding and practices to prevent fistula, utilize and deliver services for emergency obstetric care • Gathering, analyzing, and reporting data to improve the quality and performance of fistula services • Strengthening a supportive environment to institutionalize fistula prevention, repair and reintegration programs.

EngenderHealth FC project is currently implementing fistula repair/treatment and prevention services at 10 health facilities in four districts in central and western Uganda. Of the 10 health facilities, 3 of them i.e. Hoima Regional Referral Hospital herein referred to as “Hoima Hospital”, Kitovu and Kagando Mission Hospitals are being supported by the FC Project to provide both fistula repair and prevention services whereas the remaining 7 health facilities are providing only fistula prevention services. These health facilities include Masaka Regional Referral Hospital, Kalungu HC III, Karambi HC III, Nyabugando HC III, Bwera Hospital, Rwesande HC IV and Kasese Municipal HC III. Fistula prevention services include provision of family planning services, emergency obstetric care, catheterization, monitoring of labour using the partograph, using VHTs and other leaders to sensitize communities about the importance of antenatal care, delivering in health facilities, male involvement in maternal health among others.

One of the key result areas of the EngenderHealth FC project is to support the 10 health facilities to gather, analyze and report data in order to improve the quality and performance of fistula services. These health facilities use HMIS tools to collect and report data on a wide range of services that they provide. These data are submitted to the respective districts which in turn aggregate and forward them to the Ministry of Health (MOH). The MakSPH medium term Fellowship project was implemented at Hoima Hospital located in western Uganda, 184 kms away from Kampala city. Hoima Hospital is a government regional referral hospital situated in a peri-urban setting near Hoima town with a 280 bed capacity. The hospital serves five districts of Buliisa, Kibaale, Kiryandongo, Masindi and Hoima with a total population of 1.79 million people. The hospital receives referrals from Kagadi General Hospital, Kiryandongo General Hospital, Masindi General Hospital and other lower level health units in the region.

EngenderHealth carried out an assessment in all the 10 health facilities it supports to determine their capacity to collect, store and utilize data for decision making. Records/data personnel in each of the sites were interviewed, patient registers reviewed and observations made to verify existence of proper filing systems, management information systems, dedicated data rooms among others. Results of the assessment were used to determine how each of the sites should be supported to improve data management and use in decision making.

2.0 LITERATURE REVIEW

According to Singh A (2006) strengthening of health systems has become a top priority of many global and national health agendas as a way to improve health outcomes. With the global health context becoming increasingly complex, national health systems are beginning to move away from a focus on disease-specific health responses to comprehensive strengthening of health systems. The global community agrees that without a systems approach, health outcomes will not further improve and health-related development goals such as the United Nation's Millennium Development Goals (MDGs) for 2015 will not be met. Good quality and timely data from health information systems are the foundation of all health systems. However, too often data sit in reports, on shelves or in databases and are not sufficiently utilized to inform policy and program development, improvement, strategic planning and advocacy. Without specific

2 interventions aimed at improving the use of data produced by information systems, health systems will never fully be able to meet the needs of the populations they serve. (Tara Nutley and Heide W. Reynolds 2013)

The World Health Organization's framework for health systems strengthening identifies six attributes of a health system. The attributes or building blocks include a health workforce, health services, health financing, governance and leadership, medical products, vaccines, and technologies, and health information. While each building block of the WHO framework is important to improving health systems and ultimately health outcomes, quality and timely data from health information systems are the foundation of the overall system and inform decision making in each of the other five building blocks in the health system. For example, for a workforce to be trained and deployed in adequate numbers to deliver quality services, information about disease burden, the geographic distribution of target groups, and available infrastructure and commodities is necessary. Health systems require quality data from HIS to plan for and ensure that the workforce is fully funded and equipped with the necessary commodities, infrastructure, resources, and policies to deliver services. (WHO 2007)

2.1 Utilization of Health Data for Decision Making

Too often data sit in reports, on shelves, or in databases and are not sufficiently used in program development and improvement, policy development, strategic planning, or advocacy. Part of the reason for the breakdown in the process is that health information systems (HIS) are inherently complex, and the outputs of HIS (quality data) are not proximately related to improved service delivery (Hotchkiss et al, 2012). The output of improving the health workforce for example is directly related to improvements in service quality and coverage, while the output of improved information systems is higher quality and timely data. The complexity of how organizations are contributing to and using HIS, of decision-making processes, of the flow of information, and of the time lag between the availability of data and use of data and the eventual changes in services and health outcomes all contribute to a breakdown in the causal pathway and an underutilization of data in decision making (Harrison T and Nutley T, 2010). The existence of quality data is insufficient to ensure use because data use has not been adequately integrated into decision-

making processes and the information needs of decision makers are often not adequately represented in data collection efforts (Lomas J, 1997).

An example of data users and producers working together comes from Madagascar, where policy makers at the Ministry of Health and Family Planning (MOHFP) worked with researchers to link key program questions with the available data and jointly analyze and interpret data. The MOHFP was interested in the strategy of allowing community based workers to distribute the injectable contraceptive method depot medroxyprogesterone acetate (DMPA), but they wanted research evidence that quality DMPA services could be provided by community workers and that this method of delivery was acceptable. At the beginning of the study to assess safety of the strategy, different data users were identified, such as providers and policy makers, and they were included in the development of study questions to ensure that the research addressed their questions and concerns. These stakeholders were invited to join a study advisory committee, and there were regular communications during the study with this group. Stakeholders were given meaningful roles in the study during data collection to help increase their understanding of the research process. During data analysis, stakeholders were involved in data interpretation and gave rich context to the results, and development of recommendations was led by stakeholders. This process to link data users and data producers was considered successful in that the intervention allowing community based workers to distribute DMPA was eventually adopted by the MOHFP and was scaled up (Nutley T et al, 2011).

2.2 Improving Data Quality and Availability

For consistent data use to occur, data need to be of high quality so that data users are confident that the data they are consulting are accurate, complete, and timely. Without quality data, demand for data drops, data-informed decision making does not occur, and program efficiency and effectiveness will suffer (Mavimbe JC, 2005). Data quality protocols need to be developed, communicated, and implemented, as well as training and retraining of health professionals on data quality techniques and approaches. An example of activities to improve data quality comes from the field of routine immunization services. Bosch-Capblanch et al, 2005 reviewed 41 countries’ data quality performance from 2001 to 2005. Six of the 41 countries had two rounds

4 of data quality assessments (DQAs) 2–3 years apart because they failed to meet the accuracy targets in the first round and had to produce data quality improvement plans. During the second rounds of DQAs, it was observed that the accuracy and quality of the reporting system improved, there was an increase in the availability of guidelines for electronic data management, and demonstrated better use at the district level of immunization performance monitoring tools for example e.g. tables and charts showing coverage.

2.3 Capacity Building in Data Management and Use

To improve sustainable demand for and use of data in decision making, individual capacity in core competencies to demand and use data must exist at all levels of the health system. Competencies include skills in data analysis, interpretation, synthesis, and presentation, and the development of data-informed programmatic recommendations. For data producers, these competencies should be built as part of standard monitoring and evaluation (M&E) training or basic research training, but often training programs have a short-term perspective (1–4 weeks) with limited follow up. Skills are not fully developed and newly trained professionals are underequipped to apply their new skills in the work setting (Clotteau G et al, 2011).

Capacity building of all staff at health facilities that complete monthly reporting has been recognized as vital in addressing challenges of using data for decision making and informing policy. Samoa (2013) says that enhanced capacity is also needed at all levels of the health system from staff at health facilities that complete monthly reporting sheets and doctors certifying cause of death to data entry clerks at information units and all the way up to senior decision makers who need to use the information for resource allocation and planning.

A 2009 regional assessment of health information systems by the Pacific Health Information Network (PHIN) found that one of the key challenges for countries was integrating data from a range of sources into an accessible shared system. Other key issues identified for HIS were: the need for stronger leadership and governance; the limited “culture of information use”; building capacity among individuals and institutions; limited (or non-existent) infrastructure and support for information technology; timeliness of information; and data completeness. PHIN

recommended the need for institutions to have human resource and structural capacity, complemented by the presence of a monitoring and evaluation function that ensures the production of consistent, timely and accurate data. This ensures increased availability of well documented quality data which is key in improving data use in policy formulation, program planning and monitoring and evaluation.

Without specific policies and interventions aimed at improving the use of data produced by information systems; health systems will never fully be able to meet the needs of the populations they serve. To date, clear guidance on how to comprehensively improve data-informed decision making is lacking.

3.0 STATEMENT OF THE PROBLEM & PROJECT JUSTIFICATION

3.1 Statement of the Problem

Hoima Hospital is one of the health facilities being supported by the FC project to provide fistula repair and prevention services. In August 2012, an assessment was carried out to determine its capacity to collect, store and utilize health data for decision making. Medical records personnel at the hospital were interviewed, HMIS registers and reports reviewed to assess data quality dimensions (especially focusing on completeness, accuracy and timeliness).Observations were made to verify existence of a proper filing system and dedicated data room.

Findings showed that all HMIS registers for the different services except family planning were available. Data for family planning was being captured in a counter book but it was not complete and accurate. Monthly summaries in the HMIS maternity, outpatient and antenatal care registers were not regularly compiled as expected. Maternity and family planning data captured in the monthly HMIS 105 report did not tally with what was in the respective registers for example whereas 485 deliveries were indicated in the monthly HMIS 105 report of July 2012, only 466 were captured in the maternity register. Poor storage of data in the medical records room was evident with many files heaped on the floor and not properly arranged according to the specific services provided and months when it was collected. In such a state it would not be easy to retrieve data for reference or verification purposes. Data issues were rarely discussed in meetings

6 and there was no functional data review committee in place. There were few staff at the hospital trained in using health facility data for decision making.

Proper data management is vital in collecting, aggregating, analyzing, storing, retrieving and reporting of data to measure health program performance. Good quality data is essential in monitoring and evaluating progress made in achieving health facility objectives and targets. The data collected can be used in planning, resource allocation, program design, quality improvement and effectiveness of health interventions. The MakSPH Fellowship project herein referred to as “the M&E project” addressed the gaps identified in order to strengthen data management and use at the hospital.

3.2 Justification for the project

The M&E project strengthened data management and use owing to the fact that the management of Hoima Hospital was very committed to addressing the undesirable situation as described in the problem statement. It was hoped that the positive changes/outcomes in six months of the project would motivate Hoima Hospital to sustain the interventions and also cascade them to lower level health facilities that it supervises. Also looking at the time frame (6 months), the project was feasible and all planned activities were implemented.

4.0 GENERAL & SPECIFIC OBJECTIVES

4.1 General objective

• To strengthen data management and use at Hoima Regional Hospital by September 2013.

4.2 Specific Objectives

• To improve data management at Hoima Hospital. • To promote the collection and reporting of good quality of data at the health facility specifically focusing on completeness, accuracy and timeliness. • To build the capacity of health workers in using data in decision making.

5.0 METHODOLOGY

The M&E project was implemented through several activities including engagement of health facility staff and management, an assessment of the data related training needs, formation of a data review committee, training, mentoring and coaching of health facility staff and refurbishment of the medical records office. Below is a detailed description of the interventions.

5.1 Project Inception Meetings

At the beginning of the project, three meetings were held i.e. the first meeting with key FC staff including the institutional mentor and other staff who were to be directly involved in project implementation. The purpose of the meeting was to present key highlights of the M&E project including the planned activities, timelines, budget implications and the roles of each staff member. The second meeting was held with the Hoima District Health Officer and Biostatician to brief them about the M&E project and to solicit for buy in and support in terms of providing technical guidance in training of health workers and conducting data review meetings at Hoima Hospital. The last meeting was held with selected staff at Hoima Hospital including the Hospital Director, the Senior Principal Nursing Officer, the Principal Hospital Administrator, medical records personnel and heads of department to brief them about the M&E project, planned activities, timelines, roles and levels of effort needed for each department in the hospital. During these meetings, Fellows were able to explain and clarify any issues not clear so as to promote common understanding and buy in from all stakeholders, to ensure integration and enhance the potential for sustainability of the activities.

5.2 Assessment of Hoima Hospital

An assessment exercise was carried out at the hospital to understand the training needs and knowledge levels of selected staff (heads of department and medical records personnel) in using data for decision making. Interviews were also held with medical records personnel to further understand the problem and to know what had been done since the last assessment that took

place in August 2012. The medical records office was also visited to see where the data shelves were to be installed.

5.3 Formation of a Data Review Committee

A data review committee comprising of 20 key staff from the different units/departments within the hospital was put in place. Terms of reference to guide the operations of the data review committee were developed by the Fellows and shared with committee members. The mandate of the committee chaired by the Hospital Director was to meet once every quarter to assess health facility performance by comparing data on key HMIS indicators collected over that period with the set performance targets. It also assessed the strengths and weaknesses of the data collected (data quality issues) and agreed on how to use it for decision making. Heads of units/departments including maternal and child health, outpatients, surgery, maternity, paediatric, HIV/ART, pharmacy, medical records and the laboratory sat on the committee. More specifically the data review committee performed the following roles and responsibilities; • Reviewed data collected in order to determine whether set targets were met, discussed explanations for deviations from the target and what needed to be done to improve performance levels. • Deliberated on data quality issues specifically focusing accuracy, completeness, timeliness and precision. • Advised the health facility management on actions that needed to be taken to improve the quality of care based on the data collected. • Documented decisions made based on the data collected. • Disseminated key performance data to all staff especially during general meetings.

5.4 Data for Decision Making Training

All members of the data review committee were equipped with basic knowledge and skills in using health facility data in decision making. A training manual on data for decision making earlier developed by EngenderHealth in collaboration with MOH was used by the facilitators to

prepare for the training. The training covered a number of the topics including an overview of data management, assessing data quality and its importance, data analysis, data presentation and utilization for decision making.

5.5 Mentoring and Coaching

This approach was used to provide ongoing support to medical records personnel and the data review committee at the hospital to address data quality issues (completeness, accuracy and timeliness), data storage, analysis, presentation and use. The Fellows worked alongside medical records personnel and other health workers to identify data quality issues from the different HMIS registers, analyzed and presented data collected. The Fellows also participated in all the three quarterly data review meetings to help committee members to synthesize data presented and to identify decisions that need to be taken to improve performance and quality of care.

5.6 Refurbishment of the Medical Records Office

Wooden shelves were installed in the medical records room and 250 box files were procured so as to facilitate proper filing and easy retrieval of data. A decision was reached in consultation with the hospital management to file data starting with 01 st July 2012 going forward owing to the fact that the hospital generates huge quantities of data on a routine basis and therefore it was impossible to file data retrospectively for more than one financial year. Data was filed according to the specific services provided and reporting period. A desktop computer and internet modem were also purchased and stationed in the medical records office to aid in electronic data entry into the DHIS2, storage, analysis and presentation.

6.0 PROJECT OUTCOMES

6.1 Improved Data Management and Storage

At the start of the M&E project, poor data management and storage in the medical records room was evident with many patient files, HMIS reports and registers heaped on the floor and not properly arranged as expected. The medical records room was too small and congested making it very difficult to reorganize it. Hoima hospital management accepted to relocate the medical records room to a more spacious room, painted it before shelves were installed using Fellowship funds. Selected hospital staff were able to file data according to the specific services provided and months when the data was collected. Box files were also distributed to the different departments/units in the hospital so that health workers can start filing data on a routine basis as patients are discharged.

Baseline situation Data filing improved after the M&E project

6.2 Data for Decision Making Capacity Building

To promote use of health facility data for decision making, a number of interventions were carried out including training of health workers, mentoring and coaching and holding quarterly data review meetings. Three quarterly data review meetings were chaired by the Hospital Director i.e. in April, July and October 2013. Presentations were made by each department/unit with in the hospital and decisions were made on how to use the data for decision making.

6.3 Improved Antenatal and Postnatal Attendance

In the first meeting held in April 2013 to review data for the January – March 2013 period, data showed that few pregnant mothers were coming back for the 4 th ANC visit as compared to the 1 st ANC visit i.e. Fig 1 shows that 1205 pregnant mothers came for the 1 st ANC visit as compared to 203 who turned up for the 4 th ANC visit. A decision was taken to intensify health education on the importance of completion of four ANC visits and returning for post natal care. This partly contributed to improved performance in the April–June and July –September 2013 period where 349 and 461 mothers attended four ANC visits respectively.

Fig 1: Improvement in ANC Utilization Jan-Sept 2013 However post natal service utilization

Jul-Sept 461 picked up slowly from no client utilizing 2013 1049 the service in the January –March period to 46 in the quarter that followed and 62 Apr-Jun 349 4th ANC 2013 1176 1st ANC in the July –September 2013 period.

Reporting period Jan-Mar 203 2013 1205

0 500 1000 1500

No of ANC mothers

6.5 Improved Procurement Forecasting for Drugs and Other Consumables:

Fourteen (14) maternal deaths were reported to have occurred during the January –March 2013 period due to post-partum hemorrhage (excessive bleeding) and the hospital was not able to save those mothers partly because of shortage of blood for transfusion and stock outs of misoprostol. A decision was taken to immediately order for misoprostol from National Medical Stores and to ensure regular supply of blood for transfusion from Nakasero Blood Bank. Anti- rabies and anaethesia drugs were reported to be out of stock in the April –June 2013 period. Injectables were rapidly being depleted in the pharmacy as the most preferred family planning methods by

clients and there was need to replenish stocks. As a result the pharmacy team added those drug supplies on the procurement plan before presenting it to the Medicines and Therapeutic Committee of the hospital for approval. Consequently they formed part of the next consignment of drugs delivered by National Medical Stores.

6.6 Improved Partograph Use in Monitoring of Labour

MOH guidelines state that all deliveries (labour) are supposed to be monitored using the partograph - a low-tech, paper based tool for graphically monitoring labor. However in the first data review meeting, data showed that only 56% (656 out of 1181 deliveries) were monitored. A decision was taken to mentor all staff in the labour ward on consistent and correct plotting of the partograph. As a result partograph use increased to 89% in the April –June 2013 period.

Training participants engaged in group work A health worker presenting during one of the data review meetings

6.7 Data Review Meetings at Departmental Level

The main focus of the M&E project initially was to ensure that all departments meet at least once every quarter to present data collected in the previous quarter in order to determine how to use it for decision making. However, in the first data review meeting it was realized that not all key data would be presented and discussed in the time allocated for each department. Therefore all heads of departments were encouraged to go further and hold data review meetings or integrate data issues into their routine meetings within their units so as to create more avenues for

discussions. As a result the HIV/ART unit started meeting every month to assess performance of selected indicators with technical support from the SUSTAIN project whereas the OPD, paediatric, maternity, maternal and child health units integrated discussion of data issues into their monthly meetings.

6.8 Data Quality Improvement

The Fellowship also aimed at improving the quality of HMIS data collected, compiled and entered/reported into the DHIS2. Medical records personnel and other health workers were mentored on how to improve data quality especially focusing on completeness, accuracy and timeliness. As a result there was a marked improvement in completeness of patient data, accuracy of monthly summaries for all HMIS registers and timeliness of reporting into the DHIS2 as illustrated below;

Table 1: DHIS2 Timeliness of Reporting Summary for January to September 2013

Type of Report Jan-March April –June 2013 July – Sept 2013 2013 (Baseline) (Midterm) (End of project) HMIS 105 0% (0 out of 3 67% (2 out of 3 67% (2 out 3 of reports on time) reports on time) reports on time) HMIS 009a Option B+ Addendum 33% (1 out of 3 100% (3 out of 3 100% (3 out of 3 Monthly Report reports on time) reports on time) reports on time) HMIS 033b Weekly Surveillance 0% (0 out of 13 46% (6 out of 13 38% (5 out of 13 Report reports on time) reports on time) reports on time) ARV/PMTCT NMS Monthly Report 0% (0 out of 3 67% (2 out of 3 100% (3 out of 3 reports on time) reports on time) reports on time) HMIS 106 Health Unit Quarterly 100% (1 out of 1 100% (1 out of 1 100% (1 out of 1 Report report submitted report submitted report submitted on time) on time) on time) Source: DHIS2

Table 1 shows the timeliness of reporting for five key DHIS2 reports. As a proxy measure of timeliness of reporting, the DHIS2 report summary for January to September 2013 was used to find out whether there was an improvement during the time the M&E project was implemented at Hoima Hospital. Data for the January – March 2013 period was used as a baseline, April – June as midterm and July – September 2013 as endline period. At baseline the average

timeliness of reporting was at 27%, increased to 76% at midterm and 81% at the end of September 2013.

Left: Incomplete monthly maternity register summary (Feb 2013) Right: Complete monthly maternity register summary (July 2013)

6.9 Support to other Health Facilities

At the start of the project, it was envisaged that Hoima Hospital will cascade data management and use interventions to lower level health facilities based on the interventions implemented, skills acquired and lessons learnt. However this was not possible because the six months for project implementation were not enough to realize such a secondary outcome. On the other hand EngenderHealth supported Kagando Hospital to establish a data review committee that currently meets every quarter to deliberate on data collected in the previous quarter in order to determine how to use it for decision making.

7.0 LESSONS LEARNT

• Sustainability of the data review committee and scale up of all other interventions is dependent on the commitment of the hospital management. The hospital management must be at the forefront to champion holding of regular data review meetings and to ensure that key decisions agreed upon are implemented.

• Improving health facility data management and use is a responsibility of all health workers. The common misconception that data issues only concern medical records personnel should be dispelled at every opportunity because data is one of the key pillars of the health system. • Continuous mentoring and coaching goes hand in hand with training health workers in using the data to make decisions. Training only stops at equipping health workers with knowledge and skills but on job mentoring and coaching is key in building their competences to collect good quality data, collate, analyze, present and use data for decision making.

8.0 CHALLENGES FACED

• The decision to shift the medical records office to a more spacious environment took four months to be implemented thereby delaying other processes namely installation of shelves, procurement of box files and the desktop computer. During that waiting period, Fellows started on procurement processes including solicitation of quotations for the desktop computer, shelves and box files in compliance with EngenderHealth SOPs. When the medical records office was finally shifted, Fellows fast tracked all the pending activities. • Sorting out data for filing from where it was initially heaped was difficult with patient records for some months missing. A team of health workers at the facility worked hard to trace all the missing records.

9.0 SUMMARY AND CONCLUSIONS

through training, mentoring and coaching them on site and holding quarterly data review meetings. Three meetings were held in which key decisions were made based on the data analyzed and presented. To foster more detailed and focused data discussions, the HIV/ART unit started holding monthly data review meetings to assess performance of selected indicators with technical support from SUSTAIN project whereas the OPD, paediatric, maternity and MCH departments integrated discussion of data issues into their monthly meetings. There was a marked improvement in the completeness of patient data, accuracy of monthly summaries for all HMIS registers and timeliness of reporting into the DHIS2 increased from 27% at baseline to 81% by the end of the M&E project. Strengthening data management and use at a regional referral hospital is a viable venture that is bound to succeed once the hospital management is committed and willing to put in place necessary structures.

10. RECOMMENDATIONS

• The medium term Fellowship should be extended to last one year. The six months allocated for project implementation are not enough to realize key outcomes and foster sustainability of interventions. • MakSPH –CDC Fellowship Program should require host institutions to make some financial contribution to cater for additional costs including transport, fuel and accommodation especially when Fellows are travelling to distant places to implement project interventions. This would ensure that a big proportion of Fellowship funds allocated goes into actual project implementation. EngenderHealth contributed UGX 3,173,000/= to cater for all costs of transport, accommodation, meals and other incidentals for the Fellows while in the field.

11. SCALE-UP/SUSTAINABILITY AND DISSEMINATION PLAN

In order to ensure sustainability of interventions, the Hoima District HMIS Office, senior management of Hoima Hospital, medical records personnel and the data review committee were involved in the planning and implementation of the project. The hospital management committed itself to always recharge the internet modem and to include box files on the budget

for stationary to ensure their steady supply. Convening of data review meetings does not have any cost implications and therefore management is committed to holding regular meetings. The District HMIS Office has recognized the importance of data review committees and intends to work with Hoima Hospital to support Kikube and Kigorobya HC IVs to properly file their data and start holding data review meetings.

EngenderHealth will continue supporting efforts aimed at strengthening data management and use at Hoima hospital and will scale up similar interventions to four more hospitals it supports including Masaka Regional Referral Hospital, Bwera District Hospital, Kagando and Kitovu Mission Hospitals.

The results of the project were recently disseminated in Hoima District and among the participants present were officials from the DHOs Office, the District HMIS Office and selected staff of Hoima Hospital. A similar meeting was held at EngenderHealth/Fistula Care project offices to share the findings with FC project staff. The Fellows will also present the results of the project at the end of the MakSPH CDC medium term Fellowship dissemination meeting scheduled to take place on 22 nd November 2013. Plans are underway to write a manuscript for publication in a peer reviewed journal and an abstract for presentation at a major national or international health conference.

REFERENCES

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Harrison T and Nutley T. A Review of constraints to using data for decision making: recommendations to inform the design of interventions. Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center; 2010.

Hotchkiss D, Diana M, Foreit K. How can routine health information systems improve health systems functioning in low-resource settings? Assessing the evidence base. Chapel Hill, NC: MEASURE Evaluation, Carolina Population Center; 2012.

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Nutley T, Moreland S and Hoke T. High impact research: building of data ownership and improvement of data use. The Lancet 2011; Supplement to: GHME Conference Organizing Committee. Shared innovations in measurement and evaluation: 93. DOI: 10.1016/S0140- 6736(11)60169-4. Publisher Full Text

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APPENDICES

Appendix 1: Terms of Reference for the Data Review Committee

The terms of reference describe the purpose, roles and responsibilities, composition and leadership of health facility data review committees.

Description and Purpose

A data review committee comprises of staff from the different units/departments within a health facility whose mandate is to meet at least once every quarter to look at the data collected over that period, its strengths and weaknesses (data quality issues) and determine how to use it for decision making.

Composition and Leadership

The data review committee has the responsibility to select a chairperson, vice chairperson and secretary to ensure that it remains functional and achieves its purpose. The chairperson should be an individual holding a top leadership position in the health facility e.g. Hospital Director/Health Center In charge; Medical Superintendent or Head of Department. The committee is at liberty to add other leadership positions on top of the three. Other representatives on the committee should preferably be heads of department or in charges of units or their deputies. Typically each department/unit should be represented by at least one or two individuals depending on the size of the health facility and the committee should not exceed 20 members. Examples of units/departments that need to be represented include the outpatients department, ANC/Post natal unit, family planning unit, the maternity/labour unit, HIV/AIDS unit and the medical records department among others.

Roles and Responsibilities

• To review data collected in order to determine whether set targets have been met, discuss explanations for deviations from the target and what needs to be done to improve performance levels. Data review should also help in comparing performance across different departments in order to explore areas of integration and related synergies. • To deliberate on data quality issues including accuracy, reliability, completeness, timeliness and precision. • To provide guidance to the health facility management on actions that need to be taken to improve the quality of care based on the data collected. • To document decisions made based on the data collected. • To work closely with the medical records team to analyze and display performance data in each of the departments/units with in the health facility. • Dissemination of key performance data to all staff especially during general meetings.

Frequency of meeting

The data review committee should meet at least once every quarter (in the second or third week of the month after the quarter has ended) to review the data collected in the previous quarter.

Documentation

The secretary of the data review committee should be able to document all the proceedings during the meeting including the action points and decisions made based on the data collected. The minutes should be shared at least a month before the next meeting.

Appendix 2: Sample of the Agenda for a Data Review Meeting

HOIMA REGIONAL REFERRAL HOSPITAL QUARTERLY DATA REVIEW MEETING Date: 24 th October 2013 Program for the Day Chairperson: Dr. Francis Mulwanyi Secretary: Nicholas Macho Activity Presenter Time Official opening by the Director and Dr. Francis Mulwanyi 09:00 - 09:10am Participant introductions Remarks from the Hoima District David Kabagambe 09:10 - 09:20am Biostatician Review of the minutes of the previous Sr. Florence Acheng 09:20 - 09:25am meeting Out Patients Department Presentation Sr Sunday Beatrice 09.25 - 09: 40am MCH Presentation Sr. Mary Tibamwenda 09:40 - 09: 55am Maternity/Labour Ward Presentation Sr. Rita Mbabazi 09: 55 - 10:10am Plenary Discussion All 10: 10 - 10:30am Break Tea All 10:30 – 11:00am Laboratory Presentation Dan Mulindwa 11:20 - 11: 30am HIV Presentation Nicholas Macho 11:30 - 11: 45am Paediatric Department Presentation Dr. Tom Ediamu 11:45 - 11:55am Plenary Discussion All 11:55 - 12: 15pm Pharmacy Presentation Margaret Abigaba 12:15 -12: 25pm Surgical Ward Presentation Dr. Winnie Kabuleta 12:25 - 12:35pm Dental Unit Dr. John Wobusobozi 12:35 -12:45pm Medical Records – Overall Performance Habib Byarufu 12:45 -12:55pm Presentation Plenary Discussion (Comments on data All 12:55 -01: 15pm presented, Key Decisions to be taken and Way Forward) Closing Remarks by the Hospital Director Dr. Francis Mulwanyi 01: 15 - 01: 20pm

Note: This schedule is not a standard one but it can be tailored to meet different needs

Appendix 3: Members of the Data Review Committee

No. Names Title 1 Dr. Francis Mulwanyi Hospital Director 2 Florence Achieng Senior Principal Nursing Officer 3 Deogratius Obel Principal Clinical Officer 4 Dr. Tom Ediamu Consultant Paediatrician 5 Florence Achieng Principal Nursing Officer 6 William Olum Senior Pharmacist 7 Beatrice Sande Nursing Officer 8 Rita Mbabazi Senior Nursing Officer 9 Winifred Mbabazi Senior Nursing Officer 10 Habib Byarufu Medical Records Officer 11 Miriam .H. Akello Nursing Officer 12 Stella Kachope Nursing Officer 13 Nicholas Macho Data Officer – SUSTAIN Project 14 Dr. John Wobusobozi Senior Dental Surgeon 15 Paska Awachango Nursing Officer 16 Margaret Nyakaisiki Nursing Officer 17 Mary Tibamwenda Senior Nursing Officer 18 Betty Bogere Nursing Officer 19 Daniel Mulindwa Laboratory Technician 20 Margaret Abigaba Pharmacist