We organized the findings under four major themes. attitudes against DHIS2, challenges faced, enabling factors and finally recommendation to improve DHIS2 implementation for RMNCAH data collection and use at different level of health system
Section 1: Attitude against DHIS 2
The majority of study participants expressed a strong, positive attitude toward using DHIS 2 for RMNCAH data collection. They described DHIS 2 as a dynamic system that has improved overall medical record keeping and the accountability of data reporting from community clinics at the periphery to district-level hospitals.
“Online is a perfect system. Previously I used to collect data in papers, and at the end of the year my office gets full of papers. It was also very difficult to retrieve data from thousands of piled up paper forms. Now, in online, by clicking the date or by name or phone number of the patients, I can easily check the data. I am getting the data collection form even in my mobile, by which I can fill up the form, from any place and any time! So, it is easier.” — Community health care provider, IDI
The supervisory team perceived that initiating such technology has contributed to instant monitoring, cross-checking of collected data, setting priorities, and making decisions, which was time-consuming with the previous paper-based system. With the DHIS2, statisticians are assigned to tabulate the data from DHIS 2 and share the generated summary reports with district and divisional health managers. Managers observe and flag the gaps in service delivery and noted achievements. Findings are discussed at monthly review meetings in the presence of field staff. At these meetings, which are held in each sub-district, district, and divisional health manager’s office, comparisons are made with the previous month, present month, and yearly national targets to track improvements in performance and identify any hindrances to achieving targets. Most respondents, from the community to the national level, identified this review meeting as a platform for RMNCAH-related data observation, monitoring, and instant planning for the coming weeks
“From DHIS 2, along with [the] national scenario, we can see the status of districts and sub-districts, even unions and wards. All the field staff are forwarding data on rate of using contraceptives, maternal death, amount of IUD [intrauterine device] delivered, and number of oral contraceptives supplied”. — Information communication technology focal person, IDI
Some additional factors also played strong influence on user perception about DHIS2. These were both individual and at institutional level. DHIS2 users who were more frequent on using it and had sufficient training perceived the true need of it. Availability of sufficient technical equipment like laptops, desktops and tablet personal computers at the field level made them more enthusiastic.
The demand of using DHIS2 is going beyond RMNCAH. Key informants who had been involved with DHIS 2 since its inception explained that the software is maturing continually. During 2009, when DHIS 2 was launched, it was not used for data visualization and decision making because accessing the system was challenging. Since DHIS 2 introduced the dashboard concept in 2012, it has drawn the attention of directors working at the national level, who demanded the platform be used for their own reporting. As a result, the online data entry forms increased from 12 in 2012 to 32 in 2013. The perceived need of DHIS2 can be better explained from the below quote
In 2013, the DHIS 2 log in dashboard became much popular, all users could access it. At that time, 5,000 to 6,000 graphs were made using DHIS 2, which eventually increased to 15,000 to 16,000. It means, people were trying to use it. To justify my argument I must say, these much of graphs were prepared by users from 64 districts not by a single use,, that means people are using it!— HMIS expert, KII
A few health managers expressed a contrasting view, arguing that staff orientation and adaptation to technology is somewhere working as major obstacle to electronic HMIS implementation.
“In some places . . . a complex device, [like a] computer has been handed over to the hand of an old community health worker, hence she cannot use it.”----Upazila health manger KII
DHIS2 has been used to report aggregated data on monthly basis. CHCP need to maintain both paper and electronic form as automated data reporting is not possible within the current system. This make the data entry process time-consuming and complicated, hence less use or misreporting at the end. Moreover, insufficient understanding on the RMNCAH indicators sometimes act as cause of unintentional errors in data entry
Section 2: Challenges to RMNCAH Data Collection and Analysis with DHIS 2
DHIS 2 Platform
Several technical challenges with the DHIS 2 platform were highlighted during the KIIs. There is no provision of automated calculation for aggregated data, and key informants expressed that its absence increased the possibility of data disparity and generating errors.
“DHIS 2 has a problem. . . . There are [boxes] for entering aggregated data. But, now, it is needed to use the formula. Many of the staff do not understand these formulas. In training sessions, I provide them the formula, explain this using multimedia presentation. Many [field staffs] do not understand it. In several cases, they put the value of one indicator in boxes designated for other indicator”. — IT expert for MIS, KII
In addition, DHIS 2 has the provision to “SKIP” for all indicators, which contributes to data incompleteness. With incomplete data, it is difficult to retrieve valid results from DHIS 2.
Respondents also referred some technical issues with the data collection forms that should be checked to decrease misreporting and improve efficiency.
“In [the] individual server, first, I put mother's name, her EDD [estimated date of delivery], date of enrolment, and then a box will pop up for gender. There is male, female and transgender. The data is on a pregnant mother, which is clear from this information, I don’t understand what the need of gender then? There should be a system that [the] computer would recognize the gender automatically when pregnant women has been marked. We should not put it manually. Here our field workers are making mistake[s]”— District statistician, FGD
Instead of using unique health identification numbers to track patients, their cell phone numbers are used. However, it is difficult and time-consuming to search the database with a cell phone number. To get around this, CHCPs prefer to enroll follow-up patients as new ones. This raises a data quality issue since repeat clients are identified in the system as new clients. According to the key informants, this has created a gap in the system, as it is not possible to track the health status of a single patient in the existing system during data analysis and visualization. It was suggested that the system could be linked to Bangladesh’s National Identification Database. It was also noted that the platform design makes data validation challenging.
Updating the data entry forms to facilitate comparisons among data variables is challenging. DHIS 2 has started with version 2.6 on 2009, which was upgraded, version-by-version, to 2.13 at the end of 2013 to make the system faster. Each time the data entry forms are changed it becomes more difficult to compare the old and new data because the software cannot match the data variables, resulting in invalid findings.
“For those, who are computer literate, for them, version change is an “attraction.” “Let us explore, what are the new features?” But, our CHCPs do not perceive it in this way. They think, there was a box here in the older version, where did the box goes now with the newer version? They don’t understand, we are trying to make their work easier! It will take some time, to change the culture”. — HMIS expert, KII
Several informants reported that in the existing system, searching for sub-districts is a time-consuming process.
At the supervisory level, district and sub-district health managers could not find the time to use DHIS 2 on a daily basis because they were involved in other activities. Sometimes they can escape the use of DHIS 2 too.
“A health manager knows clearly about his district's targets on immunization coverage, or ANC coverage, or even for facility births from their years of experience. So they do not need to open the computer and get into the DHIS 2. The mechanism is such; you cannot trap him for this reason”. — Senior programmer, KII
The DHIS2 is an additional task for the statisticians with other regular administrative duties (e.g., preparing salary sheets, drafting letters). They need to do extra hour work for that. National-level key personnel acknowledged the shortage of statisticians or other staff trained in data analysis. They admit that in many areas, qualified statisticians have not been recruited. Even so, many statisticians are not efficient in using computer software and do not understand health indicators and data compilation. In many areas, statisticians do not even attend trainings.
“The job description and responsibilities of statistician should be separate. But, in many districts there is no designated statistician. . . . In area “YY,” a ward boy does all the work of statistician; you cannot expect anything better from him! There should be an assigned person, who will do research [with data]”. — District health manager, KII
The RMNCAH data collected by the MIS Division of DGHS have also been used by the RMNCAH line directorate of DGHS. However, data retrieval from the DHIS 2 platform is not the regular practice for the RMNCAH line directorates; like all other directorates they rely on their own reporting format.
Although the participants said the number of electronics provided for data collection is sufficient, slow Internet connectivity makes real-time data entry difficult. As one CHCP described,
“At dawn, sometimes the Internet speed is better. In most cases, I enter the data at this time. It happened, I could not report for one week, two weeks, as the speed was slow. With a weak connection, I cannot even log in into the system”…………………. CHCP, IDI
The provision of offline data entry could make the things little easier. The process of sending broken tablets to capital city for repairs and transporting them back to the community took a long time. The majority of respondents reported internet modem shortages as well. In many areas, sub-district and district health managers personally obtain a modem and Wi-Fi router.
Statisticians reported not receiving any specific training on DHIS 2; rather it was a part of computer literacy training. Participants received DHIS 2 training manuals, though these were not updated to reflect changes in newer versions of the software and forms. Since DHIS 2 was introduced, all the line directorates want to incorporate their relevant indicators to be collected and analyzed through DHIS2 using same workforce.
“Now everybody wants their data from DHIS 2. Non-communicable Disease division add some indicator[s], RMNCAH add some too. In some cases, the reporting format is also different than the one used by DHIS 2. For example, if [the] EmNOC [emergency newborn and obstetric care] reporting format for [the] MIS division and RMNCAH would be same, I can get the report by clicking on DHIS 2 data. But [the] EmNOC report for RMNCAH directorates have 27 indicators while it is 25 in DHIS 2 database”. — Sub district statistician,IDI
Section 3: Facilitators to RMNCAH Data Collection and Analysis with DHIS 2
Mandatory quality checks at different tiers and regular monthly feedback meetings have played a significant role in improving data quality.
A national-level expert shared his experience with checking data validity:
For example, when we check MMR [maternal mortality ratio], we locate where the ratio is high. Then we review the ratio of that particular district for consecutive months to explore the consistency of data and reporting status, either it was low or high for the previous months. We check all these. Then we send an e-mail, to respective authority, to look into the matter. — HMIS expert,KII
So far, DHIS 2’s performance has been measured from the perspective of timeliness and completeness. A positive competition for service improvement has been nurtured. The best-performing district or division receives recognition from the national level.
“In our monthly meeting we discuss our shortfall; we plan how to improve the reporting rate. We always analyze the data, hence our performance is better!! We have a silent competition with other districts of this division and we do better always and got national award as model district” — District health manager, KII
International donors strongly support strengthening Bangladesh’s HMIS. They share financial costs with the government for national- and international-level training for the staff, IT equipment purchases, and other needs. In collaboration with other NGOs, like icddr,b, they are providing technical support to the IT programmer for online platform improvement and organizing a training on the DHIS 2 manual for staff working at different tiers of health system. Donor organizations have demonstrated a strong commitment to the successful implementation of DHIS 2 by deploying their staff as monitoring officers at each administrative division and ensuring their physical presence and participation during monthly coordination meetings at the divisional and central levels.
The government has limited capacity and could not develop that capability till now. From the side of development partners, we are giving them that support. If development partners withdraw their support, how will the system run? But the DHIS 2 dashboard is already sustainable, and its automatic; staff have training and they can handle it. The government is cordial, and they have sufficient resources, training arrangement, hardware. In this context, strict monitoring and defined role of staffs are important. In addition, ownership of data is a major concern, many health managers do not own the data. — HMIS expert from donor, KII
Factors affecting the DHIS 2 implementation in Bangladesh context are highlighted through Figure 2.
Section 4. Recommendations for Strengthening the HMIS to improve RMNCAH Outcomes
Based on the study findings, the participants’ major recommendations for strengthening the HMIS to ameliorate RMNCAH outcomes in Bangladesh are elaborated below.
The DHIS 2 platform should be programmed to generate automated data for specific RMNCAH indicators. A pop-up box with the indicator definition, calculation (if applicable), and any possible disaggregation should be included. This will provide instant help to the CHCPs and standardize data collection. The software should be translated into Bangla (the local language) to help create a clear understanding of instructions and RMNCAH indicators. An online dashboard should be installed in the platform where instant RMNCAH-related reporting and performance status updates should be exhibited automatically at the sub-district and district levels. Statisticians should be informed in advance about software updates and notified of specific changes so they can prepare the CHCPs.
Data collection forms should be simplified to ease the data collection process and data reporting. Creating unique health identification numbers for patients and issuing individual health cards will decrease the time spent on data entry and help mitigate data duplication. Since the system will contain clients’ contact information, statisticians can verify the collected data through random phone calls. A geographic information system should be installed in CHCPs’ electronic devices used for data collection to track the providers’ movement. Users should be able to enter data into DHIS 2 daily, as aggregated data increase the risk of errors, thus compromising data quality.
Since DHIS 2 is used at different levels of the health system, the DHIS 2 training curriculum should be tailored to the needs of health professionals working at different levels. The IDIs and FGDs revealed a need for separate training sessions on medical terminology for community and sub-district level staff. After every update to the software or data collection forms refresher trainings should be organized to improve staff knowledge and efficiency. A standardized training curriculum and tools are also needed. Furthermore, soft copies of training manuals should be shared with staff via e-mail so they can be easily updated and disseminated.
Along with a statistician, another staff member should be trained in data compilation and analysis to complement the statistician’s work and support the statistician in his/her absence. A separate MIS unit can be formed comprising, at a minimum, a statistician and a supporting staff member who will be assigned to perform all MIS-related tasks only. Sub-district and district health managers should be more involved in data reporting and analysis to develop ownership and a regular practice of using DHIS 2.
Computers and other electronic devices for data collection should be repaired at the local level to save money and time. Providing CHCPs with an Internet data subscription can ensure timely reporting. The number of modems at the subdistrict and district levels should be increased, and each municipality should have its own dedicated laptop for the statisticians to use to ensure timely reporting.
The country would benefit from a national e-health strategy and implementation framework to facilitate a culture of DHIS 2 use for planning, setting priorities, and decision making among different stakeholder groups. This strategy should include how the country intends to provide the resources to fund DHIS 2’s long-term sustainability when donor support is no longer available.