The Transformation from Data-Dismissive Attitudes to Data-Driven Practices at a Primary Health Care Unit in Ethiopia

January 11th, 2023 | News


On October 29, 2022, Jamel Ahmed, head of Lera Primary Health Care Unit (PHCU) in the West Azernet Berbere District of the Southern Nations, Nationalities and Peoples’ (SNNP) Region of Ethiopia, welcomed visitors with a wide smile. Regional health information system (HIS) workers from 11 zonal health departments and seven special districts were visiting to share experiences of the PHCU, which has six health posts (HPs) reporting to it. Recently, the facility has become a popular learning hub at which regional HIS workers learn how to implement the Ministry of Health’s (MOH) Information Revolution (IR) strategy.

The Process of Change

Before becoming an intervention site for the Ethiopia Data Use Partnership (DUP), a collaborative initiative between the MOH and JSI, in 2019, Lera PHCU struggled with a culture of poor data quality and use. A 2019 assessment revealed that it had suboptimal HIS and monitoring and evaluation (M&E) infrastructure and arbitrary decision-making practices, which led to poor service delivery. The PHCU scored 63 of a100 in its implementation of the IR—a national strategic directive to transform management and use of health information to ensure evidence-based actions. The score indicated that the health facility was unable to perform the minimum requirement for information use due to lack of proper implementation skills, functioning M&E structures, and information technology infrastructures.

The DUP team supported HIS strengthening in the facility. First, it ensured that staff understood its major intervention activities, which included digitizing HIS tools, assuring data quality, and improving data use culture. Then it trained almost 50 staff from Lera and its six HPs on IR implementation, district health information software-2; data analytics and visualization; health management information systems (HMIS); and community health information system.

Next, DUP’s team focused on identifying and ending processes and behaviors that prevented data-driven decision. Revitalizing the performance monitoring teams (PMTs)—comprising health workers who review performance, identify gaps, and develop and implement corrective actions—was a top priority. Beyond reinstating the PMT at the management level, DUP helped establish and operationalize PMTs at the case-team level, the lowest and smallest unit within Lera’s organizational structure. DUP provided supportive supervision to monitor health worker progress and mentoring to improve data recording and documentation practices. As a way to sustain the results and outcomes achieved from the activities, intervention efforts also focused on infusing a cultural change in staff data practices from indifference to evidence-based.

In addition to building staff capacity, DUP supplied Lera PHCU with information communication technology equipment that included computers, tablets, and data visualization tools. DUP also refurbished two standard cardroom shelves and reorganized the medical records unit room to ensure access and ability to track patient data. “DUP-led support has made all the difference. It has improved skill and knowledge to implement health information-transformation initiatives. Similarly, material supports in the form of computers, tablets, shelves, and others provided the resources to translate acquired knowledge to actions,” said Jemal.

Abhara Aba, HMIS officer at Lera PHCU. Photo: Benti Ejeta
Abhara Aba, HMIS officer at Lera PHCU.

“The Bedrock for the Change”

The most recognizable effect of DUP’s intervention was that workers have come to appreciate and value data. “This change in behavior is the bedrock for the change in culture…it led to an improved use of data for actions,” said Abdulfeta Mohamed, head of West Azernet Berbere District Health Office. The PMT was also transformed from an irregular, inconsequential meeting convener to a vibrant and productive platform that thoroughly reviews performance and takes actions to solve problems. “Unlike [other] places, PMTs are also active and functional at all six HPs,” said Gebeyehu Dejene, DUP SNNP Region coordinator.

There was also a change in Lera PHCU’s data quality assurance process: staff now verify data on a daily basis, and aggregate and report them to the case team, which further scrutinizes and confirms quality. Once a month, case teams submit a performance report to the overall PMT, which conducts its own review. This data quality assurance pathway is applied at the six HPs under the PHCU. Health extension workers (HEWs) record, evaluate, and report data to the kebele-level PMTs, which, unlike most in Ethiopia, are functional. The kebele PMT, chaired by the kebele administrator, reviews HP performance, identifies gaps, takes action, and approves and submits reports to the PHCU. Because of these processes, staff have become more sensitive to and responsible for the data that they generate.

The close relationship between the PHCU and HPs has contributed to the improvement in the HIS performance, too. Lera PHCU has established a robust supportive supervision mechanism through which a team of experts, including the HMIS staff, visit HPs weekly and provide on-the-job support to the HEWs. “Engaging and embedding HMIS staff, who are mostly are idle throughout HPs in Ethiopia, in the routine data quality assurance process is a practice that should be replicated across the country. Rather than sitting and waiting for data to come to them, the HIT worker visit HPs and different case teams to resolve data inconsistences,” said Gebeyehu.

The new culture of information use catalyzed a transformation at Lera PHCU. Its overall IR implementation score is now 97, enabling it to exchange information in- and externally. Lera leadership’s commitment to and involvement in supervising and availing required supports was one of a multitude of contributing factors for this turnaround. Another feature that enabled this change was the PHCU’s creativeness in optimizing previously underused human and material resources to improve health service delivery.

Photos by Benti Ejeta

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