Rapid Appraisal of DHIS

Rapid Appraisal of District Health Information System
REPORT DEVELOPERS
This report has been developed by a team headed by Dr. Farooq Azam Jan, DHIS Expert in close coordination of Mr. Syed Khalid Hussain and Mr. Asad Afzal - HIS Consultants under the technical supervision of Dr. S.M. Mursalin, Technical Coordinator HIS, WHO. WHO issued contracts /APWs to following professionals to support this study.
Dr. Farooq Azam Jan WHO Registration: 2011/173410-0 P.O. 200451300 EMPAK1005227 / 3.1.3 / 57225 Mr. Khalid Hussain Shah WHO Registration: 2011/185121-0 P.O. 200457286 EMPAK1005227 / 3.1.3 / 57640, 57225 Mr. Asad Afzal Humayoun WHO Registration: 2011/183433-0 P.O. 200457230 EMPAK1005227 / 3.1.3 / 57640, 57225
Table of Contents
ACKNOWLEDGEMENT ABBREVIATIONS EXECUTIVE SUMMARY 1. BACKGROUND 1.1 1.2 1.3 1.4 1.5 Introduction Objectives Districts Selected for Survey Methodology Operational Hierarchy 04 05 06 10 10 10 11 11 12 13 13 13 13 13 14 14 15 16 16 16 17 17 17 18 18 19 19 19 20 20
2. DATA ANALYSIS AND OBSERVATION 2.1. DHIS Functionality at Facility Level 2.1(a) DHIS Infrastructure & Functionality i. Respondents by Facilities and Designation ii. Flood Impact on Health Facilities & DHIS Functionality iii. DHIS Trained Staff at the Health Facilities iv. Status of DHIS Trained Staff Compiling Monthly DHIS Data at Facilities v. Availability of DHIS Data Collection Tools and Daily Update 2.1(b) DHIS Data Quality Parameters i. Availability of DHIS Procedure Manual & TORs ii. Staff Understanding on DHIS Reporting Tools vs Inconvenience iii. Knowledge and Practice of Monthly Submission of DHIS Reports iv. Reporting Regularity v. Feedback to Facilities vs Type of Feedback vi. Use of DHIS Data for Planning & Management vii. Situaiton of DHIS Tools at the Health Facilities viii. Keeping up Record of the Monthly DHIS Reports 2.1(c) DHIS Operational Needs i. Staff Trainings Needs ii. Replenishment of DHIS Tools Supply iii. Need of for Other DHIS Resources
2.2 DHIS Functionality at Managerial Level 2.2(a) DHIS Infrastructure & Functionality i. Respondents at Districts by Designation and DHIS Functionality ii. Availability of DHIS Trained Human Resources at Districts iii. Status of Monthly DHIS Reporting Compliance vs Time of reporting iv. Data Accuracy of the Field Units 2.2(b) DHIS Quality Parameters i. Usage of Different Quality Factors of the System ii. Validation of DHIS Data Reported in October 2011 2.2(c) DHIS Operational Needs i. Initial / Refresher DHIS Training ii. Need of Other Resources 3. CONCLUSIONS 4. RECOMMENDATIONS ANNEXURES A. B. C. D. E F. G. H. I. J. K. Selected District & Total Number of Health Facilities Visited List of Offices/ Facilities Visited List of DHIS Data Instruments Ensuring Data Quality Study Supervision and Team Timeline of Activities / Work Plan Field Data Collection Questionnaire (Managerial Level) Field Data Collection Questionnaire (Facility Level) Surveyed Data Output Tables Monthly DHIS Reporting Form (PHC) Monthly DHIS Reporting Form (Secondary Hospitals)
20 20 20 20 21 21 22 22 23 24 24 24 25 26
28 29 31 32 33 34 35 38 41 47 51
Acknowledgement
In any healthcare system the one most exciting input is the availability of an efficient Health Management Information System. Though, the national health status of Pakistan yet to show more achievements compared to many other countries. Federal Ministry of Health, in early 90s took concrete steps for setting up a coherent and a uniform system of data collection known as Health Management Information System (HMIS) initially for public health sector. Several international partners assisted this initiative. Later on to make this system more comprehensive at the district level it was transformed to District Health Information System. DHIS gathers information not only from first level care services but also from District and Tehsil Hospitals. The ultimate objective of all these efforts is to produce timely information of good quality for decision makers at various levels of working. Since the implementation of DHIS at all the districts of Punjab province in 2008, this performance assessment exercise was unique in its kind. Prime objective of this study was to realize if the new system is meeting the intended targets and its functionality adequately as was designed. I am confident that this report would help Provincial and District Health Managers to improve evidence based decision making in their respective areas. Here I would like to thank Dr. Anwar Janjua, former Director Health Services (MIS) Punjab for his kind support and tremendous cooperation that enabled me and my team to collect the desired data and other necessary information from the district and health facilities. Further, I would like to appreciate the overall technical supervision extended by Dr. S.M. Mursalin, Technical Coordinator, Health Information Management Unit/WHO. Significant inputs made by Mr. Imran Majeed especially during the study design phase and development of questionnaire are to be acknowledged. Here I would also thank my colleagues Mr. Khalid Hussain and Mr. Asad Hamayoun for their hard work and concerted efforts in completing this assignment and finalizing the End Assignment Report.
Dr. Farooq Azam Jan Team Leader
January 31, 2012
Abbreviations
ANC BHU CD DHIS DHQ DOH DEO EDO-H FLCF FP GRD HMIS HR LHS LHV LHW LQAS MCH MOH NGO OPD PHC RHC SHC THQ WHO Antenatal Care Basic Health Unit Civil Dispensary District Health Information System District Headquarters District Officer Health Data Entry Operator Executive District Officer-Health First-Level Care Facility Family Planning Government Rural Dispensary Health Management Information System Human Resources Lady Health Supervisor Lady Health Visitor Lady Health Worker Lot Quality Assurance Sampling Maternal and Child Health Ministry of Health Non Governmental Organization Outpatient Department Primary Healthcare Rural Health Center Secondary Healthcare Tehsil Headquarters Hospital World Health Organization
Executive Summary
The provision of timely and effective healthcare services is the key objective of any countrys health system. To maintain the health system in a good functioning status it is imperative to regularly monitor it through an efficient Health Information System. This system should be able to provide timely and qualitative information for evidence based decision making process. Realizing the impact of this very important factor specially in the public health sector government initiated a nationally standardized data generation system at all levels called Health Management Information System (HMIS) in early 90s. Given the experience both in the development of information systems, the new information needs and also, the initiation of several new programs this system has been modified to District Health Information System (DHIS) in 2007. DHIS now have a much wider scope than the old HMIS. The process led to revision of data collection indicators, tools and software. The upgraded version of DHIS was completed in 2007 and its implementation at district levels. But as this implementation was supposed to be carried out by the provincial health departments thus its timeframe varied from province to province. It was encouraging to note that Punjab Health Department took the lead to implement this program in all its 36 districts by end 2007. It was therefore high time to assess if the new system is being implemented as was primarily envisaged. This assessment study is based mainly on three focused areas of the system e.g. (i) Infrastructure & Functionality (ii) Data Quality and (iii) DHIS Operational Needs . Firstly to analyze and document the existing functionality of DHIS in districts, mainly to get sense of its functioning and work out immediate needs with regards to availability of Instruments, equipment and training needs, software issues, data recording and its transmission. Second, despite regular flow of data from the first level care facility (FLCF) to District HIS Cells and then to Provincial or National Cells there still exist serious concerns among the provincial and district managers on data quality and validity. Question is what additional measures are needed to improve data quality and use. Thirdly to identify the operational needs and areas of future support for improving the efficiency of information system To facilitate this process a very simple coded questionnaires was developed both for managerial and facility information. The theme of the questionnaire was based on three key assessment areas of the district health information system e.g. (i) DHIS Infrastructure & Functionality (ii) Data Quality and (iii) DHIS Operational Needs. Both close and open ended questions were included in the questionnaire. Further the questions were derived from the DHIS Procedures Manual and the monthly DHIS reporting forms to be used at Primary Health Care and Secondary Health Care Facilities Based on the originally approved/agreed plan between DHIS Directorate, Provincial Health Department and WHO, in total 10 districts were to be selected comprising districts both from flood and non flood affected districts. Therefore, to keep a balance, five districts were selected from flood affected areas and other five from non affected areas. The final selection of district names was made by the Provincial Health Directorate, which was primarily based on resource availability for the study and to ensure an even geographical coverage.
The districts included in this survey were; Rawalpindi, Jhelum, Sheikhupura, Okara, Faisalabad, Bhakkar, Layyah, Muzaffargarh, Dera Ghazi Khan and Rajanpur. In total 15 health facilities were planned to be visited per district with the aimed at to consider a mixtures of various types of health facilities from each district. Therefore a total of 150 facilities were visited. From these 10 Forms (annex-A) and 150 Forms (annex-B) were finally collected. The collected data was finally entered into the computer software SPSS (V-16) and analyzed both in graphical and tabulation form. Following are some major findings of this rapid appraisal; (a) DHIS Status at Facility Level i. DHIS Infrastructure & Functionality All health facilities affected by the flood of 2010-2011 were found re-habilitated. DHIS functioning observed to be an integral part of the public sector healthcare delivery system, as each and every health facility either it is primary or secondary healthcare, are regularly generating the health information of their respective areas. The 80% of the facilities incharges (e.g. 133 out of 150) got DHIS training, whereas the remaining 20% were observed as either untrained or self-trained. Among the staff deputed for preparation of monthly DHIS reports at the facilities it was observed that 92% (138 out of 150) were properly trained for this task. The availability of different data recording tools/registers was seen at 82% and 75% facilities do daily updation of these registers. ii. DHIS Quality Better understanding of the staff about DHIS forms was reported at 91%, whereas the remaining staff reported to face difficulty in understanding the Section-II, III and Section-VIII of the forms. Besides the junior rank officials, some Senior Medical Officer, Medical Officers and Female Medical Officers were also included in this category. DHIS procedure manual was found at 71% facilities (i.e. 107 out of 150). Similarly DHIS relevant TORs of the staff seen at 51% facilities. Almost all the staff had correct knowledge and practice regarding submission of monthly DHIS reports to their respective EDO-Health. During the last 12-months, 100% reporting regularity was observed at the facilities, however only three (03) facilities missed their five reports due to floods. It was encouraging to note that the 72% of the visited facilities (108 out of 150) confirmed that they regularly receive feedback from their respective EDOs-Health. However majority of the feedback 44% (66 facilities) was through discussion on monthly targets of the facilities and their performance. Almost half of the surveyed facilities (54%) used DHIS data for their routine planning.
A considerable number of facilities faced shortage of DHIS tools, as during 2011; 18% (27 out of 150) of the surveyed facilities faced this problem. Almost all the targeted facilities kept copies of their monthly sent reports for record. iii. DHIS Operational Needs There was a dire need for the supply of DHIS Tools / instruments in most of the facilities/ Districts. DHIS tools replenishment needed by 67% of the facilities and majority of them need one year supply in advance. The need of trained staff was reported by 43% (64) of the facilities. Whereas, 41% (61) facilities needed DHIS tools supply and some 23% (35) expressed for other kind of needs (e.g. Computer supplies/software). Other important expressed need was for online DHIS Data Entry System. (b) DHIS Situation at Managerial Level i. DHIS Infrastructure & Functionality. Comparing districts, the managerial level questionnaires was responded by the Statistical Officers/DHIS Coordinators (80%), whereas only 20% EDOs-Health participated in this survey. All desired hardware and the corresponding DHIS software was found available at all ten districts. Further the DHIS activities are being handled by an independent DHIS Cell, which is very encouraging. All the District DHIS Coordinators received DHIS training, but only six Data Entry Operators reported to have a regular training whereas the rest four did not have. The monthly reporting compliance by the districts was observed to be excellent. The data accuracy or consistency among facilities and districts HMIS units was observed to be excellent (81% - 100%).
ii. Data Quality. Almost all districts surveyed were found using DHIS data for LQAS techniques, (Lot Quality Assurance sampling), for both-way feedback, their service monitoring and district health planning. In the context of planning, it was observed that EDO-H didnt use data for strategic planning, but they did use this for day to day managerial issues. A negligible difference of reported figures collected from the health facilities and with the one with respective EDOs Health was observed. iii. DHIS Operational Needs. It was observed that District DHIS Office staff at the districts already reported to be trained on DHIS functionality, however they asked for further training. Regarding the need of resources out of those ten interviewed, nine district level respondents asked for refresher training, eight requested for system maintenance, six demanded computer hardware and four asked for updated DHIS software. Half of the districts asked for computer operators.
1. Background 1.1 Introduction National HMIS Cell, being is functioning since 1998 and has the mandate to assist Health Sector in development and launch of a nationally standardized Health Information System. National Health Information System is a mechanism of data collection, transmission, analysis and information feedback for all health related information. Over the years National Health Information System has become one of the major data source for the health sector in the country. Based on long implementation experience and demand from end users the existing system is now being transformed to a more efficient District Health Information System (DHIS). The reformed system, unlike the previous system, would gather and collate information from secondary hospitals (i.e. DHQ, THQ Hospitals) and some other important health care levels, as well. Currently out of 134 districts, staff from 96 districts have been successfully trained and shifted on District Health information System (DHIS). From these, nearly 65 districts have started regular reporting since last six months. This HIS Unit sponsored by WHO is responsible for data collection and analysis for the health data. Many partners including, WHO have been providing institutional support for development and the improvement of National Health Information System at the Federal, Provincial and District levels. Punjab Implemented the new system DHIS in all districts (36). Health Department of Punjab has requested WHO to conduct this appraisal for improvement and strengthening the system. 1.2 Objectives. Since 2009 DHIS is fully implemented and reporting at each District of Punjab province, thus there is a need for a quick rapid appraisal of District Health Information System mainly for improving the efficiency of DHIS. Following were the more specific objectives; To realize the current situation of Infrastructure & Functionality To assess the available Data Quality and To assess the DHIS Operational Needs
10
1.3 Districts Selected for Survey The selection of the districts was made from two basis i.e. one where the devastating flood of 2010-2011 damaged the public health settings and the second non flood affected areas. The list of selected districts can be seen from the table below. Non-Flood Affected Districts 1. Rawalpindi 2. Jhelum 3. Sheikhupura 4. Okara 5. Faisalabad Flood Affected Districts 1. Layyah 2. Bhakkar 3. Muzaffargarh 4. Dera Ghazi Khan 5. Rajanpur
1.4 Methodology a) Sampling Protocol: Based on the originally approved/agreed plan between DHIS Directorate, Provincial Health Department and WHO, in total 10 districts were to be selected comprising districts both from flood and non flood affected districts. Therefore, to keep a balance, five districts were selected from flood affected areas and other five from non affected areas. The final selection of district names was made by the Provincial Health Directorate, which was primarily to ensure an even geographical coverage in non flood affected districts. Regarding the total number of health facilities to be surveyed per district, a convenient random sampling technique was adopted. This aimed at to consider a mixtures of various types of health facilities from a district. In total 15 health facilities were planned to be visited per district. Therefore a total of 150 facilities were visited. From these 150 Forms (annex-B) were finally collected. Provincial Health Departments are adopting same procedure for monitoring and data quality in their respective districts, called Lot Quality Assurance Sampling Technique. (LQAS) The type/ list of these 15 health facilities/district is as follows; (i) Managerial Office (ii) Health Facilities; DHQ THQ MCH Centre Dispensary/CD/GRD RHC BHU = = = = = = Total = 1 1 3 3 3 4 16
11
1 (EDO-H office)
b) Data Collection Tool/Questionnaire A very simple and easy to understand questionnaire was developed both for managerial and facility information. The theme of the questionnaire was based on three key areas of the district health information system e.g. (i) DHIS Infrastructure & Functions (ii) Data Quality and (iii) DHIS Supply/Other Needs. Both close and open ended questions were included in the questionnaire. Further the questions were derived from the DHIS Procedures Manual and the monthly DHIS reporting forms to be used at Primary Health Care and Secondary Health Care Facilities. Moreover, to check the respondents knowledge and practice regarding monthly DHIS reporting activities, relevant questions were included in questionnaire. LQAS being an authenticated way of observing data quality, figures pertaining to five basic monthly reported indicators were also surveyed (see questionnaires at annexure). c) Data Collection Approach For the field visits, ten Data Collectors/Enumerators were engaged (i.e. one per district), where the District Focal Person (DHIS Coordinator of the respective district) joined them from respective districts. They also helped them for selection of facilities and preparation of field visit routing plan. Enumerators were given one day training at Islamabad on data collection strategy and on the understanding of data collection tools (questionnaires). d) Data Analysis Tool The collected data was entered and analyzed in computer software SPSS (V-16) and the analytical views and observations are given both in graphical as well as tabulated form.
1.5 Study Operational Hierarchy
12
2. Data Analysis and Observation

Study team was much satisfied with the collection of desired data as a total of ten filled-in forms were received from the managerial offices/levels (EDOs-Health) and 150 from the targeted facilities. The collected data was entered into the computer software SPSS (V-16), aiming at to get appropriate data analysis. The point-wise data analysis & discussions based on the data collection questionnaire for both facility and managerial levels are as follows; 2.1 DHIS Functionality at Facility Level 2.1(a) DHIS Infrastructure & Functionality i. Respondents by Facilities and Designation The field survey at the targeted health facilities revealed that in total nine District Headquarters Hospitals were interviewed against the planned ten. Reasoning of this when confirmed was that DHQ Hospital, Rawalpindi doesnt report the monthly DHIS data to their EDO-Health. However, to cover the sampling size in number, an additional Tehsil Headquarters Hospital of Rawalpindi district i.e. total 11 THQ Hospitals instead of planned 10 were included. The other facilities e.g. MCHCs, GRDs, RHCs and BHUs were covered according to approved plan (see table # annexure-H). Out of the selected 150 health facilities majority of the respondents (88) were professionals and qualified officials, which significantly compliment the credibility of our data. The graph below shows the number and type of respondents in this study. Status of Respondents by Designation
50 45 40 35 30 25 20 15 10 5 0
43
Numbers
26
24
24 14
12 4 1 1 1
Medical Dispenser Officer
LHV
Sr. Medical Officer
Medical Medical Woman Supdtt. Technician Medical Officer
DOH
Pharmasist Statistical Officer
ii.
Flood Impact on Health Facilities & DHIS Functionality It is observed that out of the total 75 health facilities, selected from the five flood affected districts (i.e. Layyah, Bhakkar, Muzaffargarh, DG Khan & Rajanpur), only five (05) facilities were reported to be seriously affected by floods. All were later rehabilitated by the health departments.
13
An encouraging point was that the monthly DHIS data reporting is now being considered as an integral part by all the District Health Offices. Resultantly, almost all the health facilities either primary or secondary type is regularly generating the health information for District Health Offices. iii. DHIS Trained Staff at the Health Facilities A timely, accurate and reliable data generation is well desired from this District Health Information System. It is observed that this is more or less and this is absolutely dependent upon the incharge of the health facilities. Therefore, their training on the DHIS Data Collection and Reporting tools becomes critical. It was found during the survey that out of 150 incharges of the facilities, 133 (80%) got DHIS training, whereas for remaining 17 health facilities, no staff was formally trained in DHIS. So the DHIS is being maintained either by untrained or a self-trained person. In this context the situation by districts revealed that almost all the (100%) incharge of the visited facilities at districts of Bhakkar, D.G. Khan, Jhelum, Muzaffargarh and Okara got DHIS training. This was followed by Rawalpindi, Rajanpur, Sheikhupura and Layyah with 80% - 87% interviewed staff trained Somehow, comparatively less number of DHIS trained staff/ incharges (53% ) were found trained in District Faisalabad. This needs to be further explored. Status of DHIS Trained Staff by District
100 100 100 100 100 87 87 80 80
100 90 80 70 60 50 40 30 20 10 0
(Percent)
53
iv.
Status of DHIS Trained Staff Compiling Monthly DHIS Data at Facilities DHIS reports are to be submitted on monthly basis from the health facilities to districts. Therefore the training of health facility staff, preparing such reports becomes mandatory for some good information. (i.e. DHIS-21 & DHIS-22).
14
Fortunately, the received data analysis showed some good results. As out of the 150 staff interviewed, 138 (92%) had DHIS Training on Data Collection Tools. While analyzing for the type of staff trained, it was found that higher number of dispensers got this training that was 81/87 (i.e. 93%). Other staff interviewed included LHVs. Where all l22 were trained, Out of 20 Medical Officers interviewed 16 were trained. For Medical Technicians out of 13 interviewed all were trained), nurses (total 2 interviewed) both were trained. Out of five (5) Statistical Assistants, four (4) were Status of Trained vs Untrained Staff Deputed for Monthly DHIS Reporting
100 80 Numbers 60 40 20 0
Dispenser Staff Deputed Trained Staff 87 81
LHV 23 22
Medical Officer 20 16
Medical Technician 13 13
Nurse 2 2
Statistical Assistant 5 4
found trained. v. Availability of DHIS Data Collection Tools and Daily Up-date Availability of different data recording tools/registers (list annexed) and their daily update was also observed during the survey. The overall analysis of the ten surveyed districts showed that data collection tools were available in 82% of the facilities surveyed. However, the daily updation was being done at 75% of the health facilities. Status of Availability of Different Data Tools and Their Daily Update by District
100 90 80 70 60 50 40 30 20 10 0
97 86 84 83 83 82 82 77 73
71
Percentage
Tools Availability (%age) Daily Updation (%age)
15
The graph above shows that most of the health facilities of district Muzaffargah, Bhakkar, Faisalabad, Layyah and Okara update their activity registers on daily basis, which is very encouraging. On the other hand, some of the health facilities belonging to districts of DG Khan, Sheikhupura, Rawalpindi, Rajanpur and Jhelum do not update their record on daily basis. 2.1 (b) DHIS Data Quality Parameters i. Availability of DHIS Procedure Manual & TORs One of the basic parameter for having good quality of data is to have DHIS Procedural manual for ready reference. So that in case of some ambiguity this manual could be consulted. . The study revealed that out of 150 health facilities DHIS procedure manual was available only at 107 facilities. On the other hand roles and responsibilities (TORs) with respect to DHIS were found available at only 77 selected facilities. . Status of Availability of DHIS Procedures Manual & TORs
15 12 9 6 3 0
Availability of Manual Availability of TORs
Among districts, considerable disparity in availability of procedure manual was observed in the districts of Muzaffargarh, DG Khan, Jhelum, Okara and Rajanpur. However, better availability of TORs was observed at districts of Muzaffargarh, Layyah, Bhakkar and Faisalabad. However, comparatively lesser availability of DHIS Manual was observed at Sheikhupura, Rawalpindi and Layyah. ii. Staff Understanding on DHIS Reporting Tools vs Inconvenience Better understanding of the staff deputed at the health facilities (136 out of 150) on the chapters and indicators of monthly DHIS form (DHIS-21) was observed in the Districts of Bhakkar, DG Khan, Jhelum and Layyah. However, lesser understanding (14 out of 150) was noted in the districts Rajanpur, Rawalpindi, Sheikhupura and Faisalabad. Here majority of the staff faced difficulty mainly to understand the Sections-II, III and VIII. It is pertinent to mention here that Section-II of the form related to monthly performance of the health facility with reference to set their monthly targets. SectionIII gives data of OPD by gender and the age group and whereas Section-VIII relates to maternal and child health activities.
16
# Facilities Visited
It was noted that both junior levels staff (Medical Technician & LHVs) and the senior rank officers i.e. Senior Medical Officer, Medical Officers and Woman Medical Officers, also face difficulty in understanding DHIS forms and thus need necessary refresher training in some of the districts. iii. Knowledge and Practice of Monthly Submission of DHIS Reports A question about the exact dates of submission of monthly report was asked. It was observed that almost all the incharges of the health facilities had knowledge and practice regarding the timing of submission of monthly DHIS reports to their respective EDOs-Health. However, some variation between the knowledge and practice was observed at Bhakkar, Faisalabad and Layyah district and this may be due to certain follow up delays. Reporting Regularity In principle each health facility has to submit monthly report. It was seen that almost all the health facilities compiles its monthly DHIS report and send regularly to their respective EDO-Health office. In this context, as per facilities record, it was noted that only three (03) health facilities out of 150 surveyed missed their only five reports due to floods. Otherwise all of these sent their monthly reports. These facilities included; Civil Dispensary, Gajanthal/ DG Khan (missed one report), BHU Kotla Nasir / Rajanpur (one report) and THQ hospital, Jampur / Rajanpur (three reports). Regarding the data quality, it was noted that standardized monthly DHIS reporting form is being used at all type of health facilities. In principle the routine healthcare activities varies from each type of health facility. The review team observed that monthly data forms being reported by a CD/GRD contained incomplete figures compared to the information obtained from RHC or BHU level facility. v. Feedback to Facilities vs Type of Feedback A proper and timely feedback mechanism plays key role not only to cover the short falls of the missing data to be reported from the health facilities, but also, to positively improve the healthcare services delivery at each level. Therefore, when inquired, out of the 150 selected facilities, 108 (72%) informed said that these are regularly receiving feedback from their respective EDO-Health. Remaining 42 (28%) facilities informed that these didnt receive such Status of Health Facilities Received feedback from higher formations. Among districts, relatively better response was obtained from the districts of Okara, DG Khan, Jhelum, Sheikhupura and Rawalpindi. However, EDO-Health Faisalabad, DG Khan and Rajanpur need to enhance feedback to their health facilities. .
Feedback From EDO-Health on DHIS Reports
No Feedback (28%)
iv.
Receive Feedback (72%)
17
To a question on type of feedback the health facilities received. It was observed that majority of the facilities 66 (44%) told by their respective EDO-Health to visit EDOs office and discuss the monthly targets and their performance etc. Some 26 (17%) facilities responded that, their high ups called them to discuss the administrative and managerial issues. At the 15 (10%) facilities correction of the monthly DHIS data was asked. However, only one facility found to be received feedback on their stock and supplies. vi. Use of DHIS Data for Planning and Management Adequate and appropriate health data is desired not only for day to day operational use but also for planning and management of the health services. During the survey, the facilitys incharges were asked; either they use DHIS data for any kind of planning or for any other management functions. It was realized that nearly half of the targeted facilities (54%) use this data for their routine planning, whereas the remaining half (46%) didnt use it for any purpose rather sent to their Health Facilities used DHIS Data EDOs-H.
for Planning
Among districts, comparatively good responses were received from the districts of Jhelum, Muzaffargah, Sheikhupura and Bhakkar. On the other hand facilities of D G Khan didnt use DHIS data for any kind of planning. Similar response was also reported from the Districts of Rajanpur and Faisalabad.
No (46%)
Yes (54%)
It was asked as to what kind planning is done .It was found that they use data for multiple reasons like for managing the medicine stock, setting of monthly OPD targets, follow-up of disease pattern, field/seasonal planning, provision of maternal & child healthcare and family planning services, EPI services planning, performance evaluation of the staff and organization of community meetings. vii. Situation of DHIS Tools at the Health Facilities To keep up the daily records of the different healthcare activities at any health facility, sufficient stock of registers is essential. It was noted that during 2011 a considerable number of health facilities e.g. 18% (27 out of 150) reported to have faced DHIS tools shortage. Among districts, better stock position was observed at district DG Khan and Rawalpindi. It was followed by Faisalabad, Layyah, Okara, Bhakkar and Muzaffargah. However, comparatively high stock-out of DHIS tools was observed at Sheikhupura, Jhelum and Rajanpur.
18
To identify the duration of this shortage, it was noticed that 15% (20) health facilities faced such shortage for three months or more, which could be a matter of concern for the district health managers. On the other hand, 3% (7) facilities told that DHIS tools shortage is there for one month only.
Status of Facilities Faced Shortage of DHIS Tools

1-Month Shortage (15%)
Facilities Didn't Faced Shortage (82%)
Facilities Faced Shortage (18%)

3-Month shortage (3%)
viii.
Keeping up Record of the Monthly DHIS Reports Since no computerized data management is being done currently at the health facilities, therefore, pervious months records of monthly report is desired to be kept at the facilities. This past record is essential for making comparison regarding OPD burden, disease patterns and other healthcare activities. It was noticed that almost all the targeted health facilities were found be kept such record. Only four facilities of district Faisalabad reported not keeping up such record.
2.1(c) DHIS Operational Needs Needs i. Staff Training Needs. It was realized that there is a significant need for training on DHIS tools and mechanism. About 85% (128 out of 150) of the health facilities incharges recommended for having refresher training in DHIS. Though, there were some extensive training organized in DHIS but still a need was felt for Status of Staff Needs DHIS Trainings improvement of their skill. This survey revealed that out of the total 150 Trainings interviewed staff, 65% (97) Not Needed (15%) asked for training in DHIS indicators analysis, which is a healthy sign. Some 11% (18) staff needs training on LQAS technique and 9% (13) officials informed that they need training on DHIS forms filling.
LQAS Technique (11%) Staff Need Training (85%) Indicators' Analysis (65%)
Forms Filling (9%)
19
ii.
Replenishment of DHIS Tools Supply To overcome the shortage of DHIS tools, it was enquired as to what kind of supply or replenishment of DHIS tools is desired by the health facilities. The data analysis pointed out that 67% (100 out of 150) of the facilities needed replenishment of tools. Further investigation revealed that 27% (41 out of 100) need six months advance supply. However, 39% (59 out of 100) of the health facilities desired to have whole year supply of DHIS tools (see table # 14 at annexure-H). Need for other DHIS Resources To a question on what kind of DHIS relevant resources they needed, multiple answers were given by the respondents e.g. 160 responses were recorded from the 150 targeted interviewees. Further data investigation concluded that 43% (64) wanted to have additional human resources for DHIS. This was followed by 41% (61 responses) for DHIS Tools and some 23% (35 responses) for various miscellaneous things.
iii.
2.2 DHIS Functionality at Managerial Level 2.2(a) DHIS Infrastructure & Functionality i. Respondents at Districts Level by Designation and DHIS Functionality Comparing across districts, it was observed that majority of the managerial level questionnaires 80% (8 out of 10) were responded by the Statistical Officers, who are also performing at the districts as DHIS Coordinators. However, 20% (2 out of 10) were the responded by EDO-Health. Respondents Status by Designation Further the data analysis 10 revealed that at all 10 selected 8 districts DHIS was implemented in letter and spirit. And all the 6 financial and technical support 4 for this program was extended by the provincial health 2 department.
# of Districts 0 EDO-Health Distt. Coordinator It was also noted that all desired hardware and the corresponding DHIS software was provided to all the 10 targeted districts. Moreover, the DHIS activities are being managed by an independent District level DHIS Cell, which was an encouraging sign.
ii.
Availability of DHIS Trained Human Resources by District Regarding the availability of type of staff trained in DHIS (e.g. EDO-Health, Distt. Coordinator & Data Entry Operator), it was observed that all the District Coordinators got DHIS training. On the other hand, 60% (six out of ten) EDO-Health were trained. Another potential factor involved in this system is data entry operators. It was found that 70% of the data entry operators are exposed to DHIS Training.
20
120 100 Percentage 80 60 40 20 0
District Level Health Staff Trained in DHIS by Type. 100

70 60
Dist. Coordinator
DHIS Computer Operator
EDO Health
iii.
Status of Monthly DHIS Reporting Compliance vs Time of Reporting In almost all the districts visited it was observed the monthly DHIS reporting compliance was in perfect condition. All the surveyed districts were found to be sending their monthly reports to Provincial DHIS Cell regularly. Regarding the timing of sending monthly DHIS reports by the EDO-Health office to their provincial DHIS Cell, it was observed that out of the ten surveyed districts, seven districts (70%) were observing stipulated time schedule i.e. 15th of next month. Status of Timing for Sending Monthly DHIS Reports to Provincial DHIS Cell
Not as per schedule (30%)
However, other three (30%) though send their reports regularly, but with some extra delay, which might be due to some administrative reasons. These three districts were Districts of Rawalpindi, DG Khan and Rajanpur. iv. Data Accuracy of the Field Units The quality of data at district level depends upon what is being received from the health facilities. . When asked from District Health Office about data accuracy it was informed by the interviewed officials that 40% of their field units achieved the level of (80 100%) data accuracy. The other 30% achieved just level-2 (i.e. 71% - 80%) and level-3 (i.e. 51% - 70%).
As per schedule, 1 5th of month (70%)
21
Among districts, better result was reported from Jhelum, Muzaffargah, Bhakkar and Rajanpur. However, comparatively low data accuracy was observed at Districts of Sheikhupura, Faisalabad and Layyah. Based on the analysis, it is suggested that this area of data quality needs to be addressed in a benefitting manner.
Data Accuracy of Field Units

51% - 70% (30%)
80% - 100% (40%)
71% - 80% (30%)
2.2(b) DHIS Data Quality Parameters i. Usage of innovative Lot Quality Assurance Sampling Method An Innovative system was designed as part of DHIS development process to assess and improve the quality of data being produced by DHIS. This technique was labeled as LQAS (Annex-D). The findings of the survey revealed that all the surveyed districts were using LQAS techniques for checking data quality and observing both-way feedback and service monitoring. In the context of planning, this review highlighted that at the district level, DHIS is not being used for strategic planning, but to sort of District Health Plans. of Different DHIS Quality Data Usage Use Status of Different Data Quality Assessment Methods
100 90 80 70
Percent
60 50 40 30 20 10 0
Use LQAS Technique Sent Feedback to Facilities Receive Feedback Use Data for Services Use Data for Health from Provincial DHIS Monitoring Planning Cell 100 100 100 90 90
22
ii. Validation of DHIS Data Reported in October 2011 In order to validate the monthly reported data, survey team collected the figures for some basic indicators for the month of October 2011, both from the health facilities and respective EDOs office. The comparison of the figures for both the levels showed that there is a very slight difference of figures. Though this difference is minor however it could challenge the credibility of both the institutions..
Validation of Data for 5-Indicators of DHIS Reports (Oct'2011) District Figures Reported by Health Facilities Total # of OPD 56811 56811 65894 65894 128771 128774 48863 48846 52552 52552 109869 109869 14701 13689 40721 51125 45397 49414 71180 70725 634759 647699 Total # of suspected Malaria 539 539 1147 1147 277 277 622 307 842 842 3977 3977 169 155 2223 2223 680 690 328 328 10790 10485 Total # Family Plg. visits 365 365 1163 1163 1618 1617 593 593 506 506 1048 1048 715 686 761 777 916 894 747 747 8432 8396 Total # of 1st ANC visits 1660 1660 2619 2619 2767 2749 1480 1479 1212 1212 1802 1802 957 907 1592 1592 1316 1350 3137 3137 18542 18507 Total # of community meetings 36 36 36 36 35 34 133 132 17 17 37 37 14 14 64 64 61 101 174 174 607 645
Bhakkar
EDO Office Health Facilities
D G Khan
Faisalabad
Jhelum
Layyah
Muzaffargarh
Okara
Rajanpur
Rawalpindi
Sheikhupura
EDO Office 150-Health Facilities 10-EDO Offices
Overall 10Districts
23
2.2 (c) DHIS Operational Needs i. Initial / Refresher DHIS Training Though, DHIS relevant staff at the districts already reported to be trained on DHIS functionality, however they need further training. The training demands by cadre it was observed that 90% of the surveyed Data Entry Operators need such training. Further eight EDOs were also found to be trained in DHIS. In 60% of the surveyed District DHIS Coordinators also requested for the training. Training Need Assessment for DHIS Functioning at Districts
90 80 60
100 90 80 70 60 50 40 30 20 10 0
Percentage
Data Entry Operator
EDO-Health
Distt. Coordinator
ii.
Need of Other Resources The respondents were given six options to answer their requirement related to DHIS improvement. Since multiple responses were recorded, therefore the data analysis concluded that 90% (9 out of 10) respondents asked for refresher training. It was followed by system maintenance (80%), hardware and tools demanded by 60%. Half of the districts asked for computer operators and 40% respondents requested for updated DHIS software. Status DHIS Resources Needed by Districts
100 90 80 70 60 50 40 30 20 10 0
90 80 60 60 50 40
Percent
Refresher Training System Maintenance Hardware DHIS InstrumentsComputer / Tools operatorSoftware
24
3. Conclusions
The District Health Information System (DHIS) has been designed for collecting and reporting information so that the Managers of health institutions can manage, plan, monitor and evaluate the operations and performance of the health facilities and disease patterns in their respective districts. This study has demonstrated various encouraging findings. The findings suggest that efforts made by the Provincial and District HIS stakeholders have now bore fruit and DHIS have become truly functional in selected districts, which is a much commendable effort. However certain deficiencies have become evident from this survey this included lack of capacity of the data relating health personnel and non use of information for evidence based decision making especially for planning and management of health services. Results show that there is still a need for refresher training. Staff are facing difficulties in filling various sections of the monthly reporting forms especially section-II which is of prime importance in assessing the performance indicators of the respective health facilities. Therefore thus a need for the enhancement of the capacity of healthcare providers especially related to data collection, its entry and particularly as the data analysis. In this regard a refresher training of all the healthcare providers including incharge of the facilities becomes imperative. It was encouraging to note that the reporting regularity of most of the health facilities was in optimal state Data accuracy remained with acceptable limits. This study suggested specific training for the healthcare providers with emphasis on use of information and evidence based decision making. Prime aim of DHIS is not the gain of data or information but to improve health conditions based on data. The current situation of DHIS as evident from the results of this study demands that the decision makers has to take initiative for further collaborations among various vertical health programmes. For this an integrated approach be adopted which will not only save the resources but also improve the efficiency of the District Health Information System in totality. There is need to enhance the use of information at the facility level by improving capacity of the Health Managers and health providers. On the basis of the results of this report signify that training and system strengthening strategies for improving performance are continuous processes and need regular attention of health care managers.
25
4. Recommendations
To improve the quality of Services and optimizing utilization of resources, the District Health Managers, Medical Officers / In-charge of the Health Facilities need to be encouraged to use information generated through DHIS. For this purpose quarterly meetings / Supervisory visits and discussions among information generators and users are mandatory. To realize the real use of information special efforts are required to establish a regular feedback mechanism between health facilities and District DHIS Cell. Basic training to the new staff, not previously exposed to the DHIS or refresher training is to be ensured training. There is a need for building capacity of DHIS Focal persons and Statistical Officers in data analysis and use of information. There is continuous need for improvement of DHIS Software specially for making this user friendly. Need for regular estimate/ forecasting and availability of DHIS Printed supplies at district and facility levels. Need for reasonable budgetary allocation to maintain the system in working conditions. Filling of the vacant posts of technical staff by posting / recruitment in the district is required on priority basis. Establishment of online DHIS reporting system at Health facility level needs to be implemented in future for rapid data transmission. A need was that such assessment study should become a regular feature of DHIS implementation in districts in order to improve efficiency of health information system.
26
Annexures
27
Rapid Appraisal of District Health Information System Annexure-A
Selected Districts
Number of Total Health Facilities Visited

District
Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Total
DHQ 1 1 1 1 1 1 1 1 0 1 9
THQ 1 1 1 1 1 1 1 1 2 1 11
RHC 3 3 3 3 3 3 3 3 3 3 30
BHU 5 4 4 4 5 4 4 8 4 4 46
MCH 2 3 3 3 2 3 3 1 3 3 26
GD/CD 3 3 3 3 3 3 3 1 3 3 28
Total 15 15 15 15 15 15 15 15 15 15 150
28
Annexure-B
List of Offices/Facilities Visited

District Sr #
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Name of Office/Facility
EDO-Health, Rawalpindi THQ Hospital Gujjar KHan THQ Hospital Taxila MCH 1 Gujjar Khan MCH Dhab Ali Asbar MCH S. Town GRD Walayatabad GRD Shakrial GRD Sorasi RHC Khayabane Sir Syed RHC Mandra RHC Kotli Satiyan BHU Devi BHU Jatli BHU Salargah BHU Bijincal EDO-Health, Sheikhupura DHQ Hospital Sheikhupura THQ Hospital Mureedke MCH Centre 1 MCH Fish Form MCH Khokhar Town GRD Khanpur GRD Burj Attari GRD Ferozwala RHC Kharianwala RHC Jandial Sher Khan RHC Sharqpur Sharif BHU Ranikey BHU Chapka Minara BHU Bhiki BHU Nabi pur EDO-Health, Okara DHQ Hospital Okara THQ Hospital Depalpur MCH Mucipal MCH Okara MCH ShairghaR GRD 18 GRD 34 GRD-39/3R RHC Wasawala RHC Shah Bor RHC Renala Khurd BHU Fazal Shah BHU Bhoman Shah BHU 4/42 BHU 23/2L
District
Sr #
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Name of Office/Facility
EDO-Health, Jhelum DHQ Hospital Jhelum THQ Hospital Jhelum MCH Kehwra MCH Kala Gujran MCH Shandar Chowk GRD Rathian GRD Khurd GRD Lahri RHC Domaili RHC Dina RHC Jalalpur Sharif BHU Dherila Jalip BHU Sohan BHU Banth BHU Kala Gujran EDO-Health, Faisalabad DHQ HJospital Faisalabad THQ Hospital Samundary MCH Ravi Mohallah MCH Khalidabad MCH 224/RB CD 76/GB CD 72/GB CD 248/RB RHC Satyana RHC 65/GB RHC 229/GB BHU 267/RB BHU 468/GB BHU 474/GB BHU 198/GB EDO-Health, Layyah DHQ Hospital Layyah THQ Hospital Karor MCH Layyah MCH Choubara BHU 366 GRD 150 GRD 98 ml GRD Sumra thal RHC Fateh pur RHC Jaman RHC Azam Chowk BHU 157 TDa BHU 151- TDA BHU Sammarpur BHU 306 TDA
Rawalpindi
Sheikhupura
Layyah
Okara
Faisalabad
Jhelum
29

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. EDO-Health, Bhakkar DHQ Hospital Bhakkar THQ Hospital Kalarkot MCH Kalorkot MCH Bhakkar BHU Saeed wala GRD GD 42 TDA GRD City RHC Behal RHC Jandawala RHC Dewala BHU Dagger BHU 67 ml BHU Kohawar Kalam BHU Kotta Jam EDO-Health, Dera Ghazi Khan DHQ Hospital D G Khan THQ Hospital Taunsa RHC Tibbi Qaisrani RHC Shah Sadar Dir RHC Chotti Zarin CD Gagan Thal CD Jinnah Colony GRD Drehama MCH 3 MCH Taunsa MCH 1 BHU Haghi Ghazi BHU Nutkani BHU Ghausabad BHU Hairo Sharqi 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. EDO-Health, Muzaffargarh DHQ Hospital Muzaffargarh THQ Hospital Kot Addu MCH Kot Addu MCH Muzaffargarh MCH Ali Pur CD TMA CD Darbar Muhammad Musa CD Binda Ishaq RHC Sinwan RHC Khan Garh RHC Shabir Sultan BHU Khanpur BHU Jadaywala BHU Mariain BHU Dani EDO-Health, Rajanpur DHQ Hospital Rajanpur THQ Hospital Jam Pur MCH Jam Pur BHU Jahan Pur BHU Kota Subzal BHU Kot Lafasan BHU Murghat CD Khal Chas RHC Mithan Kot RHC Fazal Pur RHC Muhammad Pur BHU Wang BHU Kotla Nasir BHU Noor Pur BHU Tabbi Londan
Dera Ghazi Khan
Rajanpur
Muzaffargarh
Bhakkar
30
Annexure-C
List of DHIS Data Instruments

DHIS 01 (R) DHIS 02 (F) DHIS 02-A (F) DHIS 03 (R) DHIS 04 (F) DHIS 05 (R) DHIS 06 (R) DHIS 07 (R) DHIS 08 (F) DHIS 09 (R) DHIS 10 (R) DHIS 11 (R) DHIS 12 (C) DHIS 13 (R) DHIS 14 (C) DHIS 15 (R) DHIS 16 (R) DHIS 17 (R) DHIS 18 (R) DHIS 19 (R) DHIS 20 (R) DHIS 21 (MR) DHIS 22 (MR) DHIS 23 (MR) DHIS 24 (YR) DHIS 25 (YR) DHIS 26 (M) DHIS 27 (M) DHIS 28 (M) DHIS 29 (M) Central Registration Point Register OPD Ticket Medicine Requisition Slip Outpatient Department Register OPD Abstract Form Laboratory Register Radiology/Ultrasonography/CT Scan/ECG Register Indoor Patient Register Indoor Abstract Form Daily Bed Statement Register Operation Theater (OT) Register Family Planning Register Family Planning Card Maternal Health Register Antenatal Card Obstetric Register Daily Medicine Expense Register Stock Register (Medicine/Supplies) Stock Register (Equipment/Furniture/Linen) Community Meeting Register Facility Staff Meeting Register PHC Facility Monthly Report Form Secondary Facility Report Form Tertiary Hospital Monthly Report Form Catchment Area Population Chart Health Institute Database (HID) Report Form Training Manual for Trainers for DHIS Participants Manual for DHIS Procedures Manual for DHIS DHIS Software Users Manual
31
Annexure-D
ENSURING DATA QUALITY USING LOT QUALITY ASSURANCE SAMPLING (LQAS) TECHNIQUE
Data Accuracy Check Sheet Randomly Selected Data Elements from the monthly reporting form 1
1. OPD monthly report section 2. OPD monthly report section 3. EPI monthly report section 4. Family Planning monthly report section 5. Mother Health monthly report section 6. LHW monthly report section 7. Community meeting monthly report sec. 8. Stock monthly report section 9. 10. 11. 12.
Write down month for which data accuracy is Checked Figures from Figures Do Figures from the Monthly counted from Column 2&3 report form registers match? 2 3 Y N
LQAS Table: Decisions Rules for sample sizes of 12 and coverage Targets/Average of 20-95 Average Coverage (Baselines)/Annual Coverage Targets (Monitoring and Evaluation)
Sample Size Less than 20% N/A 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%
12
10
11
32
Annexure-E
Study Supervision and Team

Study Team Dr. Farooq Azam Jan, Team Leader/ DHIS Review Study Mr. Khalid Hussain Shah, HIS Consultant/Member Review Team Mr. Asad Afzal Hamayoun, HIS Consultant/Member Review Team WHO Technical Supervision Ms. Fatma Giha, Information Management Coordinator Dr. S.M. Mursalin, Technical Officer, HIS Mr. Imran Majeed Malik, Data Management Supervisor, / Study Design Mr. Zeeshan Abbas, Data Analysis support Punjab Health Department Dr. Muhammad Anwar Janjua, Director MIS Mr. Farooq Ahmed, Data Management Officer, MIS Cell District Health Office Ch. Ali Ahsan, District Focal Person, Rawalpindi Dr. Roadab Irfan, District Focal Person, Jhelum Miss Noor Fatima, District Focal Person, Sheikhupura Ms. Sajida Tufail, District Focal Person, Okara Mr. Ijaz Hussain, District Focal Person, Faisalabad Mr. Muzamil Mubeen, District Focal Person, Layyah Mr. Javed Aziz, District Focal Person, Bhakkar Mr. Saleemullah, District Focal Person, Dera Ghazi Khan Ms. Tahira Saleem, District Focal Person, Muzaffargarh Mr. Tahir Mehmood, District Focal Person, Rajanpur
33
Annexure-F TIMELINE OF ACTIVITIES / WORKPLAN (October January, 2011) October Wk Wk -2 -3 November Wk Wk Wk Wk -5 -6 -7 -8 December Wk Wk -10 -11 January Wk Wk -14 -15
Activities Technical Coordination Team Formation Development of working paper / technical material Consultative Meeting for Questionnaire
(development & finalization)
Wk -1
Wk -4
Wk -9
Wk -12
Wk -13
Wk16
Logistic Arrangements Preparatory & Coordination Meeting Field Activity Data Collection, Synchronization, and Entry Analysis and report development Report Review Finalization of Report & Dissemination Dissemination of Results
34
Annexure-G
REVIEW OF DISTRICT HEALTH INFORMATION SYSTEM

(In selected districts of Punjab)
(District Managerial Level Questionnaire)
District: ________________________ Respondent Name: ________________________ PART-I DHIS INFRASTRUCTURE & FUNCTIONING 1.
1.1 1.2 1.3 1.4
Date of Visit ___________________ Designation. (1) EDO, (2) Dist. Coord.
Is DHIS implemented at your district?

If YES, then tell since when (Year) it was implemented. Does DHIS Cell exists in EDO Office (Please observe) Is your DHIS Cell affected by flood (2010-2011) If YES, does it re-habilitated after flood. What is your monthly (Oct11) DHIS reporting compliance to your Prov. DHIS Cell? 1: (81% - 100%), 2: 71% -80%), 3: 51%-70%), 4: (50% or Less than 50%)
1
Yes
No
Yes Yes Yes 2 Yes 3
No No No 4 No
2. 3.
3.1
Are DHIS Instruments (Registers) available (As per Requirement)?

If YES, for how much Period
4. 5. 6. 7.
7.1 7.2 7.3
What is the Funding Source of DHIS Functioning? Is a separate Hardware Computer available for DHIS? Corresponding Functioning of DHIS Software Available Are the Human Resources Trained on DHIS functioning?
EDO Dist Coordinator (DHIS) DHIS Computer Operator Yes Yes Yes
Yes Available 1 2 Yes Yes No No
No No No
No Not Available 3 4
8.
8.1
Is there a defined DHIS specific Terms of Reference / Roles & Responsibility of each level (EDO, Distt. Coord. Health Facility Staff).
If YES, Please provide a copy. (Please get copy, if possible)
9. 10.
10.1
What is the data accuracy of your field units?

1: (81% - 100%), 2: 71% -80%), 3: 51%-70%), 4: (50% or Less than 50%)
When did you sent your past-month (Oct11) DHIS data (electronically) to the Provincial DHIS Cell?
(1) As Per Schedule - 15 of the Month, (2) Not as per schedule Verify from system (email etc) when the last report (Oct11) was sent.
th
2 Not as per schedule
As per schedule
35
-2PART-II DHIS DATA QUALITY 1. 2. 3. 4. 5. 6. 7.

7.1
Do you have DHIS Procedural Manual in your office? Is your DHIS data entry operator fully understands the DHIS reporting Forms? Do you check the data quality of your field units through LQAS? Do you send the data feedback to your health facilities? Do you receive regular feedback from your Prov. DHIS Cell? Do you analyze the monthly DHIS data for service monitoring? Do you use the DHIS data for your district health planning?
If YES, Please explain.
Yes Yes
No No
Yes Yes Yes Yes Yes
No No No No No
8.
Please get data of following indicators by Health Facilities (For Oct2011) from respective DHIS Cell of the district.
Name of Health Facilities (only selected for survey)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Total # of OPD Total # of suspected Malaria Total # Family Planning visits Total # of 1st ANC visits Total # of community meetings
PS. Cross check with concerned facility monthly report of the same month (as per Facility Level Questionnaire).
36
-3PART-III 1.
1.1 1.2 1.3
DHIS SUPPLY/OTHER NEEDS
Is your Human Resource need any DHIS training?

EDO Dist Coordinator (DHIS) DHIS Computer Operator Yes Yes Yes
Yes
No No No
No
2.
2.1
Is the supply of DHIS Data Collection Tools (Registers) needs to be replenished? (Normally supply of Tools issued for 2-months)
If YES, then tell what kind of replenishment. (1-In advance 6 month, 2-Whole year stock)
3.
3.1 3.2 3.3 3.4 3.5 3.6
Do you need relevant resources (if not available) to run DHIS?

DHIS Computer Operator Hardware Software System Maintenance DHIS Instruments / Tools DHIS Refresher Trainings Yes Yes Yes Yes Yes Yes No No No No No No
Name of Data Collector: _________________________________
37
Rapid Appraisal of District Health Information System Annexure-H
REVIEW OF DISTRICT HEALTH INFORMATION SYSTEM

(In selected districts of Punjab)
(Facility Level Questionnaire)
Name of Facility ______________________________ Facilitys ID ___________________Type: ______________________ Union Council _________________________ Tehsil __________________________ District __________________________ R/Name (Preferably Facility In-Charge) ________________________________ Designation: __________________ Health Facility Affected by Flood 2010-11 (Yes / No), if YES Does it Re-habilitated (Yes / No) PART-I DHIS FUNCTIONING What is your length of service in the Health Department? 1.
(1) Less than 1 year (1) Less than 1 year (2) 1-5 Year (2) 1-5 Year
(3) 6-10 Year (4) More than 10 Year (3) 6-10 Year (4) More than 10 Year
1 1 1 Y
2 2 2
3 3 3 N
4 4
2. 3. 4.
4.1
Since how long you are working at this Facility?
Since how long you have been assigned DHIS Functioning/Reporting?

(1) Less than 1-Year (2) 1-3 Year (3) More than 3-Year
Are you trained on DHIS Data Collection Instruments (Registers)?

If YES, then tell the source (Agency) from where you got the training?
5.
5.1
Who fill the DHIS Monthly Reporting Form (Designation)?

Is above staff/person trained for this task?
Y N
6.
6.1
Are the following data resources (Tools) available for monthly DHIS recording & reporting?
1. Monthly DHIS Reporting Forms 2. OPD tickets 3. Abstract register 4. Laboratory register 5. Mother Health 6. Child Health 7. Catchment Area Population chart 8. Stock register 9. Family Planning Register 10. Meeting & Yearly attendances register.
Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N
6.2
Are the Registers updated on daily basis? (see any one of the register for validation)
38
PART-II
1. 2. 3.
3.1
DHIS DATA QUALITY

Y Y Y N N N
Do you have DHIS Procedural Manual at your facility? Do you have defined DHIS related Roles & Responsibility of each staff? Do you fully understand the DHIS reporting Forms?
If NO, then which section you feel difficult to understand. (write Form Sec. #)
4. 5. 6. 6.1 7. 8. 8.1 9.
9.1
Do you know when the monthly DHIS reporting Form should be sent to EDO office? (1) Within 7-Days (2) Within 15-Days (3) Within 30-Days From where you get the data to fill DHIS reporting Forms? Do you submit monthly DHIS Forms to your EDO-H regularly?
If NO, State the reason
When did you submit your monthly DHIS report to your EDO-H?
(1) 5th of each month (2) 15th of each month (3) After 30-days.
Do you remember how many monthly reports were not submitted by your facility to EDO-H during last 12-Months? (State in numbers)
If YES, State the reason
Do you receive any feedback of your monthly report?

If YES, then state the kind of feedback.
10. 11.
11.1
Which section of the DHIS reporting form you often analyze (I - XVII)? Is your facility using the DHIS data for planning?
If YES, what kind of planning you usually do?
Y N
12.
12.1
Have you faced any shortage of DHIS Tools (Registers) at your facility during 2011?
If YES, then state the shortage in months. (1) 1-Month (2) 2-Months (3) 3-Months or more
1
Y 2 Y
N 3 N
13.
13.1
Do you keep the copy of monthly DHIS reported forms for your record?
If YES, then check the final figures of past-month (Oct-11) of following indicators from their copy. (If NOT then see their Registers). 1. Total # of OPD 2. Total # of Suspected Malaria 3. Total # Family Planning visits 4. Total # of 1st ANC visits 5. Total # of community meetings
39
PART-III
1.
1.1.
DHIS SUPPLY/OTHER NEEDS

Y 1 Y 1 Y 2 N 2 N N 3
Do you need any training of DHIS on reporting mechanism?

If YES, then tell kind of training. (1) Form filling (2) LQAS check (3) Indicators analysis etc.
2.
2.1
Is the supply of DHIS Tools (Registers) needs to be replenished?

If YES, then tell what kind of replenishment. (1) In advance 6 month (2) Whole year stock
3.
Do you need relevant resources (if not available) for DHIS functioning?
If YES, state the kind of resource (Could be Multiple Responses) i) HR Tools
Y Y Y
N N N
3.1
ii) iii) Others (Elaborate others, if YES for data entry purpose e.g. write below the response in your own words)
40
Rapid Appraisal of District Health Information System Annexure-I Table # 1: Designation DOH Dispenser LHV Medical Officer Medical Supdtt. Medical Technician Pharmacist Sr. Medical Officer Statistical Officer Woman Medical Officer Total 10-Districts DHQ 0 1 0 0 5 1 1 0 1 0 9 Respondents by Type of Facility THQ 0 0 0 2 9 0 0 0 0 0 11 MCH 1 1 23 1 0 4 0 0 0 0 30 GRD 0 18 1 8 0 2 0 0 0 1 30 RHC 0 1 0 5 0 0 0 23 0 1 30 BHU 0 5 0 27 0 5 0 1 0 2 40 Total 1 26 24 43 14 12 1 24 1 4 150
Table # 2: District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10-Districts
Status of Facility Incharges Trained on DHIS Trained Not Trained # of Facility % # of Facility % 100 0 15 0 100 0 15 0 53 47 8 7 100 0 15 0 87 13 13 2 100 0 15 0 100 0 15 0 80 20 12 3 80 20 12 3 87 13 13 2 133 89 17 11
Total Facility Visited 15 15 15 15 15 15 15 15 15 15 150
Table # 3:
Status of Tools Availability &Their Daily Update at selected Facilities.
District Muzaffargarh Jhelum Bhakkar D G Khan Rajanpur Faisalabad Layyah Okara Rawalpindi Sheikhupura Overall 10-Districts
Tools Availability (%age) 97 86 84 83 83 82 82 77 73 71 82
Daily Update (%age) 97 80 84 50 72 82 82 77 68 62 75
41

Table # 4: Status of Availability of DHIS Manual and TORs of Staff
District
Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10-Districts
Manual Available (# of Facility)

11 14 11 13 9 15 11 10 9 4 107
% 73 93 73 87 60 100 73 67 60 27 71
TORs Available (# of Facility) 14 2 10 2 15 15 0 8 7 4 77
% 93 13 67 13 100 100 0 53 47 27 51
Table # 5: Respondents Understanding of DHIS Forms vs Sections Difficult to Understand
District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10-Districts
Understand (# Respondents) 15 15 14 15 15 15 15 8 11 13 136
Not Understand (# Respondents) 0 0 1 0 0 0 0 7 4 2 14
Forms Section Difficult to Understand Section-II 7 3 1 11 Section-III 1 1 2 Section-VIII 1 1
Table # 6: Status of Knowledge and Practice regarding Monthly DHIS Report Submission Knowledge Practice Within Within Within 5th of 15th of After 30 District 7-days 15-days 30-days Month Month Days Total N N N N N N Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10-Districts 15 14 15 15 15 14 15 15 11 14 143 0 1 0 0 0 0 0 0 0 1 2 0 0 0 0 0 1 0 0 4 0 5 15 15 15 15 15 15 15 15 15 15 150 14 15 14 15 14 15 15 15 12 14 143 1 0 1 0 1 0 0 0 0 1 4 0 0 0 0 0 0 0 0 3 0 3
Total 15 15 15 15 15 15 15 15 15 15 150
42

Table # 7: Status of Health Facilities Received Feedback from their EDO-Health
District
Yes N
10 15 4 14 11 9 15 5 12 13 108
No %
67 100 27 93 73 60 100 33 80 87 72
N
5 0 11 1 4 6 0 10 3 2 42
%
33 0 73 7 27 40 0 67 20 13 28
Total
15 15 15 15 15 15 15 15 15 15 150
Table # 8: Status of Issues and Type of Feedback Received from their EDO-Health To discuss Admin & Ask for Stock & District target/ Managerial correction in Medicine performance Issue the forms Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura
Overall 10-Districts
Total 10 15 4 14 11 9 15 5 12 13 108
7 9 3 8 6 6 5 3 8 11 66
2 6 0 6 3 3 0 0 4 2 26
1 0 1 0 2 0 10 1 0 0 15
0 0 0 0 0 0 0 1 0 0 1
District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10-Districts
Table # 9: Is your facility using the DHIS Data for Planning Yes No N 10 0 5 15 9 15 7 2 7 12 82 % 67 0 33 100 60 100 47 13 47 80 55 N 5 15 10 0 6 0 8 13 8 3 68 % 33 100 67 0 40 0 53 87 53 20 45
Total 15 15 15 15 15 15 15 15 15 15 150
43
Table # 10: Status of Shortage of DHIS Tools at Health Facilities
Yes District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura
No % 13 0 7 40 7 20 13 33 0 47 18 N 13 15 14 9 14 12 13 10 15 8 123 % 87 100 93 60 93 80 87 67 100 53 82 Total 15 15 15 15 15 15 15 15 15 15 150
N 2 0 1 6 1 3 2 5 0 7 27
Table # 11: Status of Shortage of DHIS Tools at Facilities

District
Facilities Surveyed
15 15 15 15 15 15 15 15 15 15 150
Facilities Facing Shortage of Tools N %

2 0 1 6 1 3 2 5 0 7 27 13 0 7 40 7 20 13 33 0 47 18
Shortage in Months 1-Month

1
%
7 0
3-Month
1
%
7 0
1 4 0 0 0 1
7 27 0 0 0 7 0
0 2 1 3 2 4
0 13 7 20 13 27 0
0 7
0 5
7 20
47 13
44

Table # 12: Facilities Keep Record of the Monthly DHIS Reports
Yes District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura
No % 100 100 73 100 100 100 100 100 100 100 97 N 0 0 4 0 0 0 0 0 0 0 4 Total % 0 0 27 0 0 0 0 0 0 0 3 15 15 15 15 15 15 15 15 15 15 150
N 15 15 11 15 15 15 15 15 15 15 146
Table # 13: Facility's Incharges Need Trainings vs Kinds of Trainings they Needed
District Total Facilities Visited 15 15 15 15 15 15 15 15 15 15 150 Facility's Incharges Need Training N 14 15 14 11 15 15 8 15 9 12 128 % 93 100 93 73 100 100 53 100 60 80 85 Forms Filling 3 0 6 2 1 0 1 0 0 0 13 % 20 0 40 13 7 0 7 0 0 0 9 Kinds of Training Needed LQAS Check 2 0 2 1 0 0 5 2 4 2 18 % 13 0 13 7 0 0 33 13 27 13 12 Indicators' Analysis 9 15 6 8 14 15 2 13 5 10 97 % 60 100 40 53 93 100 13 87 33 67 65
Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Overall 10Districts
45

Table # 14: Status of DHIS Tools Supply Replenishment Total Facilities Visited 15 15 15 15 15 15 15 15 15 15 150 Facilities Need Replenishment N 7 15 1 4 11 14 15 14 4 15 100 % 47 100 7 27 73 93 100 93 27 100 67 6-Months Advance Supply 1 0 0 3 10 2 3 13 2 7 41 Kinds of Replenishment % 7 0 0 20 67 13 20 87 13 47 27 Whole Year Supply 6 15 1 1 1 12 12 1 2 8 59 % 6 15 1 1 1 12 12 1 1 8 39
District
Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Total
Table # 15: Status of DHIS Relevant Resources Facilities Needed District Bhakkar D G Khan Faisalabad Jhelum Layyah Muzaffargarh Okara Rajanpur Rawalpindi Sheikhupura Total # of Facilities Visited 15 15 15 15 15 15 15 15 15 15 150 # Facilities Needed Resources N 7 15 7 8 5 15 2 11 9 9 88 % 47 100 47 53 33 100 13 73 60 60 59 N 5 5 7 7 4 12 2 10 8 4 64 Kinds of Resources Needed HR % 33 33 47 47 27 80 13 67 53 27 43 N 5 15 2 2 3 15 2 9 1 7 61 Tools % 33 100 13 13 20 100 13 60 7 47 41 N 1 0 2 8 0 0 0 8 6 10 35 Other % 7 0 13 53 0 0 0 53 40 67 23
46
Rapid Appraisal of District Health Information System Annexure-J
47
48
49
50
Annexure-K
51
52
53
54
55

Rapid Appraisal of DHIS

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Rapid Appraisal of DHIS

Hochgeladen von

Copyright:

Verfügbare Formate

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Dr. Farooq Azam Jan Team Leader

January 31, 2012

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

1.5 Study Operational Hierarchy

Rapid Appraisal of District Health Information System

2. Data Analysis and Observation

Medical Dispenser Officer

Sr. Medical Officer

Medical Medical Woman Supdtt. Technician Medical Officer

Pharmasist Statistical Officer

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Dispenser Staff Deputed Trained Staff 87 81

Tools Availability (%age) Daily Updation (%age)

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Receive Feedback (72%)

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Status of Facilities Faced Shortage of DHIS Tools

Facilities Didn't Faced Shortage (82%)

Facilities Faced Shortage (18%)

Forms Filling (9%)

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

120 100 Percentage 80 60 40 20 0

District Level Health Staff Trained in DHIS by Type. 100

DHIS Computer Operator

Not as per schedule (30%)

As per schedule, 1 5th of month (70%)

Rapid Appraisal of District Health Information System

Data Accuracy of Field Units

80% - 100% (40%)

71% - 80% (30%)

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Data Entry Operator

Refresher Training System Maintenance Hardware DHIS InstrumentsComputer / Tools operatorSoftware

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System Annexure-A

Number of Total Health Facilities Visited

Rapid Appraisal of District Health Information System

List of Offices/Facilities Visited

Rapid Appraisal of District Health Information System

Dera Ghazi Khan

Rapid Appraisal of District Health Information System

List of DHIS Data Instruments

Rapid Appraisal of District Health Information System

Rapid Appraisal of District Health Information System

Study Supervision and Team