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Indian Journal of Community Medicine

Management of Health Information System in RCH Programme

Author(s): S. Lal, B.M. Vashisht, M.S. Punia, Vijay Kumar, Ramesh Kumar & Sonal Jain

Vol. 27, No. 2 (2002-04 - 2002-06)

Deptt. of S.P.M., Pt. BDS PGIMS Rohtak

Abstract:

Research question: What records and reports are maintained at the level of subcentre and how this information is used at the level of subcentre.

Objectives: To determine the process of recording and reporting of health information. To determine the extent of use of health information and management of information at the level of subcentre.

Study design: Cross-sectional - case study - (qualitative observational study).

Participants: Health workers female (n=35).

Setting: Rural area.

Study variables: Nature of records, village and household information, eligible couple and children register, survey registers, service registers, stock registers and surveillance data, monthly report for subcentre.

Results: Management of health information system of 35 subcentres in rural areas revealed that the workers are over burdened with 13 different registers to generate data and to report information to higher levels. Most commonly used records were eligible couple and family welfare services, Maternal and child services registers, birth and death and inventories of stocks and supply registers. Use of data was restricted to enumeration and registration of beneficiaries and reporting of services rendered to mothers and children. The information was seldom used for planning of work schedule, prioritization of clients, community needs assessment and the supervisors never used the information as management tool to monitor and evaluate the services and development of health teams at subcentre level. The health information was never shared with community (panchayats and organized women groups).

Keywords : Health information system, Management, RCH programme, Subcentre

Introduction:

At the level of subcentre in the state of Haryana 13 registers are being used to collect/record and report information to higher formation1. Each register has specific purpose.

Subcentre register 1: Subcentre and village information register provides village information, gives an overview of subcentre area and of the villages to be covered in terms of population and their characteristics and of the resources and facilities available in the area for planning and operational use and baseline data for deriving indicators such as coverage and their trends for monitoring and evaluation.

Subcentre register 2: Household information. This register helps assessing the health status of each individual in the household and its environment, as also for identification of eligibles for initiating relevant health care activities.

Subcentre register 3: Eligible couple and children information. This register provides a summary of the number of eligible couples for family welfare services and of the children for immunization, for each of the villages covered by the subcentre and also list of married couples and their family welfare practices for identifying priority couples for initiating and sustaining relevant care. It also provides information on children less than 5 years with their immunization for initiating and follow-up for full immunization.

Subcentre register 4: Family welfare services. This register provides an account of family welfare services given to the eligible person/couple and their follow-up and to record complication if any.

Subcentre register 5: Maternal care services. The purpose of this register is to record relevant information on the antenatal, natal and post-natal care given to pregnant women, identification of priority cases requiring special care, ensuring continuity, timeliness and adequacy in the provision of services and describing outcome of pregnancy. This also serves as basis for planning for defaulter/follow-up visits.

Subcentre register 6: Child care and immunization services. Its purpose is to capture relevant information on the care given to the children in respect of immunization, nutritional status, prophylaxis against anaemia and blindness including those for identifying priority cases requiring special care ensuring continuity in the provision of infant care and complete immunization to the children aged below 2 years and when applicable date, age and cause of infant deaths.

Subcentre register 7: Tuberculosis and leprosy control. Its purpose is to capture the relevant information on the care given to tuberculosis and leprosy cases in respect of type of cases, treatment and outcome.

Subcentre register 8: Malaria and blood smear and treatment. Purpose of this register is to capture relevant information on malaria cases in respect of the results of smear examinations and continuity in treatment given.

Subcentre register 9: Home visit diary, helps health workers to record daily activities, as also enables the health workers to plan their home visits with the objective of providing follow-up care to all defaulters and priority cases.

Subcentre register 10: Clinic register. This serves to capture relevant information on outpatient attendance at subcentre as also referrals of patients.

Subcentre register 11: Stock and issue register. This enables the health workers to monitor their own stock position in respect of vaccines, medicines and other supplies and equipments.

Subcentre register 12: Vital events - births. The purpose of this register is to capture information on births occurring in subcentre area for initiation of relevant family welfare and child care services including immunization and then ensure continuity of care to the mother and child.

Subcentre register 13: Vital events - deaths. This register gives information on deaths occurring in the area to enable the worker to study the health status of the village and plan relevant health care activities. These registers serve as basis for planning for defaulters/follow-up visits, preparing monthly reports and also to be used by supervisors as a management tool to monitor the performance of health workers1.

Material and Methods:

The registers and reports of 35 subcentres for the year 1999-2000 were analyzed. The observations were corroborated by interviewing the health workers and cross checking the information of several records maintained during the year 1999-2000. Annual report of the reference year of every subcentre was used to collect information on actual coverage versus planned coverage and the data of annual report was corroborated with the recorded information in the respective register. Teams of 10 medical interns, 3 postgraduates and 2 teachers were trained and used for collection of desired information on pretested format. Use of data of each register was determined through actual observations and finally the uses were compiled and classified into broad headings in accordance with the specified uses of each register given out by the health information system version 2.01.

Observations and Discussion:

Table I: Actual use of health information at the level of subcentre.

Spectrum of use of information No. of subcentres covered (n=35)
No. (%)
Enumeration & registration of eligible clients and counting of population. 17 (48.6)
Contact clients and provide services, motivate and follow-up. 35 (100)
Identification and referral of high risk mothers and children. 5 (14.3)
To prepare reports 35 (100)
To know status of immunization and health 20 (57.2)
Surveillance of diseases/deaths/births/ disability 35 (100)
To monitor stocks and supplies 35 (100)
Knowing performance against planned activities 35 (100)
To prepare subcentre action 35 (100)
plans Audit purpose 35 (100)

Nearly half (48.6%) of the subcentres used the records for enumeration, registration of clients and to count down the number of clients and population. Under this category of use it was observed that the subcentre and village information register has been used only once since its inception to enumerate and register various health related facilities such as total villages, practitioners, traditional birth attendants, anganwadis, wells, schools, post-offices and village leaders, women organizations etc. Only male workers resorted to chlorination of wells. Household information register was primarily used to enumerate households in the area, population of each household with age and sex, eligible couples, source of drinking water and type of latrine. On many accounts this register was incomplete, as morbidity status, chronic diseases and disability columns were left blank and, similarly, the column of significant event, if any, was left blank. Eligible couple and children register was used to register couples in reproductive age group and to enumerate and register infants and under 5 children. Registration of antenatals, deliveries and post natal mothers was done by using a separate register innovated by workers themselves. Though the exercise of updating these registers is built in the programme through annual surveys undertaken in the month of February-March but it is done by the workers half heartedly as new registers are seldom provided and the workers make additions and alterations in the same register and one could observe over-writing, erasing and rewriting. Most workers resorted to recording of events of services of enumeration of clients in their home visit diary or a note book in the absence of home visit diary. Under-enumeration and under-registration was widespread phenomenon as was evident from studies undertaken in this block area in the recent past. Data on births recorded and missed by different agencies in this block in 1997 indicated that the system of anganwadis under ICDS was most efficient to register births and ensure full immunization and other services. The multipurpose health worker missed 22.3% of births while village chowkidar missed half of the births and only recorded 51% of total births.

Similarly, death registration with health workers was incomplete as they missed 25% of deaths, while chowkidar missed 35.5% of deaths.

In all the 35 subcentre areas the records were being used to contact and motivate clients for family welfare services, reproductive and child health services/care and follow-up of clients to ensure continuity of care. The major services and follow-up was provided for immunization. Immunization services were universal and multiple contacts were ensured with mothers and children and along with this other services such as Vitamin A, Iron and folic acid prophylaxis were added at most of the subcentres with variable coverage. Systematic use of eligible couple register to contact, motivate and provide services was a bit discouraging though all the 35 subcentre workers made use of this register but they could contact very low proportion of registered couples (7.5% only) in the past one year. Coverage and performance of contraception service was low on account of poor plan of contact and prioritization of most needy and most vulnerable. Records in relation to medical termination of pregnancy and pregnancy wastages and abortions were deficient at the level of subcentre on account of poor contacts and registration as also non disclosure.

All the workers of 35 subcentres made use of maternal care services to render antenatal, natal and postnatal care as also early neonatal care. The critical observation of records and reports revealed that registration of antenatals per annum was quite impressive as 94% of coverage level was achieved along with the efforts of anganwadi workers, however, only 24% of antenatals were given 3 or more check-ups and only 4% of antenatals were referred to higher formation. Only 14.3% of subcentres used the records for identification and referral of high risk mothers and children. Antenatal care/services is the second most predominant service at the level of subcentre after immunization. Need assessment of pregnant mothers and their categorization for preferential services needs to be upgraded at the level of subcentre. This is most frequently used record by all the health workers in rural area and some of the workers have evolved their own registers in view of erratic supply of these registers. The postnatal care record's columns were left blank and so was the story with early childhood care (neonatal care) records. System of subcentres could ensure only 1.5% of total deliveries and postnatal care to 14.2% of women under the prevailing circumstances as the health workers female were non-resident and were not available to conduct deliveries and render post-natal and early childhood care at the village level and consequently the records were deficient in relation to these essential services.

Child care and immunization register was used by all the subcentres and record was quite impressive and complete and workers used this register to ascertain the immunization and health status of the young children, however, weighing at birth was seldom undertaken and weighing of children of 0-6 years was seldom done by health workers and contacts with children were maximum because of regularity of out breach sessions and high level of coverage of immunization was ensured in the area along with the ICDS system.

In all the 35 subcentre areas, active and passive surveillance for malaria was being persued as per guidelines and standards. Separate records for malaria surveillance are being maintained under the National Antimalaria Programme. Health worker male is responsible for active surveillance while passive surveillance is done by both (female and male health workers). Surveillance of other diseases is limited to acute diarrhoeal diseases and acute respiratory infections in young children.

Since the system of subcentre action plan has been introduced in this area and there is built in system in the monthly monitoring report to compare the actual performance versus planned performance during the month and the cumulative performance during the year. All the 35 subcentres were complying with this activity and used various registers to prepare monthly reports and measure their performance (self evaluation). One could observe substantial over-reporting of eligible couples contacted, births weighed and post-natal care coverage. Disease surveillance in relation to vaccine preventable diseases was not at all recorded and reported.

Records of stock and supply registers were maintained by all the subcentres and major use was to submit these records for audit purposes or to handover or takeover in the event of transfers. All the subcentres used some information for preparing subcentre action plans which was once a year phenomenon and, thereafter, this plan was seldom put to use or seen by any health worker. The subcentre workers described this plan as paper tiger and not real plan and never understood and not at all used for planning the work and persuing the activities in routine. The workers felt that the monthly report was too cumbersome and asked for too much of information.

Table II: Areas of inadequate and negligible use of records at the level of subcentre.

Areas No. of subcentres (n=35)
No. (%)
Analysis of survey data 2 (5.71)
Prioritization of clients for preferential contacts 0 (-)
Planning work-schedule 0 (-)
Community needs assessment 0 (-)
Sharing of information with community PRI - women groups 0 (-)
Sharing of information with other sectors (Anganwadi) 35 (100)
Sharing of information with other sectors (birth attendant) 5 (14.3)
Sharing of information with other sectors (village chowkidar) 3 (8.6)
Use of records by supervisors and health managers at the level of PHC 0 (-)
Feed back on monthly reports Happens at the sector meeting

The wealth of records available and generated by the health workers of 35 study subcentres in rural area was not utilized for planning of work schedule, prioritization of clients and assessment of community needs. The exercise of community needs assessment is on the paper. It is not understood and not put into practice by any of the health worker of these 35 subcentres. No information is shared with community and its organized groups like village panchayats and mahila swasthya sanghs. However, the information is shared profusely with anganwadi workers at the level of village and sector meeting, which was quite encouraging observation. Only two out of 35 subcentres (5.71%) analysed their survey data. Though workers are required to analyse the eligible couples parity-wise and contraception method used by them, but it is not used for prioritization of couples and contact programme. The health supervisors did not use these records/information for monitoring and evaluation of performance of workers. The managers and supervisors never used the information as a management tool to improve the functions of subcentre team or to build confidence of community.

Sector meeting of a primary health centre area occurs once a month in the last week of every month. It is a joint venture of anganwadi workers, health workers and supervisors of health and ICDS. The data on monitoring reports is obtained from individual anganwadi workers by the supervisors (Health and ICDS), this covers performance of various service components of mothers and children, records of vital events, beneficiaries, supplies and educational material. This opportunity is also utilized for joint planning of activities for the next month besides continuing education of functionaries. Identified problems are solved on the spot and feed back from the health workers and anganwadi workers is given to the health managers. Performance of each worker is reviewed and performance of different workers is compared and reasons of poor/low performance are discussed. Current performance is compared with previous performance. This is a unique forum to develop health teams, to achieve co-ordination and learn from each other's experience and to share the information between workers for better understanding of each other's functions. However, the district and PHC/CHC managers attitudes towards sector meetings is indifferent and they continue to persue their own track to generate data and information in isolation and synergies are seldom worked out and put into practice. Example of synergies between two sectors on integrated health information generation and utilization thereof are rare indeed.

The most common use of various registers/records happened to be enumeration of eligible clients for care/services such as eligible couples, infants, children between 1-5 years, pregnant women, lactating women and clients with chronic diseases like tuberculosis, leprosy, blindness and malnutrition etc. The data is generated by the health workers themselves at the level of subcentre and they are responsible for ensuring appropriate health action based on the information. The enumeration and registration of clients tends to be incomplete and falls short of expected level. Full coverage is not ensured.

The other predominant use of information by health worker was tracking the clients for providing services to ensure continuity of care and follow-up. The care/services consisted of contraception, immunization, maternal care (antenatal, natal and post-natal services), treatment and prophylaxis for anaemia, in women and children, Vit A prophylaxis and treatment of childhood illnesses (ARI and diarrhoeal diseases). Services provided are first recorded in the home visit diary and subsequently transcribed to relevant registers, which is quite cumbersome exercise, as it happens to be labour intensive activity, consequently many columns under the services registers were incomplete or left blank. Inevitably the multiple registers and records consumed substantial time of the workers and the capacity of the workers was limited to accomplish enormous task. Major thrust was on the quantity rather than continuity of care/services.

Predominantly the workers used maternal care services and child care services registers to provide services to antenatal mothers and immunization to infants besides family welfare services to eligible couples. Adhoc use and preparation of records for pulse-polio immunization and outbreak response were in vogue for the past four years or so. Special drives like family health awareness campaigns, disability detection, cancer detection, blindness survey necessitate preparation of list of relevant clients and reporting thereof to designated authority.

Reasonable use of health information/records for identification of high risk antenatals and referral thereof was limited to five subcentre areas (14.3%) and in the remaining subcentres this practice was absent. Only 8.6% of complicated deliveries were referred to higher formation.

Subcentre action plan is prepared as a ritual exercise once a year in the month of Feb.-March2,3. The workers pick up the figure of total population from their household register and multiply this figure with the borrowed birth rate of the same block or district to arrive at projected antenatal cases per annum. To account for pregnancy wastage, 10% of the projected antenatals are added to arrive at total load of antenatal mothers in the subcentre. Both birth rate and pregnancy wastage rate are borrowed figures and there is no ownership of the magic figures thus worked out. Lot of data generated by the workers themselves is not put to use for annual action plans. Total antenatals registered in the past one year and validated with the records of anganwadi workers should form the basis of annual action plans. Similarly, actual number of births surviving under age one should form the basis of action plan for immunization. Similarly, DT at age 5 and TT at age 10 and 16 should have actual performance of the last year and it should be worker's own data. It was encouraging to observe that all health workers mentioned the performance of last year for different components of reproductive and child health services. Action report data relevant of reproductive tract infections is generated through family health awareness campaign and many workers reflect this information in their annual action plans. Past year performance of contraception is picked up and enhanced to the extent of 5% from the basis of projected annual plan. Data on ARI and diarrhoeal diseases is picked up from clinic register of subcentre.

Subcentre action plan is submitted annually as a mere compliance document and this is seldom seen/used subsequently by the health workers or by the managers, workers rely on the actual performance2,3. No feedback is ever given on subcentre action plans. On the basis of household and eligible couple survey, data is not analysed for segmentation of clients for priority services or priority follow up.

Subcentre Kit-A and Kit-B have standard items and supplied twice every year without any flexibility and the supplies have no correspondence with the projected action plans of the workers. The supplies have been determined centrally on the basis of national average disease burden, including anaemia, diarrhoea, acute respiratory infections, the situation may differ from subcentre to subcentre. All eligible couples, who have unmet needs and those using spacing methods must be contacted.

All the workers used the data and information for preparing monthly and annual reports. The information is lifted from various registers (mostly from Family welfare services, Maternal care and immunization register as also from Clinic register). The monthly performance reports are invariably inflated, 100% of births are shown as weighed and classified into two categories, over 2.5 Kg. and under 2.5 Kg. Similarly, postnatal care is reported universally but the facts are otherwise. Report in relation to surveillance of vaccine preventable diseases is left blank and report on number of eligible couples contacted is arbitrary and inflated heavily. Share of deliveries by health worker female is marginal though the early neonatal, late neonatal and post neonatal deaths and deaths from 1-5 years are reported but the cause of death is not reported and recorded. There is under-reporting of vital events like pregnant women, births and deaths and marriages registration has just begun but it is not reported.

The health workers generate lot of family based household data and information at the community level. Despite the evidence that much of the information tends to be irrelevant, of poor quality, redundant, therefore, nonetheless some useful data is available. Further, the workers seem to perceive that the collection of information is an end in itself. Follow-up actions are seldom ensured.

The present study at micro level documents that information use is limited. The valuable information collected is not used by health teams at subcentre level for assessing community health needs, segmentation of clients, prioritization of clients for services, preparation of efficient work schedule for coverage of clients, tracking the clients for continuity of services4. The subcentre action plans and monthly performance reports data/information is seldom shared with the community and organized groups whose life it affects in a profound manner. In summary, voluminous data and information gathered under RCH programme is seldom analysed, poorly understood and not acted upon locally for decision making or to improve the quality of services. The system remains data driven rather than action driven.

Smith, Hansen & Karim, 1988; WHO, 1988 b; De Koelt 1989 reported that information use was found to be especially weak at the district, health centre and community levels. Decentralization of planning and planning at community level for RCH services raises serious concerns in view of results of present evaluation study. Dunn (1980) observed that planning and management staff rely primarily on "gut feeling" to formulate adhoc decisions rather than seek pertinent data. Training, continuing education of health workers and mangers is imperative to promote effective management of health information system under RCH programme5,6.

References:

  1. Health Management Information System (version 2.0) Subcentre Registers and Reporting formats (Model) Govt. of India, Ministry of Health and Family Welfare, Nirman Bhawan, New Delhi, April, 1992.
  2. Community Needs Assessment Approach (CNAA). Revised version of Forms and Formats. Proposed by the committee on CNAA to review formats and registers under CNAA constituted by the Ministry of Health and Family Welfare, Deptt. of Family Welfare, Govt. of India. Draft July, 2000.
  3. Manual on Community Needs Assessment Approach (Formerly Target Free Approach) in Family Welfare Programme. Department of Family Welfare, Ministry of Health and Family Welfare, Govt. of India, New Delhi, Jan. 1998.
  4. Manual on Target Free Approach in Family Welfare Programme, Ministry of Health and Family Welfare, New Delhi, 1996.
  5. Teaching Health Statistics. Lesson & Seminar Outline. Second edition. Edited by Lwenga S.K., Cho-yook Tye, O. Ayeni. World Health Organization, Geneva 1999.
  6. Design and implementation of health information systems. World Health Organization, Geneva 2000. Edited by Theo Lippeveld, Rainer Sauerborn, Claude Bodart.
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