Interventional Study for Improving Health Information System in Khyber Pakhtunkhwa, Pakistan

Objective To assess the improvement in the health information system in the district Nowshera by integrating the data reporting of the Expanded Program on Immunization (EPI) and Lady Health Worker (LHW) programs in the existing system. Methodology The study was conducted at district Nowshera and Swabi, Pakistan between May 2015 and May 2016 for a duration of one year. The data collection instruments used in the study were adapted from the Performance of Routine Information System Management (PRISM) tool package. The study was conducted in three phases during a period of one year. The first three months were utilized for baseline assessment. The next six months were being used for implementing the integration of the EPI and LHW, and the next three months were being used for the post-intervention evaluation. Microsoft Excel software was used to enter and analyze the data. A p < 0.05 was considered as the cut-off value for significance. Results The results indicated that the integration of data from the EPI and LHW with that of the existing Health Information System (HIS) is possible and has the potential for improving the existing system. The least significant results were produced by the use of information, which depicts that the utilization of data in decision making or policy making is still needed to be improved. Moreover, we reported a lack of enforcement and regulation by the authorities in monitoring the feedback system in the HIS. Conclusion The current study revealed significant improvements in the use of information, data quality, and behavior of staff. It is essential to properly train the team on how to operate the District Health Information System (DHIS) to gain adequate and timely data on health status and determinants. Additionally, the integration would benefit in managing the data at not only the national level but at the district level too.


Introduction
The health information system (HIS) provides reliable, authentic, and timely information on the health status of a region and aids in analyzing large amounts of data in summarized forms, which further guides the policymakers to improve upon the healthcare system [1][2]. HIS helps the policymakers to detect issues and make evidence-based decisions on health policies and programs; hence, improving the healthcare system [3].
HIS is one of the essential core elements of a healthcare system, as described by the WHO framework [4]. A reliable and trustworthy information system gives the pivot to make decisions about the structure of health organizations at any level. However, discrepancies and untimely information in the HIS system may render the system useless, further deteriorating the overall healthcare situation in any country [5]. The data regarding DHIS performance, the efficacy of the managers and their subordinates, the use of DHIS data by the district office, and supervision by the district health office were assessed using the abovementioned questionnaires. The intervention of integration was carried out in the district Nowshera while the Swabi served as a control district. The two districts share similar sociodemographics [11]. The total number of health facilities being operational in Nowshera was 33 at the time of the study conducted. Out of these 33 facilities, 13 facilities were selected randomly. Besides evaluating the technical capabilities of the district, the culture of using the health information system for assessing the progress of the health system is also evaluated. For that purpose, a set of questions were prepared according to the score of which the acceptability of using the DHIS was analyzed. The study population was categorized into two major groups, the administrative units included the district/health facilities and the second group included the employees that managed the health information systems. All the primary and secondary level health facilities in the public sector were involved in the process of integration.
After baseline evaluation, the health staff of the health information system was trained in data collection and timely reporting. Intervention (intervention in the shape of an integrated form of the process of data collection and timely reporting) was conducted in district Nowshera. After six months of the interventional approach, findings were compared with district Swabi. The process of data collection was carried out through various stakeholders. As described earlier, the PRISM package consists of three inbuilt tools: Use of information, quality of data, and Organizational & Behavioral Assessment Tool (OBAT). SPSS version 26 (IBM Corp., Armonk, NY) was used to enter and analyze data. Chi-square test and Mann-Whitney-U were used to analyze the pre-and post-intervention data. A p-value of less than 0.05 was considered statistically significant.
In the pre-intervention period, all three tools produced non-significant results. However, after intervention and integration of EPI and LHW programs, we found significant improvements in DHIS, Nowshera with respect to compilation of the reports containing the DHIS data and in receiving the feedback report from the DHO office. In displaying the information about the health of the mother, child, and disease surveillance again we got significant results. After the integration of DHIS in the Nowshera district, the significant results could also be seen in the decision-making process while using the information obtained from the Nowshera's facilities. A significant change was also marked in the behavior of the district health officer as he started visiting the facilities in three or six months. The record-keeping, the maintenance of the record, and using that record in making the decision and setting the health targets showed a significant response ( Table 1)  Upon assessing the OBAT, the staff was more punctual and set targets regularly for them to achieve postintervention. Staff practiced saying no to any decision which was not supported by the evidence or facts and the culture of accepting the mistakes and rectifying it later flourished inside the facilities. The Nowshera staff were more capable and self-efficient in interpreting the data and on the basis of data made graphs and charts to depict the monthly progress of the facility compared to the control district, i.e. Swabi, in the postintervention phase ( Table 2).

TABLE 2: Organizational and Behavioral Assessment Tool (OBAT) (Post Intervention)
The quality of data after integration improved as many queries from the PRISM tool package showed significant differences. The process of reporting and meeting the deadlines for the submission of these reports improved post-intervention ( Table 3).

Discussion
In Pakistan, adequate and timely information from the District Health Information System (DHIS) is hindered by lack of facility to record the data systematically, lack of feedback system, lack of utilization of knowledge in taking decisions and disease surveillance, inefficient management, power politics, and the incapability of the staff to adapt to the modern system [11][12][13]. The current study assessed routine health information systems in two districts of Khyber Pakhtunkhwa using a modified conceptual framework, PRISM.
Considering the findings of the current and the previous studies, we can conclude that one of the obstacles in improving the HIS is the poor management of the existing resources. The reasons behind this include poor management of data, low quality of data due to data duplication, selection of data without taking the technicalities into account, lack of proper channel for timely and updated transmission of data to the national level and lack of coordinated efforts to address the problems of the periphery to the district and then to the national level respectively. The health workers do not have access to the proper and standardized training through which they could develop an understanding of the procedure for the collection and processing of the data [14]. Furthermore, there is a lack of motivation and financial incentives for the health services workers due to which they tend to lose interest in their work, and chances of errors increase. The lack of a feedback system is another reason behind this low quality of data [13][14][15].
The current study used a modified PRISM tool to highlight the main issues concerning the DHIS. It was noted that there was no proper management system to ensure the timely transmission of the data from district to provincial and from provincial to the national level. This resulted in outdated, low-quality data, which further affected the decisions made without any sound evidence. Additionally, in many facilities computers were not being used as the staff was not skilled in operating a computer. The utilization of some straightforward and sophisticated programs like GIs, and EPlINFO was also not very popular in the health sector in Pakistan. Similar findings were found in previous studies [16][17].
The research has shown that we lack the management along with the resources. The integration of EPI & LHW data with the data of HIS in the DHIS software is a positive initiative for upgrading the health information system from the district level. Still, this integration needs a strict follow-up procedure that ensures that the system keeps on working the way they are supposed to do. The HMIS operating in the facilities could be used as the most powerful tool for planning and managing health services. To establish a system that could prove to be efficient enough to respond to the needs of making a decision based upon the information from the healthcare delivery system, we need to have a vast health information system that should have the ability to process all over the country in terms of infrastructure and networking. On a general assessment of the existing health system, it was found out that the overall design is very feeble, the data collection system is not that organized, and information is disseminated in fragments. Because of this situation, efforts should be arranged where the prime focus should be on the organization of data, utilization of the data, and dissemination of the data to the respective stakeholder.

Conclusions
The current study used the PRISM framework to highlight the main challenges in improving DHIS in Khyber Pakhtunkhwa. It was found that there was no proper management system that ensured the timely transmission of the data from district to provincial and from provincial to the national level. This resulted in outdated, low-quality data which further affected the decisions made without any sound evidence. Additionally, in many facilities computers were not being used as the staff was not skilled in operating a computer. After the integration of EPI and LHW programs, significant improvements in the use of information, data quality, and behavior of staff after the intervention were observed. In short, it is important to properly train the staff on how to operate DHIS in order to gain adequate and timely data on health status and determinants. The integration would benefit in managing the data at not only the national level but at the district level too.    A (Strongly disagree), B (Somewhat Disagree), C (Disagree), D (Neither Agree nor disagree), E (Agree), F (Somewhat agree), G (Strongly agree).

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.