Participant characteristics
In this study, 27 respondents participated through KII. Among the participants, six were female, and the rest were male. Besides, 22 respondents were from the health centers, and six were from the woreda health offices. Most participants have an overall experience of more than ten years and have worked at least four years at their current position. Most participants were HMIS officers and facility heads and had a BSc level of education. (Table 01).
Table 01: Socio-demographic characteristics of the study participants
No
|
Characteristics
|
Level
|
Frequency
|
|
-
|
Age
|
<= 30 years
|
7
|
|
30 – 35 years
|
11
|
|
> 35 years
|
9
|
|
-
|
Sex
|
Male
|
16
|
|
Female
|
11
|
|
-
|
Institution
|
Health centers
|
14
|
|
Hospitals
|
3
|
|
Woreda health offices
|
6
|
|
Zonal health department
|
2
|
|
City administration
|
2
|
|
-
|
Total years of experience
|
<= 5 years
|
4
|
|
5 – 10 years
|
12
|
|
> 10 years
|
11
|
|
-
|
Total years of experience in the current position
|
<= 5 years
|
17
|
|
> 5 years
|
10
|
|
-
|
Position
|
HMIS officers
|
12
|
|
Service providers
|
4
|
|
M&E officer
|
2
|
|
Plan officer
|
2
|
|
Facility heads
|
7
|
|
-
|
Level of education
|
Masters of Public Health (MPH)
|
6
|
|
Bachelor of Science (BSc)
|
13
|
|
Diploma
|
8
|
|
Total
|
27
|
|
Main findings
The study identified the understanding, perceived benefits, enablers, and barriers of HIS accountability framework implementation and respondents' suggestions to design and implement an effective HIS accountability framework. The findings are presented into six themes: understanding of HIS accountability framework, perceived benefit, practice, enablers, barriers, and suggestions. Figure 01 summarizes the synthesized themes and key points of the study.
Understanding of HIS accountability framework
Awareness and understanding are very important for successfully implementing an intervention(17). The participants explained their understanding of HIS accountability framework in different ways. Some respondents described HIS accountability as a system of controlling the HIS activities using administrative protocol. Simultaneously, some described it as a method of overseeing and regulating HIS actions by defining the duties and obligations of healthcare providers.
Respondents from the Zonal health department and Woreda health office better explain the HIS accountability framework. They describe the HIS accountability framework as a working document or system of ensuring the implementation of HIS-specific tasks by clearly stating the HIS's roles and responsibilities. A respondent stated:
"HIS accountability framework is a system of controlling HIS activities using a governing protocol that explains in detail the roles and responsibilities of health professionals and the consequences for not adhering to the protocol." (A 43 year old M&E officer)
Other respondents explained that the HIS accountability framework is a regulatory and administrative document that ensures the proper implementation of HIS-specific activities by the implementers. A respondent stated:
"HIS accountability framework is a governance document that clearly states what to do and not to do and makes answerable the implementers for their work results related to HIS activities" (A 39 years HMIS officer)
Another respondent also defines the HIS accountability framework as:
"HIS accountability framework is a procedural standard that is used to govern or cascade the HIS activities …" (A 34-year-old facility head)
Perceived advantage of HIS accountability framework
Perceived advantage is the benefit of an intervention stated from the target audience's perspective. In this study, the perceived advantage has explored the benefit of the HIS accountability framework from the implementer's perspective. The key informants explained the role of the HIS accountability framework for the HIS program and the health system in different ways.
Many respondents revealed that developing and implementing the HIS accountability framework will improve the practice of HIS activities as per the national standard by managing the behavioral problems of implementers. By applying administrative actions, they stated that the intervention would help control recurrent HIS errors due to negligence and poor attitude. A respondent stated
"If the HIS accountability framework is implemented, it will govern the behavioral-related problems of the health professionals and be used to manage and control the recurrence of HIS-related errors based on the tangible guideline or protocol." (A 28 years old HMIS officer)
Other respondents also described the role of the HIS accountability framework as it will help to objectively monitor and control HIS tasks and give practical feedback to the practitioners. They stated that the accountability framework is one crucial organizational input for implementing leadership practices effectively. A key informant said:
"If the HIS accountability framework is introduced at the institutions, it will bring a good culture to give specific and targeted feedback to the implementers, enhancing the health professionals' sense of ownership of the HIS data."
Another respondent added
“Without an accountability framework, it is difficult to say we are applying the proper leadership practices. Even if it is not the only input, HIS accountability framework is one key factor for effective HIS leadership” (A 43-year-old M&E officer)
Other groups of respondents stated the HIS accountability framework's role in improving health professionals' adherence and commitment to HIS activities. They narrated that the HIS accountability framework will be used as a good alarming/stimuli intervention to take corrective actions and to give recognition based on the HIS work results. A respondent stated:
"HIS accountability framework will be used as a stick and carrot strategy to give recognition for good performances and take corrective action for the reverse one. This strategy will alarm health professionals and improve their commitment to HIS activities." (A 36 year old Facility head)
Besides, it was also explored that the HIS accountability framework intervention will help ensure health data quality, informed decision-making, local data use for patient clinical care and admin-level decisions, sustainability of HIS activities, and healthcare quality. It was stated as:
"The HIS accountability framework will help to produce quality health data and enhance the local data usage for decision making and improving the service quality." (A 39 years old facility head)
It was also explored that the HIS accountability framework will bring a good culture and practice of health data handover and data sharing. The respondents also added the HIS governing protocol would give the facilities a legal framework to ensure data security and privacy. They stated that the facilities didn't have any legal ground or framework to practice data handover during staff rations, transfers, and leaves due to the lack of a governing protocol. The informant stated
"As you know, when there are staff transfers and rotations, there is the handover of different institutional resources, but even if health data is one of the key institutional resources, we didn't have any system and experience for health data. So, this kind of governance framework will help bring this culture to the institutions." (A 43 years old M&E officer)
It was also stated that the HIS accountability framework will help with quality data generation, storage, and legal data sharing for intended users. This helps to provide quality data for different researchers and helps to generate valid research output. A respondent stated:
“As you know, most health researchers use patient level and aggregate secondary data as a data source for their objectives. But, most of the time, the secondary data sets are either incomplete or inaccurate, affecting the reliability and validity of the research findings. So, the HIS accountability framework will help to address this problem and to generate valid research findings” (36 years ZHD M&E officer)
Practice of HIS accountability framework
Practice is the application of an intervention for the sake of achieving a desired target or objective. The practice of the HIS accountability framework was assessed through respondents' experience at their respective institutions on applying the intervention to implement HIS tasks. The respondents explored how they control the implementation of the HIS activities and the different strategies they used. Most respondents stated they didn't have a HIS-specific accountability framework document prepared by their institution or forwarded from the higher officials.
The key informants stated they use supportive supervision and review meetings as potential strategies to follow the HIS tasks. A key informant said:
"We didn't have any formal and written governing document specifically for HIS task management, but we use supportive supervision and review meetings to discuss the HIS program implementation and to forward directions." (A 36 years old plan officer)
Other respondents described using the PMT platform to monitor the key HIS activities and internal HMIS task audits by selected health professionals, followed by targeted and constructive feedback. These approaches are used to identify the gaps and to give corrective feedback, but they don't have any role in taking any administrative actions. A respondent stated:
"We didn't have any specific protocol designed for HIS task monitoring, but we are using the monthly PMT platform and bi-monthly HMIS task audit to assess the HIS tasks, and regular feedback is forwarded to each unit." (A 35 years old HMIS officer)
Enablers to implement HIS accountability framework
Enablers are the internal and external opportunities that enhance the successful implementation of the program or the intervention. Enablers in this study explored the potential opportunities that precipitate the implementation of an HIS accountability framework from the respondents' perspective.
Many key informants stated that national priority given to the HIS program, positive progress in HIS program performance, and advancement in skill and number of HITs were potential enablers to initiate the HIS accountability framework. They stated that IR is one of the top health sector transformation agendas, and the scope of in-service and pre-service training for HITs is highly advanced. A respondent stated:
"As you know, currently the HIS professional's production is increasing in different levels from the BSc to PhD level. We have skilled HIS professionals and also the number is good enough." (A 43 years M&E officer)
Another respondent added:
"The HIS program performance is improved in different parameters from time to time, and this is a good motivation factor to successfully adopt and implement HIS accountability framework." (A 34 years old facility head)
Other respondents also stated that the expansion and transformation of HIS into a digital system, partner engagement, and standardization of HIS tools are potential enablers. They noted the HIS program applies digital systems like DHIS2, eCHIS, Dagu, mBrana, and others for data entry and management purposes. This enhances the attitude and value given to health data and the successful implementation of the intervention. A respondent stated:
"In the HIS program, digital systems are deployed and used for different purposes like DHIS2, eCHIS, mBrana, and Dagu. Applying these systems motivates health professionals to adhere to and value health data properly. This will be a good factor for effectively implementing the HIS accountability framework." (A 37years old HMIS officer)
Another respondent added:
"There is consistency in the standardization of HIS tools, and partners are available to support us on different HIS activities like data quality, use, and eCHIS. This helps initiate and implement our institutions HIS accountability framework." (A39 years old HMIS officer)
Barriers to implementing HIS accountability framework
Barriers are the challenges that hinder or deter an intervention's successful implementation as expected. The barriers in this study explored the potential challenges that affect the implementation of the HIS accountability framework.
Key informants explored multiple barriers that could alter the HIS intervention's effective implementation. Among the explored barriers were a poor systemic culture of accountability practice, poor leadership skill, and commitment, leadership and staff turnover, lack of national HIS governance guidelines, multiple responsibility and recording tools, political instability, and skill and knowledge.
Respondents described our system and culture of practicing and ensuring accountability as weak, which will affect the effective implementation of the new HIS accountability framework. They also explored that the lack of national guidelines on HIS governance will be a significant barrier because facilities may not have standard protocols to customize locally and basic legal grounds to implement it. It was stated:
"There is no national governance to be used as a benchmark for the health institutions, and the culture and experience of practicing accountability is limited. These issues could alter the effective implementation of the HIS accountability framework." (A 30 year old facility head)
Other respondents also noted that the skill and commitment of leadership to initiate and implement this new initiative is a challenge. They added that there are leadership skill gaps in initiating and managing change, and the commitment of top leaders is also low. Leaders primarily emphasize those political activities that are reviewed by the cabinet. But, the HIS didn't get adequate political attention. The respondent noted:
"HIS activities are not getting political attention; due to this, the top leadership didn't give attention to closely following the HIS activities and taking corrective actions. This problem might also affect the successful implementation of the initiative." (A 33 years old HMIS officer)
Many informants also explored high leadership and staff turnover as potential barriers. They stated that the leadership and staff turnover would affect the adoption of the intervention because the staff and leaders will be new to the initiative, and the newcomers might be challenged to understand and cascade the new initiative. It was stated:
"… there are stable settlements on the health professionals and even on healthcare leadership. This affects the adherence and sustainability of new initiatives like HIS accountability framework." (A 35 years old plan officer)
It was explored that pre-conditions at the health institutions are not fulfilled, like essential HIS infrastructure not being availed, and they stated that there is a high workload in which professionals work beyond the suggested standard. This makes health professionals prioritize clinical care over health data. Besides, there are a number of HIS recording tools that need time. In addition, multiple responsibilities are assigned to single individuals, like coordinating different programs, making them overloaded and not focused on health data issues. The respondent stated:
"…staffs are working in a busy schedule unless we manage the human resource need at each facility; it is difficult to design an accountability framework and order them to be governed by that framework." (A 30 year old facility head)
Political instability/insecurity is another barrier that has been explored. The respondents explained that due to security problems, they didn't have a conducive environment to implement HIS activity monitoring, such as review meetings, supervision, and mentorships. Besides, the virtual and remote HIS monitoring and communication channels are blocked due to the interruption of the internet network. This problem affects the health professionals' stability and psychology not to focus on the basic tasks and worry about other things. With these conditions, implementing such new initiatives will be challenging. A respondent stated:
"In the current condition, the health professionals are unstable and worry about other security issues. Besides, due to the interruption of the internet network, there is no means to follow and monitor the HIS tasks face to face and virtually. Due to this, it might be challenging to implement the framework in this condition." (A 37 years old M&E officer)
Suggestions
Recommendations are opinions forwarded by the respondents about their views and thoughts on a specific topic. In this study, the informant's recommendation was explored for designing an effective HIS accountability framework that will be implemented successfully.
The informants noted that the following issues must be considered during the framework design. Building skills and knowledge on HIS and leadership, making HIS the political agenda, fulfilling the basic inputs and creating a conducive work environment, engaging every concerned body, listen to the sayings, feelings, and emotions of the health professionals were among the recommended issues by the respondent.
The respondents explained that its acceptance and success are questionable unless the intervention is participatory and transparent. Due to this, engaging every actor and discussing its relevance, as well as the way to design and implement it, is crucial. It was stated:
"As to me, most interventions have failed because they are not basing the real problem on the lower-level implementers. Therefore, engaging every actor and understanding their feelings and thoughts is very important for a successful intervention. If the engagement of the implementers develops the intervention, it will enhance the sense of ownership, and its adoption will be good." (A 48 years old service provider)
The other issue forwarded by the respondents is before coming up with a new intervention, it is good to create a conducive and ready institution to adopt and implement the intervention. They stated that before initiating the HIS accountability framework, it is good to create the skill and knowledge of implementers and leaders on HIS and leadership. This will enhance the value and attitude of the implementers toward health data. In addition, they added inputs like HIS supplies and human resource issues that must be managed. A key informant stated:
"… To ask about the staff's responsibilities, initially, we need to fulfill their rights. For example, to command and order health professionals to correctly do the HIS activities as per the protocol and to take corrective actions, initially, we need to avail all requirements, including the supplies and adequate human resources." (A 40 years old facility head)