DR. CAROL NGUNU-GITUATHI MD, Msc Epidemiology

Strengthening District Health Information Systems (DHIS) for Effective Programming Lessons from PMTCT Data Verification Exercise for Nairobi County (July – Dec 2014)

HIV Burden ~1.6M Kenyans living with HIV o 10% children <14 years o 57% women 11,000 new infections among children in 2012 In 2013 in Nairobi city county 3200 new infections 8% children PMTCT program in Kenya implemented since Yr 2000 In 2012, >9,000 health facilities offering PMTCT services 180 facilities in Nairobi City County 3 *KAIS 2012 HIV prevalence among adults and adolescents aged 15–64 years by region* Men = 4.4% Women = 6.9% Pregnant = 6.5%

Towards one M & E system Multiple data sources for HIV program HIS strengthening ongoing ( HIS Policy, HISSP) Country picked to be one of the initial countries to implement Global Health Initiative All inclusive process of Indicator harmonization Development of Master Facility List Development of standards for EMR for Patient level monitoring Adoption of DHIS for aggregate facility level reporting of data Put in place mechanisms for routine data quality checks and assurance Improved Governance for the Health Sector Subsequently Kenya adopted DHIS 2 for data reporting

The District Health Information System (DHIS-2) is a Monitoring and Evaluation framework used: to collect, collate and analyze routine health information to inform programming at the health facility, sub county and national level Specific to the HIV response, DHIS 2 is useful to monitor ART service quality and coverage, and identify gaps DHIS version 1: developed in 1997 Field-level use informed the development of DHIS 2 in 2005 DHIS 2 is used in many countries in Africa e.g South Africa, Ethiopia, Nigeria, Botswana, Tanzania, Kenya and Zambia DHIS 2 was introduced in Kenya in 2010 Definition of DHIS

A central repository—All data in one place Supports collection of many different data sets Automated import from other systems like MFL, EMR, HR, Logistics Avoids duplicate systems for data collection and storage Easy access to data to all online users Anywhere, with internet & rights : access the latest data DHIS 2 is data centre for all stakeholders with access Design of DHIS

National Data Warehouse Sub County: Data by facility from summary tools Facility reports & data captured Web-based Integrated analysis, on the web DHIS2 in Kenya: FROM data by district - TO data by facility FROM spreadsheet - TO integrated database FROM FTP - TO web DHIS 2 USE OF DHIS IN HIV PROGRAM NASCOP Forms Customized in DHIS 2 (MOH 731) HTC (MOH731-1) PMTCT (MOH731-2) C&T (MOH731-3) VMMC (MOH731-4) PEP (MOH731-5) Blood Safety (MOH731-6)

Rationale For Data Verification Data is important for informed decisions Availability of timely, complete and accurate data is core to scaling up interventions for an effective& accountable response against HIV Quality of data is therefore critical WHO recommends data quality assessments (DQAs) routinely Discrepancies in PMTCT data of concern to county – ? Uptake of ART in pregnancy – HEI service uptake e.g. infant prophylaxis We therefore carried out a data verification exercise for PMTCT indicators in selected facilities in Nairobi, Kenya in order to highlight gaps and recommendations for data and care quality improvement

Materials and Methods (1/2) We conducted a cross sectional study among 72 randomly selected PMTCT facilities in all 9 sub counties in Nairobi county, Kenya The time period for which data was reviewed was July to December 2014 An adapted standard National DQA tool was used to support DQA activities in 72 GOK PMTCT facilities We had nine teams constituting 4 people each who were trained on how to conduct the DQA using the standard national tools Each team visited and assessed data from 8 facilities over a 2 week period

Materials and Methods (2/2) We assessed accuracy of data reported on 3 key PMTCT indicators: Maternal HIV Positivity Maternal prophylaxis issued at first contact Infant prophylaxis issued at first contact Data for the 3 indicators was reconstructed from the facility registers at the clinics, which was then compared with the data in the physical copy of the monthly summary report (MOH 731) submitted by the facility for the same time period and the data elements entered into the DHIS The verification involved manual counting of the numbers and accurate recording of variables from facility registers

Findings For the entire county, 494 reports were available in DHIS(66% reporting rate), with 78% submitted on time. There were discrepancies observed in data for the three indicators Maternal HIV positivity Maternal Prophylaxis issued at first contact Infant Prophylaxis issued at first contact

All subcounties except Westlands had underreported the final verified figure in the DHIS Discrepancy between facility register data and summary tool data ranged from 0.5% in Makadara & Ruaraka to 36% in Dagoretti sub county Discrepancy between summary tool data and DHIS data is also observed and ranges between 10% to 80% (LA)

Five sub counties had over reported final verified figures for maternal prophylaxis in the DHIS by 18% to 59% Only Starehe sub county had correct final verified figure in the DHIS Discrepancies were noted across board in all sub counties between the summary tools and DHIS with Langata and Kamukunji over reporting the summarised figures in DHIS by 27% and 14% respectively

There was under reporting of this indicator in both the summary tools & DHIS in Kamukunji, Emba & Makadara All other sub counties over reported by between 35% to 48%. Only Kasarani and Kamukunji had similar values in the summary tool and DHIS, all other sub counties under reported what was in the summary tool in the DHIS

On the Maternal HIV Positivity indicator, the final verified figure was 2796, which was under-reported in the summary report and DHIS by 11% and 32% respectively Final figure verified for maternal prophylaxis was 1466 which was over reported in the summary report by 14% and was almost similar to DHIS with under reporting of 0.3% Maternal prophylaxis had a final verified figure of 1876, which was under-reported in the summary tool by 24% and in DHIS by 36%

Conclusion Significant discrepancies in the three data sources identified from as low as 0.5% to as high as 80% for some indicators in some sub counties Errors noted in aggregation and collation of data from facility registers to summary tools High workload, not enough attention given to collation and data verification Poor understanding of indicators Multiple service delivery points, not all data aggregated at month end Data discrepancies between summary tool and DHIS points to transcription errors High workload resulting in hurried processes Manual systems, giving room for human error Data discrepancies hindering assessment of achievement of PMTCT targets Under reporting in DHIS while actual work done Data errors leads to errors during target setting and action planning for interventions

Action Taken Data cleaning done in the DHIS and final verified data uploaded Facility managers in the 72 facilities and sub county managers sensitized on findings through a DQA review meeting For managers to support data quality improvement activities in their facilities become more accountable for & better use their data for decisions-making and planning purposes Facilities and sub counties with the largest data discrepancies were targeted for data collection and entry support re-training on data collection and summary tools additional data clerks for entry of data to DHIS

Next Steps A comprehensive strategy has been put in place to strengthen reporting by training on indicators demand for quality data regular data utilization meetings at all levels routine comprehensive data verification exercises Integration of services to minimize number of reporting points Employment of additional health and records information officers to reduce workload Ensure availability of HIV tools and registers Scale up of electronic medical record systems which will ensure accurate automated aggregation of data for monthly reporting(15 facilities)

Acknowledgements Nairobi City County Health Department UNAIDS UNICEF National AIDS and STI Program National AIDS Control Council PACT Program-UOM Aphia Plus- Nairobi