MIS REPORT In-depth Analysis of Routine Service Delivery Data from MCHIP/Jhpiego Supported Facilities in 5 Districts of Sindh April - October 04 Aslam Fareed, M.Stats., Senior MIS Specialist Rashid Nazir, M.Sc., Manager, M&E M&E Department MCHIP/Jhpiego January 9, 05 MCHIP/Jhpiego: MNCH Services Component a
Table of Contents Introduction Data and Findings.. Overall Performance of all Five Districts..4 Conclusions...5 Monthly Performance of Individual Districts.......6 Endnotes..... Appendix A.4 Appendix B.7 Appendix C.9
Introduction MCHIP/Jhpiego has collected of Routine Service Delivery Data (RSD) data from MCHIP-supported facilities in 5 districts of Sindh from April 04. RSD data are collected on 3 selected indicators from existing DHIS registers at health facilities managed by the Sindh government s Department of Health (DoH) and the Private Public Health Initiative (PPHI). MCHIP/Jhpiego is working towards establishing a data collection system for private sector health facilities (including facilities managed by CMWs and NGOs). Data collection registers are being introduced at these facilities and some private sector facilities have started reporting RSD data. MCHIP s first MIS report, circulated on November 5, 04, was based on overall trends in antenatal care (ANC), normal vaginal deliveries (NVD) and conduct of Community Support Groups (CSG) during five months (April to August 04). The second MIS report is based on a more detailed analysis of the performance of MCHIP-supported facilities during the seven months from April to October 04. The report looks at performance in terms of ) antenatal care (ANC), ) total deliveries, 3) postnatal check-up (PNC) within days, 4) IUCDs/implants inserted and 5) community support groups (CSG) conducted around facilities. In-depth analysis of MIS data is a very cost-effective approach to extract information for programmatic decision making such as setting service delivery targets, determining the productivity of facilities, determining the effectiveness of community support groups and assessing performance in general. This in-depth analysis has the objective of providing actionable information to enable evidence-based decision-making. Methodology The cut-off date for entering routine service delivery data into MCHIP s data collection system (described in Appendix B) is the 0 th. Raw data from April to October 04 was downloaded from the system on November 6, 04. IBM SPSS statistics was used to analyze the data. Data & Findings Currently MCHIP/Jhpiego is supporting total 33 health facilities in five districts of Sindh: ) Dadu, ) Khairpur, 3) Tando Allahyar, 4) Tharparkar and 5) Thatta. District and management-wise break-up of these 33 health facilities is given in table below. Table District/Management Wise Break-up of MCHIP/Jhpiego Supported Facilities in Sindh Serial Management of facilities Dadu Khairpur Tando- Allahyar 7 3 5 Break-up by Type THQ 3 3 Tharparkar Thatta Total.0 PPHI 4 3 4 0 8 79 3.0 CMW 3 7 6 5 9 60 4,0 Private Sector (not NGO) 6 5 7 40 5.0 NGO 6 4 6.0 Total 46 58 45 37 47 33. For details please read Endnote on page. 6 3 3 4 8 44 5 4 5
3 out of 33 MCHIP/Jhpiego supported facilities (53%) are managed by DoH and PPHI and 9 out of these 3 facilities (97%) have reported RSD data during the last 7 months. The remaining 9 (47%) facilities are being managed by the private sector, including by CMWs and NGOs. Only out of these 9 private facilities have reported service delivery data in the last 7 months. There is a need to focus on collection of service delivery data from health facilities managed by the private sector to assess the effectiveness of MCHIP/Jhpiego s support to private sector facilities. In particular, there is a need to focus on data collection from facilities managed by CMWs given that project resources have been used in establishing CMW clinics in the last years. Table, below, gives district/management wise break-up of facilities reported RSD data in the last 7 months Table District/Management Wise Break-up of Facilities Reporting RSD data in last 7 months Serial Management of Dadu Khairpur Tando- Tharparkar Thatta Total facilities Allahyar Type of facilities THQ 6 3 3 5 6 3 3 4 8 43 5 4 4.0 PPHI 4 3 3 0 6 76 3.0 CMW - - - 9 4,0 Private - - - 5.0 NGO - - - - - 8.0 Total 0 38 8 6 9 3 Fig Graph showing the number of facilities not reporting RSD data Reporting RSD data Do not report RSD data 90 80 70 8 60 50 40 30 3 7 50 0 4 38 0 9 0 DOH PPHI CMW Private NGO. For details please read Endnote on page. 3
Overall Performance of all Five Districts from April to October 04 Table 3. Number of ANC visits by Type of Facility Serial Facilities managed by April May Jun Jul Aug Sep Oct Total 9,337,88 8,69 9,049,05,73 9,49 70,944.0 PPHI 7,03 7,093 6,957 6,39 7,076 7,03 5,708 47,77 3.0 CMW 83 46 3 6 90 4,80 4.0 Private 4 3 5 3 39 4 0 5.0 NGO - - - - - - - - 6.0 All facilities 6,656 8,79 5,9 5,609 8,430 9,043 5,363 9,9 Table 3.3 Number of Total deliveries by Type of Facility Total,83,030,84,355,66,94,946 6,554.0 PPHI 64 335 358 47 487 55 49 805 3.0 CMW 80 66 9 7 94 30 9 663 4.0 Private 0 5 3 8 0 48 5.0 NGO - - - - - - - - 6.0 All facilities,57,436,75,845 3,46 3,597 3,54 0,070 Table 3.3 Number of PNC visits by Type of Facility Total,6,90,085,058,597,54,64 8,779.0 PPHI 638 65 679 706 839 949 75 54 3.0 CMW 5 7 8 5 98 85 4.0 Private 0 5 0 0 5 0 5.0 NGO 6.0 All facilities,84,854,775,77,453,609,03 4,300 Table 3.4 Number of Long Term Reversible Methods (IUCD/Implants) by Type of Facility Total 35 9 65 40 39 0.0 PPHI 3 5 3 9 40 35 66 3.0 CMW 4 0 4 0 3 74 4.0 Private 0 0 0 0 0 0 0 0 5.0 NGO - - - - - - - - 6.0 All facilities 5 46 34 35 8 80 87 44 4
Table 3.5 Percentage of facilities around which at least one CSG * was conducted Serial DoH & PPHI facilities April May Jun Jul Aug Sep Oct Total % facilities had CGS 5 4 48 5 6 * One CSG means at least group meetings were held around a PPHI or DoH facility Table 3.6 District Wise Distribution of Total Deliveries at MCHIP/Jhpiego Facilities Serial Visits Total Dadu Khairpur Tando Allahyar Tharparkar Thatta Total deliveries 0,070 5% 6% 9% % 9% Total population * 5,47,883 % 30% 9% 8% % * Based upon the 998 Census Conclusions During last 7-month period, DoH facilities were the major contributor to total ANC, delivery and PNC volumes as 59% ANC visits, 8% deliveries and 6% PNC visits took place at 43 DoH facilities in 5 focus districts. 37% of ANC visits, 4% of deliveries and 38% of PNC visits took place at PPHI facilities in the 5 focus districts. Performance of CMWs facilities was negligible as only % of total ANC visits, 3% of total deliveries and % of total PNC visits took place at 9 out of 59 facilities managed by CMWs. Number of women who obtained long term reversible FP methods (IUCDs/Implants) is very low. In total, 444 women (IUCDS: 8 and implants: 360) obtained long term methods from 3 MCHIP/Jhpiego facilities in 5 focus districts. Thatta (9% deliveries against % population) and Dadu s (5% deliveries against % population) share in total deliveries is higher than their share in total population of all five districts Limitation Due to the non-availability of routine service delivery data of 98 (50 CMW, 38 private and NGO) out of 9 private sector facilities, the private sector s contribution is not reflected in the overall performance of MCHIP/Jhpiego supported facilities in these 5 districts. Recommendations There is a need to initiate data collection from the remaining 98 private sector facilities as soon as possible so that private sector facilities performance may be analyzed and resources may be allocated to private sector facilities on the basis of their performance. 5
Monthly Performance of Individual Districts on 5 Selected Indicators 4-District Dadu Table 4. Average number of ANC visits per month per facility 48 485 63 759 603 97 650 4 5 86 58 85 738 65 65 673 46 46 65 386 386.0 PPHI 77 88 9 99 99 85 3.0 All facilities 43 4 06 36 77 56 Table 4. Average number of deliveries per month per facility Serial Facilities managed by April May Jun Jul Aug Sep Oct 93 78 5 9 79 7 304 75 8 348 84 8 78 35 309 7 35 340 8 39.0 PPHI 4 4 4 6 6 8 8 3.0 All facilities 6 9 3 37 37 4 47 Table 4.3 Average number of PNC visits per month per facility 50 95 36 48 35 80 75 4 85 84 36 4 57 45 40 76 37 63 4 30.0 PPHI 4 4 5 5 9 6 3.0 All facilities 9 34 8 3 4 46 4 Table 4.4 Total Long Term Reversible FP Methods provided Serial FP Methods April May Jun Jul Aug Sep Oct IUCDs 9 5 4 4 0 0 Implants 4 0 4 9 8 3 Total 33 5 8 33 8 6
Table 4.5 Percentage of facilities around which at least one CSG was conducted Serial DoH & PPHI facilities April May Jun Jul Aug Sep Oct % facilities had CGS 5 35 45 75 56 95 95 5-District Khairpur Table 5. Average number of ANC visits per month per facility 983 3 344 90 77 0 34 3 43 07 99 0 5 33 95 36 09 356 30 97.0 PPHI 30 3 7 8 5 3 34 3.0 All facilities 76 86 64 48 5 79 6 Table 5. Average number of deliveries per month per facility 06 34 37 8 0 33 8 34 50 308 6 6 8 539 60.0 PPHI 4 6 6 7 9 8 8 3.0 All facilities 3 4 9 0 4 3 3 Table 5.3 Average number of PNC visits per month per facility 73 8 0 4 0 4 5 97 5 88 5 5 68 0 60 74 7.0 PPHI 9 9 9 6 4 3.0 All facilities 3 6 3 8 Table 5.4 Total Long Term Reversible FP Methods provided Serial FP Methods April May Jun Jul Aug Sep Oct IUCDs 0 0 0 0 0 0 0 Implants 0 0 0 4 7 3 Total 0 0 0 4 7 7
Table 5.5 Percentage of facilities around which at least one CSG was conducted Serial DoH & PPHI facilities April May Jun Jul Aug Sep Oct % facilities had CGS 6 6 7 6-District Tando Allahyar Table 6. Average number of ANC visits per month per facility 555 49 66 463 6 86 649 6 49 575 4 98 86 49 5 75 48 34 64 54 37.0 PPHI 53 9 5 6 3 3.0 All facilities 76 58 58 4 59 49 Table 6. Average number of deliveries per month per facility 6 45 3 4 56 6 69 5 4 73 5 6 3 9.0 PPHI 6 8 9 9 9 9 3.0 All facilities 7 6 4 6 9 7 Table 6.3 Average number of PNC visits per month per facility 90 7 9 87 6 5 58 4 3 37 5 9 66 6 0 3 8 8 4.0 PPHI 9 9 4 3.0 All facilities 4 4 Table 6.4 Total Long Term Reversible FP Methods provided Serial FP Methods April May Jun Jul Aug Sep Oct IUCDs 0 0 Implants 7 4 4 3 Total 3 4 8 4 5 8
Table 6.5 Percentage of facilities around which at least one CSG was conducted Serial DoH and PPHI facilities April May Jun Jul Aug Sep Oct % facilities had CGS 33 33 33 39 88 7-District Tharparkar Table 7. Average number of ANC visits per month per facility 99 39 64 7 7 3 5 3 4 30 4 7 7 48 87 8 93 38 34 3.0 PPHI 3 6 30 8 34 7 3.0 All facilities 50 5 6 48 6 43 4 Table 7. Average number of deliveries per month per facility 5 58 66 5 53 73 9 65 86 46 49 49 38 5 6 4 9 48.0 PPHI 3 3.0 All facilities 5 5 4 4 4 3 Table 7.3 Average number of PNC visits per month per facility 63 4 0 84 5 5 54 3 59 8 57 0 63 4 3 44 9.0 PPHI 4 4 4 5 6 7 6 3.0 All facilities 9 9 8 9 Table 7.4 Total Long Term Reversible FP Methods provided Serial FP Methods April May Jun Jul Aug Sep Oct IUCDs 0 0 0 6 0 Implants 0 0 4 3 0 3 Total 0 0 6 9 0 9
Table 7.5 Percentage of facilities around which at least one CSG was conducted Serial DoH & PPHI facilities April May Jun Jul Aug Sep Oct % facilities had CGS 0 0 0 0 0 9 38 8-District Thatta Table 8. Average number of ANC visits per month per facility 383 3 0 497 9 53 3 63 34 383 4 556 73 96 493 8 68 493 99 48.0 PPHI 84 9 97 90 0 7 65 3.0 CMWs 4 8 5 7 4 7 4 4.0 Private 4 3 5 3 9 5 5.0 All facilities 83 98 87 35 9 Table 8. Average number of deliveries per month per facility 383 30 7 375 30 6 33 35 8 47 39 5 45 6 9 474 64 6 50 65 8.0 PPHI 3 4 8 3.0 CMWs 6 4 6 4 9 4.0 Private 0 5 3 3.0 All facilities 4 3 4 6 35 35 35 Table 8.3 Average number of PNC visits per month per facility 0 8 7 33 5 4 3 8 3 7 74 5 34 6 0 4.0 PPHI 9 6 7 9 9 4 3.0 CMWs 3 8 4.0 Private 0 5 0 0 3 0 3.0 All facilities 4 9 5 8
Table 8.4 Total Long Term Reversible FP Methods provided Serial FP Methods April May Jun Jul Aug Sep Oct IUCDs 6 5 0 7 Implants 5 6 40 4 37 3 Total 6 7 50 44 44 Table 8.5 Percentage of facilities around which at least one CSG was conducted Serial DoH and PPHI facilities April May Jun Jul Aug Sep Oct % facilities had CGS 33 37 3 33 47 45
Endnotes Endnote : The primary mechanism through which MCHIP will contribute to the strengthening of DHIS will be through the review and use of DHIS data. DHIS data is not currently being used widely for decision-making. By examining trends in service delivery at health facility levels, MCHIP will increase the use of DHIS data for decision-making. DHIS data will be reviewed by MCHIP s district teams, who did not previously have access to this information. This will help district teams to determine where programmatic interventions need to be strengthened. MCHIP s senior management will also be able to identify which interventions are succeeding and which are not. Another way that MCHIP will strengthen DHIS data is by initiating collection of data on high impact interventions such as Helping Babies Breathe. Endnote : Under the USAID MCH Program, MCHIP is currently supporting 33 facilities 53% of these facilities are managed by the Department of Health or PPHI and 47% by the private sector. At PPHI or DoH facilities, providers enter data into registers which are part of the District Health Information System (DHIS). The Government of Sindh has not provided access to the DHIS to USAID implementing partners such as MCHIP. As a result, MCHIP has had to develop a mechanism for collecting data directly from DHIS registers. The implementation of this system was divided into two phases: First phase of implementation: In the first phase, a system was developed to collect routine data from DoH and PPHI health facilities by MCHIP s district-based staff. MCHIP s district-based staff were trained in July 04 to collect this data from various health registers that exist at public sector health facilities. MCHIP s technical and program identified 3 indicators needed to monitor progress of different interventions. These indicators are shown in Appendix A. Of the 3 indicators identified as being needed to monitor project progress, data was being collected on 9 either in DHIS registers or in the LHW-MIS. For 3 indicators which were related to Helping Babies Breathe (HBB) and Chlorohexadine, with the support of the DG Health office, stickers were developed and introduced in DHIS registers. MCHIP s field-based staff started visiting public sector facilities in August 04 to collect data on indicators from DHIS registers. The data collected was from April onwards. It was collected on Android tablets and submitted electronically via the web to MCHIP s server. Appendix B illustrates the roles and responsibilities of MCHIP staff at Karachi and districts offices for data collection, data review, data storage and management, data analysis and result sharing. Service delivery data on health facilities is now being collected on a monthly basis through this system. Second phase of implementation: The first phase of implementation of this data collection system has been successful and analysis of routine service delivery data has been initiated. MCHIP district-based staff will now train private health providers to collect data on the 3 indicators which MCHIP is collecting data on DoH and PPHI facilities. For the first 5 districts in which MCHIP is working, trainings of private providers on MCHIP s data collection register will be conducted in January 05. The register in which indicator data has to be collected have been developed and are being printed. Appendix C shows the register which have been developed for data collection from private facilities. relevant materials and on the job support for this
data collection at private sector facilities will be provided on a regular basis by MCHIP district-based staff, who will be supported by the M&E Department. While MCHIP expects to put this data collection system in place by February 05, we expect that it make take a few months before reliable information can be elicited from health facilities since it will require substantial behavior chance on the part of private providers to record and provide this information. Meanwhile, efforts will be continuously made to instill the habit of recording service delivery statistics. 3
Appendix A Monthly Facility Reporting Format (Data sources) District Name: Facility Name: DHIS/Facility Code: Reporting Month: Reporting Person: Designation: Sr No Indicators Data Source Output : Increased use of MNCH services DHIS Pvt Facility Register Number of ANC visits Monthly Report: Section VIII (ANC- + ANC Revisit) Total of column F Number of pregnant women with Hb < g/dl Monthly Report: Section VIII Total of column G Number of deliveries conducted 3 Normal Vaginal Delivery Monthly Report: Section VIII 4 Vacuum / Forceps Monthly Report: Section VIII Total of column R 5 Cesarean OBSTETRIC REGISTER Complications 6 Complications of Abortion OBSTETRIC REGISTER 7 Postpartum Hemorrhage (PPH) OBSTETRIC REGISTER 8 Pre-Eclampsia/ Eclampsia OBSTETRIC REGISTER Total of column S 9 Prolonged/ Obstructed Labors OBSTETRIC REGISTER Puerperal Sepsis OBSTETRIC REGISTER Number of live births in the facility Monthly Report: Section VIII Total of live births under column K 4
Sr No Indicators DHIS Pvt Facility Register Number of live births with LBW Monthly Report: Section VIII 3 Number of still births in the facility Monthly Report: Section VIII Count the circles under column L Total of still births under column K 4 Number of births with asphyxia 5 Number of newborn successfully resuscitated OBSTETRIC REGISTER (From Sticker under comments column, total of BA having value Y) OBSTETRIC REGISTER (From Sticker under comments column, total of RA having value Y) Total of column M Total of column N 6 Number of women provided uterotonics after delivery. OBSTETRIC REGISTER (Under " procedure done" Column) Total of column P 7 Number of newborns to whom chlorhexadine gel is applied to umbilical stumps Introduce CHX mark on HBB Sticker and capture value Total of column O 8 Number of clorhexadine gels distributed to pregnant women in the community for application to umbilical stump LHW-MIS Not aplicable in Pvt facilities 9 Number of misoprostol tablets distributed for PPH prevention to pregnant women in the community LHW-MIS Not aplicable in Pvt facilities 0 Number of pregnant women to whom misoprostol prescribed during ANC visit at facility MATERNAL HEALTH REGISTER Under "other services" column Total of column H Number of PNC visits (within two days) Monthly Report: Section VIII Total of column F Number of maternal deaths reported in DHIS Monthly Report: Section VIII Total of column Q 3 Number of women received TT- Injection Monthly Report: Section V Total of column J 4 Number of PPIUCD inserted Monthly Report: Section VII Total of column V 5 Number of implants inserted Monthly Report: Section VII Total of column W 5
Output : Increased capacity to deliver quality MNCH services Facility met minimum standards as per biannual clinical audit Health facility In-charge Indicator A Number of deliveries referred to higher level facilities for complications management OBSTETRIC REGISTER Total of Column T 3 MgSO4 is available in the delivery room Health In/Stock Reg. Indicator B 4 Number of skilled birth attendants trained in newborn resuscitation MCHIP/IP Field Office Indicator C 5 MNCH centers equipped with resuscitation devices Health facility In-charge Indicator D Output 3: Increased demand for MNCH services Number of community support groups that conduct at least meetings per month LHW-MIS Not required from Pvt Facilities Facility has list of local transporters displayed at facility, Observation Indicator E 6
Appendix B Data Flow and Role & Responsibility for Routine Data Collection - Development of data collection mechanism and train data collectors. -Field visits to strengthen the data collection mechanism and remote help desk support. 3- Conduct data quality audits 4- Review and analysis of submitted data. 5- Sharing and dissemination of results. MCHIP M&E Team - Review the submitted data of all facilities and approve for analysis. - Timely submission of data from all facilities on monthly basis. 3- Ensure that all registeres are maintained well and all clients are recorded in registers. District Coordinator/ M&E Manager IP - Store all health facilities monthly data. - Provided access to all relevant users. MCHIP Database Server - NCH Coordinators will lead the data collection system and train M&E and MIS staff based in districts. - Conduct field visit with M&E and MIS staff for data verification and collection. 3- Train private health facility staff how to fill client information register. NCH Coordinator - Check the completeness of data and ensure registers are maintained properly. - Record indicators value from registers 3- After filling the electronic form, send information to MCHIP Database Server M&E Assistant MIS Assistant - Record client information - Maintain record keeping registers upto date Health Facility Health Facility 7
Data Submission timeline: Data collection at facilities will be completed before 0 th of every month. MCHIP s District Coordinators, Implementing partners and MCHIP s M&E Manager will review collected data of all facilities before the 5 th of every month. On the day of the visit, data collectors will capture the information of the last month rather than of the current month. Data will be collected from the month of April 04 onwards. 8
Appendix C 9
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