Assessing the gaps in knowledge of female health workers about monthly HMIS reports and its utilisation

INTRODUCTION

The World Health Organization has identified health information systems as one of the six key attributes, or building blocks, of a health system.^1,2 The other building blocks are health workforce, leadership and governance, health service delivery, health systems financing, and access to essential medicines. While each of the six building blocks are essential, health information systems are critical for decision-making within each of the other five building blocks, hence forming the foundation of health systems.³ Good health information systems are crucial for addressing health challenges and improving health service delivery in developing countries.⁴ Even if high-quality data was collected does not mean it will be used.⁴ Too often, though, data was ignored or under-used and data-informed decision making does not occur.⁵

In this study an attempt was made to assess the utilization of monthly reports prepared by ANMs. The factors influencing the preparation, the understanding and feedback from supervisor for monthly reports were also evaluated.

METHODS

The cross sectional study was conducted in the RaipurRani block, District Panchkula of Haryana. The area was selected purposively as the Department of Community Medicine, SPH, PGIMER provides some service in the area and thus the area is accessible.

Sampling and size

Community Health Centre of a district in Haryana has 4 Primary Health Centres (PHCs) and 19 subcentres. The data was collected from CHC, each PHC and one subcentre of each PHC. Thus a total of 9 health facilities were selected that covered at least 30% of the health facilities in the area according to the WHO recommendation.⁶

One subcentre was selected from each PHC by random sampling using lottery method. Thus a total of 4 subcentres were selected by random sampling using lottery method.

Study participants

Health worker (females) also known as auxilliary nurse midwives (ANMs) of selected subcentres that were available and gave consent for interview.

Data collection, processing and analysis

Author first informed the ANMs about the study personally over telephone. Data was collected after prefixing the interview with those who had consented, using structured questionnaire.

A semi-structured questionnaire was used to interview ANMs to assess their knowledge about the monthly reports and its utilization, understanding and the feedback from supervisor on the reports.

RESULTS

Total 9 ANMs were interviewed, out of which 8 were from selected from the subcentres, one was from PHC. The level of education showed that 4 of them were matric, 3 have completed their senior secondary and 2 were graduate. They were within the age of 28-53 years old (Table 1).

Training

Out of nine ANMs, four were regular and five were contractural employees. Out of nine ANMs, five of them had undergone training to fill the single line proforma. From these five, two were regular employee and three were contractual employee. From every centre, one ANM is trained except one centre that has only one ANM (Table 2).

Preparation of reports

More than half of the ANMs said that they take at least two days to prepare the report. Two of them said that they take one day and two of them said that they take three days for the preparation of reports as shown in Figure 1.

Feedback

5 ANMs said that their reports got checked by either doctor or Information assistant but LHV of all the three subcentres check their report and give them regular feedback.

Only two ANMs of same subcentre said that their reports are neither checked by any person and nor they get any feedback. “Our doctor or LHV does not know that how we prepare the report”. The feedback which they get is mostly verbal. ANMs of one subcentre told that they get written feedback as shown in Figure 2.

Completion of report

90% of them said that they have to leave some questions blank. The questions which were left unfilled were either from one specific part of proforma i.e. preconception care package report or from Infant young child feeding practices.

Submission of report

More than half said that they have never submitted a late report. Rest of them told that either they get explanation letter or may have salary issues on late submission of report as shown in Figure 3.

Motivating factors

5 of them said that there are no motivating factors for reporting. 3 of them told that LHV motivates them and 1 told that even doctor motivates them as shown in Figure 4.

Demotivating factors

On contrary, even two third told that there are no demotivating factors. Two out of nine told that undue scolding of seniors demotivates them. “The undue scoldings of seniors and higher officials that too in front of our patients demotivate us. Even if we are doing good job, instead of appreciating us they scold us and say that we have fabricated the report”.

Overburdened

Almost half of them feel overburdened because of reporting of many programmes as it is too long. “When we joined the job, we had to fill only some forms but now we have to maintain so many registers that we are left with no time for field visit”.“Few indicators are asked from us as well as from ASHA workers. The format should be revised, so that there is no duplication of work. It will reduce our burden”.

Usefulness of report

Almost all ANMs told that this report showed their monthly work. None of them ever utilized their report for planning, budgeting or for evaluation of services. “I think these reports are garbage and ultimately go to dustbin only”.

Suggestions given by ANMs

Two third of ANMs had asked for revision and simplification of proforma and for the training. “The format should be both in Hindi and English”. “The unnecessary questions which are not applicable should be removed”. “We prepare the report with the help of our seniors but we need to undergo training”.

Timeliness

All the reports were submitted within scheduled period.

DISCUSSION

ANMs do not put much value to the data. The huge gaps were found between data generation and data usage. They feel that it is just garbage and no one uses the data. They feel that these reports just reflect their work. The low level of education, limited training on data interpretation and use of information might have created the gap. The findings were consistent with the limited competence in data analysis, interpretation and problem solving at the health facilities. There is need to simplify the reporting tool and to sensitize more health workers on the advantages and use of their own data. The similar types of findings were seen in study conducted by Nyamtema et al who revealed gaps in the HMIS and linked them to lack of training, inactive supervision, staff workload pressure and the lengthy and laborious nature of the system.⁷

This indicates that more importance is placed on collecting data primarily for reporting rather its use for local decisions. This “mailbox syndrome” whereby crucial information generated at the health facility level is mailed rather than used locally may be because the supervisors including medical officers and senior medical officers had not placed any importance to the data use and they were not interacting with ANMs on monthly reports.⁸

Another reason for not using the data by ANMs could be that some ANMs were not yet trained. This was despite of the fact that they were not newly recruited and was in service for nine years on average. Trainings were not cascaded down to the peripheral health facilities as expected as all the ANMs are not yet trained. There were no sufficient opportunities for continuous transfer of skills through on the job-training or orientation mechanisms.

More than half of the ANMs had quoted that there were no motivating factors. Only one third have told that they got demotivated by the rude behaviour and scoldings of senior officials. During training, they were only told how to fill the format but none of the trained ANM told that if some higher official have ever told them to use this local available data.

With respect to timeliness of reports, in this study we found that all the reports were sent on time within deadline. This may be due to mandatory computerization of the reports. There are inbuilt date bound mechanisms in the computer software. ANMs use standard monthly reports and submit to information assistants for timely data entry.

This study had some limitations. The study was restricted to one block and 4 health facilities. This may not be the true representative of all health facilities and all districts. There is also no control arm to make the comparison.

Despite of such low motivation on use of HMIS, the majority of the ANMs had positive attitude towards the system, indicating substantial acceptability, a positive potential factor for improvement.

CONCLUSION

Despite of the low skill level of data interpretation and use of information, respondents could describe at least one reason for collecting data. Further exploration should be done as to why such knowledge was not reflected on use of information. However, after interaction between ANMs the current perspective of ANMs is likely to change over the period of time.

Recommendations

State and districts should ensure that all ANMs get trainings on how to prepare and use monthly reports. Medical officers should discuss the data in routine with the ANMs. ANMs should be encouraged to use data generated locally for programme improvement.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee, PGIMER, Chandigarh

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