STREAMLINING HMIS REPORTING AT BUMANYA HEALTH SUB …

STREAMLINING HMIS REPORTING AT BUMANYA HEALTH

SUB DISTRICT IN KALIRO DISTRICT

By

NANYONJO ROSETTE GENEVIEVE

MEDIUM TERM FELLOW

2013

Table of contents

Contents

Declaration ............................................................................................................................................... i

Fellow’s role in project implementation .................................................................................................. ii

Acknowledgements ................................................................................................................................ iii

Acronyms ............................................................................................................................................... iv

Abstract .................................................................................................................................................. v

1.0 Introduction and Background ............................................................................................................ 1

2.0 Literature review ............................................................................................................................... 2

3.0 Statement of the problem ................................................................................................................. 3

4.0 Justification ....................................................................................................................................... 3

5.0 Conceptual framework ...................................................................................................................... 4

6.0 Project objectives .............................................................................................................................. 5

Project Goal......................................................................................................................................... 5

7.0 Methodology ..................................................................................................................................... 5

8.0 Project implementation ..................................................................................................................... 8

9.0 Project achievements/outcomes...................................................................................................... 10

10.0 Lessons learned: ............................................................................................................................ 12

11.0 Challenges experienced and how they were overcome .................................................................. 12

12.0 Conclusions: .................................................................................................................................. 12

13.0 Recommendations: ........................................................................................................................ 13

14.0 Next steps...................................................................................................................................... 13

15.0 References: .................................................................................................................................... 13

List of Figures

Figure 1: Conceptual framework ...............................................................................................................

Figure 2 MoH Official facilitating training for In charges ........................................................................... 9

Figure 3: Status of health facilities submitting reports to HSD ............................................................... 10

Figure 4: Status of records management before project implementation .............................................. 11

Figure 5: Status of records management after project implementation ................................................ 11

List of Tables

Table 1: CQI project team ........................................................................................................................ 6

Table 2: Multi voting results ................................................................................................................... 7

3: Theme selection matrix ...................................................................................................................... 7

i

Declaration

I Rosette Genevieve Nanyonjo do hereby declare that this end-of-project report entitled

“Streamlining HMIS reporting at Bumanya Health Sub District in Kaliro District” has been

prepared and submitted in fulfilment 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 elsewhere.

Signed …………………………………… Date …………………….

Rosette Genevieve Nanyonjo, Medium-term Fellow

Signed Date …………………….

James Kakooza, Institution Mentor

Signed ………………………………………….. Date ……………………..

Dr. Benson Tumwesigye, Academic Mentor

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Fellow’s role in project implementation

This project was initiated by the Fellow together with Kaliro District and Bumanya Health Sub

District Staff. Since Kaliro District is one of the districts supported by Strengthening

Decentralization for Sustainability (SDS) Programme, it was easy to work with them. The

fellow introduced the concept of Continuous Quality Improvement (CQI) to the District Health

Team (DHT) and the Health Sub District (HSD) staff at Bumanya. The Health Management

Information System (HMIS) Focal Person together with the District Biostatistician were selected

to participate in project implementation. The Fellow initiated the idea of solving an HMIS

reporting problem to the DHT and HSD staff and led the process for problem identification,

development of counter measures, identification of practical methods and support supervision

during implementation of the project. The Fellow was not directly involved in implementation

but supervised the process and coached and mentored health facility staff in how to use the Plan

Do Check and Act (PDCA) approach to problem identification and thereafter the team

implemented the project.

iii

Acknowledgements

I wish to thank God for enabling the team to complete this project successfully.

I would like to thank Makerere School of Public Health – Centre for Diseases Control (MakSPH-

CDC) Fellowship Program for selecting me to be part of this Program. Special thanks to Mr.

Matovu KB Joseph for continuously guiding me.

To the SDS Programme for the support rendered to ensure smooth implementation of the Project.

Special thanks to Ms Ella Hoxha, Chief of Party, and Mr James Kakooza, my Institutional

Mentor.

I would also like to thank Dr. Benson Tumwesigye, my Academic Mentor, for his continuous

support and guidance.

Not forgetting the staff of Bumanya HSD and Kaliro DHO’s Office, Jafali Muhamed, Dr. Allan

Katamba and Joshua Mugweri, you were a wonderful team to work with.

Fellow CQI Fellows, thanks for the positive feedback during class time.

iv

Acronyms

CQI Continuous Quality Improvement

DHIS District Health Information System

DHO District Health Officer

DHT District Health Team

HMIS Health Management Information System

HSD Health Sub District

HUMC Health Unit Management Committee

HU Health Unit

MIS Management Information Systems

MRO Medical Records Officer

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Abstract 1.0 Introduction: The Health Management Information Systems (HMIS) reporting guidelines

require that health facilities submit complete reports to the Health Sub District (HSD) for entry

into District Health Information System (DHIS2). In 2012, none of the 19 health facilities

submitted reports to the HSD as required. This was due to the difficulty in accessing the HSD as

compared to the District and there was no data management system at the HSD. The purpose of

this project was to initiate the process of submitting reports to the HSD with the aim of

increasing the percentage of health facilities submitting reports to HSD from 0% to 100% in 5

months.

2.0 Project Description: This project involved 3 interrelated components: (i) orientation of in-

charges on HMIS reporting tools and guidelines, health facility in-charges were also sensitized

about the importance of submitting reports to the HSD); (ii) establishment of a data management

system at HSD (i.e. filing cabinets, files & a register for incoming reports were put in place) and

(iii) training of HSD Medical Records Officer (MRO) in data management and facilitation with

internet modem for data entry into the District Health Information System 2(DHIS)).

3.0 Project Outcomes: The number of Health Facilities that submitted reports to the HSD

increased from 0 (0%) in May 2013 to 7/19 (37%) in September 2013. The target of 100% could

not be achieved because of lack of compliance by the HSD MRO which was very crucial in the

implementation of this project. Nevertheless, the level of achievement attained helped to improve

the ability of the HSD to provide feedback to the health facilities through the Health Unit

Management Committees to improve reporting and other service delivery indicators.

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4.0 Lessons learned: While HMIS reporting guidelines emphasize the need for health facilities

to report through HSD than directly to the district, they don’t empower the HSD to demand

health facilities to report to them prior to reporting to the district

5.0 Recommendations: The reporting system needs to be configured in such a way that it only

allows reports into DHIS2 that have been initially entered at the HSD.

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1.0 Introduction and Background

Bumanya HSD is located in Kaliro District and is the only HSD in the district. Kaliro District

has 20 health facilities and only one HSD to which all the health facilities report. Bumanya is

one of the oldest health facilities in the district and serves a high population as it provides

services equivalent to a hospital in the district. As an HSD, it’s mandated by the Ministry of

Health (MoH) to perform certain key functions such as receiving HMIS reports from the lower

health facilities, data quality control, and ensuring data entry into the DHIS2 among others.

Despite the fact that the HSD is mandated to perform the above mentioned functions, it hasn’t

been doing so for instance as in the case of reporting where the health facilities were submitting

the reports directly to the District instead of the HSD hence the need for an intervention.

Strengthening Decentralization for Sustainability (SDS) is a 5 year USAID funded program

aiming at improving results and sustainability of decentralized service delivery, in Health and

HIV/AIDS, at Local Government levels in Uganda. Among the functional areas that SDS

focuses on is Management Information Systems for Health and Community Based Services

where HMIS is key. It also builds capacity of District personnel to utilize data from the existing

MIS like HMIS to make management decisions to improve service delivery.SDS supported

districts to develop District Management Improvement Plans and Kaliro district as one of the

districts supported, highlighted a gap in HMIS reporting that required support. It’s for this

reason that Kaliro was selected to benefit from this project.

2

2.0 Literature review

The HMIS is a set of integrated components and procedures organized with an objective of

generating information which will improve health care management decisions at all levels of the

health system. It is also a routine monitoring system that plays a specific role in the monitoring

and evaluation process which is intended to provide warning signals through the use of

indicators.The main goal of HMIS is to provide quality information to support decision-making

at all levels of the health care system in Uganda (MoH, HMIS Manual, 2010)

All reports generated at the health facility have to be submitted to the HSD and DHO by the 7th

of the following month. During health facility meetings, performance review should focus on

timeliness, completeness and accuracy of the submitted reports. These reports are to be

discussed during the quarterly HUMC meetings. The HSD is required to review the HSD

performance based on the HMIS as the routine reporting system. The HSD Health Information

Assistant shall be responsible for compilation of the administrative and service delivery reports.

All weekly, monthly, quarterly and annual reports from health facilities should be compiled into

a single HSD report (MOH, M&E Plan for Health Sector, 2011)

According to the MoH M&E plan, the HSD Health Information Assistant is responsible for

receiving all health unit data (including those from private providers) in the HSD, enter all health

unit data info the DHIS2, analyzing the quality of HMIS reports received and ensuring follow up

for incompleteness and delays, compiling all reports into a single HSD reports, analyzing the

data for discussion by the HSD team for decision making, forward HSD report to DHO, provide

quarterly feed-back on data management to health units among others

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3.0 Statement of the problem

The Ministry of Health reporting guidelines require that health facilities submit complete reports

to the HSD thereafter the HSD enters the data into the DHIS2 and analyses data to provide

feedback to improve performance of the health facilities. The health team observed that there

was inadequate HMIS reporting in Bumanya HSD as indicated by the report which showed that

out of the 19 health facilities none reported as required. This was not in line with the MoH

reporting guidelines which require that all health facilities should submit HMIS reports to the

HSD.

Despite the fact that the district had trained health facility in charges and records assistants in

HMIS reporting, the performance remained poor. This limited the HSD from undertaking its

responsibilities including checking the data for completeness, accuracy and timeliness, compiling

it and entering it into DHIS2 as well as analysing and providing feedback to health facilities. It’s

in this interest therefore, that this project aimed to streamline HMIS reporting at Bumanya HSD

as it’s the only HSD in the district responsible for 19 health facilities.

4.0 Justification

Reporting on health indicators through the HMIS is mandatory for all districts as it enables the

Ministry monitor progress and assess where the service delivery gaps are basing on the HMIS

data. MoH developed HMIS guidelines to be followed to ensure compete reporting is done and

in the right flow from the health facilities, consolidated at the HSD& entered into DHIS2 and

sent to the District for final submission.

Kaliro District had a challenge of untimely reporting into DHIS2 and one of the root causes was

because the District Bio Statistician was overwhelmed with entering all the data yet it’s supposed

4

to be entered at the HSD which was not happening. Some of the reasons as to why there were

these significant reporting gaps could be due to long distance from the health facilities to the

HSD, the HSD information assistant not being aware of his roles and the HSD not having a clear

data management system in place. It’s for this reason that the problem of inadequate reporting to

HSD was ranked the highest by the team.

5.0 Conceptual framework

From Figure 1 above, it can be observed that inadequate HMIS reporting by health facilities is

mainly caused by the difficulty in accessing the HSD due to long distances, no clear data

management system at the HSD and limited knowledge about the MoH reporting guidelines by

the health facility records staff. A data management system was set up at the HSD and the HSD

Medical Records Officer was trained in data management (including entry and recording), filing

cabinets and files were procured and all health facility records staff were trained in MoH

reporting guidelines and oriented about the importance of submitting reports to the HSD.

Figure 1: Conceptual framework

Limited knowledge

about MoH

reporting

guidelines

Inadequate

HMIS

reporting by

health

facilities

Lack of filing

cabinets and files

at HSD

Improved data

management

at HSD

Increased

submission of

complete

reports to HSD

Timely and

complete

entry into

DHIS2

No clear data

management

system at HSD

Limited

accessibility to HSD

due to long

distances

Train HSD records

Officer in data

management

Train HU records

staff in MoH

report guidelines

Sensitize HU

records staff in

importance of

reporting to HSD

5

The interventions mentioned above significantly increased the number of health facilities

submitting complete reports to the HSD. By establishing a data management system at the HSD

and training the HSD Records Officer in data management improved the capacity of the HSD to

file the incoming reports, records them and provide feedback to health facilities for

completeness, timeliness and accuracy on the reports submitted. This also improved the capacity

of the HSD Records Officer to enter the submitted data into DHIS2 as required. This project

therefore aimed at streamlining reporting in accordance with the MoH/HMIS reporting

guidelines which helped in improving timely and compete data entry into DHIS2.

6.0 Project objectives

Project Goal

The purpose of this project was to initiate the process of submitting reports to the HSD with the

aim of increasing the percentage of HFs submitting reports to HSD from 0% to 100% in 5

months.

Specific Objectives

To train all health facility In charges on HMIS reporting guidelines in the first 2 months

To strengthen the data management system at the HSD by August 2013

7.0 Methodology

CQI Project team formation

The CQI fellow held a series of meetings with various stakeholders from the project initiation to

its completion. Some of the people met included SDS Programme Institutional Supervisors, the

DHO, District Biostatistician, HSD In-Charge and the HSD Records Officer. During the initial

meeting with the District and HSD staff, the Fellow introduced the concept of CQI and the

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members present accepted to be part of the team and hence a concrete team of 5 members was

formed as shown in table 1 below:

Table 1: CQI project team

No. Name Position

1. Rosette Nanyonjo Fellow/ M&E Specialist

2. Baker Serwambala SDS M&E Specialist (Former CQI Fellow)

3. Dr. Katamba Allan Bumanya HSD In charge

4. Jafali Muhammed District Bio statistician

5. Mugweri Joshua HMIS Focal person/HSD Records assistant

The team comprised 3 members from Kaliro District which included the HSD In-Charge, HSD,

Records Officer and the District Bio Statistician. In addition, 2 staff members from SDS

including a fellow and an alumni member from the CQI 2011 Fellowship group and colleague.

Problem Identification

In order to come up with the problem to be addressed, various steps were taken and these

included; a brainstorming session on a number of challenges faced by the District Health Office.

Some of the problems included late HMIS reporting, poor quality of reports, inaccurate

department reports, inadequate reporting by health facilities, no data analysis, limited data use

and feedback, poor filing system and others. The key problems that were zeroed on are shown in

the table below:

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Table 2: Multi voting results

Problem

letter

Problems identified Vote1 Vote 2 Vote3 Vote4 Total

A Late HMIS reporting 3 2 1 6

B Poor quality of reports 3 3 2 1 9

C Inaccurate department reports 3 3 2 8

D Inadequate HMIS reporting

by health facilities

3 3 2 2 10

E No data analysis 3 0 0 3

F Limited data use andfeedback 5 3 2 1 11

G Poor filing system 2 1 1 4

From the table above, Limited data use and feedback ranked the highest with a score of 11,

followed by inadequate HMIS reporting by health facilities and poor quality of reports. The

concept of CQI focuses on a process related problem so the team decided that the highest ranked

problem had no process attached hence decided to settle for the second highly ranked problem of

inadequate reporting by health facilities.

Table 3: Theme selection matrix

Theme Customer Impact on

external

customer

Need to

improve

Overall score

A) Inadequate HMIS

reporting by health

facilities

District, HSD,

MoH

4.5 5 9.5

B) District overwhelmed

by data from health

facilities

Health facilities,

District

3.2 4 7.2

C) Health facilities not

reporting to HSD

Health facilities,

District

3.0 4 7

Basing on the outcomes in the theme selection matrix above, it was seen that inadequate HMIS

reporting impacted on the customer more which is the district because it made the district report

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late and also the HSD because it can’t do its work if the health facilities don’t report adequately.

The conclusion therefore was that there was need to streamline reporting by the health facilities

at the HSD level.

8.0 Project implementation

Counter measures were selected by the team members basing on the root cause analysis and

practical methods were identified for each counter measure. The project then focused on

implementing the following counter measures; ensuring health facilities report to HSD, putting in

place a data management system at the HSD, training the HSD Records Officer in data management,

providing filing cabinets and files and conducting regular review meetings to assess the progress of the

project implementation as well as providing feedback to health facilities through the health unit

management committee.

Orientation of in-charges on HMIS reporting tools and guidelines

Health facility Incharges and records assistants were trained in June as the first activity for the project.

The objective of this training was to orient staff on MoH/HMIS reporting guidelines and sensitize them

about the importance of submitting reports to the HSD. Twenty Five staff were trained from all the 20

health facilities in the district and this was done with the aid of a facilitator from Ministry of Health and

Kaliro District Bio Statistician.

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Figure 2: MoH Official facilitating training for In charges

Establishment of a data management system at the HSD

The HSD had never received any reports from the health facilities hence they didnt have a data

management system in place. Filing cabinets were procured, files for all health facilities and a register to

record in coming reports for timeliness, completeness and accuracy was also put in place.All files were

filed as they were sent to the HSD.

Training of the HSD Medical Records Officer on data management.

Th HSD MRO was trained in basic data management skills. These included recording incoming reports

and filing. An internet modem was purchased to enable the HSD MROenter the data into the DHIS2 as

required by the Ministry.

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9.0 Project achievements/outcomes

Objective 1: To train all health facility In charges on HMIS reporting guidelines in the first

2 months

Health facility In charges and MROs were oriented on HMIS reporting guidelines with emphasis

on the data flow as recommended by MoH. This led to an increase in the percentage of health

facilities submitting reports to the HSD from 0% to 37% in September 2013.

Figure 3: Status of health facilities submitting reports to HSD

Objective 2: To strengthen the data management system at the HSD by August 2013

A data management system was set up at the HSD in the MRO’s office with procurement of

files, filing cabinet and a register for tracking incoming reports. The system is now up and

running, reports that come are recorded for completeness and timeliness; these reports are well

filed in their respective files as seen in the picture below.

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Figure 4: Status of records management before project implementation

Figure 5: Status of records management after project implementation

Training of the MRO in basic data management skills was done and this resulted intoentering

incoming health facility data into DHIS2 as required. Additionally, using the basic data analysis

skills, feedback on performance was shared during the Health Unit Management Committee

meeting.

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10.0 Lessons learned:

While HMIS reporting guidelines emphasize the need for Health facilities to report

through HSD than directly to the district, they don’t empower the HSD to demand HFs to

report to them prior to reporting to the district

Compliance by the HSD MRO is key for improving HMIS reporting.

Data sharing is an informative way of providing feedback that can lead to improved

performance.

The target of 100% could not be achieved because it was too ambitious.

11.0 Challenges experienced and how they were overcome

Challenge Solution

1. Non-compliance of HSD MRO Involved Management to take action

2. Distance to HSD too long compared to

district hence limiting facilities from

submitting reports to HSD

Health units were encouraged to submit 2

copies to district to be picked by HSD MRO

3. Inadequate supply of HMIS triplicated

reporting tools hindered submission of

2 copies

Advised the DHO to lobby MoH and

Implementing Partners for more reporting

tools

12.0 Conclusions:

In conclusion, all the steps that were taken to implement the project from multi voting, theme

selection, root cause analysis, identification of counter measures, practical methods and

outcomes were key in ensuring successful implementation of the project. This led to results like

increase in the health facilities reporting to the HSD as required by MoH, a functional data

management system at the HSD and increased knowledge by the HSD MRO in data management

which will ensure that this practice stays on even after the project ended. Unfortunately the

target of 100% was not achieved because it was too ambitious and other challenges.

13

13.0 Recommendations:

The reporting system needs to be configured in such a way that it only allows reports into

DHIS2 that have been initially entered at the HSD. This way all facilities will ensure to

submit reports to the HSD.

MakSPH – CDC Fellowship Program to lobby with MoH to pilot a revised system in a

few districts with a similar challenge to see if there will be a significant change.

Recommend that SDS incorporates supporting HMIS reporting in supported districts that

have similar challenges with continuous technical assistance.

Ministry of Health to design some quality improvement indicators to be used to monitor

districts with similar reporting challenges

14.0 Next steps

Kaliro District Health Team to continue supporting and supervising the HSD to ensure

the data management system is functional and data entry into DHIS2 is done.

15.0 References:

1) Ministry of Health (2010), The Health Management Information System, Volume 1:

Health Unit Procedure Manual.

2) Ministry of Health (2011), Monitoring and Evaluation Plan for Health Sector, Strategic &

Investment Plan 2010/11 – 2014/15