Rapid Appraisal of DHIS

Rapid Appraisal of District Health Information System

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REPORT DEVELOPERS

This report has been developed by a team headed by Dr. Farooq Azam Jan, DHIS Expert

in close coordination of Mr. Syed Khalid Hussain and Mr. Asad Afzal - HIS Consultants

under the technical supervision of Dr. S.M. Mursalin, Technical Coordinator HIS, WHO.

WHO issued contracts /APWs to following professionals to support this study.

Dr. Farooq Azam Jan

WHO Registration: 2011/173410-0

P.O. 200451300

EMPAK1005227 / 3.1.3 / 57225

Mr. Khalid Hussain Shah


P.O. 200457286

EMPAK1005227 / 3.1.3 / 57640, 57225

Mr. Asad Afzal Humayoun


P.O. 200457230

EMPAK1005227 / 3.1.3 / 57640, 57225


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Table of Contents ACKNOWLEDGEMENT 04

ABBREVIATIONS 05

EXECUTIVE SUMMARY 06

1. BACKGROUND 10

1.1 Introduction 10

1.2 Objectives 10

1.3 Districts Selected for Survey 11

1.4 Methodology 11

1.5 Operational Hierarchy 12

2. DATA ANALYSIS AND OBSERVATION 13

2.1. DHIS Functionality at Facility Level 13

2.1(a) DHIS Infrastructure & Functionality 13

i. Respondents by Facilities and Designation 13

ii. Flood Impact on Health Facilities & DHIS Functionality 13

iii. DHIS Trained Staff at the Health Facilities 14

iv. Status of DHIS Trained Staff Compiling Monthly DHIS Data at Facilities 14

v. Availability of DHIS Data Collection Tools and Daily Update 15

2.1(b) DHIS Data Quality Parameters 16

i. Availability of DHIS Procedure Manual & TORs 16

ii. Staff Understanding on DHIS Reporting Tools vs Inconvenience 16

iii. Knowledge and Practice of Monthly Submission of DHIS Reports 17

iv. Reporting Regularity 17

v. Feedback to Facilities vs Type of Feedback 17

vi. Use of DHIS Data for Planning & Management 18

vii. Situaiton of DHIS Tools at the Health Facilities 18

viii. Keeping up Record of the Monthly DHIS Reports 19

2.1(c) DHIS Operational Needs 19

i. Staff Trainings Needs 19

ii. Replenishment of DHIS Tools Supply 20

iii. Need of for Other DHIS Resources 20


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2.2 DHIS Functionality at Managerial Level 20

2.2(a) DHIS Infrastructure & Functionality 20

i. Respondents at Districts by Designation and DHIS Functionality 20

ii. Availability of DHIS Trained Human Resources at Districts 20

iii. Status of Monthly DHIS Reporting Compliance vs Time of reporting 21

iv. Data Accuracy of the Field Units 21

2.2(b) DHIS Quality Parameters 22

i. Usage of Different Quality Factors of the System 22

ii. Validation of DHIS Data Reported in October 2011 23

2.2(c) DHIS Operational Needs 24

i. Initial / Refresher DHIS Training 24

ii. Need of Other Resources 24

3. CONCLUSIONS 25

4. RECOMMENDATIONS 26

ANNEXURES

A. Selected District & Total Number of Health Facilities Visited 28

B. List of Offices/ Facilities Visited 29

C. List of DHIS Data Instruments 31

D. Ensuring Data Quality 32

E Study Supervision and Team 33

F. Timeline of Activities / Work Plan 34

G. Field Data Collection Questionnaire (Managerial Level) 35

H. Field Data Collection Questionnaire (Facility Level) 38

I. Surveyed Data Output Tables 41

J. Monthly DHIS Reporting Form (PHC) 47

K. Monthly DHIS Reporting Form (Secondary Hospitals) 51


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Acknowledgement

In any healthcare system the one most exciting input is the availability of an efficient

Health Management Information System. Though, the national health status of Pakistan

yet to show more achievements compared to many other countries. Federal Ministry of

Health, in early 90s took concrete steps for setting up a coherent and a uniform system of

data collection known as Health Management Information System (HMIS) initially for

public health sector. Several international partners assisted this initiative. Later on to

make this system more comprehensive at the district level it was transformed to District

Health Information System. DHIS gathers information not only from first level care

services but also from District and Tehsil Hospitals. The ultimate objective of all these

efforts is to produce timely information of good quality for decision makers at various

levels of working.

Since the implementation of DHIS at all the districts of Punjab province in 2008, this

performance assessment exercise was unique in its kind. Prime objective of this study

was to realize if the new system is meeting the intended targets and its functionality

adequately as was designed.

I am confident that this report would help Provincial and District Health Managers to

improve evidence based decision making in their respective areas. Here I would like to

thank Dr. Anwar Janjua, former Director Health Services (MIS) Punjab for his kind

support and tremendous cooperation that enabled me and my team to collect the desired

data and other necessary information from the district and health facilities.

Further, I would like to appreciate the overall technical supervision extended by Dr. S.M.

Mursalin, Technical Coordinator, Health Information Management Unit/WHO.

Significant inputs made by Mr. Imran Majeed especially during the study design phase

and development of questionnaire are to be acknowledged. Here I would also thank my

colleagues Mr. Khalid Hussain and Mr. Asad Hamayoun for their hard work and

concerted efforts in completing this assignment and finalizing the End Assignment

Report.

Dr. Farooq Azam Jan January 31, 2012 Team Leader


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Abbreviations

ANC Antenatal Care

BHU Basic Health Unit

CD Civil Dispensary

DHIS District Health Information System

DHQ District Headquarters

DOH District Officer Health

DEO Data Entry Operator

EDO-H Executive District Officer-Health

FLCF First-Level Care Facility

FP Family Planning

GRD Government Rural Dispensary

HMIS Health Management Information System

HR Human Resources

LHS Lady Health Supervisor

LHV Lady Health Visitor

LHW Lady Health Worker

LQAS Lot Quality Assurance Sampling

MCH Maternal and Child Health

MOH Ministry of Health

NGO Non Governmental Organization

OPD Outpatient Department

PHC Primary Healthcare

RHC Rural Health Center

SHC Secondary Healthcare

THQ Tehsil Headquarters Hospital

WHO World Health Organization


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Executive Summary

The provision of timely and effective healthcare services is the key objective of any country’s

health system. To maintain the health system in a good functioning status it is imperative to

regularly monitor it through an efficient Health Information System. This system should be

able to provide timely and qualitative information for evidence based decision making

process. Realizing the impact of this very important factor specially in the public health sector

government initiated a nationally standardized data generation system at all levels called

Health Management Information System (HMIS) in early 90s.

Given the experience both in the development of information systems, the new information

needs and also, the initiation of several new programs this system has been modified to

District Health Information System (DHIS) in 2007. DHIS now have a much wider scope than

the old HMIS. The process led to revision of data collection indicators, tools and software.

The upgraded version of DHIS was completed in 2007 and its implementation at district

levels. But as this implementation was supposed to be carried out by the provincial health

departments thus its timeframe varied from province to province. It was encouraging to note

that Punjab Health Department took the lead to implement this program in all its 36 districts

by end 2007. It was therefore high time to assess if the new system is being implemented as

was primarily envisaged.

This assessment study is based mainly on three focused areas of the system e.g. (i)

Infrastructure & Functionality (ii) Data Quality and (iii) DHIS Operational Needs . Firstly to

analyze and document the existing functionality of DHIS in districts, mainly to get sense of its

functioning and work out immediate needs with regards to availability of Instruments,

equipment and training needs, software issues, data recording and its transmission. Second,

despite regular flow of data from the first level care facility (FLCF) to District HIS Cells and

then to Provincial or National Cells there still exist serious concerns among the provincial and

district managers on data quality and validity. Question is what additional measures are

needed to improve data quality and use. Thirdly to identify the operational needs and areas of

future support for improving the efficiency of information system

To facilitate this process a very simple coded questionnaires was developed both for

managerial and facility information. The theme of the questionnaire was based on three key

assessment areas of the district health information system e.g. (i) DHIS Infrastructure &

Functionality (ii) Data Quality and (iii) DHIS Operational Needs. Both close and open ended

questions were included in the questionnaire. Further the questions were derived from the

DHIS Procedures Manual and the monthly DHIS reporting forms to be used at Primary Health

Care and Secondary Health Care Facilities

Based on the originally approved/agreed plan between DHIS Directorate, Provincial Health

Department and WHO, in total 10 districts were to be selected comprising districts both from

flood and non flood affected districts. Therefore, to keep a balance, five districts were selected

from flood affected areas and other five from non affected areas. The final selection of district

names was made by the Provincial Health Directorate, which was primarily based on resource

availability for the study and to ensure an even geographical coverage.


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The districts included in this survey were; Rawalpindi, Jhelum, Sheikhupura, Okara,

Faisalabad, Bhakkar, Layyah, Muzaffargarh, Dera Ghazi Khan and Rajanpur. In total 15

health facilities were planned to be visited per district with the aimed at to consider a mixtures

of various types of health facilities from each district. Therefore a total of 150 facilities were

visited. From these 10 Forms (annex-A) and 150 Forms (annex-B) were finally collected.

The collected data was finally entered into the computer software SPSS (V-16) and analyzed

both in graphical and tabulation form. Following are some major findings of this rapid

appraisal;

(a) DHIS Status at Facility Level

i. DHIS Infrastructure & Functionality

All health facilities affected by the flood of 2010-2011 were found re-habilitated.

DHIS functioning observed to be an integral part of the public sector healthcare

delivery system, as each and every health facility either it is primary or secondary

healthcare, are regularly generating the health information of their respective areas.

The 80% of the facilities’ incharges (e.g. 133 out of 150) got DHIS training, whereas

the remaining 20% were observed as either untrained or self-trained.

Among the staff deputed for preparation of monthly DHIS reports at the facilities it

was observed that 92% (138 out of 150) were properly trained for this task.

The availability of different data recording tools/registers was seen at 82% and 75%

facilities do daily updation of these registers.

ii. DHIS Quality

Better understanding of the staff about DHIS forms was reported at 91%, whereas the

remaining staff reported to face difficulty in understanding the Section-II, III and

Section-VIII of the forms. Besides the junior rank officials, some Senior Medical

Officer, Medical Officers and Female Medical Officers were also included in this

category.

DHIS procedure manual was found at 71% facilities (i.e. 107 out of 150). Similarly

DHIS relevant TORs of the staff seen at 51% facilities.

Almost all the staff had correct knowledge and practice regarding submission of

monthly DHIS reports to their respective EDO-Health.

During the last 12-months, 100% reporting regularity was observed at the facilities,

however only three (03) facilities missed their five reports due to floods.

It was encouraging to note that the 72% of the visited facilities (108 out of 150)

confirmed that they regularly receive feedback from their respective EDOs-Health.

However majority of the feedback 44% (66 facilities) was through discussion on

monthly targets of the facilities and their performance.

Almost half of the surveyed facilities (54%) used DHIS data for their routine planning.


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A considerable number of facilities faced shortage of DHIS tools, as during 2011; 18%

(27 out of 150) of the surveyed facilities faced this problem.

Almost all the targeted facilities kept copies of their monthly sent reports for record.

iii. DHIS Operational Needs

There was a dire need for the supply of DHIS Tools / instruments in most of the

facilities/ Districts.

DHIS tools replenishment needed by 67% of the facilities and majority of them need

one year supply in advance.

The need of trained staff was reported by 43% (64) of the facilities. Whereas, 41% (61)

facilities needed DHIS tools supply and some 23% (35) expressed for other kind of

needs (e.g. Computer supplies/software). Other important expressed need was for

online DHIS Data Entry System.

(b) DHIS Situation at Managerial Level

i. DHIS Infrastructure & Functionality.

Comparing districts, the managerial level questionnaires was responded by the

Statistical Officers/DHIS Coordinators (80%), whereas only 20% EDOs-Health

participated in this survey.

All desired hardware and the corresponding DHIS software was found available at all

ten districts. Further the DHIS activities are being handled by an independent DHIS

Cell, which is very encouraging.

All the District DHIS Coordinators received DHIS training, but only six Data Entry

Operators reported to have a regular training whereas the rest four did not have.

The monthly reporting compliance by the districts was observed to be excellent.

The data accuracy or consistency among facilities and districts HMIS units was

observed to be excellent (81% - 100%).


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ii. Data Quality.

Almost all districts surveyed were found using DHIS data for LQAS techniques, (Lot

Quality Assurance sampling), for both-way feedback, their service monitoring and

district health planning. In the context of planning, it was observed that EDO-H didn’t

use data for strategic planning, but they did use this for day to day managerial issues.

A negligible difference of reported figures collected from the health facilities and with

the one with respective EDOs Health was observed.

iii. DHIS Operational Needs.

It was observed that District DHIS Office staff at the districts already reported to be

trained on DHIS functionality, however they asked for further training.

Regarding the need of resources out of those ten interviewed, nine district level

respondents asked for refresher training, eight requested for system maintenance, six

demanded computer hardware and four asked for updated DHIS software. Half of the

districts asked for computer operators.


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1. Background

1.1 Introduction

National HMIS Cell, being is functioning since 1998 and has the mandate to assist Health

Sector in development and launch of a nationally standardized Health Information System.

National Health Information System is a mechanism of data collection, transmission,

analysis and information feedback for all health related information. Over the years National

Health Information System has become one of the major data source for the health sector in

the country.

Based on long implementation experience and demand from end users the existing system is

now being transformed to a more efficient District Health Information System (DHIS). The

reformed system, unlike the previous system, would gather and collate information from

secondary hospitals (i.e. DHQ, THQ Hospitals) and some other important health care levels,

as well. Currently out of 134 districts, staff from 96 districts have been successfully trained

and shifted on District Health information System (DHIS). From these, nearly 65 districts

have started regular reporting since last six months. This HIS Unit sponsored by WHO is

responsible for data collection and analysis for the health data.

Many partners including, WHO have been providing institutional support for development

and the improvement of National Health Information System at the Federal, Provincial and

District levels. Punjab Implemented the new system’ DHIS in all districts (36). Health

Department of Punjab has requested WHO to conduct this appraisal for improvement and

strengthening the system.

1.2 Objectives.

Since 2009 DHIS is fully implemented and reporting at each District of Punjab province,

thus there is a need for a quick rapid appraisal of District Health Information System mainly

for improving the efficiency of DHIS.

Following were the more specific objectives;

To realize the current situation of Infrastructure & Functionality

To assess the available Data Quality and

To assess the DHIS Operational Needs


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1.3 Districts Selected for Survey

The selection of the districts was made from two basis i.e. one where the devastating flood of

2010-2011 damaged the public health settings and the second non flood affected areas. The list

of selected districts can be seen from the table below.

Non-Flood Affected Districts Flood Affected Districts

1. Rawalpindi 1. Layyah

2. Jhelum 2. Bhakkar

3. Sheikhupura 3. Muzaffargarh

4. Okara 4. Dera Ghazi Khan

5. Faisalabad 5. Rajanpur

1.4 Methodology

a) Sampling Protocol:

Based on the originally approved/agreed plan between DHIS Directorate, Provincial Health

Department and WHO, in total 10 districts were to be selected comprising districts both from

flood and non flood affected districts. Therefore, to keep a balance, five districts were selected

from flood affected areas and other five from non affected areas. The final selection of district

names was made by the Provincial Health Directorate, which was primarily to ensure an even

geographical coverage in non flood affected districts.

Regarding the total number of health facilities to be surveyed per district, a convenient random

sampling technique was adopted. This aimed at to consider a mixtures of various types of

health facilities from a district. In total 15 health facilities were planned to be visited per

district. Therefore a total of 150 facilities were visited. From these 150 Forms (annex-B) were

finally collected. Provincial Health Departments are adopting same procedure for monitoring

and data quality in their respective districts, called Lot Quality Assurance Sampling

Technique. (LQAS)

The type/ list of these 15 health facilities/district is as follows;

(i) Managerial Office = 1 (EDO-H office)

(ii) Health Facilities;

- DHQ = 1

- THQ = 1

- MCH Centre = 3

- Dispensary/CD/GRD = 3

- RHC = 3

- BHU = 4

Total = 16


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b) Data Collection Tool/Questionnaire

A very simple and easy to understand questionnaire was developed both for managerial and

facility information. The theme of the questionnaire was based on three key areas of the

district health information system e.g. (i) DHIS Infrastructure & Functions (ii) Data Quality

and (iii) DHIS Supply/Other Needs. Both close and open ended questions were included in the

questionnaire. Further the questions were derived from the DHIS Procedures Manual and the

monthly DHIS reporting forms to be used at Primary Health Care and Secondary Health Care

Facilities.

Moreover, to check the respondent’s knowledge and practice regarding monthly DHIS

reporting activities, relevant questions were included in questionnaire. LQAS being an

authenticated way of observing data quality, figures pertaining to five basic monthly reported

indicators were also surveyed (see questionnaires at annexure).

c) Data Collection Approach

For the field visits, ten Data Collectors/Enumerators were engaged (i.e. one per district),

where the District Focal Person (DHIS Coordinator of the respective district) joined them

from respective districts. They also helped them for selection of facilities and preparation of

field visit routing plan. Enumerators were given one day training at Islamabad on data

collection strategy and on the understanding of data collection tools (questionnaires).

d) Data Analysis Tool

The collected data was entered and analyzed in computer software SPSS (V-16) and the

analytical views and observations are given both in graphical as well as tabulated form.

1.5 Study Operational Hierarchy


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2. Data Analysis and Observation

Study team was much satisfied with the collection of desired data as a total of ten filled-in

forms were received from the managerial offices/levels (EDOs-Health) and 150 from the

targeted facilities. The collected data was entered into the computer software SPSS (V-16),

aiming at to get appropriate data analysis. The point-wise data analysis & discussions based on

the data collection questionnaire for both facility and managerial levels are as follows;

2.1 DHIS Functionality at Facility Level 2.1(a) DHIS Infrastructure & Functionality i. Respondents by Facilities and Designation

The field survey at the targeted health facilities revealed that in total nine District

Headquarters Hospitals were interviewed against the planned ten. Reasoning of this

when confirmed was that DHQ Hospital, Rawalpindi doesn’t report the monthly DHIS

data to their EDO-Health. However, to cover the sampling size in number, an additional

Tehsil Headquarters Hospital of Rawalpindi district i.e. total 11 THQ Hospitals instead

of planned 10 were included. The other facilities e.g. MCHCs, GRDs, RHCs and BHUs

were covered according to approved plan (see table # annexure-H).

Out of the selected 150 health facilities majority of the respondents (88) were

professionals and qualified officials, which significantly compliment the credibility of

our data. The graph below shows the number and type of respondents in this study.

ii. Flood Impact on Health Facilities & DHIS Functionality It is observed that out of the total 75 health facilities, selected from the five flood

affected districts (i.e. Layyah, Bhakkar, Muzaffargarh, DG Khan & Rajanpur), only five

(05) facilities were reported to be seriously affected by floods. All were later re-

habilitated by the health departments.

43

2624 24

1412

41 1 1

0

5

10

15

20

25

30

35

40

45

50

Medical Officer

Dispenser LHV Sr. Medical Officer

Medical Supdtt.

Medical Technician

Woman Medical Officer

DOH Pharmasist Statistical Officer

Num

be

rs

Status of Respondents by Designation


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An encouraging point was that the monthly DHIS data reporting is now being

considered as an integral part by all the District Health Offices. Resultantly, almost all

the health facilities either primary or secondary type is regularly generating the health

information for District Health Offices.

iii. DHIS Trained Staff at the Health Facilities A timely, accurate and reliable data generation is well desired from this District Health

Information System. It is observed that this is more or less and this is absolutely

dependent upon the incharge of the health facilities. Therefore, their training on the

DHIS Data Collection and Reporting tools becomes critical. It was found during the

survey that out of 150 incharges of the facilities, 133 (80%) got DHIS training, whereas

for remaining 17 health facilities, no staff was formally trained in DHIS. So the DHIS is

being maintained either by untrained or a self-trained person.

In this context the situation by districts revealed that almost all the (100%) incharge of

the visited facilities at districts of Bhakkar, D.G. Khan, Jhelum, Muzaffargarh and

Okara got DHIS training. This was followed by Rawalpindi, Rajanpur, Sheikhupura

and Layyah with 80% - 87% interviewed staff trained Somehow, comparatively less

number of DHIS trained staff/ incharges (53% ) were found trained in District

Faisalabad. This needs to be further explored.

iv. Status of DHIS Trained Staff Compiling Monthly DHIS Data at Facilities DHIS reports are to be submitted on monthly basis from the health facilities to districts.

Therefore the training of health facility staff, preparing such reports becomes mandatory

for some good information. (i.e. DHIS-21 & DHIS-22).

100 100 100 100 100

87 8780 80

53

0102030405060708090

100

(Per

cen

t)

Status of DHIS Trained Staff by District


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Dispenser LHVMedical Officer

Medical Technician

NurseStatistical Assistant

Staff Deputed 87 23 20 13 2 5

Trained Staff 81 22 16 13 2 4

0

20

40

60

80

100

Nu

mb

ers

Status of Trained vs Untrained Staff Deputed for Monthly DHIS Reporting

97

86 84 83 83 82 8277

73 71

0102030405060708090

100

Perc

enta

ge

Status of Availability of Different Data Tools andTheir Daily Update by District

Tools Availability (%age)Daily Updation (%age)

Fortunately, the received data analysis showed some good results. As out of the 150

staff interviewed, 138 (92%) had DHIS Training on Data Collection Tools. While

analyzing for the type of staff trained, it was found that higher number of dispensers got

this training that was 81/87 (i.e. 93%). Other staff interviewed included LHVs. Where

all l22 were trained, Out of 20 Medical Officers interviewed 16 were trained. For

Medical Technicians out of 13 interviewed all were trained), nurses (total 2

interviewed) both were trained. Out of five (5) Statistical Assistants, four (4) were

found trained.

v. Availability of DHIS Data Collection Tools and Daily Up-date Availability of different data recording tools/registers (list annexed) and their daily

update was also observed during the survey. The overall analysis of the ten surveyed

districts showed that data collection tools were available in 82% of the facilities

surveyed. However, the daily updation was being done at 75% of the health facilities.


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0

3

6

9

12

15

# Fa

cilit

ies

Vis

ited

Status of Availability of DHIS Procedures Manual & TORs

Availability of Manual

Availability of TORs

The graph above shows that most of the health facilities of district Muzaffargah,

Bhakkar, Faisalabad, Layyah and Okara update their activity registers on daily basis,

which is very encouraging. On the other hand, some of the health facilities belonging to

districts of DG Khan, Sheikhupura, Rawalpindi, Rajanpur and Jhelum do not update

their record on daily basis.

2.1 (b) DHIS Data Quality Parameters i. Availability of DHIS Procedure Manual & TORs

One of the basic parameter for having good quality of data is to have ‘DHIS Procedural

manual’ for ready reference. So that in case of some ambiguity this manual could be

consulted. . The study revealed that out of 150 health facilities DHIS procedure manual

was available only at 107 facilities. On the other hand roles and responsibilities (TORs)

with respect to DHIS were found available at only 77 selected facilities. .

Among districts, considerable disparity in availability of procedure manual was

observed in the districts of Muzaffargarh, DG Khan, Jhelum, Okara and Rajanpur.

However, better availability of TORs was observed at districts of Muzaffargarh,

Layyah, Bhakkar and Faisalabad. However, comparatively lesser availability of DHIS

Manual was observed at Sheikhupura, Rawalpindi and Layyah.

ii. Staff Understanding on DHIS Reporting Tools vs Inconvenience Better understanding of the staff deputed at the health facilities (136 out of 150) on the

chapters and indicators of monthly DHIS form (DHIS-21) was observed in the Districts

of Bhakkar, DG Khan, Jhelum and Layyah. However, lesser understanding (14 out of

150) was noted in the districts Rajanpur, Rawalpindi, Sheikhupura and Faisalabad. Here

majority of the staff faced difficulty mainly to understand the Sections-II, III and VIII.

It is pertinent to mention here that Section-II of the form related to ‘monthly

performance’ of the health facility with reference to set their monthly targets. Section-

III gives data of OPD by gender and the age group and whereas Section-VIII relates to

‘maternal and child health’ activities.


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Receive Feedback

(72%)

No Feedback (28%)

Status of Health Facilities Received Feedback From EDO-Health on DHIS

Reports

It was noted that both junior levels staff (Medical Technician & LHVs) and the senior

rank officers i.e. Senior Medical Officer, Medical Officers and Woman Medical

Officers, also face difficulty in understanding DHIS forms and thus need necessary

refresher training in some of the districts.

iii. Knowledge and Practice of Monthly Submission of DHIS Reports

A question about the exact dates of submission of monthly report was asked. It was

observed that almost all the incharges of the health facilities had knowledge and

practice regarding the timing of submission of monthly DHIS reports to their respective

EDOs-Health. However, some variation between the knowledge and practice was

observed at Bhakkar, Faisalabad and Layyah district and this may be due to certain

follow up delays.

iv. Reporting Regularity In principle each health facility has to submit monthly report. It was seen that almost

all the health facilities compiles its monthly DHIS report and send regularly to their

respective EDO-Health office.

In this context, as per facilities record, it was noted that only three (03) health facilities

out of 150 surveyed missed their only five reports due to floods. Otherwise all of these

sent their monthly reports. These facilities included; Civil Dispensary, Gajanthal/ DG

Khan (missed one report), BHU Kotla Nasir / Rajanpur (one report) and THQ hospital,

Jampur / Rajanpur (three reports).

Regarding the data quality, it was noted that standardized monthly DHIS reporting form

is being used at all type of health facilities. In principle the routine healthcare activities

varies from each type of health facility. The review team observed that monthly data

forms being reported by a CD/GRD contained incomplete figures compared to the

information obtained from RHC or BHU level facility.

v. Feedback to Facilities vs Type of Feedback A proper and timely feedback mechanism plays key role not only to cover the short

falls of the missing data to be reported from the health facilities, but also, to positively

improve the healthcare services delivery at each level. Therefore, when inquired, out of

the 150 selected facilities, 108 (72%) informed said that these are regularly receiving

feedback from their respective EDO-Health. Remaining 42 (28%) facilities informed

that these didn’t receive such

feedback from higher formations.

Among districts, relatively better

response was obtained from the

districts of Okara, DG Khan,

Jhelum, Sheikhupura and

Rawalpindi. However, EDO-Health

Faisalabad, DG Khan and Rajanpur

need to enhance feedback to their

health facilities. .


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Yes(54%)

No(46%)

Health Facilities used DHIS Data for Planning

To a question on type of feedback the health facilities received. It was observed that

majority of the facilities 66 (44%) told by their respective EDO-Health to visit EDO’s

office and discuss the monthly targets and their performance etc. Some 26 (17%)

facilities responded that, their high ups called them to discuss the administrative and

managerial issues. At the 15 (10%) facilities correction of the monthly DHIS data was

asked. However, only one facility found to be received feedback on their stock and

supplies.

vi. Use of DHIS Data for Planning and Management Adequate and appropriate health data is desired not only for day to day operational use

but also for planning and management of the health services. During the survey, the

facility’s incharges were asked; either they use DHIS data for any kind of planning or

for any other management functions. It was realized that nearly half of the targeted

facilities (54%) use this data for their routine planning, whereas the remaining half

(46%) didn’t use it for any

purpose rather sent to their

EDOs-H.

Among districts, comparatively

good responses were received

from the districts of Jhelum,

Muzaffargah, Sheikhupura and

Bhakkar. On the other hand

facilities of D G Khan didn’t use

DHIS data for any kind of

planning. Similar response was

also reported from the Districts

of Rajanpur and Faisalabad.

It was asked as to what kind planning is done .It was found that they use data for

multiple reasons like for managing the medicine stock, setting of monthly OPD targets,

follow-up of disease pattern, field/seasonal planning, provision of maternal & child

healthcare and family planning services, EPI services planning, performance evaluation

of the staff and organization of community meetings.

vii. Situation of DHIS Tools at the Health Facilities To keep up the daily records of the different healthcare activities at any health facility,

sufficient stock of registers is essential. It was noted that during 2011 a considerable

number of health facilities e.g. 18% (27 out of 150) reported to have faced DHIS tools

shortage.

Among districts, better stock position was observed at district DG Khan and

Rawalpindi. It was followed by Faisalabad, Layyah, Okara, Bhakkar and Muzaffargah.

However, comparatively high stock-out of DHIS tools was observed at Sheikhupura,

Jhelum and Rajanpur.


19

Facilities Didn't Faced

Shortage(82%)

1-Month Shortage

(15%)

3-Month shortage

(3%)

Facilities Faced

Shortage(18%)

Status of Facilities Faced Shortage of DHIS Tools

Trainings Not Needed

(15%)

Forms Filling(9%)

LQAS Technique

(11%)

Indicators' Analysis

(65%)

Staff Need Training

(85%)

Status of Staff Needs DHIS Trainings

To identify the duration

of this shortage, it was

noticed that 15% (20)

health facilities faced

such shortage for three

months or more, which

could be a matter of

concern for the district

health managers. On the

other hand, 3% (7)

facilities told that DHIS

tools shortage is there

for one month only.

viii. Keeping up Record of the Monthly DHIS Reports Since no computerized data management is being done currently at the health facilities,

therefore, pervious months records of monthly report is desired to be kept at the

facilities. This past record is essential for making comparison regarding OPD burden,

disease patterns and other healthcare activities. It was noticed that almost all the

targeted health facilities were found be kept such record. Only four facilities of district

Faisalabad reported not keeping up such record.

2.1(c) DHIS Operational Needs Needs i. Staff Training Needs.

It was realized that there is a significant need for training on DHIS tools and

mechanism. About 85% (128 out of 150) of the health facilities incharges recommended

for having refresher training in DHIS. Though, there were some extensive training

organized in DHIS but still

a need was felt for

improvement of their skill.

This survey revealed that

out of the total 150

interviewed staff, 65% (97)

asked for training in DHIS

‘indicators analysis, which

is a healthy sign. Some

11% (18) staff needs

training on LQAS

technique and 9% (13)

officials informed that they

need training on DHIS forms filling.


20

0

2

4

6

8

10

EDO-Health Distt. Coordinator

# o

f D

istr

icts

Respondents Status by Designation

ii. Replenishment of DHIS Tools Supply To overcome the shortage of DHIS tools, it was enquired as to what kind of supply or

replenishment of DHIS tools is desired by the health facilities. The data analysis pointed

out that 67% (100 out of 150) of the facilities needed replenishment of tools. Further

investigation revealed that 27% (41 out of 100) need six months advance supply.

However, 39% (59 out of 100) of the health facilities desired to have whole year supply

of DHIS tools (see table # 14 at annexure-H).

iii. Need for other DHIS Resources

To a question on what kind of DHIS relevant resources they needed, multiple answers

were given by the respondents e.g. 160 responses were recorded from the 150 targeted

interviewees. Further data investigation concluded that 43% (64) wanted to have

additional human resources for DHIS. This was followed by 41% (61 responses) for

DHIS Tools and some 23% (35 responses) for various miscellaneous things.

2.2 DHIS Functionality at Managerial Level

2.2(a) DHIS Infrastructure & Functionality i. Respondents at Districts Level by Designation and DHIS Functionality

Comparing across districts, it was observed that majority of the managerial level

questionnaires 80% (8 out of 10) were responded by the Statistical Officers, who are also

performing at the districts as DHIS Coordinators. However, 20% (2 out of 10) were the

responded by EDO-Health.

Further the data analysis

revealed that at all 10 selected

districts DHIS was implemented

in letter and spirit. And all the

financial and technical support

for this program was extended

by the provincial health

department.

It was also noted that all desired

hardware and the corresponding DHIS software was provided to all the 10 targeted

districts. Moreover, the DHIS activities are being managed by an independent District

level DHIS Cell, which was an encouraging sign.

ii. Availability of DHIS Trained Human Resources by District Regarding the availability of type of staff trained in DHIS (e.g. EDO-Health, Distt.

Coordinator & Data Entry Operator), it was observed that all the District Coordinators

got DHIS training. On the other hand, 60% (six out of ten) EDO-Health were trained.

Another potential factor involved in this system is data entry operators. It was found that

70% of the data entry operators are exposed to DHIS Training.


21

As per schedule, 1

5th of month(70%)

Not as per schedule

(30%)

Status of Timing for Sending Monthly DHIS Reports to Provincial DHIS Cell

iii. Status of Monthly DHIS Reporting Compliance vs Time of Reporting In almost all the districts visited it was observed the monthly DHIS reporting

compliance was in perfect condition. All the surveyed districts were found to be

sending their monthly reports to Provincial DHIS Cell regularly.

Regarding the timing of

sending monthly DHIS

reports by the EDO-Health

office to their provincial

DHIS Cell, it was

observed that out of the ten

surveyed districts, seven

districts (70%) were

observing stipulated time

schedule i.e. 15th

of next

month.

However, other three

(30%) though send their

reports regularly, but with some extra delay, which might be due to some

administrative reasons. These three districts were Districts of Rawalpindi, DG Khan and

Rajanpur.

iv. Data Accuracy of the Field Units The quality of data at district level depends upon what is being received from the health

facilities. . When asked from District Health Office about data accuracy it was informed

by the interviewed officials that 40% of their field units achieved the level of (80 -

100%) data accuracy. The other 30% achieved just level-2 (i.e. 71% - 80%) and level-3

(i.e. 51% - 70%).

100

7060

0

20

40

60

80

100

120

Dist. Coordinator DHIS Computer Operator EDO Health

Pe

rce

nta

ge

District Level Health Staff Trained in DHIS by Type.


22

80% - 100%(40%)

71% - 80%(30%)

51% - 70%(30%)

Data Accuracy of Field Units

Among districts, better result

was reported from Jhelum,

Muzaffargah, Bhakkar and

Rajanpur. However,

comparatively low data

accuracy was observed at

Districts of Sheikhupura,

Faisalabad and Layyah.

Based on the analysis, it is

suggested that this area of

data quality needs to be

addressed in a benefitting

manner.

2.2(b) DHIS Data Quality Parameters

i. Usage of innovative Lot Quality Assurance Sampling Method An Innovative system was designed as part of DHIS development process to assess and

improve the quality of data being produced by DHIS. This technique was labeled as

LQAS (Annex-D). The findings of the survey revealed that all the surveyed districts

were using LQAS techniques for checking data quality and observing both-way

feedback and service monitoring. In the context of planning, this review highlighted

that at the district level, DHIS is not being used for strategic planning, but to sort of

District Health Plans.

100 100 10090 90

0

10

20

30

40

50

60

70

80

90

100

Use LQAS Technique Sent Feedback to Facilities

Receive Feedback from Provincial DHIS

Cell

Use Data for Services Monitoring

Use Data for Health Planning

Per

cen

t

Status of Different DHIS Quality Data UsageUse of Different Data Quality Assessment Methods


23

ii. Validation of DHIS Data Reported in October 2011 In order to validate the monthly reported data, survey team collected the figures for some basic

indicators for the month of October 2011, both from the health facilities and respective EDO’s

office. The comparison of the figures for both the levels showed that there is a very slight

difference of figures. Though this difference is minor however it could challenge the

credibility of both the institutions..

Validation of Data for 5-Indicators of DHIS Reports (Oct'2011)

District Figures Reported by Total # of

OPD

Total # of suspected

Malaria

Total # Family

Plg. visits

Total # of 1st ANC visits

Total # of community

meetings

Bhakkar Health Facilities 56811 539 365 1660 36

EDO Office 56811 539 365 1660 36

D G Khan Health Facilities 65894 1147 1163 2619 36

EDO Office 65894 1147 1163 2619 36

Faisalabad Health Facilities 128771 277 1618 2767 35

EDO Office 128774 277 1617 2749 34

Jhelum Health Facilities 48863 622 593 1480 133

EDO Office 48846 307 593 1479 132

Layyah Health Facilities 52552 842 506 1212 17

EDO Office 52552 842 506 1212 17

Muzaffargarh Health Facilities 109869 3977 1048 1802 37

EDO Office 109869 3977 1048 1802 37

Okara Health Facilities 14701 169 715 957 14

EDO Office 13689 155 686 907 14

Rajanpur Health Facilities 40721 2223 761 1592 64

EDO Office 51125 2223 777 1592 64

Rawalpindi Health Facilities 45397 680 916 1316 61

EDO Office 49414 690 894 1350 101

Sheikhupura Health Facilities 71180 328 747 3137 174

EDO Office 70725 328 747 3137 174

Overall 10-Districts

150-Health Facilities 634759 10790 8432 18542 607

10-EDO Offices 647699 10485 8396 18507 645


24

90

80

60

0

10

20

30

40

50

60

70

80

90

100

Data Entry Operator EDO-Health Distt. Coordinator

Per

cen

tage

Training Need Assessment for DHIS Functioning at Districts

2.2 (c) DHIS Operational Needs i. Initial / Refresher DHIS Training

Though, DHIS relevant staff at the districts already reported to be trained on DHIS

functionality, however they need further training.

The training demands by cadre it was observed that 90% of the surveyed Data Entry

Operators need such training. Further eight EDOs were also found to be trained in DHIS.

In 60% of the surveyed District DHIS Coordinators also requested for the training.

ii. Need of Other Resources The respondents were given six options to answer their requirement related to DHIS

improvement. Since multiple responses were recorded, therefore the data analysis

concluded that 90% (9 out of 10) respondents asked for refresher training. It was

followed by system maintenance (80%), hardware and tools demanded by 60%. Half of

the districts asked for computer operators and 40% respondents requested for updated

DHIS software.

90

80

60 60

50

40

0

10

20

30

40

50

60

70

80

90

100

Refresher TrainingSystem Maintenance Hardware DHIS Instruments / ToolsComputer operatorSoftware

Per

cen

t

Status DHIS Resources Needed by Districts


25

3. Conclusions

The District Health Information System (DHIS) has been designed for collecting and reporting

information so that the Managers of health institutions can manage, plan, monitor and evaluate

the operations and performance of the health facilities and disease patterns in their respective

districts.

This study has demonstrated various encouraging findings. The findings suggest that efforts

made by the Provincial and District HIS stakeholders have now bore fruit and DHIS have

become truly functional in selected districts, which is a much commendable effort. However

certain deficiencies have become evident from this survey this included lack of capacity of the

data relating health personnel and non use of information for evidence based decision making

especially for planning and management of health services.

Results show that there is still a need for refresher training. Staff are facing difficulties in

filling various sections of the monthly reporting forms especially section-II which is of prime

importance in assessing the performance indicators of the respective health facilities.

Therefore thus a need for the enhancement of the capacity of healthcare providers especially

related to data collection, its entry and particularly as the data analysis. In this regard a

refresher training of all the healthcare providers including incharge of the facilities becomes

imperative.

It was encouraging to note that the reporting regularity of most of the health facilities was in

optimal state Data accuracy remained with acceptable limits.

This study suggested specific training for the healthcare providers with emphasis on use of

information and evidence based decision making. Prime aim of DHIS is not the gain of data or

information but to improve health conditions based on data.

The current situation of DHIS as evident from the results of this study demands that the

decision makers has to take initiative for further collaborations among various vertical health

programmes. For this an integrated approach be adopted which will not only save the

resources but also improve the efficiency of the District Health Information System in totality.

There is need to enhance the use of information at the facility level by improving capacity of

the Health Managers and health providers.

On the basis of the results of this report signify that training and system strengthening

strategies for improving performance are continuous processes and need regular attention of

health care managers.


26

4. Recommendations

To improve the quality of Services and optimizing utilization of resources, the District

Health Managers, Medical Officers / In-charge of the Health Facilities need to be

encouraged to use information generated through DHIS. For this purpose quarterly

meetings / Supervisory visits and discussions among information generators and users

are mandatory.

To realize the real use of information special efforts are required to establish a regular

feedback mechanism between health facilities and District DHIS Cell.

Basic training to the new staff, not previously exposed to the DHIS or refresher

training is to be ensured training.

There is a need for building capacity of DHIS Focal persons and Statistical Officers in

data analysis and use of information.

There is continuous need for improvement of DHIS Software specially for making this

user friendly.

Need for regular estimate/ forecasting and availability of DHIS Printed supplies at

district and facility levels.

Need for reasonable budgetary allocation to maintain the system in working

conditions.

Filling of the vacant posts of technical staff by posting / recruitment in the district is

required on priority basis.

Establishment of online DHIS reporting system at Health facility level needs to be

implemented in future for rapid data transmission.

A need was that such assessment study should become a regular feature of DHIS

implementation in districts in order to improve efficiency of health information system.


27

Annexures


28

Selected Districts

Number of Total Health Facilities Visited

Annexure-A

District DHQ THQ RHC BHU MCH GD/CD Total

Bhakkar 1 1 3 5 2 3 15

D G Khan 1 1 3 4 3 3 15

Faisalabad 1 1 3 4 3 3 15

Jhelum 1 1 3 4 3 3 15

Layyah 1 1 3 5 2 3 15

Muzaffargarh 1 1 3 4 3 3 15

Okara 1 1 3 4 3 3 15

Rajanpur 1 1 3 8 1 1 15

Rawalpindi 0 2 3 4 3 3 15

Sheikhupura 1 1 3 4 3 3 15

Total 9 11 30 46 26 28 150


29

List of Offices/Facilities Visited District Sr # Name of Office/Facility District Sr # Name of Office/Facility

Raw

alp

ind

i 1. EDO-Health, Rawalpindi

Jh

elu

m

1. EDO-Health, Jhelum

2. THQ Hospital Gujjar KHan 2. DHQ Hospital Jhelum

3. THQ Hospital Taxila 3. THQ Hospital Jhelum

4. MCH 1 Gujjar Khan 4. MCH Kehwra

5. MCH Dhab Ali Asbar 5. MCH Kala Gujran

6. MCH S. Town 6. MCH Shandar Chowk

7. GRD Walayatabad 7. GRD Rathian

8. GRD Shakrial 8. GRD Khurd

9. GRD Sorasi 9. GRD Lahri

10. RHC Khayabane Sir Syed 10. RHC Domaili

11. RHC Mandra 11. RHC Dina

12. RHC Kotli Satiyan 12. RHC Jalalpur Sharif

13. BHU Devi 13. BHU Dherila Jalip

14. BHU Jatli 14. BHU Sohan

15. BHU Salargah 15. BHU Banth

16. BHU Bijincal 16. BHU Kala Gujran

Sh

eik

hu

pu

ra

1. EDO-Health, Sheikhupura

Fais

ala

bad

1. EDO-Health, Faisalabad

2. DHQ Hospital Sheikhupura 2. DHQ HJospital Faisalabad

3. THQ Hospital Mureedke 3. THQ Hospital Samundary

4. MCH Centre 1 4. MCH Ravi Mohallah

5. MCH Fish Form 5. MCH Khalidabad

6. MCH Khokhar Town 6. MCH 224/RB

7. GRD Khanpur 7. CD 76/GB

8. GRD Burj Attari 8. CD 72/GB

9. GRD Ferozwala 9. CD 248/RB

10. RHC Kharianwala 10. RHC Satyana

11. RHC Jandial Sher Khan 11. RHC 65/GB

12. RHC Sharqpur Sharif 12. RHC 229/GB

13. BHU Ranikey 13. BHU 267/RB

14. BHU Chapka Minara 14. BHU 468/GB

15. BHU Bhiki 15. BHU 474/GB

16. BHU Nabi pur 16. BHU 198/GB

Ok

ara

1. EDO-Health, Okara

Layyah

1. EDO-Health, Layyah

2. DHQ Hospital Okara 2. DHQ Hospital Layyah

3. THQ Hospital Depalpur 3. THQ Hospital Karor

4. MCH Mucipal 4. MCH Layyah

5. MCH Okara 5. MCH Choubara

6. MCH ShairghaR 6. BHU 366

7. GRD 18 7. GRD 150

8. GRD 34 8. GRD 98 ml

9. GRD-39/3R 9. GRD Sumra thal

10. RHC Wasawala 10. RHC Fateh pur

11. RHC Shah Bor 11. RHC Jaman

12. RHC Renala Khurd 12. RHC Azam Chowk

13. BHU Fazal Shah 13. BHU 157 TDa

14. BHU Bhoman Shah 14. BHU 151- TDA

15. BHU 4/42 15. BHU Sammarpur

16. BHU 23/2L 16. BHU 306 TDA

Annexure-B


30

Bh

ak

ka

r

1. EDO-Health, Bhakkar

Mu

zaff

arg

arh

1. EDO-Health, Muzaffargarh

2. DHQ Hospital Bhakkar 2. DHQ Hospital Muzaffargarh

3. THQ Hospital Kalarkot 3. THQ Hospital Kot Addu

4. MCH Kalorkot 4. MCH Kot Addu

5. MCH Bhakkar 5. MCH Muzaffargarh

6. BHU Saeed wala 6. MCH Ali Pur

7. GRD 7. CD TMA

8. GD 42 TDA 8. CD Darbar Muhammad Musa

9. GRD City 9. CD Binda Ishaq

10. RHC Behal 10. RHC Sinwan

11. RHC Jandawala 11. RHC Khan Garh

12. RHC Dewala 12. RHC Shabir Sultan

13. BHU Dagger 13. BHU Khanpur

14. BHU 67 ml 14. BHU Jadaywala

15. BHU Kohawar Kalam 15. BHU Mariain

16. BHU Kotta Jam 16. BHU Dani

Der

a G

ha

zi K

ha

n

1. EDO-Health, Dera Ghazi Khan

Raja

np

ur

1. EDO-Health, Rajanpur

2. DHQ Hospital D G Khan 2. DHQ Hospital Rajanpur

3. THQ Hospital Taunsa 3. THQ Hospital Jam Pur

4. RHC Tibbi Qaisrani 4. MCH Jam Pur

5. RHC Shah Sadar Dir 5. BHU Jahan Pur

6. RHC Chotti Zarin 6. BHU Kota Subzal

7. CD Gagan Thal 7. BHU Kot Lafasan

8. CD Jinnah Colony 8. BHU Murghat

9. GRD Drehama 9. CD Khal Chas

10. MCH 3 10. RHC Mithan Kot

11. MCH Taunsa 11. RHC Fazal Pur

12. MCH 1 12. RHC Muhammad Pur

13. BHU Haghi Ghazi 13. BHU Wang

14. BHU Nutkani 14. BHU Kotla Nasir

15. BHU Ghausabad 15. BHU Noor Pur

16. BHU Hairo Sharqi 16. BHU Tabbi Londan


31

List of DHIS Data Instruments

DHIS – 01 (R) Central Registration Point Register

DHIS – 02 (F) OPD Ticket

DHIS – 02-A (F) Medicine Requisition Slip

DHIS – 03 (R) Outpatient Department Register

DHIS – 04 (F) OPD Abstract Form

DHIS – 05 (R) Laboratory Register

DHIS – 06 (R) Radiology/Ultrasonography/CT Scan/ECG Register

DHIS – 07 (R) Indoor Patient Register

DHIS – 08 (F) Indoor Abstract Form

DHIS – 09 (R) Daily Bed Statement Register

DHIS – 10 (R) Operation Theater (OT) Register

DHIS – 11 (R) Family Planning Register

DHIS – 12 (C) Family Planning Card

DHIS – 13 (R) Maternal Health Register

DHIS – 14 (C) Antenatal Card

DHIS – 15 (R) Obstetric Register

DHIS – 16 (R) Daily Medicine Expense Register

DHIS – 17 (R) Stock Register (Medicine/Supplies)

DHIS – 18 (R) Stock Register (Equipment/Furniture/Linen)

DHIS – 19 (R) Community Meeting Register

DHIS – 20 (R) Facility Staff Meeting Register

DHIS – 21 (MR) PHC Facility Monthly Report Form

DHIS – 22 (MR) Secondary Facility Report Form

DHIS – 23 (MR) Tertiary Hospital Monthly Report Form

DHIS – 24 (YR) Catchment Area Population Chart

DHIS – 25 (YR) Health Institute Database (HID) Report Form

DHIS – 26 (M) Training Manual for Trainers for DHIS

DHIS – 27 (M) Participants Manual for DHIS

DHIS – 28 (M) Procedures Manual for DHIS

DHIS – 29 (M) DHIS Software User’s Manual

Annexure-C


32

ENSURING DATA QUALITY USING LOT QUALITY ASSURANCE SAMPLING (LQAS) TECHNIQUE

Data Accuracy Check Sheet Write down month for which data accuracy is Checked

Randomly Selected Data Elements from the monthly reporting form

Figures from the Monthly report form

Figures counted from

registers

Do Figures from Column 2&3

match?

1 2 3 Y N

1. OPD monthly report section

2. OPD monthly report section

3. EPI monthly report section

4. Family Planning monthly report section

5. Mother Health monthly report section

6. LHW monthly report section

7. Community meeting monthly report sec.

8. Stock monthly report section

9.

10.

11.

12.

LQAS Table: Decisions Rules for sample sizes of 12 and coverage Targets/Average of 20-95

Sample Size

Average Coverage (Baselines)/Annual Coverage Targets (Monitoring and Evaluation)

Less than 20%

20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%

12 N/A 1 1 2 2 3 4 5 5 6 7 7 8 8 9 10 11

Annexure-D


33

Study Supervision and Team

Study Team

Dr. Farooq Azam Jan, Team Leader/ DHIS Review Study

Mr. Khalid Hussain Shah, HIS Consultant/Member Review Team

Mr. Asad Afzal Hamayoun, HIS Consultant/Member Review Team

WHO Technical Supervision

Ms. Fatma Giha, Information Management Coordinator

Dr. S.M. Mursalin, Technical Officer, HIS

Mr. Imran Majeed Malik, Data Management Supervisor, / Study Design

Mr. Zeeshan Abbas, Data Analysis support

Punjab Health Department

Dr. Muhammad Anwar Janjua, Director MIS

Mr. Farooq Ahmed, Data Management Officer, MIS Cell

District Health Office

Ch. Ali Ahsan, District Focal Person, Rawalpindi

Dr. Roadab Irfan, District Focal Person, Jhelum

Miss Noor Fatima, District Focal Person, Sheikhupura

Ms. Sajida Tufail, District Focal Person, Okara

Mr. Ijaz Hussain, District Focal Person, Faisalabad

Mr. Muzamil Mubeen, District Focal Person, Layyah

Mr. Javed Aziz, District Focal Person, Bhakkar

Mr. Saleemullah, District Focal Person, Dera Ghazi Khan

Ms. Tahira Saleem, District Focal Person, Muzaffargarh

Mr. Tahir Mehmood, District Focal Person, Rajanpur

Annexure-E


34

TIMELINE OF ACTIVITIES / WORKPLAN (October – January, 2011)

Activities October November December January

Wk-1

Wk-2

Wk-3

Wk-4

Wk-5

Wk-6

Wk-7

Wk-8

Wk-9

Wk-10

Wk-11

Wk-12

Wk-13

Wk-14

Wk-15

Wk-16

Technical Coordination

Team Formation

Development of working paper / technical material

Consultative Meeting for Questionnaire (development & finalization)

Logistic Arrangements

Preparatory & Coordination Meeting

Field Activity

Data Collection, Synchronization, and Entry

Analysis and report development

Report Review

Finalization of Report & Dissemination

Dissemination of Results

Annexure-F


35

REVIEW OF DISTRICT HEALTH INFORMATION SYSTEM

(In selected districts of Punjab)

(District Managerial Level Questionnaire)

District: ________________________ Date of Visit ___________________ Respondent Name: ________________________ Designation. (1) EDO, (2) Dist. Coord.

PART-I DHIS INFRASTRUCTURE & FUNCTIONING

1. Is DHIS implemented at your district? Yes No

1.1 If YES, then tell since when (Year) it was implemented.

1.2 Does DHIS Cell exists in EDO Office (Please observe) Yes No

1.3 Is your DHIS Cell affected by flood (2010-2011) Yes No

1.4 If YES, does it re-habilitated after flood. Yes No

2. What is your monthly (Oct’11) DHIS reporting compliance to your Prov. DHIS Cell? 1: (81% - 100%), 2: 71% -80%), 3: 51%-70%), 4: (50% or Less than 50%)

1 2 3 4

3. Are DHIS Instruments (Registers) available (As per Requirement)? Yes No

3.1 If YES, for how much Period

4. What is the Funding Source of DHIS Functioning?

5. Is a separate Hardware Computer available for DHIS? Yes No

6. Corresponding Functioning of DHIS Software Available Yes No

7. Are the Human Resources Trained on DHIS functioning?

7.1 EDO Yes No

7.2 Dist Coordinator (DHIS) Yes No

7.3 DHIS Computer Operator Yes No

8. Is there a defined DHIS specific Terms of Reference / Roles & Responsibility of each level (EDO, Distt. Coord. Health Facility Staff).

Yes No

8.1 If YES, Please provide a copy. (Please get copy, if possible) Available Not Available

9. What is the data accuracy of your field units? 1: (81% - 100%), 2: 71% -80%), 3: 51%-70%), 4: (50% or Less than 50%)

1 2 3 4

10. When did you sent your past-month (Oct’11) DHIS data (electronically) to the Provincial DHIS Cell? (1) As Per Schedule - 15

th of the Month, (2) Not as per schedule

1 2

10.1 Verify from system (email etc) when the last report (Oct’11) was sent. As per schedule Not as per schedule

Annexure-G


36

-2-

PART-II DHIS DATA QUALITY

1. Do you have DHIS Procedural Manual in your office? Yes No

2. Is your DHIS data entry operator fully understands the DHIS reporting Forms?

Yes No

3. Do you check the data quality of your field units through LQAS? Yes No

4. Do you send the data feedback to your health facilities? Yes No

5. Do you receive regular feedback from your Prov. DHIS Cell? Yes No

6. Do you analyze the monthly DHIS data for service monitoring? Yes No

7. Do you use the DHIS data for your district health planning? Yes No

7.1 If YES, Please explain.

8. Please get data of following indicators by Health Facilities (For Oct’2011) from respective DHIS Cell of the district.

Name of Health Facilities (only selected for survey) Total # of OPD

Total # of suspected

Malaria

Total # Family

Planning visits

Total # of 1st ANC visits

Total # of community

meetings

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

PS. Cross check with concerned facility monthly report of the same month (as per Facility Level Questionnaire).


37

-3-

PART-III DHIS SUPPLY/OTHER NEEDS

1. Is your Human Resource need any DHIS training?

1.1 EDO Yes No

1.2 Dist Coordinator (DHIS) Yes No


2. Is the supply of DHIS Data Collection Tools (Registers) needs to be replenished? (Normally supply of Tools issued for 2-months)

Yes No

2.1 If YES, then tell what kind of replenishment. (1-In advance 6 month, 2-Whole year stock)

1 2

3. Do you need relevant resources (if not available) to run DHIS?


3.2 Hardware Yes No

3.3 Software Yes No

3.4 System Maintenance Yes No

3.5 DHIS Instruments / Tools Yes No

3.6 DHIS Refresher Trainings Yes No

Name of Data Collector: _________________________________


38

REVIEW OF DISTRICT HEALTH INFORMATION SYSTEM (In selected districts of Punjab)

(Facility Level Questionnaire)

Name of Facility ______________________________ Facility’s ID ___________________Type: ______________________

Union Council _________________________ Tehsil __________________________ District __________________________

R/Name (Preferably Facility In-Charge) ________________________________ Designation: __________________

Health Facility Affected by Flood 2010-11 (Yes / No), if YES Does it Re-habilitated (Yes / No)

PART-I DHIS FUNCTIONING

1. What is your length of service in the Health Department? (1) Less than 1 year (2) 1-5 Year (3) 6-10 Year (4) More than 10 Year

1 2 3 4

2. Since how long you are working at this Facility? (1) Less than 1 year (2) 1-5 Year (3) 6-10 Year (4) More than 10 Year

1 2 3 4

3. Since how long you have been assigned DHIS Functioning/Reporting? (1) Less than 1-Year (2) 1-3 Year (3) More than 3-Year

1 2 3

4. Are you trained on DHIS Data Collection Instruments (Registers)? Y N

4.1 If YES, then tell the source (Agency) from where you got the training?

5. Who fill the DHIS Monthly Reporting Form (Designation)?

5.1 Is above staff/person trained for this task? Y N

6. Are the following data resources (Tools) available for monthly DHIS recording & reporting?

6.1 1. Monthly DHIS Reporting Forms Y N

2. OPD tickets Y N

3. Abstract register Y N

4. Laboratory register Y N

5. Mother Health Y N

6. Child Health Y N

7. Catchment Area Population chart Y N

8. Stock register Y N

9. Family Planning Register Y N

10. Meeting & Yearly attendances register. Y N

6.2 Are the Registers updated on daily basis? (see any one of the register for validation) Y N

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PART-II DHIS DATA QUALITY

1. Do you have DHIS Procedural Manual at your facility? Y N

2. Do you have defined DHIS related Roles & Responsibility of each staff? Y N

3. Do you fully understand the DHIS reporting Forms? Y N

3.1 If NO, then which section you feel difficult to understand. (write Form Sec. #)

4. Do you know when the monthly DHIS reporting Form should be sent to EDO office? (1) Within 7-Days (2) Within 15-Days (3) Within 30-Days

1 2 3

5. From where you get the data to fill DHIS reporting Forms?

6. Do you submit monthly DHIS Forms to your EDO-H regularly? Y N

6.1 If NO, State the reason

7. When did you submit your monthly DHIS report to your EDO-H? (1) 5th of each month (2) 15th of each month (3) After 30-days.

1 2 3

8. Do you remember how many monthly reports were not submitted by your facility to EDO-H during last 12-Months? (State in numbers)

8.1 If YES, State the reason

9. Do you receive any feedback of your monthly report? Y N

9.1 If YES, then state the kind of feedback.

10. Which section of the DHIS reporting form you often analyze (I - XVII)?

11. Is your facility using the DHIS data for planning? Y N

11.1 If YES, what kind of planning you usually do?

12. Have you faced any shortage of DHIS Tools (Registers) at your facility during 2011?

Y N

12.1 If YES, then state the shortage in months.

(1) 1-Month (2) 2-Months (3) 3-Months or more 1 2 3

13. Do you keep the copy of monthly DHIS reported forms for your record? Y N

13.1 If YES, then check the final figures of past-month (Oct-11) of following indicators from their copy. (If NOT then see their Registers).

1. Total # of OPD

2. Total # of Suspected Malaria

3. Total # Family Planning visits

4. Total # of 1st ANC visits 5. Total # of community meetings


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PART-III DHIS SUPPLY/OTHER NEEDS

1. Do you need any training of DHIS on reporting mechanism? Y N

1.1. If YES, then tell kind of training.

(1) Form filling (2) LQAS check (3) Indicators’ analysis etc. 1 2 3

2. Is the supply of DHIS Tools (Registers) needs to be replenished? Y N

2.1 If YES, then tell what kind of replenishment.

(1) In advance 6 month (2) Whole year stock 1 2

3. Do you need relevant resources (if not available) for DHIS functioning? Y N

3.1

If YES, state the kind of resource (Could be Multiple Responses)

i) HR Y N

ii) Tools Y N

iii) Others (Elaborate others, if YES for data entry purpose e.g. write below the response in your own words)

Y N


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Table # 1: Respondents by Type of Facility

Designation DHQ THQ MCH GRD RHC BHU Total

DOH 0 0 1 0 0 0 1

Dispenser 1 0 1 18 1 5 26

LHV 0 0 23 1 0 0 24

Medical Officer 0 2 1 8 5 27 43

Medical Supdtt. 5 9 0 0 0 0 14

Medical Technician 1 0 4 2 0 5 12

Pharmacist 1 0 0 0 0 0 1

Sr. Medical Officer 0 0 0 0 23 1 24

Statistical Officer 1 0 0 0 0 0 1

Woman Medical Officer 0 0 0 1 1 2 4

Total 10-Districts 9 11 30 30 30 40 150

Table # 3: Status of Tools Availability &Their Daily Update at selected Facilities.

District Tools Availability (%age) Daily Update (%age)

Muzaffargarh 97 97

Jhelum 86 80

Bhakkar 84 84

D G Khan 83 50

Rajanpur 83 72

Faisalabad 82 82

Layyah 82 82

Okara 77 77

Rawalpindi 73 68

Sheikhupura 71 62

Overall 10-Districts 82 75

Table # 2: Status of Facility Incharges Trained on DHIS

District Trained Not Trained Total Facility

Visited # of Facility % # of Facility %

Bhakkar 15 100 0 0 15

D G Khan 15 100 0 0 15

Faisalabad 8 53 7 47 15

Jhelum 15 100 0 0 15

Layyah 13 87 2 13 15

Muzaffargarh 15 100 0 0 15

Okara 15 100 0 0 15

Rajanpur 12 80 3 20 15

Rawalpindi 12 80 3 20 15

Sheikhupura 13 87 2 13 15

Overall 10-Districts 133 89 17 11 150

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Table # 4: Status of Availability of DHIS Manual and TORs of Staff

District Manual Available

(# of Facility) %

TORs Available (# of Facility)

%

Bhakkar 11 73 14 93

D G Khan 14 93 2 13

Faisalabad 11 73 10 67

Jhelum 13 87 2 13

Layyah 9 60 15 100

Muzaffargarh 15 100 15 100

Okara 11 73 0 0

Rajanpur 10 67 8 53

Rawalpindi 9 60 7 47

Sheikhupura 4 27 4 27

Overall 10-Districts 107 71 77 51

Table # 5: Respondents Understanding of DHIS Forms vs Sections Difficult to Understand

District Understand

(# Respondents) Not Understand (# Respondents)

Forms Section Difficult to Understand

Section-II Section-III Section-VIII

Bhakkar 15 0 - - -

D G Khan 15 0 - - -

Faisalabad 14 1 - - 1

Jhelum 15 0 - - -

Layyah 15 0 - - -

Muzaffargarh 15 0 - - -

Okara 15 0 - - -

Rajanpur 8 7 7 - -

Rawalpindi 11 4 3 1 -

Sheikhupura 13 2 1 1 -


Table # 6: Status of Knowledge and Practice regarding Monthly DHIS Report Submission

District

Knowledge Practice Within 7-days

Within 15-days

Within 30-days Total

5th of Month

15th of Month

After 30 Days Total

N N N N N N

Bhakkar 15 0 0 15 14 1 0 15

D G Khan 14 1 0 15 15 0 0 15

Faisalabad 15 0 0 15 14 1 0 15

Jhelum 15 0 0 15 15 0 0 15

Layyah 15 0 0 15 14 1 0 15

Muzaffargarh 14 0 1 15 15 0 0 15

Okara 15 0 0 15 15 0 0 15

Rajanpur 15 0 0 15 15 0 0 15

Rawalpindi 11 0 4 15 12 0 3 15

Sheikhupura 14 1 0 15 14 1 0 15

Overall 10-Districts 143 2 5 150 143 4 3 150


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Table # 7: Status of Health Facilities Received Feedback from their EDO-Health

District Yes No

Total N % N %

Bhakkar 10 67 5 33 15

D G Khan 15 100 0 0 15


Jhelum 14 93 1 7 15

Layyah 11 73 4 27 15


Okara 15 100 0 0 15

Rajanpur 5 33 10 67 15




Table # 8: Status of Issues and Type of Feedback Received from their EDO-Health

District To discuss

target/ performance

Admin & Managerial

Issue

Ask for correction in

the forms

Stock & Medicine

Total

Bhakkar 7 2 1 0 10

D G Khan 9 6 0 0 15


Jhelum 8 6 0 0 14

Layyah 6 3 2 0 11


Okara 5 0 10 0 15

Rajanpur 3 0 1 1 5




Table # 9: Is your facility using the DHIS Data for Planning

District Yes No

Total N % N %

Bhakkar 10 67 5 33 15

D G Khan 0 0 15 100 15


Jhelum 15 100 0 0 15

Layyah 9 60 6 40 15


Okara 7 47 8 53 15

Rajanpur 2 13 13 87 15





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Table # 10: Status of Shortage of DHIS Tools at Health Facilities

District

Yes No

Total N % N %

Bhakkar 2 13 13 87 15

D G Khan 0 0 15 100 15


Jhelum 6 40 9 60 15

Layyah 1 7 14 93 15


Okara 2 13 13 87 15

Rajanpur 5 33 10 67 15




Table # 11: Status of Shortage of DHIS Tools at Facilities

District Facilities Surveyed

Facilities Facing Shortage of Tools

Shortage in Months

N % 1-Month % 3-Month %

Bhakkar 15 2 13 1 7 1 7

D G Khan 15 0 0 0 0


Jhelum 15 6 40 4 27 2 13

Layyah 15 1 7 0 0 1 7

Muzaffargarh 15 3 20 0 0 3 20

Okara 15 2 13 0 0 2 13

Rajanpur 15 5 33 1 7 4 27


Sheikhupura 15 7 47 0 0 7 47

Overall 10-Districts 150 27 18 7 5 20 13


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Table # 12: Facilities Keep Record of the Monthly DHIS Reports

District Yes No

Total N % N

%

Bhakkar 15 100 0 0 15

D G Khan 15 100 0 0 15


Jhelum 15 100 0 0 15

Layyah 15 100 0 0 15


Okara 15 100 0 0 15

Rajanpur 15 100 0 0 15




Table # 13: Facility's Incharges Need Trainings vs Kinds of Trainings they Needed

District Total

Facilities Visited

Facility's Incharges Need Training

Kinds of Training Needed

N % Forms Filling

% LQAS Check

% Indicators'

Analysis %

Bhakkar 15 14 93 3 20 2 13 9 60

D G Khan 15 15 100 0 0 0 0 15 100

Faisalabad 15 14 93 6 40 2 13 6 40

Jhelum 15 11 73 2 13 1 7 8 53

Layyah 15 15 100 1 7 0 0 14 93

Muzaffargarh 15 15 100 0 0 0 0 15 100

Okara 15 8 53 1 7 5 33 2 13

Rajanpur 15 15 100 0 0 2 13 13 87

Rawalpindi 15 9 60 0 0 4 27 5 33

Sheikhupura 15 12 80 0 0 2 13 10 67 Overall 10-

Districts 150 128 85 13 9 18 12 97 65


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Table # 14: Status of DHIS Tools Supply Replenishment

District Total

Facilities Visited

Facilities Need Replenishment

Kinds of Replenishment

N % 6-Months Advance Supply

% Whole Year

Supply %

Bhakkar 15 7 47 1 7 6 6

D G Khan 15 15 100 0 0 15 15


Jhelum 15 4 27 3 20 1 1

Layyah 15 11 73 10 67 1 1

Muzaffargarh 15 14 93 2 13 12 12

Okara 15 15 100 3 20 12 12

Rajanpur 15 14 93 13 87 1 1

Rawalpindi 15 4 27 2 13 2 1

Sheikhupura 15 15 100 7 47 8 8

Total 150 100 67 41 27 59 39

Table # 15: Status of DHIS Relevant Resources Facilities Needed

District # of Facilities

Visited

# Facilities Needed Resources

Kinds of Resources Needed

HR Tools Other

N % N % N % N %

Bhakkar 15 7 47 5 33 5 33 1 7

D G Khan 15 15 100 5 33 15 100 0 0

Faisalabad 15 7 47 7 47 2 13 2 13

Jhelum 15 8 53 7 47 2 13 8 53

Layyah 15 5 33 4 27 3 20 0 0

Muzaffargarh 15 15 100 12 80 15 100 0 0

Okara 15 2 13 2 13 2 13 0 0

Rajanpur 15 11 73 10 67 9 60 8 53

Rawalpindi 15 9 60 8 53 1 7 6 40

Sheikhupura 15 9 60 4 27 7 47 10 67

Total 150 88 59 64 43 61 41 35 23


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Annexure-J


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Annexure-K


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Rapid Appraisal of DHIS

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