World Reliefs CS Health Information System

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World Reliefs CSHealth Information System

• CCIH ME Workshop May 28, 2005
• Melanie Morrow
• World Relief

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Presentation

• Overview of World Reliefs Vurhonga CSP in
  Mozambique
• Key components of the Vurhonga HIS
• Regular surveys to monitor progress
• Community HIS
• Tracking mortality

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WR Vurhonga Dawn CSPs

• Vurhonga 1 1995-1999
• Guija Mabalane Districts
• 107,000 population
• Vurhonga 2 1999-2003
• Chokwe District
• 2350 Volunteers trained in 173 Care Groups
• 130,000 (140,000 EOP) pop
• C-IMCI HIV BS
• Expanded Impact 2004-09
• 5 New Districts in Gaza Province
• C-IMCI HIV

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Major Program Components

• Educating and mobilizing the community to prevent
  illness and seek appropriate treatment
• Creating and training VHCs to address health
  issues at village level
• Increasing access to care at village level

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Vurhonga 2 Care Group Structure
5 Supervisors
26 Animators
Care Groups of 10-15 Volunteers
10 HH per volunteer
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Reach Every HH

• One trainer can train supervise 8 care
  groups, each with 8-10 volunteers.
• Each volunteer is responsible for the 10-15
  households on her block.
• In Vurhonga 2
• 26 trainers reached 24,500 HH via 2350
  volunteers trained in 173 Care Groups

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Care Group Meetings

• Volunteers verbally report and discuss statistics
  from the C-HIS
• Problem solve as a group
• Between meetings, Volunteers conduct home visits
  for the 10-15 HH in their block

Animator trains volunteers in interventions using
pictures, stories, songs and drama
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Home visit

• Volunteers greet family and inquire about their
  wellbeing
• Address current health concerns in HH
• Teach health lesson learned during most recent
  care group mtg.
• Make mental note of births, deaths or pregnancies

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Other Care Groups

• Churches Care Groups for pastors to teach BCC
  they share with their congregations.
• Grannies Care Groups for grannies ensure support
  of elders.

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Village Health Committees

• Membership includes
• Chef de Saude
• Village leader
• Health Post Socorrista
• Care Group leader
• Neighborhood reps (max 5)
• Church leader
• Member of OMM (womens organization)

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Vurhonga HMIS Components

• Full count of beneficiaries at baseline and
  repeated as needed (can include retrospective
  birth and mortality questions)
• Baseline and Final KPC Survey
• Monitoring surveys to track progress towards
  project objectives (every 3-6 months)
• Community-HIS (monthly Care Group statistics) for
  monitoring vital events

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Monitoring Surveys

• Abbreviated version of KPC instrument
• Similar to LQAS in that the sample is based on
  supervision areas Random selection of 1 Care
  Group per animator
• Staff trade supervision areas and interview all
  HH with children lt2 pertaining to that CG (sub
  sample OK)
• Track progress towards objectives

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Monitoring Survey Form
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Data use

• Revise strategies as appropriate (e.g. message
  re mosquito nets new pictures for reproductive
  health)
• Track performance by staff supervision areas, by
  individual villages by district
• Share with care groups, VHCs and MOH to motivate
  and engage in problem solving
• Identify and respond to problems early

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C-HIS (Monthly Care Group Stats)

• Care groups form the basis for a sustainable
  community-HIS. Volunteers verbally report on
  vital events (births, deaths, pregnancies) that
  they discuss in their meetings. The information
  is shared with the community and MOH without
  dependence on project staff. Village Health
  Committees (VHCs) and the MOH make decisions
  using these data. Volunteers are motivated by
  the measurable impact they are having.

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Care Group Statistics

• Volunteers verbally report vital events (births,
  deaths, pregnancies) for their block
• Mortalities are reported with the following
  information Name, sex, age at death, date of
  illness onset, signs of illness, date of death.
• Literate volunteer records data

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C-HIS (cont.)

• Discussion of illness signs during meeting used
  to determine most likely cause of death.
• Questions of the month can be added
• Bi-directional learning with Animator
• Summary data given to Vurhonga Animator and to
  village Socorrista
• Project staff together discuss monthly results
  and implications during regular meetings, and
  take action.

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Information Flow

• .

CSP
MOH
Animator
VHC
Care Group
Socorrista
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Sustainability of Info Flow

• .

MOH
VHC
Care Group
Socorrista
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Vurhonga I volunteer retention 20 months post
project

• Vols active at end of project 1457
• Vols who left post/moved (92)
• Vols who died (44)
• Replacement volunteers 40
• TOTAL No.VOLS STILL ACTIVE 1361or 93
• Attrition 6.59
• 50 of HH were visited by their volunteer in
  two weeks before survey

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Time Cost of C-HIS Tabulation

• 30 minutes during CG meeting once/month
• 15 minutes for socorrista to compile village-wide
  data
• 30 minutes for district-wide tabulation at
  District Hospital

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VHCs and CGs take action

• VHCs of 25 de Septembro and other villages noted
  increase in malnourished children in early 2002.
• Initiated Hearth community nutrition
  rehabilitation sessions using Care Group
  volunteers.
• Underweight children decreased from 13 in March
  2002 to 7.2 in July despite food shortages.

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Community goal setting

• Mapapa VHC noted that 19 HH lacked latrines Set
  goal for all HH to have latrines within 3 months.
• 25 de Septembro VHC helped pass a local law
  requiring any HH that didnt build a latrine to
  pay for the labor of others sent by VHC to do it
  for them.

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Community-based accountability

• Muzumia village VHC noted pregnant women not
  using hygienic delivery huts assisted by TBA
• Data prompted community investigation
• Found TBA was demanding unauthorized payment
• Involved MOH to resolve issue

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MOH preparedness

• Increases in diarrhea cases helped the MOH in
  Chokwe district to anticipate and stave off a
  cholera epidemic that other districts were
  unprepared for.
• Community has louder voice when backed by data

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Benefits of community-specific data

• Local data used at local level prompted
  communities to
• Tackle malnutrition
• Identify underlying problems
• Involve district MOH in relevant matter
• Set goals
• Pass local laws
• And appreciate impact of volunteers

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Project benefits of regular HMIS feedback

• Keep project in touch with community
• Motivate staffcan see impact
• Results graphed on office wall
• Identify and respond to problems
• Personnel
• Intervention/communication strategy
• Justify continued funding

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Ingredients for Success

• Analysis and application of data by those
  involved in collecting it
• Only collect what actually use
• Link to lasting community structures (CGs and
  VHCs)
• Sustained volunteer participation (lt2 drop out
  per year)

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Volunteer Incentives

• Examples of tangible incentives
• Year one head scarf
• Year two kapulana traditional skirt
• Year three project T-Shirt
• Intangible incentives
• Communication of respect and appreciation
• Social support
• Community recognition

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End Result

• As a result of CGs and VHCs using the C-HIS, the
  community has an effective system for monitoring
  and governing its own healthas well as
  interfacing with district MOH authorities.

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2003
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FutureGenerations
Reasons to measure mortality rates and changes in
a CS project
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Measurement of Mortality Rates and Causes of
Mortality

• An Essential Tool for Maximizing Program
  Effectiveness?
• A CORE Function in Child Survival Programs?

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The Initial Three-Tiered Approach to Monitoring
and Evaluation

• Tier One Counting the number of services
  provided
• Tier Two Measuring coverage in the project
  population
• Tier Three Measuring mortality impact

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Arguments FOR Monitoring Mortality

• Is THE key indicator
• Can guide programming/increase program
  effectiveness
• Motivates staff
• Guides program policy formulation

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Arguments AGAINST Monitoring Mortality

• Is too complicated, too time consuming, and takes
  high-level expertise, and must be carried out by
  outsiders
• Requires a control population
• Is too expensive
• Takes too many years to achieve impact
• Takes a very large population in order to
  document significant impact

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Gold Standard for Demonstrating Mortality Impact

• Have an intervention and comparison area
• Show that mortality rates in these two areas were
  similar before the intervention
• Show that the mortality decreased significantly
  more in the intervention area than in the control
  area
• Demonstrate that the mortality reduction should
  be attributed to the intervention

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Disseminating results

• Village chief and health committee are regularly
  informed of deaths and involved in discussion to
  learn from event.
• Trends are shared less often, at most every 6
  months.
• Data are aggregated by project staff and (in
  Mozambique) by MOH, to promote sustainability.

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C-HIS Information Flow from Care Groups
CSP
MOH
Animator
VHC
Care Group

• Socorrista

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Sustainability of data flow from Care Groups to
Village Health Committees District MOH
MOH
VHC
Care Group
Socorrista
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Moz U5 cause specific mortality
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Cambodia of deaths attributable to EPI
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Calculating mortality rates

• Infant Mortality Rate
• deaths children 0-11 mo/1000 live births
• Child Mortality Rate
• deaths in children age 12-59m/1000 live births
• Under five mortality rate
• deaths in children U5/1000 live births
• Counts also useful if dont know births

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Problems with Prospective Tracking

• Under-reporting of birthsneed to use a pregnancy
  register to catch all births
• Sensitivity needed to discern when culturally
  appropriate to visit family without waiting too
  long so that people forget important details.
• Hard to independently verify if all deaths have
  been captured.

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Retrospective tracking of Mortalities in
Mozambique

• Midterm count of all beneficiaries included
  inquiry about all births and deaths during
  preceding two years.
• Possible underreporting because
• respondents inclined to leave out events that
  occurred on the border of time asked about
  (though bounded by flood)
• Less likely to include more distant events

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Mortality Data from Census/HIS
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Retrospective tracking using pregnancy history

• At final eval, sample of 250 women interviewed
  about all pregnancies they have had during their
  lifetime and their outcomes.
• Intervals spanning 3 or more years without a
  birth were probed for possible miscarriages or
  unreported mortalities

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Mortality Data from Pregnancy Histories
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Comparison of Census vs. Pregnancy History
Pregnancy History data for 2000 includes flood
deaths
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Pregnancy History (cont)

• Pro get complete history, has been validated in
  literature for accurate mortality estimates going
  back 10 yrs.

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Problems with Retrospective Studies

• Recall bias leading to under-reporting
• If dont use own staff, population reluctant to
  talk about deaths if use own staff scientific
  community reluctant to believe results
• Making lists is sometimes considered a suspect
  (politically destabilizing) activity
• Cultural definitions of child deaths (e.g. baby
  not considered a person until reaches a certain
  milestone or named)

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Problems with Retrospective Studies (cont.)

• Determining adequate sample size for
  retrospective pregnancy history can be difficult
• Sample size can be quite large
• High maternal mortality rates could skew results
• Many confounders

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Staff and Volunteers in Mapapa Village
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Project Action

• Quarterly survey results showed children's ITN
  use changed as follows
• Sept 1999 0
• April 2001 93
• Aug 2001 68
• Refocused BCC to promote ITN use even in winter
  months
• July 2002 81

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Key Ingredients for Success

• Analysis and application of data by those
  involved in collecting it
• Only collect what actually use
• Link to lasting community structures (VHCs)
• Sustained Volunteer Participation

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Vurhonga I volunteer retention 20 months post
project

• Vols active at end of project 1457
• Vols who left post/moved (92)
• Vols who died (44)
• Replacement volunteers 40
• TOTAL VOLS STILL ACTIVE 1361
• Attrition 6.59
• 50 of HH visited by volunteer in preceding two
  weeks

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Volunteer Attrition in other WR CSPs

• 13.2 in Cambodia at end of year three (excluding
  deaths and relocation)
• Lack of community identity
• 10 in Malawi at end of year one
• Both men and women as volunteers
• Association with established health institution
  led to expectation of employment

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Volunteer Motivation for Vurhonga

• Examples of tangible incentives
• Year one head scarf
• Year two skirt
• Year three project T-Shirt
• Intangible incentives
• Communication of respect and appreciation
• Social support
• Community recognition

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Benefits

• Accountability
• Contact with community
• Consensus-building
• Strengthening of partnerships
• Empowering communities to take responsibility for
  their health