Improving cause-of-death statistics in health facilities Workshop Accra, 21-22 April 2016 Workshop Report
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Background information Mortality statistics are collected in countries on a routine basis from civil registries as well as from hospitals. However in low-resource settings, many countries collect mortality data through either vertical programmes or routine health management information system using administrative patient registers. Cause of death certification is only implemented in some hospitals and cause of death statistics are not always generated according to international standards: the international medical certificate of the cause of death form is not used, data are collected according to local lists of causes of death which might not be compatible to international ICD standards, the concept of underlying cause is not used, admission diagnoses are recorded instead of the eventual causes of death and there is no mechanism to validate the quality of information. The complexity of ICD implementation is one of the reasons for inadequate implementation in countries. This has prompted action from WHO to find innovative and simplified solutions to overcome such challenges in order to make the ICD-10 more accessible, practical and scalable. In 2015 WHO has developed a Start-Up Mortality List (SMoL), a simplified list of broad cause of death fully in line with the ICD-10 structure. It contains 107 causes and 17 sub-categories. To facilitate the use of SMoL, WHO in collaboration with the University of Oslo have developed a module in the District Health Information Software (DHIS2) that comprises: 1. the Start-Up Mortality List (SMoL) 1 a simplified standard list of causes of death (107 causes and 17 optional subcategories) 2. WHO international form of the medical certificate of the cause of death 2016 version 3. a specific training manual for certifiers and coders 4. a user-friendly interface into DHIS2 to input and store the data in one place 5. the IRIS 2 automated coding tool 6. a dictionary of medical diagnostic terms 7. routine validation checks and statistical reports Objectives of the workshop The overall objective of the workshop is to empower low-resource countries of Africa in starting and improving their collection of cause of death information by: familiarizing participants to the various components of the module training certifiers in completing the medical certificate of the cause of death according to international standards training health management information officers and coders on the selection of the underlying cause of death according to a set of rules supporting countries in their implementation, integration and roll-out plan 1 http://www.who.int/healthinfo/civil_registration/icd_10_smol.pdf?ua=1 2 http://www.dimdi.de/static/en/klassi/irisinstitute/index.htm 3
Participants The workshop was attended by 94 participants including facilitators and international partners. Participants were from 20 Ghana hospitals: 10 provincial hospitals, 4 teaching hospitals and 6 CHAG (Christian Health Association Ghana) hospitals: an average of 2 medical doctors and 2 health information officers/coders from each of them. In addition there were 2 participants from Liberia ad representatives from Bloomberg D4H, CDC and World Bank. A summary list of Ghana participants is included in Annex B. Structure and content The workshop was intended to be a training of trainers. During each of the two days, the workshop was structured with facilitators providing training instructions and country participants doing practical exercises. At the end of each session, there was a review and discussion on the outcome of the exercises. The agenda of the workshop is found in Annex A. A USB key containing the presentations, SMoL training manual, certification and coding exercises and answers was given to participants to enable them to conduct similar national training. Workshop summary Day 1 The Director-General of Ghana Health Service welcomed the participants and affirmed the crucial need to collect data in particular to measure the Sustainable Development Goals of the 2030 agenda, drive health policies and measure impact of interventions. He also emphasized the importance of moving the CRVS agenda forward. The Director of Administration and Chief Director in the interim of the Ministry of Health and representative from WHO Ghana country office also gave some opening remarks. A presentation on the situation in the African countries, common barriers to implementing ICD-10 and the fundamental steps to obtain cause-of-death data was given. Participants were instructed on how to complete the medical certificate of the cause of death according to ICD-10 and were requested to complete some of the said certificates from some case examples. In the afternoon sessions, participants were introduced to the concept of the Start-Up Mortality List and the DHIS2 CoD module. SMoL rules were explained with exercises to complete. The DHIS2 CoD electronic platform was presented. Day 2 Participants were provided with some genuine-completed medical certificates of the cause of death and requested to apply the SMoL rules to select the underlying cause of death. They also accessed the DHIS2 CoD electronic platform to practice entering the information as well as to get a sense of the integrated functionalities of the module. Instructions were provided to participants focussing on the way forward following the workshop. After the workshop a meeting with the representatives of Ghana Health Service, Ministry of Health, Birth and Death Registry and international partners was held in order to have a common agreement 4
on the way to move ahead with the SMoL. Separately the Liberian teams also met with WHO facilitators. Recommendations and next steps Ghana has operationalized DHIS2 in all health facilities and is already implementing ICD-10 and producing cause-of-death statistics. However their practices are not fully aligned with international standards for producing cause-of-death statistics, thus impacting on their data quality. A priority for Ghana is to review its current form of medical certificate of cause of death to be in line with the WHO international form of the medical certificate of cause of death for doctors or certifiers to complete. Following discussions at the workshop and in common agreement, both the health sector and Birth and Death Registry will adopt the WHO standard international form of the medical certificate of the cause of death. The next phase would be to print the new forms and implementation of the SMoL could start in the major hospitals. There is a need to redesign the flow of information from Ghana Health Service to Birth and Death Registry to ensure that both parties have consistent information on causes of death. Overall feedback from workshop participants was highly positive. The SMoL was seen as accessible and realistically applicable and scalable. The participants were confident that they would be able to conduct a similar training in their own health facilities. WHO in collaboration with Bloomberg D4H would provide support to Ghana in implementing the SMoL. 5
Annex A Agenda Workshop for improving cause-of-death statistics in health facilities Organized by WHO in Accra, Ghana, 21-22 April 2016 Day 1: 21 April 2016: Time Session Presenter 08.30 : 09.00 Registration All participants 09.00 : 09.30 Welcome Ghana Health Services WHO Ghana Office WHO HQ 09.30 : 10.00 Introduction to workshop Doris Ma Fat 10.00 : 10.30 Medical certification Linda Best 10.30: 11.00 Coffee break 11.00: 11.30 Discussions All participants 11.30 : 12.00 Medical certification: exercises All participants 12.00 : 13.30 Lunch 13.30 : 14.00 Feedback on exercises Linda Best 14.00 : 14.30 Introduction to the Start-Up Mortality List (SMoL) Doris Ma Fat 14.30 : 15.00 DHIS2 CoD platform Olav Poppe 15.00 : 15:30 Coffee break 15.30 : 16.00 SMoL : rules 1-7 Linda Best 16.00: 16.30 SMoL: exercises Group work 16.30: 17.00 Feedback on SMoL exercises Linda Best 6
Day 2: 22 April 2016 Time Session Presenter 09.00 : 09.10 Recap of previous day discussions Doris Ma Fat 09.10 : 10.30 SMoL: remaining rules Linda Best 10.30: 11.00 Coffee break 11.00 : 12.00 Exercises: Specific to remaining rules covering all SMoL rules Group work 12.30 : 13.00 Feedback on SMoL exercises 13.00 : 14.30 Lunch and closure (all Ghanaian participants can leave) 14.30 : 15.30 Meeting with Ghana Health Services, MOH, Birth and Death Registry and partners: plans for implementation and roll-out 15.30 : 16:30 Meeting with Liberian participants: project planning Doris Ma Fat, Olav Poppe, Antony Ofosu WHO Ghana office Doris Ma Fat, Olav Poppe 7
Annex B. Participants from Ghana Type of Staff Institutions Total Participants Medical Doctors 2 MDs per each of 10 regional hospital 20 Coders/Health Information Officers/Biostatistician 2 person per each of 10 regional hospital 20 Coders/Health Information Officers/Biostatisticians at Central level 2 persons from Central Level - Ghana Health Service 2 DHIS2 Experts 2 persons from Ghana Health Service 2 Directors 4 Directors from Ghana Health Service 4 Registrars Birth and Death Registry 2 New Additions Medical Doctors 2 MDs per each of 4 Teaching Hospitals 8 Coders/Health Information Officers/Biostatistician 2 person per each of 4 Teaching hospital 8 Medical Doctors 1 MDs per each of 6 CHAG Hospitals 6 Coders/Health Information Officers/Biostatistician 1 person per each of 6 CHAG Hospitals 6 GRAND TOTAL 78 50 28 8