ClementAvoka (Ghana)

IMA Level 1 certification course in data improvement planning (Fall 2018)

Week 2 Community assignment

Step 1. Select a country for this assignment .

Answer: The Country selected for this Assignment is Ghana

Step 3. Identify the questions you want to answer about data flow, data tools, and the performance of your country’s monitoring system.

List and prioritize 2-5 questions that you want to answer toward the improvement of data for decision-making. Answer: I intend to address the following questions in this assignment:

How does data flow in Ghana Health Service?

Answer: Data follow in the Ghana health service have a two way flow. From the bottom to the up and receive feedback from the up to the bottom. That is data collection is basically done at the lower level from the CHPS and health facilities level by Community Health Nurses/Officers, Field Technicians, midwives, Enrolled Nurses, Nurses and Doctors in the hospitals and reported to the upper level and receive a feedback from the vice visa follow. Data collection tools such as tally sheets, registers and vaccine ledgers are used to collect the data at the lower level and use the monthly reporting forms to collate the report and submit to the sub-district to be submitted to the district or directly to district level. The data is reviewed, cleaned and then entered into the DHIMS2 platform by 15th of every ensuing month for the regional level to have access to the data. Regional analysis the data, validate it and generate feedbacks and make the data to the national level by 25th of the ensuing month.

Data in the Ghana Health service are collected on the following time lines

Monthly reporting from the CHPS to Sub-district (by 3th of the ensuing month)
Monthly reporting from sub-district to District (by 5th of the ensuing month)
Monthly reporting from District to Regional level (15th of the ensuing month),
Monthly reporting from Regional to National (by 25th of the ensuing month) and then to the International level.
Quarterly reporting- Usually feedbacks are given from the higher level to lower level on quarterly basis.
Annual Reviews are also conducted to assess and address performance issues

(The flow is as follows; CHPS level by CHO/CHN Sub-district/ health centre level by the PA, Midwife, FT etc. District level by Health Information Officer/ Disease Control Officer Regional Level by the Regional Health Information Manager, Regional Disease Control Officer, Regional Programme Officers etc, National level by National Programme Managers to the International level (WHO/CDC/UNICEF))

The Arrows below depicts the flow of data in different levels of the Ghana Health Service

CHPS/FACILITY ⇒ SUB-DISTRICT ⇒DISTRICT ⇒REGIONAL ⇒NATIONAL ⇒INTERNATIONAL

What are the different reporting layers (that is, who reports to whom) and what are the requirements for timeliness and reporting frequencies?

Answer: The various reporting layers are as follow;

Data collection starts from the CHPS/community/facility level as follows; CHO/CHN/EN reporting from the CHPS level to the PA/Midwife at the Health centre/ Sub-district level, The PA/Midwife, Nurse reporting from the sub-district/ health centre level to the District programme focal persons/, The District EPI focal person/Health Information Officer reports to the Regional EPI focal person/ Health Information manager at the regional level, The regional EPI focal person/ Health Information manager reports to the National Programme manager and National EPI programme Manager to Director General, Health Minister and to the International Agencies and Partners. These arrows in the diagram below indicate how data is reported in the Ghana Health Service.

The Arrows  below depicts the levels of reporting data to different levels of the Ghana Health Service

CHO ⇒PA/Midwife ⇒District Focal Person⇒Regional Focal Person ⇒National Programme Manager ⇒Director General, Minister, and International agencies and partners

Who first collects the data, prepares paper reports, enters data into electronic systems, receives and reviews reports?

Answer: The data is first collected by the service providers usually by Community Health Officers, Community Health Nurses, Midwives, Physician Assistants, and Field Technicians etc. and prepare paper reports and send them to the sub-district and a summary is done by the sub-district head and forward to the district. The district health information officer together with specific programme focal persons received and validates the reports from the sub-district level. After validation the district officers enter the data into the DHMIS2 platform. Sometimes sub-districts who have the capacity to enter data directly into DHIMS2 platform do so after validation with the district data validation teams.

What measures and procedures are in place for data verification, cleaning and feedback? What process is followed if data seems to be wrong?

Answer: At the district level, every month after the data is verified and entered into the DHIMS2 Platform, the district data validation committee meets on the second week to review that data, comparing what have been entered with hard copies to ensure that no mistake was committed and that all the data is aggregated as expected. It is after the validation that the feedbacks are then given back to the sub-district and facility level. If mistakes are detected they are quickly corrected and the necessary updates are made to ensure data accuracy. This validation is suppose to be done at the lower level too by comparing the source documents with the summaries that were sent to the district level, however, this is not regularly done. And if any time a validation is carried out at the lower level and mistakes are identified, the change of data form is completed by the officer at the lower level who is requesting for the data changed and then forwarded to the District Health Information Officer who would affect the changes as appropriate.

Who are relevant players/stakeholders at each level? What do they do with the data (for example, collect, enter into electronic system, analyze, use to make decisions, etc.)?

Answer: Relevant players/stakeholders at each level include;

Server providers including;

Community Health Officers, Community Health Nurses, Midwives, Physician Assistants, and Field Technicians who collect/generate the data at the service delivery point

Meddle level Managers

District programme focal persons/District data managers, verify, collate, validates and enters the data into the electronic system /DHIMS2 platform. Do some data analysis, generate feedbacks and ensure utilization of data for planning and decision making purposes by the District director of Health Services is done at the district level by programme focal persons
Regional programme focal person/HIO do analysis of the data for decision making and give feedback to the districts, The Regional health information Officer also analyses the data for accuracy, timeliness and completeness and advise the Regional Directors of Health Services on performance issues.

Programme Managers

The National level is where data is mostly used for Planning purposes, decision making and policy making by the National Programme Managers, Ministers, Directors etc.
The International level also uses the data for planning and decision making purposes

You can find additional information about systems assessment in the Handbook on the use, collection, and improvement of immunization data (Section 3, Phase 1: system assessment, pp. 46-48)

Step 4. Identify and collect relevant background documents and other sources of information for your selected country.

Answer: DQS for Ghana 2016, SOPs for health information management, Immunization in Ghana, 2016 Review, Ghana Demographic and Health Survey and the Comprehensive Multiyear Plan for Immunization (2015- 2019)

You may want to start with what you already know (usually from experience) or what you can learn from your colleagues. However, in order to build a compelling analysis, you need to rely on evidence that is not only anecdotal.

Potentially useful sources of information include:

recent data-related reviews such as data quality self-assessments (DQS) or service availability and readiness assessments (SARA)

strategic plans like the comprehensive multi-year plans (cMYPs) and annual plans of action

recent programme reviews: EPI reviews, post-introduction evaluations (PIEs), surveillance reviews and other EPI-related reviews

country documentation on surveillance standards (including case definitions);

standard operating procedures (SOPs) for data collection, archiving and reporting;

data collection tools; and annual reports

paper-based tools and information systems for data entry, management, and analysis

country documentation or SOPs on data tools (paper or electronic) including SOPs on responsibilities and financing of printing the monitoring tools

organigram of the EPI team, HMIS team, and if available, post description of data managers or other staff dealing with monitoring, systems, and analysis

other available documentation related to immunization data: country bulletins, peer-reviewed literature, ad hoc reports, and other descriptions of the information system.

Step 5. Share the most useful resources you find in our Scholar community SHARES. Go to our community SHARES to upload the most useful documents that you find. https://cgscholar.com/community/community_profiles/ima-level-1-english-fall-2018/community_share

The country name must be included in the title.

Each SHARE must include a description. Summarize why you are sharing this document and how it useful.

In the “Credit” section, cite the source (organization and/or authors) if you know.

You may also choose to share the most useful documents you find with members of your country WhatsApp group.

Step 6. Perform a rapid review of these sources and evidence for data flow, tools, and performance of your country’s monitoring system.

Limit your review to find:

Reliable sources (if they exist) that describe the data flow and data tools used in your country’s monitoring system; and

Answer:

In Ghana, reliable source of data flow I reviewed included; the Data quality Self Assessment, Standard Operation Procedures, Immunization review in Ghana 2016, 2014 Ghana demographic and health survey, Comprehensive Multiyear Plan for Immunization (2015- 2019), etc, all described how immunization data is collected analyzed to determine coverage. From these documents, the immunization programme is doing very well in Ghana in terms of administrative coverages. Ghana as a country has a very good monitoring and evaluation systems in place to monitor vaccination performance. Some gaps identified across the review of these sources basically included; population issues, especially with regards to the denominator. Vaccination data seems to be fairly consistent across all documents reviewed. However there have been some variations between administrative coverages, WHO/UNICEF standard estimations and survey data respectively. This could be due to target estimation differences inthese methodes of assessment 

 

The table below described how immunization paper tools are used

Type of data tool	Level of use	Persons Responsible	Frequency of use	Reported in DHIMS (Yes/No)	Use of Information (By/for)
Tally sheet	Service delivery site	CHN/CHO, FTs, Midwives	Daily	Yes	Used by facility heads to fill the monthly vaccination return forms
CWC register	Service delivery site	CHN/CHO, FTs, Midwives	Daily	Yes	Registration of clients, tracking attendance and trace defaulters
Child health record Books	Service delivery site	CHN/CHO, FTs, Midwives	Daily	No	Service providers for documenting child details, services received, counseling and also used by caregivers
Monthly vaccination returns form	Health facility, sub-district & district	CHN/CHO, FTs, Midwives & DCO	Monthly	Yes	CHN/CHO, FTs, Midwives & DCO, EPI focal persons, enter data into DHMIS2
Vaccine ledger	Health facility, sub-district & district	CHN/CHO, FTs, Midwives & DCO	Daily	Yes	By service providers, cold chain managers to track vaccine usage
Temperature monitoring chart	Health facility, sub-district & district	CHN/CHO, FTs, Midwives & DCO	Daily (Morning and evening)	Yes	By service providers, cold chain managers to monitor vaccine temperature
Immunization monitoring chart	Health facility, sub-district & district	CHN/CHO, FTs, Midwives & DCO	Monthly	No	Used by Service providers, CHN/CHO, FTs, Midwives & DCO to monitor monthly performance of vaccination programmes

Step 7. Summarize the quality of the available evidence.

Summarize the quality and completeness of your findings. If you rely on personal experience or the experience of colleagues, please state this explicitly. Consider these questions: Were you able to answer the questions you listed? It is acceptable for your review to be incomplete. What is the strength or level of evidence for what you have found? Can you identify gaps in the sources you reviewed? If your findings are incomplete, what else would you need to know to build a more comprehensive picture?

Answer: Yes to the best of my ability, I have addressed all the questions that I intended to address in this assignment.

Step 8. Describe the data flow of your country.

Map out the data flow of your context, drawing on your findings.

Prepare a flow chart showing data flows and data tools being used across all levels.

Answer Data follow in Ghana

The vaccination data follow in Ghana starts from the service delivery points at the Outreach points, CHPS centers, health centers, hospitals, etc where service providers such as CHN/CHOs, Midwives, Nurses, institutional data officers uses tools such as tally books, registers, temperature monitoring charts, etc. to capture the data manually at the point of delivering services. The data is then collated onto the monthly vaccination reporting forms, and forwarded to the sub-district level where it is further collated and sent to the district level. The district EPI focal person/District Health Information Officer receive the data; review it with the officer who prepared the paper work at the lower level. The data is then entered into the DHIMS2 platform. In two weeks time the data would all be aggregated in DHIMS and is ready for validation and any analyses for feedback to those who generated the data at the lower level. The regional, National and the international levels can pull this data from DHIMS2 platform for further analysis for decision making.

The flow chart below shows how vaccination data follows in Ghana

Step 9. Make a SWOT analysis.

Make a SWOT analysis for the monitoring system in your country. Analyze the Strengths, Weaknesses, Opportunities, and Threats.

Answer:

Strong commitment of national level program managers
Very youthful working force for immunization
Available data collection tools
SOPs available to guide data collection, analysis and quality improvement
The EPI leadership and staff at all levels under the challenges facing the program

Weakness

Inadequate data analysis tools at the lower levels
Inadequate capacity of lower level staff to do data analysis
Lack of ownership of data by those who generate them
Inadequate utilization of data at all levels
Inadequate in-service training and on-the job coaching of service providers on data capturing
Inadequate cold chain equipment in the sector

Opportunities

Other partners have interest in data quality (WHO, UNICEF CDC, etc)
Training institutions available and committed in training health information officers

Threats

Donor –fatigue and majority of them pulling out quickly
Too many data capturing and reporting formats to complete manually at time sometimes by only one staff
Growing concerned of population issues

If you are not familiar with SWOT analysis, Google it or start with this Wikipedia article:

https://en.wikipedia.org/wiki/SWOT_analysis

To this end, the following components of the monitoring system may be examined:

a governance foundation;

the people at all levels of the hierarchy;

the processes for data collection and verification;

the tools that are used for collection, reporting, and use (both paper-based and electronic systems);

the extent to which data are used.

Step 10. Summarize what you learned from all of the other steps.

Answer

I have learned a lot from the all the steps involved in this assignment. I learned how Ghana immunization data is collected as well as the major stakeholders involved. I also learned how the data flows from one level to the other. I have also learned the Ghana’s data quality monitoring systems.