Ministério da Saude Ministério da Justiça Designing Better Hospital Mortality Systems Improving hospital systems in Mozambique ACHIEVEMENTS, CHALLENGES & OPPORTUNITIES 2006-2015 CAIRO, EGYPT 2015 Dra Cidália Baloi, MOH Dra. Esperança Nhagumbe, MOJ Mr. Ivan Mabote, UEM-Moasis/Jembi (on behalf of Dr. Alessandro Campione)
MOASIS is a non-profit organization of University Eduardo Mondlane, Living Lab created and supported entirely by JEMBI with support of IDRC, CDC, WHO, Rockefeller and others ORG. We aim to: Strengthen HIS local capabilities involving the public, private and academic sectors Reference and link between the MOH and public/private partners Set up a South-South cooperation model JEMBI/MOASIS model
Rationale Before 2006: Mortality data collected through census/surveys and ad hoc studies 2006: pilot implementations of mortality and morbidity reporting using ICD-10 coding in 2 hospitals MOH recognized the need for mortality statistics at hospital level and lacking of vital statistics in the country Strategy to address the need MOH and partners revised entirely the national death registration system aiming to: Strategic Priority: National level system for hospital mortality registration Contribute to CRVS national reform (medium/long term) Expansion to extra-hospital deaths in coordination with all CRVS stakeholders (Long term)
Background (cont.) Revision of Mortality registration System 2015 Strengthening of the whole CRVS system and inter-institutional cooperation 2013 2010 2009 2008 2007 SIS-ROH expanding to all Mozambique (till Sept 2015 = 44 sites, >100,000 records) Enhancement of electronic tool for intra-hospital mortality register (SIS-ROH) Review of mortality system In health sector First ICD-10 Hospital Mortality System Little pilot
CRVS COMPONENT UEM-Moasis supported the creation Inter-institutional Group for Civil Registration and Vital Statistics Mozambique is one of the few African country that have this formalized and with a Work Plan and is considered a best practice in the field of Mortality System implementation. Set up cooperation with Medical Research Council, WHO and STAT-SA Promoted MoH as active member of WHO-FIC community Constituted the Inter-institutional Vital Statistics Working Group (MoU) MOH, MOJ, UEM/MOASIS, INE, MI. Performed the In-depth assessment of CRVS and plan of action for CRVS Reform in Mozambique Participate to the CRVS reform and working group Visit to Stats SA WHO-FIC Conference Cape Town
JEMBI-MOASIS active role in the CRVS in-depth assessment Planning stage (including the revision of the inquiry form for death registry and cause of death) Technical and financial support in the filed work (e.g. Boane) Support and facilitated the consolidation meeting and training of the 2 components) Support the draft, conclusion and approval from GITEV of the CRVS operational plan
Mortality Registry System in Mozambique 2007-2008 2008-2013 2013-2015 Expansion to 44 SITES extra-hospital deaths Expansion ICD-10 adopted as national standard FULL AND REDUCED LIST - Analysis of death certification process - New national regulation - New death certificate Set up of ELECTRONIC Intra-hospital mortality register (SIS- ROH) Training >300 STAFF on ICD- 10 and death registration SIS-ROH official death registration of national health system -Expansion to 14 hospitals hospitals -New Death certificate approved First national mortality analysis based on routinely collected data Update of analysis Report of Assessment of Death and Cause of Death Registration (CRVS Assessment) SIS-ROH APPLICATION VERSION 2.0 (web-based) 3 rd National Mortality Data Analysis Report published Cuamba Rural Hospital Independent Mortality Data Analysis Report (Independent)
SUCCESS FACTORS
1. FOCUS ON THE WHOLE SYSTEM NEED ASSESSMENT REQUIREMENTS MANY FOCUS HERE TRAINING DATA QUALITY PUBLICATION AND USE IT PROBLEM & TECHNOLOGY CLINIC/PUBLIC HEALTH PROBLEM PROJECT, AGREEMENTS FUNDRISING COMMITMENT DEPLOYMENT INTEGRATION MAINTENANCE SUPPORT AND SUSTAINABILITY
2. Institutional and Stakeholder support Bottom-up approach Start little, be pragmatic Respond to needs of health workers first Obtain concrete results and grow based on success Local ownership and MOH commitment Informatics solutions suitable to the country setting basic computer technology modular design, open source minimum data set and introduction of standards Creation of high level WG was a milestone to reach governmental commitment to strengthen the overall CRVS
Institutional and Stakeholder support (cont.) MOH/ UEM-MOASIS/JEMBI Collaboration for SIS-ROH MOH has the ownership and provide overall direction and supervision to all joint projects UEM-MOASIS: UEM project design an all aspects, supports development of system and software, implementation and maintenance of all tools and training at the national level Jembi: South African NGO, provides technical and financial support to UEM-MOASIS
3. SIS-ROH SOFTWARE (success factor) Simple Individual based electronic register Registration of: Demographic data Data on hospitalization Causes of death (underlying and direct) Filing support Data used locally, in real time and highly accepted by users Data used at national level for health policy (yearly) Increasing geographical coverage with stable data quality Data & standard reports available at hospital and national level
4. Country specific solutions SIS Compact Station (Internet 3G) Connectivity issues mitigated, low virus contamination, dedicated to national HIS micd ICD-10 Short list
5. IT In the Provinces IT technicians supporting Health facilities at the district and provincial Constant IT support and maintenance, correction of bugs and errors, helpdesk, troubleshooting to ensure proper functioning of the HIS and infrastructure at HF level 1 technician present in every province of the country (MOH/DIS with support from UEM- MOASIS/JEMBI).
6. Quality Assurance Mechanisms Training: At central and provincial level: TOT on death certification and ICD-10 Training on SIS-ROH software for long term maintenance In each new implementation site: Training on death certification and ICD-10 for clinical staff and Statistical unit staff Training on SIS-ROH software for data management, filing, backup, maintenance SIS-ROH inbuilt data validations (cause of death coding according to age, gender, etc.) Routine data analyses, presentation/discussion and publication Data Quality assessments and supervision Use of data at local and national level
OPPORTUNITIES & FUTURE PROSPECTS
SIS-ROH VERSION 2.1 New Version of the Death Registration system Web-based Standardized reports Inclusion of maternal and foetal deaths Expansion to extra hospitals deaths Expansion to the community certification Migration of SIS-ROH 2.1 into DHIS 2 platform tracker module (testing)
Integration of SIS-ROH with other HIS in Mozambique Ongoing the SIS-ROH2 interoperability and integration with some national HIS including the greater national CRVS System, supported by UEM-MOASIS/JEMBI including: SIS-H = hospital IS based on short lists of ICD-10 for morbidity reporting SIBI = patient based system for chronic patients SIS-MA = national M&E information system
Systems Integration & Interoperability (CRVS) CURRENT STATUS IN MOZAMBIQUE
Systems Integration & Interoperability (CRVS) (cont.) POSSIBILITIES FOR SYSTEMS INTEGRATION & INTEROPERABILITY AMONG SYSTEMS & DATA SHARING
Mozambique CRVS Information Exchange Proposal
ACHIEVEMENTS AND IMPACT
SIS-ROH (Death Registration System) Implemented in 44 sites (36 HF) at national level (All Central & Provincial Hospitals, some rural hospitals) Training materials/it support/on the job training/refresher by UEM-MOASIS/JEMBI supporting MOH Use of ICD-10 codes for causes of death (reduced list at first, now full ICD-10 coding) >300 staff trained Expanded to Extra-hospital death Increase in death registration (2009-2013)
IMPACT SIS-ROH training Before 2006, mortality data was acquired from census and surveys 2009: Mozambique produced first data analysis mortality report (extracted from SIS-ROH) 3 National reports to date have been produced (The latest published data from 2009-2013) Cuamba Rural Hospital Report (done by national staff at own initiative) >100.000 deaths registered Data are also shared and used by INE for specific epidemiological and statistical analyses Regular use in Health Units for quality of care and planning
DATA ANALYSIS, PUBLICATION AND USE AT NATIONAL AND LOCAL LEVEL: posters national and international, articles, regular governmental statistic publications, specific study etc.
SIS-ROH NEW SIMPLIFIED DATA FLOW CYCLE PROCESS
THE LATEST PUBLISHED DATA FROM 2009-2013 250 copies reproduced and distributed by the MOH to INE (Body of National Statistics), to the provincial levels (DPS), and the national MOH Directorates.
Intra-hospital mortality rates in Central Hospital of Maputo by department, 2008-2013 18 16 14 12 10 8 6 4 2 0 Surgery Gyneco/Obst Medicine Orthopedics Pediatrics 2008 2009 2010 2011 2012 2013
Causes of death in the Paediatrics department of Central Hospital of Maputo, 2009-2013 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2009 2010 2011 2012 2013 Intestinal infectious diseases Protozoal diseases Influenza and pneumonia Malnutrition Infections of the perinatal period HIV disease Respiratory and cardiovascular disorders of the perinatal period
Intra-hospital deaths by type of admission and level of referral hospital, Mozambique, 2013 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Central Hosp. Provincial Hosp. General Hosp. Rural/District Hosp Health Centre Birth and outpatient Transfer from other HF Emergency
Mortality by cause of death, Mozambique 2009-2011 Broad Category Hematological dis. 2% Endocrine and metabolic dis. 4% Nervous system dis. 3% Respiratory dis. 5% External causes 6% Digestive dis. 2% Neoplasms 5% Cardiovascular dis. 8% Pregnancy, delivery, puerp. Other causes 2% 7% Infectious and parasitic dis. 37% Disorders of perinatal period 19%
Mortality by cause of death Details per category: Infectious diseases Other infectious diseases 6% TB 6% HIV/AIDS 73% Infectious diarrea 5% Malaria 10%
Mortality by cause of death Details per sub-category: HIV/AIDS 1,1% 0,3% 0,4% 0,2% 2,5% 2,9% 0,4% 4,2% 5,0% 11,2% 71,9% HIV not specified HIV + TB HIV + multiple infections HIV + encephalopathy HIV + bacterial infections HIV + Kaposi sarcoma HIV + mycotic infections HIV + Burkitt lynphoma HIV + other malignant neoplasm HIV + pneumonia (pneumocystis)
Distribution of the causes of death by age group or other demographic data 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Outras causas Causas externas D. do sistema nervoso D. hematológicas e imunitárias D. endócrinas e nutricionais Neoplasias Sintomas, sinais e achados anormais D. do aparelho circulatório D. do aparelho respiratorio Afecções do período perinatal D. infecciosas
Causes of death: trends over time (>1 year, national level), 2010-2013 25000 20000 15000 10000 5000 0 2010 2011 2012 2013 All other causes HIV disease Malaria Tubersulosis
CHALLENGES
Expansion to all Health Facilities, out of the Health System at community level (cultural barriers, poor access to information, low coverage health and civil registration services) Full implementation of Mother and child section of the SIS-ROH2 system Full integration in the national M&E system (SIS-MA) Full Connection and integration with the Civil Registration system Conduct regular training on death certification and ICD-10 Ensure improvements in Data Quality Boost IT Infrastructure, other equipment and materials (ICD-10 manuals)
Kanimambo! Ministério da Saude Obrigado! Ministério da Justiça Dra. Cidália Baloi Dra. Esperança Nhagumbe Mr. Ivan Mabote