Bridging the gaps in the Health Management Information System in the context of a changing health sector

<p>Abstract</p> <p>Background</p> <p>The Health Management Information System (HMIS) is crucial for evidence-based policy-making, informed decision-making during planning, implementation and evaluation of health programs; and for appropriate use of resources at all levels of the health system. This study explored the gaps and factors influencing HMIS in the context of a changing health sector in Tanzania.</p> <p>Methods</p> <p>A cross sectional descriptive study was conducted in 11 heath facilities in Kilombero district between January and February 2008. A semi-structured questionnaire was used to interview 43 health workers on their knowledge, attitude, practice and factors for change on HMIS and HMIS booklets from these facilities were reviewed for completeness.</p> <p>Results</p> <p>Of all respondents, 81% had never been trained on HMIS, 65% did not properly define this system, 54% didn't know who is supposed to use the information collected and 42% did not use the collected data for planning, budgeting and evaluation of services provision. Although the attitude towards the system was positive among 91%, the reviewed HMIS booklets were never completed in 25% - 55% of the facilities. There were no significant differences in knowledge, attitude and practice on HMIS between clinicians and nurses. The most common type of HMIS booklets which were never filled were those for deliveries (55%). The gaps in the current HMIS were linked to lack of training, inactive supervision, staff workload pressure and the lengthy and laborious nature of the system.</p> <p>Conclusions</p> <p>This research has revealed a state of poor health data collection, lack of informed decision-making at the facility level and the factors for change in the country's HMIS. It suggests need for new innovations including incorporation of HMIS in the ongoing reviews of the curricula for all cadres of health care providers, development of more user-friendly system and use of evidence-based John Kotter's eight-step process for implementing successful changes in this system.</p

Importance of leadership and management to support improved quality in maternal and newborn care

Effective leadership and management (L&M) have a wide range of functions in improving quality in maternal and newborn health care. In Tanzania, maternal and perinatal adverse outcomes have been attributed to ineffective L&M (Assisting Safe Deliveries in Tanzania/ASDIT audits). This brief presentation reviews why leadership and management are important attributes of health care delivery in terms of maternal and child health.Global Affairs Canada (GAC)Canadian Institutes for Health Research (CIHR

Requirements and costs for scaling up comprehensive emergency obstetric and neonatal care in health centres in Tanzania

The objective of this study was to identify and determine the costs of essential components of a resource package and strategies for scaling up comprehensive emergency obstetric and neonatal care services in Tanzania. Essential components were identified through lessons learned during implementation of comprehensive emergency obstetric and neonatal care and regular discussions with key stakeholders. The related costs were collected from the health centres, Tanzania Medical Store Department and non-governmental organizations that had upgraded health centres for comprehensive emergency obstetric and neonatal care services provision. The results showed that the estimated costs of upgrading a health centre to provide comprehensive emergency obstetric and neonatal care services was $256,650 (USD) for infrastructure and equipment,$4,463 per person for upgrading skills in either in comprehensive emergency obstetric and neonatal care or anaesthesia for three months and $43,500 per year for medicines and supplies. The total cost for all components per health centre was estimated at$560,802. Scale up required many complementary strategies at all health system levels. Scale up of comprehensive emergency obstetric and neonatal care services in health ccentres in underserved areas is feasible and urgently needed in resource-limited countries. &nbsp; L'objectif de cette étude était d'identifier et de déterminer les coûts des composants essentiels d'un ensemble de ressources et de stratégies pour étendre les services complets de soins obstétricaux et néonatals d'urgence en Tanzanie. Les éléments essentiels ont été identifiés grâce aux enseignements tirés lors de la mise en oeuvre de soins obstétricaux et néonatals d'urgence complets et de discussions régulières avec les principales parties prenantes. Les coûts correspondants ont été collectés auprès des centres de santé, du département de pharmacie de Tanzanie et d'organisations non gouvernementales qui avaient modernisé les centres de santé pour une prestation complète de services de soins obstétricaux et néonatals d'urgence. Les résultats ont montré que les coûts estimés de la modernisation d'un centre de santé pour fournir des services complets de soins obstétricaux et néonatals d'urgence étaient de 256 650 $(USD) pour l'infrastructure et l'équipement, 4 463$ par personne pour la mise à niveau des compétences en soins obstétricaux et néonatals d'urgence complets ou en anesthésie pour mois et 43 500 $par an pour les médicaments et les fournitures. Le coût total de toutes les composantes par centre de santé a été estimé à 560 802$. La mise à l'échelle a nécessité de nombreuses stratégies complémentaires à tous les niveaux du système de santé. L'extension des services complets de soins obstétricaux et néonatals d'urgence dans les centres de santé des zones mal desservies est faisable et urgente dans les pays à ressources limitées &nbsp

Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania

<p>Abstract</p> <p>Background</p> <p>Effective maternal and perinatal audits are associated with improved quality of care and reduction of severe adverse outcome. Although audits at the level of care were formally introduced in Tanzania around 25 years ago, little information is available about their existence, performance, and practical barriers to their implementation. This study assessed the structure, process and impacts of maternal and perinatal death audit systems in clinical practice and presents a detailed account on how they could be improved.</p> <p>Methods</p> <p>A cross sectional descriptive study was conducted in eight major hospitals in Dar es Salaam in January 2009. An in-depth interview guide was used for 29 health managers and members of the audit committees to investigate the existence, structure, process and outcome of such audits in clinical practice. A semi-structured questionnaire was used to interview 30 health care providers in the maternity wards to assess their awareness, attitude and practice towards audit systems. The 2007 institutional pregnancy outcome records were reviewed.</p> <p>Results</p> <p>Overall hospital based maternal mortality ratio was 218/100,000 live births (range: 0 - 385) and perinatal mortality rate was 44/1000 births (range: 17 - 147). Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed.</p> <p>Conclusions</p> <p>Maternal and perinatal audit systems in these institutions are poorly established in structure and process; and are less effective to improve the quality of care. Fundamental changes are urgently needed for successful audit systems in these institutions.</p

How can Canadian, African and other health systems benefit from each other?

Innovating for Maternal and Child Health in Africa (IMCHA) and Dalhousie University co-hosted a virtual event which provided a platform for exchange regarding implementation research on health systems strengthening, and an opportunity for participants to reflect on research gaps. This report covers key points from the plenary sessions: Delivering integrated health services for neonates; Integrating mental health into routine maternal care in low- and middle-income countries; The importance of leadership and management; Strengthening quality through the use of health data; and, Quality of care and safety standards.Canadian Institutes of Health ResearchGlobal Affairs Canad

Improving access, quality and safety of caesarean section services in underserved rural Tanzania: The impact of knowledge translation strategies

This research was designed to study different approaches to improve access to, and quality of caesarean section services in underserved Tanzania and translate evidence into practice. In 2016, 42 associate clinicians from five health centers were trained in teams for three months in comprehensive emergency obstetric and neonatal care and anesthesia followed by post-training supportive supervision and mentorship. From 2016-2019, 2,179 caesarean sections were performed in the intervention and 969 in the control health centers. Catchment population-based caesarean section rates increased significantly in all five intervention health centers and were more than 10% in three facilities. The risk of a woman dying from complications of caesarean section in the intervention health centers was 2.3 per 1,000 caesarean sections (95% CI 0.7 - 5.3). This educational program was adopted by the government and can be used to meet the demand for caesarean section services in other underserved areas in Africa. &nbsp; Cette recherche a été conçue pour étudier différentes approches pour améliorer l'accès et la qualité des services de césarienne en Tanzanie mal desservie et traduire les preuves en pratique. En 2016, 42 cliniciens associés de cinq centres de santé ont été formés en équipes pendant trois mois aux soins obstétricaux et néonatals d'urgence complets et à l'anesthésie suivis d'une supervision et d'un mentorat post-formation. De 2016 à 2019, 2 179 césariennes ont été réalisées dans les centres de santé d'intervention et 969 dans les centres de santé témoins. Les taux de césariennes dans la population desservie ont augmenté de manière significative dans les cinq centres de santé d'intervention et étaient supérieurs à 10 % dans trois établissements. Le risque qu'une femme meure des complications d'une césarienne dans les centres de santé d'intervention était de 2,3 pour 1 000 césariennes (IC à 95 % 0,7 - 5,3). Ce programme éducatif a été adopté par le gouvernement et peut être utilisé pour répondre à la demande de services de césarienne dans d'autres régions mal desservies d'Afriqu

Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania

Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH) in rural Tanzania in order to generate information upon which to base interventions. Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94%) had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC) were proposed and implemented as a result of audit. Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented

Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project

Objectives During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. Design The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. Results 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282–232 cases/100 000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. Conclusions This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it

A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project: Table 1

Objectives The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way. Design Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice. Participants During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme. Results Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others. Conclusions The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country

Building leadership and managerial capacity for maternal and newborn health services

Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania. The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings. Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building. Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.Global Afairs Canada (GAC)Canadian Institutes of Health Research (CIHR