Objective="Performance monitoring to improve services."
Details for Reform Option "Rationalised and computerised Health Management Information System (HMIS) for Public Health Information, Himachal Pradesh"
The existing information system (mostly running as part of the vertical disease control and Reproductive and Child Health programmes) was inadequate for the changing needs of the health system. Also for reasons of poor data quality it was neglected as a tool to support and improve decision-making and lacked the necessary ownership and commitment of its users. In addition, recording health activity data and merging the various registers was a time consuming process, which overburdens health workers. It involved completing 13 registers and preparing monthly reports.
A modified Health Management Information System (HMIS) system was started in 2002 as a pilot project in three districts (Hamirpur, Bilaspur and Kangra district) with the help of the German Agency for Technical Cooperation in India, GTZ. The basic theme was of “Reliable Data for Informed Decisions” specifically aimed at public health and NOT hospitals. In the new system the following modifications were introduced:
(i) Family Health Card (FHC): Health workers gave an FHC to each family at the time of annual survey. It has 22 sections. Each section has information related to the 13 different registers maintained by the health workers (See References). The basic data captured in the FHCs not only related to the RCH programme, but also to other vertical programmes like RNTCP, Blindness, Leprosy etc. In the FHC, the wife of the earning member is considered the household head. The card is kept by her and is brought every time a family member visits a health facility where it is filled by the Auxiliary Nurse Midwife (ANM).
(ii) Family Health Register (FHR): For each village one register is maintained by the ANM. This register includes information on all the sections covered by the FHC.
(iii) Monthly report compilation: This is prepared by the ANM in a format assigned by the Reproductive and Child Health Programme (Form no. 6) for each sub centre. The major departure from the earlier existing Form-6 was the inclusion of other vertical health programmes. An other “new” feature was that Form-6 was to be filled by all the health institutions, whereas earlier, it was filled only by Sub Centres.Services related to RCH and other vertical programmes, that were delivered by Primary Health Centres (PHC) but not captured in Form-6, were captured in Form-7.Similarly, services of hospitals at sub-division and district level that were not captured in Form-6 were captured in Form 8.
(iv) Computerisation of data entry and analysis at the block level: Sub Centres report monthly through Form-6, PHCs through Forms 6 and 7, and hospitals (sub-district and district level) through Forms 6 and 8. These forms not only capture service statistics (related to vertical programmes) for each facility, but also include “input” statistics like supplies and consumables, staff, etc., related to these vertical programmes.
The lowest level of computerisation is at the Block level, where data captured in Forms 6, 7 and 8 by all the health institutions in the Block is entered in a tailor made HMIS software (Front-end – “Visual Basic”, and Back-end – “Access”). After data entry, aggregate reports at PHC level and Block level are generated by the software, which is used for monthly feedback meetings at Block level. The aggregate data is transferred (through Floppy) to District level computers, where data for institutions above Block levels are also entered, and then an aggregate district report (Form-9) is generated by the software. This report is used in monthly meeting at district level.
The data is then transferred from the district to the state level server, where various state level reports are generated.
Also, in the software, there are checks and cross-checks for data entry, which helps in weeding out unscrupulous data.
Evaluation of the modified reporting system is underway but it has definitely reduced the health worker’s workload in filling in records and reports by reducing the number of registers. Authentic data in the form of disaggregated information (for each individual health facility) and also aggregated form (at PHC, Block, District and State level) exists for all vertical health programmes. The software also generates ranking reports and graphs for easy and quick performance monitoring at all levels of health facility.The generation of feedback to the sub centre has also helped the PHC Medical Officer (MO) monitor the reasons for poorly performing ANMs in different sub centres. This information is used for review and action at all levels in monthly review meetings.
A revised format of Family Health Cards were from UNFPA, printing of which was supported by the Basic Health Project HP.After initial installation of hardware and software along with basic training in the handling of computers and software, approximately INR 10,000 per annum per block is required on average to meet out the variable costs.
The new HMIS was piloted in three districts namely, Hamirpur (computers at Block as well as District), Bilaspur (computers only at District) and four of the twelve blocks in Kangra (computers at pilot Blocks and District), starting in 2002.
After successfully piloting for more than a year, it was decided to roll out to all the remaining districts, with computers at all the Blocks. At present (October 2005) the new HMIS is functional in all 12 districts of Himachal Pradesh.
Development and modification of the data entry forms (Forms 6, 7 and 8) took around nine months through a series of consulting workshops with users at all levels.
Development and stabilisation of software took around a year, although adding new features is an ongoing activity.
Installation and orientation of users takes around two days per site, with additional “Basic Computer Training” of two weeks.
Saves time: Number of registers maintained by the ANM is reduced from 13 to one. It has eliminated the duplication of information in many registers as well as saving worker’s time filling them.
Performance monitoring: Comparison of the performance of the ANMs by sub centre helps to provide a better understanding of reasons and gives ways to improve them.
Improved managerial decision making: Quick access to reliable information and visual graphical display on the health facility’s performance helps identify problems and possible solutions with the existing constraints.
Rationalised allocation of the resources: It is possible to rationalise and reallocate resources in almost real-time, to address any emerging health problem (like sudden increase in infant deaths, communicable diseases, in some particular areas).
Maintenance of software: Training was not given at the CHCs for maintaining software so every time there was a problem the headquarters at Shimla had to be approached.
Cards lost: Around 5-10% of FHCs are lost in each district. For this reason and because there is a migrant population, cards must be redistributed periodically every 5 years.
Sceptical users at field level: Some view computerisation as additional burden.
Training: ANMs need one day’s orientation training from their supervisors / MO to maintain the FHC and FHR.Statisticians also need training in additional software (Excel, Access, Windows) and in same basic hardware maintenance.
Identification of users need and projection of the financial resources: clear identification of the needs of the users in the foreseeable future is needed, along with the funds for procuring hardware and development of the software (either in-house or through outsourcing).
Who needs to be consulted
Users at all levels and technical experts.
It is easy to implement and cost effective in terms of finance and time. But it does depend on the level of commitment of managers at district and state level, availability of funds for procurement, development, maintenance and trainings.
Chances of Replication
Can be replicable in any other states of the country. However the reporting hierarchy of health institutions have to be defined and mapped before adopting the HMIS software.
It can form the base for decentralised health plans, involving public health and national health programmes. For smooth running, it is essential to have commitment towards the new system at all levels; along with a problem solving attitude, rather than fault finding attitude.
But care now needs to be taken that a dual reporting system does not evolve during the establishment of the State’s new HMIS system which itself is in the transition phase.
Dr. Anuradha Davey, Research Consultant, National Institute of Medical Statistics, April 2006.