Use of Embedded IR During African Health Initiative Phase 2 in Ethiopia, Ghana, and Mozambique

Ethiopia (Data Use Project)Ghana (CHPS+)Mozambique (IDEAs)
Target programHealth Sector Transformation Plan 1 (2015–2020), which called for an Information Revolution to create an information-use culture at all levels of the health care system.The national PHC program, CHPS.The national maternal, newborn, and child health programs, led by the MOH.
Evidence-based interventionData quality improvement and use for point-of-care decision making in PHC.CHPS+, the health interventions package (Ghana Essential Health Interventions Program) that strengthened CHPS in Phase 1.MOH-adopted essential interventions to reduce maternal, child, and newborn deaths.
Implementation strategyThe Data Use Project has supported several interventions, including the Capacity Building and Mentorship Program. The key focus areas were promoting use of quality data for decision making, digitization, and strengthening governance of HIS and implementation research for evidence-based programming.CHPS+ comprises a combination of approaches, including peer exchanges between “systems learning districts” and “trainee districts” to transfer best practices for putting lessons from the Ghana Essential Health Interventions Program into place and flexible catalytic funding for implementation teams in systems learning and trainee districts to make implementation changes based on lessons learned.Building on data quality and use improvements in Phase 1 and the MOH prioritization of maternal, child, and newborn interventions, IDEAs implemented an enhanced A&F strategy to link district and facility management teams and promote facility teams’ use of data to plan, set goals, track, and benchmark progress vis-à-vis implementation of adopted interventions to reduce maternal, child, and newborn mortality.
Health system level(s)At national and regional levels, covering all regions of Ethiopia. Data were also collected from selected sites in Addis Ababa City administration to generate qualitative data on point-of-care data use practices within PHC.In Northern and Volta regions of Ghana, 4 “systems learning” and trainee districts.
IR engages district health management teams, CHPS supervisors at district and subdistrict levels, community health officers, community health management committees, and volunteers.
In 7 districts in Manica and Sofala provinces
IR engages national, provincial, district, and facility health system leadership and PHC workers at facilities.
Examples of research question(s)Do interventions designed and implemented under the Information Revolution improve HIS performance? What are the factors that help or hinder the effectiveness of Information Revolution interventions at the point of care?What systems weaknesses, implementation challenges, and capacity gaps should be prioritized to best support the spread of CHPS+ in “trainee districts”? Were CHPS+ interventions acceptable and feasible? Do stakeholders perceive them as effective? Do these interventions contribute to measurable changes in health services and population outcomes?What factors explain poor maternal and newborn outcomes and care practices? What factors help or hinder the IDEAs strategy to improve MNCH guideline implementation? Has MNCH guideline implementation improved during the project?
Research team affiliation – policy decision makerCo-investigators were from the MOH Policy, Planning, Monitoring and Evaluation Division; Health Information Technology Directorates; and regional health bureaus.Co-principal investigator of CHPS+ was the director of the Policy Planning, Monitoring and Evaluation Division of the Ghana Health Service.Co-principal investigator is the national director for Public Health and at the MOH.
Research team affiliation – implementation leaderCo-investigator from John Snow Research and Training Institute, Inc., Ethiopia Office oversaw research implementation. Staff of Regional Health Bureau participate in study design and interpretation of findings.CHPS+ consults district-, facility-, and community-level PHC staff multiple times per year to obtain insight on implementation challenges and prioritize those that require deeper investigation.IR priorities are elicited annually from provincial leadership nationwide. National research institutions were engaged to codevelop protocols with provincial health authorities, as well as conduct and disseminate research as co-investigators on these studies. National, provincial, and district leaders were selected for degree-offering training in public health and implementation science at national universities and at the University of Washington.
Research team affiliation – research partnerCo-investigators from Addis Ababa University, University of Gondar, Mekelle University, Hawassa University, Haramaya University, and Jimma University.Co-principal investigator of CHPS+ from University of Ghana, University of Development Studies, and University of Health and Allied Sciences train PHC staff in CHPS+ districts on IR.Co-principal investigators from national research institutions, including the National Institute of Health, Beira Operations Research Center, and provincial research nuclei.
The national research institutions trained district and provincial health staff in embedded IR on MNCH guideline implementation.
MethodsQualitative semistructured interviews and focus group discussions; analysis of HIS data.Semistructured interviews and focus group discussion conducted every year.
Baseline, midline, and endline household survey data used to gauge community perceptions of CHPS.
Qualitative semistructured interviews and focus group discussions, analysis of quantitative data from HIS, supervision reports, and facility assessments.
Examples of findingsQualitative data suggest that data quality and use improved due to IR implementation. Drivers of this were the way in which performance management teams engaged leaders, coaching, and mentoring of PHC workers at the point of care and use of incentives. Barriers to optimal data use practices and quality were the presence of multiple and sometimes duplicative HIS tools in facilities, weak HIS infrastructure, paucity of HIS technicians, and negative attitudes about data among PHC workers.Baseline qualitative and survey research identified PHC worker shortages, poor community engagement practices, lapses in supply chain, and lack of essential transportation. Capacity development priorities were logistics management, community engagement, and management of referrals at the CHPS level. Midline qualitative assessments indicated that CHPS+ was acceptable and effective at promoting learning, cooperation, planning, and adapting good practices—importantly, practices related to district stakeholder engagement for resource mobilization. This helped trainee districts to address capacity gaps, fill some resource gaps, and improve community engagement.Factors that helped the IDEAs A&F strategy were a positive and encouraging learning environment, strong networks for communication and circulation of new information, and strong leadership of district managers and supervisors especially with respect to applying pressure and motivating performance improvement at facilities. Barriers were the inability of the intervention to address financial and human resource constraints that undermine performance improvement, as well as implementers’ perception that the intervention was narrowly focused on MNCH guidelines and should instead address a wider range of PHC challenges.
Policy/program recommendationsTo establish an information use culture in the health system, the MOH should invest in strategies to build capacity of health care workers in data visualization and interpretation, expand the presence of performance monitoring teams, and use a combination of monetary and nonmonetary incentives to promote data use at the point of care.Combining peer exchanges with catalytic funding supports adaptation and scale-up of CHPS; however, structural interventions remain necessary to address chronic workforce and logistical problems that undermine the sustainability of improvements achieved and constrain impact.Leaders should establish an enabling environment for performance improvement by promoting opportunities to learn, adapt, and explore new ways to solve problems; supporting information and experience sharing; and making visible efforts to motivate implementation teams and hold them accountable for performance. To be most effective, A&F strategies should address both national and local priorities.
  • Abbreviations: A&F, audit and feedback; CHPS, Community-based Health Planning and Services Initiative; HIS, health information system; IDEAs, Integrated District Evidence-to-Action program to improve maternal, newborn, and child health; IR, implementation research; MNCH, maternal, newborn, and child health; MOH, Ministry of Health; PHC, primary health care.