IDEAS presented to the Uttar Pradesh Technical Support Unit (a project funded by the Bill & Melinda Gates Foundation to support the work of the Uttar Pradesh health system) on 3 September 2014 on a study of how the private sector can share data with the public sector to help the public sector with resource planning:



Study overview

In support of TSU’s Objective 3a

• Sub-obj: Create robust systems for data collection, analysis, and planning to improve programme management (e.g.HMIS)

Utility of the findings

•To jointly develop and test a strategy for data sharing on key MNCH services with the private health sector in UP.

Aim of the present study

•To explore current data management and reporting systems for MNCH data in the private sector, and barriers and facilitators to obtaining private sector data and setting up such system

Gautham, M

Gupta, Sanjay

IMPACT

Mishra, Nirmala

Public Health Foundation of India

Spicer, N

Subharwal, Manish

LSHTM Research Online

Gautham, M; Spicer, N; Subharwal, Manish; Gupta, Sanjay; Mishra,Nirmala Public Health Foundation of India, IMPACT; IDEAS Pri-vate Sector Study of Maternal Newborn Child Health Data Sharingin Uttar Pradesh, India. In: Presentation to Uttar Pradesh’s Techni-cal Support Unit, 3 September 2014, Lucknow, India. (Unpublished)Downloaded from: http://researchonline.lshtm.ac.uk/1931459/DOI:Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/IDEAS Private Sector Study of MNCH Data Sharing Improving health worldwide ideas.lshtm.ac.uk    Dr Meenakshi Gautham, IDEAS-LSHTM Dr Manish Subharwal, IMPACT  Dr Sanjay Gupta, IMPACT Ms Nirmala Mishra, PHFI Dr Neil Spicer, IDEAS-LSHTM Lucknow, September 3, 2014 IDEAS Overview • IDEAS: Informed DEcisions for Actions in maternal & newborn health • 5 year measurement, learning & evaluation grant • Funded by Bill & Melinda Gates Foundation • Delivered by London School of Hygiene & Tropical Medicine, with local partners • Evaluation of Bill & Melinda Gates Foundation maternal and newborn health strategy across three countries. • Working in Ethiopia, NE Nigeria and Uttar Pradesh, India  Study overview In support of TSU’s Objective 3a •  Sub-obj: Create robust systems for data collection, analysis, and planning to improve programme management (e.g.HMIS) Utility of the findings • To jointly develop and test a strategy for data sharing on key MNCH services with the private health sector in UP.    Aim of the present study • To explore current data management and reporting systems for MNCH data in the private sector, and barriers and facilitators to obtaining private sector data and setting up such systems  Private sector in healthcare (UP-AHS, 2012-13) % of institutional deliveries (UP) % of deliveries in govt. institutions % of deliveries in private institutions 56.7 39.0 17.6 Table 1: Institutional deliveries % seeking care for acute illnesses, any source % seeking care from govt. sources % with chronic illnesses, getting regular treatment % seeking regular treatment from govt. sources 97.4 5.4 58.7 15.6 Table 2: Care seeking for acute and chronic illnesses  Method Approach  • Qualitative: 54 in-depth interviews with stakeholders Sampling • Districts:  Largest number of Level 3 (tertiary) facilities – Allahabad  Largest number of Level 1 (basic primary) facilities - Hardoi • Constituencies: government; professional associations; private commercial health facilities; significant NGO programmes • Respondent selection: leadership and knowledge; involvement in data processes; engaged in MNCH services (esp. deliveries and newborn care)  Process of facility/stakeholder selection (district level) 1. DPMU                                                                                      Overview of district processes & facilities, who’s who, HMIS 2. CMO’s office (to  select blocks)                                                                                         Overview of registered private facilities,                                  Reporting hubs for PCPNDT, MTP, deliveries, births and deaths  Monthly Progress Report (MPR) consolidation 3. Selected block PHCs & CHCs (to select block facilities)                                                                              Discussions with key informants  to identify private facilities 4. Local pharmacies/pathology centres/other local clinics          Cross verifiy information on facilities 5. Visits to selected local health facilities                              Interviews/scheduled appointments Example – Allahabad   Rural (20 blocks) • 16 have zero reporting out of which Koraon, dhanupur, pratappur, manda have no nursing homes at all. • Chaka – 45 deliveries/June; 10-12 kms from the city • Holagarh – 32 deliveries; 32 kms • Sohraon – 25 deliveries; 22 kms • Kaurihar – 11 deliveries; 20 kms • Jasra is zero reporting and is within 20 kms. • Mauaima is zero reporting and 35 kms. • Phoolpur is zero, and within 40 kms but its on the main road and has a lot of nursing homes (and the names of nursing homes are given on PHC reports). Volume Hardoi (14 facilities) Allahabad (11 facilities) Reporting Non Reporting Reporting Non Reporting High  Facilities: 2 Facilities: 2 Facilities: 2 Facilities: 3 Beds:  18, 100 Beds 20, 100 Beds: 200, 200 Beds: 3, 20, 30 Deliveries:100, 144 Deliveries 95, 100 Deliveries:100, 200 Deliveries:100, 40,100 Medium Facilities: 4 Facilities: 3 None Facilities: 4 Beds: 20, 20, 20, 20 Beds: 5, 10, 60 Beds: 15, 15, 15, 10 Deliveries: 15, 10, 10, 20 Deliveries: 15, 8, 25 Deliveries: 12, 10, 12, 10 Low None Facilities: 3 None Facilities: 2 Beds: 10, 20, 30 Beds: 10, 10 Deliveries 1, 2, 2-8 Deliveries 2, 2 Facilities interviewed    Part 1: Availability of MNCH data in private facilities  Private facilities report and maintain data on ultrasounds, MTPs and deliveries No. of private facilities registered  Reporting on ultrasounds (PCPNDT Act)/total regstd. Reporting on MTPs / total regstd. Reporting on deliveries  Hardoi  34  19/19  8/8  7  Allahabad  283  217   9  ??(na) Standardised formats for ultrasound reporting Standardised formats for MTP reporting Records maintained by pvt. facilities Types of registers  - OP/IP register; OT register; labour/ delivery  register; paediatric/ immunization        - max may be 20 registers (incl. medicines & accounts)        - manual but some places computerised Register clientele  - ANC cases, deliveries, newborns, children  Types of data (varies across facilities)  -name, age, address, date of admission &                                                                    discharge  -normal / casearean delivery, order of birth  -newborn: sex, birth weight, live/dead,                                                                                       full term/preterm, time of birth Quality issue: Formats used for reporting deliveries are not standardised Types of records at pvt. facilities Facility records are updated frequently • Data updating on deliveries is very frequent, every delivery is recorded almost as soon as it happens – on the same day or within a couple of days.  • However, deaths may not be recorded even in the facility’s own registers; either maternal or newborn  Unregistered facilities & reporting • Not registered, but well known even to the formal establishment • But no exact estimates  • Providers informally trained / AYUSH • Cheap and popular; high delivery loads • Tie ups for quick and affordable referrals; and for birth certificates (with a doctor) • NO RECORDS AT ALL Private sector barriers and enablers to maintaining MNCH records  BARRIERS No formal, standardised formats • Existing ones not developed in consultation with private sector Varying needs and interest • Each keeps records that are enough for their needs.   • Govt is more interested in preventive aspects and the private sector in curative aspects Systems and effort • Computer system not available everywhere.  • Time consuming to maintain detailed records. Large numbers of unregistered facilities • Out of any reporting requirements  Private sector barriers and enablers to maintaining MNCH records  ENABLERS The need to keep records • Bigger hospitals keep records as a safety net against medico legal cases, • All need some birth proof to give their patients Basic system is in place • Some staff time available everywhere for keeping records–multi tasking staff that also look after records.  General willingness to maintain and share records • Even those with rudimentary records are not averse  • Unregistered also willing if asked • Associations willing to cooperate  Public sector barriers and enablers to maintaining MNCH records  BARRIERS Lack of information and sustained follow up of the private sector • Many private facilities say that they’ve never been asked to maintain and submit records on deliveries, especially the newer hospitals.   • No sustained or systematic efforts made by the public sector to get private facilities to maintain and submit data on deliveries.  Public sector barriers and enablers to maintaining MNCH records  ENABLERS Importance attached to official communication by the public sector • The hospitals that do submit delivery records (older and more established ones) say that they received a communication and a format from the CMO’s office.  • So a communication from the health department does carry weight. Basic data is similar to the ‘Births and Deaths Registration’ data, so formats can be easily standardised   FEEDBACK AND DISCUSSION     Part 2: Data collection, sharing & utilisation  Pathway of ultrasound and MTP reporting: strictly enforced Ultrasound and MTP Private Nursing Homes, Hospitals and Ultrasound Units Nodal Officer PCPNDT Act Dy CMO (Admin) Director General Medical Health Pathway of reporting deliveries also exists Institutional Deliveries Private Nursing Homes and Hospitals (City) Private Nursing Homes and Hospitals (Block) Block PHC/CHC Consolidated with PHC/CHC Report ARO (CMO Office) District Health Visitor  DPMU Director General Family Welfare Dy CMO (RCH) HMIS (NRHM) Private hospital deliveries reported in the MPR but not in the HMIS June 2014 MPR June 2014 HMIS  Allahabad   113 (R) 571 (U)  0 (blank cells)   Hardoi  84(R) 308 (U)  0 (blank cells)                   Institutional deliveries - MPR 2014   HMIS June 2014  HMIS: Source data does not include private sector deliveries  MPR: Format available but inconsistent/ incomplete data  MPR: main problems • No precise estimate of facilities providing delivery services • Delivery data is not reported by all nursing homes; only a few that have been reporting continue to report • PHCs/CHCs follow up only with those that report regularly • Only data on number of deliveries, and in few case on C-Sections is consolidated into the MPR  • Unclear how other data on birth weight, order of birth, gestational maturity, live/stillbirth, gender of child is used.  • Different methods of data collection by AROs/ANMs: receive reports, view facility registers, verbal reports etc. • HMIS – only JSY deliveries included; and only rural ones so far   Reporting of Birth and Death Data – RBD Act 1969 Reporting of births and deaths is mandatory by law.   The designated authority (‘informant’) of a facility has to report births, stillbirths and deaths, together with some of their characteristics in the prescribed reporting form to the concerned Registrar to facilitate registration of the event.         -Section 8 & 9 of the Act    Form 1 – Birth report formats and characteristics Process of reporting RBD data Birth and Death Private Nursing Homes and Hospitals Respective Municipal Corporations Nodal Officer B&D Dy CMO (RCH) Director General Medical Health Issues in birth and death reporting under the RBD Act  • Only urban facilities required to report to Nagar Palika; rural to panchayats; rural/urban demarcation may just be a road • Not all facilities report births and deaths to anyone; typically just give a proof of birth to the family of the newborn • Link between Panchayats and Nagar Palika or CMO’s office? • Good data on all reported births compared with the data on institutional deliveries can provide a good overview of all births, and home births vs institutional deliveries.  Enablers: Why do some hospitals report deliveries? Perceived as mandatory  ‘This is a law – that those who do deliveries, have to send the numbers every month. We had a circular from the govt about 7-8 years ago for submitting their report and we have been submitting since then. Format was given by the govt, but copy of that format is not available now. But we use the same columns as were given in the format.’  - If accredited for JSY (e.g. Kamla Nehru Memorial Hospital) A system has been in place  - ANM follows up on a fixed date every month  - ‘Have been submitting data since the last 8 years. First we used to send birth and death data to nagar palika (municipal authority)– about births and deaths. Then they did not do it well, so responsibility was given to the CHC.’  - Its never been stopped! Personal motivation / hospital credibility  - I live here 24 hours and work on the computer. No other entertainment, so keep doing this. My family lives in Lucknow, I go only on Wednesdays.  - ‘ we are a big hospital, anyone can visit anytime’.    Other enablers – private sector    Used to recordkeeping and reporting Used to submitting very rigorous records in a timely manner (e.g. PCPNDT & MTP ) Overall willingness Willingness to share data if the health department asked for it. Professional bodies like IMA and UPNHA are willing to influence their members if the associations are roped in and involved. Birth data cannot be hidden  Although fear of income tax exists, but at the same private  facilities have to give some birth proof to all their patients, so  that  necessarily requires reporting accurate data on deliveries.      Enablers – public  sector    Available system and mandate   A system for reporting deliveries exists which can be strengthened    A legal cover provided by the RBD Act which can be invoked.   RBD system has initiated an online registration system which is not yet well known or well utilised, but it is there.     Reasons why most hospitals do not report Never been asked to Haven’t been asked to submit any reports so far…can submit if required Low volume of deliveries We don’t perform so many deliveries – just one or two Not perceived as a hospital duty Getting births registered is the responsibility of patients Effort required Need a person to go there and submit..tedious process Perception that reports are anyway treated as garbage They just throw away our reports anyway  No motivation Not paid for submitting, so why submit? If paid, maybe all will submit   Other barriers – private sector   Lack of communication or follow up by the public sector ....with those facilities that do not report. Limited  interactions with public sector ....in forums like DHS etc. Fears.. ... that govt will use this information for calculating income tax. Package multiplied by number of cases will disclose the income.  ....that it will lead to additional work. .....of unfriendliness of government staff -rough attitudes, especially when hospital staff go to submit any reports.  .... of harassment especially for reporting any deaths. They will be asked all kinds of questions with no understanding as to the contextual circumstances ...of inviting visits and having their quality standards exposed. Lack of incentives  No monetary incentives or other incentives to report. Barriers to reporting – Public Sector System in place and being used for the MPR but  -data collection processes and formats are not standardised  -not covering all the hospitals that provide MNCH services MPR and HMIS issues -Two parallel systems with different data entry persons -Different provisions for private sector reporting at source -Overburdened data entry at DPMU level (in Allahabad, the district data entry assistant is also managing accounts) -Lack of ownership of the HMIS in the system -Limited feedback on private sector reporting by the state offices -Cross analysis of birth/death registration with delivery data?  Barriers to reporting – Public Sector Lack of a central coordination cell • No central coordinating body in either CMO office or DPMU for private sector No exchange of commodities   for which public sector can ask for a return utilisation certificate. E.g. vaccinations. Conflict of interest • Govt doctors in private practice. Some also have their own nursing homes.  Limited capacity  • Limited ability to analyse the data – and also limited computers and skills. • Limited feedback from the state (especially for the MPR system)– for incomplete or erroneous data • Also a concern that if the data starts coming in, how will the govt handle this data? Are they equipped to handle it? Disinclined to use • Public sector may sometimes not want to draw attention to adverse situations reported by the private sector. So may not be comfortable to report any data that shows their district health system in a bad light.    Suggestions for improving reporting Strengthen the system • Use the provision of law by the RBD Act. • Get orders passed, issue a letter • A coordinating body for the private sector – could be linked with the Clinical   Establishments Act authority • Cross sharing with the Birth and Death registration data • Govt should take responsibility; it should not be left to the choice of the pvt   sector Improve engagement and interactions • Include pvt sector in training cum review workshops of district health officials • More public private platforms and increased opportunities for interaction in   existing platforms Suggestions for improving reporting Design a user friendly system • Develop formats in consultation with pvt bodies • Prioritize the most critical data • Either password protected online data entry system; or streamlined data collection systems • The system should be simple and should not create extra burden • Rationalize reporting frequency  • System that enables self analysis for the pvt facilities also Capacity building • Technical assistance for setting up the system – training etc. • Meetings and follow ups to explain and guide Suggestions for improving reporting Motivation • Orientation to highlight the importance of data sharing • Simple incentives – financial and non-financial (including for public sector officials too) • Disincentives for non-submission • Periodic facility inspections • Engage health insurance to increase need for reporting Address fears • Reassurance against any potential harassment by government • Confidentiality and risk cover • Govt approach -less fault findings, more strengthening Summary • Private sector is already reporting, even on deliveries • Not showing up in HMIS, but it is in MPR, due to gaps in source data • But even in MPR, it is incomplete and processes and formats not standardised • Good data on births and newborns, but how is it/will be used? • Private facilities do have data and are willing to share; good system has to be set up • Legal cover is available via the Birth and Death registration Act. • Major barriers : system lacking; communication &engagement; effort; data utilisation; effort required; fears; HMIS vs MPR; unregistered facilities • Major enablers: RBD Act; a patchy system exists; general willingness; used to recordkeeping • Key suggestions: system strengthening; regular engagement and interactions; designing a user friendly system; capacity building; motivation; address fears Contact us IDEAS Project London School of Hygiene &  Tropical Medicine 4th floor Keppel Street London WC1E 7HT  Email: ideas@lshtm.ac.uk Website: ideas.lshtm.ac.uk Newsletter sign up: eepurl.com/j3iBz Twitter: @LSHTM_IDEAS Meenakshi Gautham IDEAS Country Coordinator Based at: Public Health Foundation of India No. 47, Sector 44 Gurgaon 122002 Ph: +91-9871145571 E-mail: Meenakshi.gautham@lshtm.ac.uk Thank You 

IDEAS Private Sector Study of Maternal Newborn Child Health Data Sharing in Uttar Pradesh, India

http://researchonline.lshtm.ac.uk/1931459/1/IDEAS_private%20sector%20study%20MNCH%20data%20sharing_MGautham.pdf

IDEAS Private Sector Study of Maternal Newborn Child Health Data Sharing in Uttar Pradesh, India

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