A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI Lessons Learned from Introducing a Village Health Registry in Malawi Prestor J Kubalalika Centre for Community Health Promotion, Chichiri, Blantyre3, Malawi Abstract The Village Health Registry (VHR) was a community health data collection tool introduced in 1998. It was first introduced in Mwanza district of Malawi with the objectives of collecting community-based data, analyzing and taking action in a local setting. The tool was collecting and updating data such as demography, immunization status for children under one year, growth monitoring for children under five, monitoring of all pregnant women, incidence of malaria, acute respiratory infections, diarrhea cases, water and sanitation and deaths, by visiting households in every village every month. The tool was able to collect all targeted information as required. The data collected by the tool appeared to be more reliable than that obtained through a national information system used by the Ministry of Health (MoH) for the same district and the same year. It was easy for health centers to accurately order supplies based on actual requirements, to follow-up cases during disease outbreaks and to identify deficiencies in immunization coverage rates. Despite promising results, the VHR registry fell into disuse following the establishment of a national register. The MoH’s Health Information System (HIS) data used projections which normally did not represent the actual situation on the ground while the VHR registry gave real physical data which was representative and verifiable. The potential of the VHR outweighed that of the HIS. Although the HIS had been rolled out nationally, there were shortfalls which MoH could consider rectifying to reach its full potential. In conclusion, the VHR was worth adopting as it would give MoH realistic statistics to be effectively used at all levels. Keywords: Village Health Registry, Mwanza district, Ministry of Health, Community Health Workers, Health Information System. Correspondence: Prestor J Kubalalika, Director, Centre for Community Health Promotion, P.O. Box 31247, Chichiri, Blantyre3, Malawi. prestorkubalalika@gmail.com DOI: 10.5210/ojphi.v10i2.9117 Copyright ©2018 the author(s) This is an Open Access article. Authors own copyright of their articles appearing in the Online Journal of Public Health Informatics. Readers may copy articles without permission of the copyright owner(s), as long as the author and OJPHI are acknowledged in the copy and the copy is used for educational, not-for-profit purposes. mailto:prestorkubalalika@gmail.com A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI INTRODUCTION The Village Health Registry (VHR) was a community health data collection tool which was introduced in Mwanza district of Malawi in January 1998. The tool was established after the District Health Management (DHM) had realized that there was no reliable community data collection tool for different programs. The district had no accurate data collection methods therefore the information used was mostly based on projections from figures generated by either the National Statistical Office (NSO) or from previous year’s data files. Such figures were seen to be inaccurate in that they were not representing the actual physical situations on the ground. To make matters worse, even Health Centers (HCs) did not know their actual catchment areas’ populations as well as targets for specific services. The notable anomalous situation was discovered in the Expanded Program on Immunization (EPI). During the program’s monthly routines and or mass immunization campaigns, the program was registering coverage as high as more than 100% for the presumed under one year target population for services such as Polio, DPT3, Measles and Vitamin A supplementation. Due to such unreliable demographic data, it was later discovered that there were some sporadic occurrences of measles outbreaks in areas where coverage for both routine and mass campaigns was registering above 100%. These observations and others therefore, made the DHM decide to create a community- based demographic data collection tool. The tool was at that time intended for EPI services only and it was provided for every village in the district hence the name Village Health Registry (VHR). In this registry, the sections include; (a) Household (hh) where every member was recorded, (b) Immunization for children aged under one year, where every child under one year in the village was entered and followed on its immunization status. (c) Growth Monitoring (GM) and Vitamin “A” supplementation for children aged under five, where all children from birth to five years were registered. (d) Antenatal Care, for every pregnant woman who was monitored until delivery. (e) Death for every death from these villages together with the indicated cause, and finally (f) Summary where total figures of each section were collated at the end of every year. LITERATURE REVIEW Health Management Information System (HMIS) are one of the six building blocks essential for health system strengthening. According to Measure Evaluation (2016), HMIS is a system where data are collected basically for supporting health facilities and organizations in their planning, management, and decision making. Health Information Systems (HIS) provide a broad overview of healthcare information systems with emphasis on historical foundations and current issues. Major issues include healthcare overview through use of information technology, medical and public health informatics, information technology infrastructure, computing ethics, computer security, consumer informatics, clinical software, clinical education computing, research computing, health information exchange, and the future of healthcare computing. The World Health Organization (2014) observed that over the years, most developed health systems are either technology-driven or adopted with no consideration to local settings which A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI prompted it (WHO) to publish the “Developing Health Management Information System”. This is a guide for Developing Countries aiming at providing health managers and designers of health information with a set of practical guidelines for a logical approach to develop HIS taking into consideration a country-specific setting. In Malawi, the existing HIS are unnecessarily fragmented and incapable of generating quality information at the needed time. It is for this reason that concerted efforts have been underway, in collaboration with partners, to harmonize and synthesize various data-management systems in the entire health sector (MoH 2015). The Ministry of Health (MoH) further noted that despite those concerted efforts, they still face challenges in the areas of data collection, analysis, dissemination, and use. These are further exacerbated by continued existence of problems of data accuracy, timelines of reporting, analysis, and completeness (MoH 2015). Village Health Registry This paper reports the experience and outcome of a Village Health Registry (VHR) as a community health data collection tool which was introduced in the Mwanza district of Malawi in January 1998. The VHR was established after the District Health Management (DHM) had realized that there was no reliable community data collection tool for different programs. The district had no accurate data collection methods therefore the information used was mostly based on projections from figures generated by either the National Statistical Office (NSO) or from previous year’s data files. We compared the information obtained by the registry in its first year of operation, 1998, with data of the same year within the same area as published by the National Health Information System. METHODS Population studied: Mwanza is one of the districts situated in the Southern-Eastern region of Malawi. It lies between 15˚ and 16˚ South and 34˚ and 35˚ East. The district borders with Ntcheu district to the North, Blantyre district to the East, Chikwawa district to the South and Mozambique to the West. The district covers an area of 2,259 km2 with various topography ranging from valleys to plains and hills which influence climatic conditions. It comprises a population of 166,443 in 239 villages and 14 health centers. Development of the registry The Registry was paper based and was developed by Mwanza District Health Management in 1998 and comprised of sections including; (a) Household (hh); where every hh and its members were recorded, (b) Immunization for children aged under one; where every child under one year in the village was entered from their hhs and followed on their immunization status. (c) Growth Monitoring (GM) and Vitamin “A” supplementation for under five children; where all children from birth to five years were registered and monitored for five years. (d) Antenatal Care; for every pregnant woman monitored until delivery. (e) Death; every death from these villages was A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI registered with their causes indicated, and finally (f) Summary; where total figures of each section were collated at the end of every year. Collection of information Community Health Workers (CHWs) were initially trained in the use of the tool by the district Maternal and Child Health (MCH) Coordinator who was one of the architects of the tool for three days. Every village in all the 14 health facilities was assigned a registry book which had all the components and these registry books were given to all the CHWs Known as; “Health Surveillance Assistants (HSAs)”. Each HSA was given the number of registry books according to villages he/she was working in. These CHWs/HSAs visited every household in these villages once every month to either record any new information occurring during the month or to update the already registered information. Utilization of the VHR information –at the village and Health Centre level: Every month CHWs would describe coverage for any of the registered indicators for each village purely based on the VHR data. These data were then shared with community-based health volunteers such as Village Health Committees (VHCs). These volunteers together with their CHWs after analyzing each village’s monthly data would then seek audience with local leaders i.e. village heads to give them monthly updates about the collected data. The village heads would later convene special meetings for everyone for feedback. This was mostly so if and when a certain indicator wasn’t performing well and needed people to promptly act upon either an individual or as a group. Otherwise these meetings were routinely scheduled after every three months (quarterly). CHWs together with VHCs would thereafter plot and or update performance graphs for each indicator per village. This action helped CHWs at village level to; i. Closely monitor all performance indicators ii. Identify health problems and take immediate action iii. Make proper and realistic monthly work plans iv. Consult relevant community leaders for action (if any) on specific issues v. Know populations for every age groups in each village vi. Give logical and realistic information to their HCs on village health performance indicators vii. Know all the new born babies for every village every month viii. Make consistent follow ups of children under one year old on immunization and GM for under-fives. ix. Identify pregnant women and advise them to start attending ANCs x. Be well conversant with particular hh’s health needs and offered on the-spot advice. xi. Strengthen relationships and understanding between them and individual hhs plus local leaders. xii. Have at hand all village/community health related data at all times A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI This village data would thereafter be taken to the Health Centre level where all CHWs under the HC summed up monthly indicator performance data for all villages under the HC. They would later together plot and/or update monthly performances graphs from the collated data. Before sending the data to the district level however, they would analyze the data and the graphs by identifying underperforming indicators and the corresponding villages. Solutions were discussed and possible actions decided upon at that level. This monitoring system, allowed the HCs to; a) Become aware of any looming dangers which would make them take immediate actions (as HFs) before it was too late. b) Consult with responsible underperforming villages as early as possible to seek their prompt action or response. c) Know exactly what their target populations for various services were which enabled them realistically order supplies for their facilities. d) Make follow-ups on defaulters of various monitored indicators e) Monitor performance coverage for various vaccine antigen and other services f) Know actual villages with low immunization coverage within their HC catchment areas g) Come up with exact physical target and total populations for each HC h) Have readily available community health related data at hand for each village at all times i) Know numbers of deaths with causes Utilization of the VHR information – at district level: Upon compilation and/or collation of HC data, every HC sent the data to the district for an overall aggregation. Each HC data were accompanied by a write up attachment explaining any weak areas and actions decided or taken to abate them or sought help and or advices from the district health office. The district would thereafter be able to; a) Collate data from all HCs and come up with realistic physical total population and its break down by age groups. b) Know the actual number of children from the district alone to those from outside of it c) Come up with meaningful target populations for specific services d) Identify actual underperforming HCs and villages with low immunization, antenatal attendances and WATSAN coverage, high malaria, diarrhea and ARI incidences. e) Identify straggling HCs and offer specific targeted assistance such as supportive supervision and/or supplies. f) Know the most prevalent communicable diseases and strategically apply targeted intervention measures. g) Come up with performance and determinant graphs for each indicator h) Order and distribute supplies based on realistic figures and requirements i) Easily compile districts’ deaths figures/rates with precision and accuracy A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI RESULTS Data obtained from the VHR and routine registries Tables 1 and 2 show the demographic data obtained by the VHR and the national HIS. We noted small differences in numbers between the two. Tables 3 and 4 show the data on immunization coverage for both systems. The data from the national HIS appear to indicate some immunization rates of more than 100%. The rankings of immunization rates between different health centers differ in different tables according to the source of the data. Table 1 shows the VHR demographic data from 1998, the initial year of VHR data collection, for each of the 14 health centers. TABLE 1: VHR DEMOGRAPHIC DATA for 1998 HEALTH CENTRE TOTAL POP UNDER1 POP UNDER5 POP WCBA # OF VGES Neno-Parish 9,985 500 1,701 2,490 14 Kunenekude 9,854 494 174 2,475 20 Tulonkhondo 8,854 445 1,499 2,224 13 MDH 30,865 1,541 5,256 7,712 56 Chifunga 6,654 335 1,135 1,652 07 Magareta 7,653 342 1,309 1,921 10 Neno-Rural 25,439 1,278 4,329 6,368 14 Matandani 8,795 446 1,505 2,191 10 Thambani 10,009 506 1,711 2,502 26 Lisungwe 16,123 798 2,756 4,021 26 Luwani 5,543 285 956 1,396 03 Matope 7,761 394 1,328 1,942 18 Nkula 5,643 285 964 1,444 5 Nsambe 13,265 669 2,261 3,328 17 Totals 166,443 8,318 26,884 41,666 239 A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI TABLE 2: NATIONAL (HIS) DEMOGRAPHIC DATA HEALTH CENTRE TOTAL POP UNDER1 POP UNDER5 POP WCBA Neno-Parish 10,354 518 1,760 2,589 Kunenekude 10,223 511 1,738 2,556 Tulonkhondo 9,223 461 1,568 2,306 MDH 31,246 1,562 5,312 7,812 Chifunga 7,023 351 1,194 1,756 Magareta 8,022 401 1,364 2,006 Neno-Rural 25,808 1,290 4,387 6,452 Matandani 9,164 458 1,558 2,291 Thambani 10,378 519 1,764 2,595 Lisungwe 16,492 825 2,804 4,123 Luwani 5,912 296 1,005 1,478 Matope 8,130 407 1,382 2,033 Nkula 6,012 301 1,022 1,503 Nsambe 13,634 682 2,318 3,409 Totals 171,621 8,581 29,176 42,905 Table 3 below shows the VHR data on immunization aggregated for each of the health centers, as well as the numbers and causes of deaths recorded by the registry in that year. We see that immunization coverage was generally high, ranging from 82% for measles to 90% for BCG. One health center had a measles immunization rate of only 71% and another DPT3 rate of only 75%. Table 4 shows the immunization coverage based on routine data. Most of the health centers’ coverage is above the target population. These data were the ones being used in HIS which did not represent the actual population on the ground. Although the data were considered as for Mwanza, some of the children were not from the district. Some belonged to neighboring districts while others from across the border with Malawi. A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI TABLE 3: VHR IMMUNIZATION DATA for 1998 1998 VHR VACCINE COVERAGE DEATHS HEALTH CENTRE TOTAL POP TARGET POP BCG % DPT3 % OPV3 % MEASLES % UNDER ONE DEATHS No. Common Cause Neno-Parish 9,985 500 451 90 412 82 399 80 353 71 4 Malaria Kunenekude 9,854 494 426 86 419 85 421 85 402 81 6 Pneumonia Tulonkhondo 8,854 445 441 99 438 98 437 98 420 94 4 Malaria MDH 30,865 1,541 1312 85 1,302 84 1,302 84 1,293 84 28 Malnutrition & malaria Chifunga 6,654 335 329 98 318 95 312 93 301 90 2 Malaria Magareta 7,653 342 302 88 289 85 283 83 251 73 5 Measles & malnutrition Neno-Rural 25,439 1,278 1192 93 1,072 84 1,083 85 1,001 78 7 Malaria, pneumonia & diarrhea Matandani 8,795 446 442 99 440 99 438 98 422 95 3 Diarrhea Thambani 10,009 506 466 92 422 83 417 82 369 73 6 Measles, cholera & malaria Lisungwe 16,123 798 621 78 601 75 603 76 589 74 8 Malnutrition, malaria & fever Luwani 5,543 285 280 98 278 98 274 96 269 94 2 Cholera Matope 7,761 394 361 92 349 89 341 87 333 85 6 Malaria, malnutrition & diarrhea Nkula 5,643 285 239 84 221 78 216 76 209 73 3 Pneumonia & fever Nsambe 13,265 669 661 99 650 97 652 97 643 96 5 Malnutrition & diarrhea Totals 166,443 8,318 7523 90 7,211 87 7,178 86 6,855 82 98 A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI TABLE 4: ROUTINE IMMUNIZATION COVERAGE DATA for 1998 1998 ROUTINE IMMUNIZATION COVERAGE HEALTH CENTRE TOTA L POP TARGET POP BCG % DPT 3 % OPV 3 % MEASL ES % Neno-Parish 10,354 518 522 100.8 517 99.8 521 100.6 536 103.5 Kunenekude 10,223 511 513 100.4 526 102.9 518 101.4 511 100.0 Tulonkhondo 9,223 461 471 102.2 470 102.0 469 101.7 473 102.6 MDH 31,246 1,562 1,601 102.5 1,573 100.7 1,582 101.3 1,599 102.4 Chifunga 7,023 351 350 99.7 349 99.4 355 101.1 361 102.8 Magareta 8,022 401 398 99.3 412 102.7 408 101.7 411 102.5 Neno-Rural 25,808 1,290 1,306 101.2 1,296 100.5 1,289 99.9 1,293 100.2 Matandani 9,164 458 462 100.9 462 100.9 458 100.0 449 98.0 Thambani 10,378 519 604 116.4 582 112.1 591 113.9 624 120.2 Lisungwe 16,492 825 951 115.3 851 103.2 841 101.9 853 103.4 Luwani 5,912 296 294 99.3 296 100.0 298 100.7 300 101.4 Matope 8,130 407 505 124.1 438 107.6 451 110.8 466 114.5 Nkula 6,012 301 420 139.5 306 101.7 312 103.7 320 106.3 Nsambe 13,634 682 753 110.4 691 101.3 689 101.0 690 101.2 Totals 171,621 8,581 9,150 106.6 8,769 102.2 8,782 102.3 8,886 103.6 A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI LIMITATIONS There are, however, a number of limitations of the VHR. Although the VHR had shown enough potential to collect important and accurate data, there were some notable limitations which still made it unable to effectively achieve its intended purpose. One clearly observed limitation was impact limitation. This had been due to limited knowledge of CHWs on how to effectively use the tool. Most of them were not trained therefore made them unable to understand how they could collect data using this registry. This again was compounded by limited or insignificant supportive supervision by MoH to districts and within districts on the tool. There was little consultation to relevant experienced stakeholders before nationally rolling out this tool. This made the MoH miss some important and critical operational information which could make the registry as reliable as expected. This was why there was need for thorough and comprehensive consultation and adequate training to all CHWs and supervisors. The other limitation was data-based. For this register to show real impact there was need for enough data to be collected. At that point, there was little VHR data available at all levels of MoH system which could be aggregated to make significant impact. This was the case because CHWs did not use the tool to collect the needed data anymore as most of them were not knowledgeable of it. There was need therefore to equip all CHWs with knowledge and maximum supportive supervision at all levels. The MoH had weak data management systems in place at all levels which made it difficult for the VHR data to stand out as expected. Districts did not have enough resources and knowledgeable personnel to effectively manage and later on supervise the flow of VHR data from community to HC and district levels as expected. The MoH system did not have VHR data storage at any of its HMIS levels. Finally, there was no reliable and sustainable funding for the implementation of the register, or important operations such as trainings, supervisions and procurement of supplies. DISCUSSION The results of immunization rates obtained from the VHR and the national HIS are quite different. The data from the national HIS appears to indicate immunization rates of more than 100%, suggesting a problem in either the numerators of number of children immunized, or denominators of the population, or both. The rankings of immunization rates between different health centers differ in different tables according to the source of the data. This has serious implications as some of the data obtained by the VHR indicate problems with low immunization rates – if these are missed by an inaccurate HIS, remedial measures to improve rates will not be undertaken which will result into potential implications for population health. This VHR approach of data collection appears to be more reliable as the information is based on physical count rather than extrapolation or intuition. Data from this registry were more genuine as the registry books were conveniently village based. The information from this registry was more accurate and readily available as it could easily be accessed and verified at Health Centre, village and household levels at any time. Every individual was well accounted for and could easily be physically identified using unique code numbers. Both total and target populations were A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI established through physical counting rather than estimations as is the case with the national system. The data were updated at the household level where every individual was entered. Any upward or downward variations to the data due to migration, death or births were spontaneously noticed and captured within a month by responsible CHWs. The data excluded all those from outside villages and districts hence no HC had its total and target population exceeding the actual as was the case with the national routine system. Follow-up of the data were so simple at HC, village and household levels when needed. The MoH has weak data management systems in place at all levels which makes it difficult for the VHR data to stand out as expected. Districts do not have enough resources and knowledgeable personnel to effectively manage and later on supervise the flow of VHR data from community to HC and district levels as expected. The MoH system does not have VHR data storage at any of its HMIS levels. Finally, there is no reliable and sustainable funding for the implementation of the registry, or important operations such as training, supervisions and procurement of supplies. This registry could be a vital community-based health data collection tool if it were used appropriately. It has the potential of being a reliable data collection instrument with accurate and verifiable community level health statistics. Despite this, however, more needs to be done on its development and implementation to ensure the realization of its maximum intended potential. It is a shame that the registry has fallen into disuse, and lessons need to be learned from this experience. There was need to fully consult relevant stakeholders who had experience, as in any information system, before nationally rolling it out. Thorough and conclusive training needed to be done to all CHWs before giving them the task of using the tool. There was also need to officially pilot it in a few districts with maximum support which would be taken as reference points when rolling it out. For constructive supervision at all levels, deliberate Training of Trainers (ToTs) sessions need to be done. This will equip such trainers with knowledge and ability to understand the registry and be able to also train others in their respective districts. The trained DHMT members and program managers would in turn be able to effectively supervise CHWs at health center level. Strong and coherent data management flow systems from village to health center and district levels which can easily be followed and verified should be put in place. For security and safety of this data, every health center needs to have a special computer and trained personnel specifically for managing this information. CONCLUSION Based on experience with VHR, it is indeed worthwhile adopting it at a national level. However, it needs to be implemented step by step rather than in a hurry as was the case. Wide and extensive consultations with relevant stakeholders were required. Before rolling it out, there was need to pilot it in a few districts which would be used as reference points. Enough training and refreshers could also be conducted to all CHWs and their supervisors. Finally the MoH had to incorporate other interested partners to help it with some other aspects of the tool. A Lessons Learned from Introducing a Village Health Registry in Malawi Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 10(2):e217, 2018 OJPHI REFERENCE 1. Chaulagai CM. Moyo & R Pendame (2015). Health Management Information System in Malawi: Issues and Innovations. https://www.researchgate.net/publication/265048139_Health_Management_Information_Sy stem_in_Malawi_Issues_and_Innovations 2. Johns Hopkins School of Public Health. (2014). 312.633.81 Health Management Information Systems. http://www.jhsph.edu/courses/course/20055/2014/312.633.81/health- management-information-systems 3. Measure Evaluation. (2016). 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(2004) Developing Health Management Information Systems: A Practical Guide for Developing Countries. http://www.wpro.who.int/publications/pub_9290611650/en/ Lessons Learned from Introducing a Village Health Registry in Malawi INTRODUCTION LITERATURE REVIEW Village Health Registry METHODS Population studied: Development of the registry Collection of information Utilization of the VHR information –at the village and Health Centre level: Utilization of the VHR information – at district level: RESULTS Data obtained from the VHR and routine registries LIMITATIONS DISCUSSION CONCLUSION REFERENCE