Indicators Definitions and Reporting Guidelines

The Health Informatics Monitoring and Evaluation Division (formerly Div-HIS) of the MOH developed the standard operational definitions for all audited indicators at national level. However, the audit team noted that most facilities had no written documents on indicator definitions. Facility-level recording staff mostly relied on their common knowledge from pre-service training or verbal instructions given by DHRIOs or colleagues for definitions of indicators.

The audit team observed lack of common understanding of operational definitions for some indicators such as HIV/AIDS treatments, family planning, child immunization and underweight indicators. It was found to be difficult for recording officers to clearly distinguish new patients from revisiting clients for preventive ARVs, family planning, and high blood pressure indicators as outlined below:

i. Number of HIV+ pregnant mothers receiving preventive ARVs

The definition of preventive ARV indicator for pregnant women required counting pregnant women tested HIV positive who received ARV prophylaxis on their first visit to the ANC. However, there

was no clear guideline to ascertain when the clients knew their HIV positive status, and the majority of service providers filled in the column for every visit. This resulted in double counting in cases of treatments during re- visits which are also recorded in the register and included in the

monthly summary

reports. It was also unclear how to count

missing clients whose lab results were positive and received ARV prophylaxis on their subsequent visits.

ii. Total Number of patients currently on prophylaxis - Cotrimoxazole

The definition for ‘patients currently on Cotrimoxazole prophylaxis’ refers to both new patients registered in the reporting period plus existing patients excluding dropouts, transfers and those who died in the previous reporting period. This complex definition was not well understood by some staff who compile summary reports; particularly new employees and those who had not received training on the same. Furthermore, there are no clear instructions given in the MOH711 on what to count and how to aggregate and fill out summary tool. In most cases patients were supplied with drugs that lasted for more than one reporting period (one month) therefore was not clear how to count them. In addition, the manual counting process across periods was complex and tedious. During the verification process, it was observed that most errors occurred in the process of compiling monthly summary reports by aggregating thousands of cases

Figure 9: EPI Register illustrating column for FIC left blank even where records show children have completed their schedule as required

across sex and age categories, as well as across subsequent or prior monthly periods for clients who received supplies for more than one month.

iii. Number of women of reproductive age receiving family planning

In the case of family planning indicator, in some facilities it was not clear what to count: whether numbers of clients who received method(s) or number of methods received by clients in the reporting period. For example, condoms received by a client were counted instead of counting clients. Though the indicator refers to women of reproductive age, there were also cases where males receiving condoms were included in summary reports. Double counting also occurred due to inclusion of re-visits for counselling, removal of IUD, and method shifts within the same reporting period.

iv. Number of fully immunized children

The definition for fully immunized children indicator was one of the more difficult indicators and less understood by those who are in charge of preparing summary reports. Determining immunization status of a child was not directly observable in the register; it required checking vaccination history of the child retrospectively. Different children may have started immunization at different ages and therefore one had to check in order to identify children who were fully immunized by the time they reached their first birthday. The column for recording immunization status in the MOH510 register was often left blank and therefore was difficult to verify summary report based on incomplete records as shown in Figure 9.

Where immunization date was not clearly indicated, the auditing teams used Measles dates and checked all antigen dates in retrospect for 11 months to determine the number of fully immunized children for the reporting period.

Some facilities had the definition of fully immunized child as one who has received 1st Measles under 1yr regardless of whether other vaccinations had been completed, others-as one who has received all the vaccination including the 1st Measles and another definition was a child who received the 2nd jab of

Measles at 18 months. Over-reliance on tally sheets as a source document mainly for counting was also observed as another cause of poor data quality as well as improper storage of completed registers (See Figure 10).

v. Number of children under 5 treated for malaria

The definition for ‘number of children under age 5 treated for malaria’ required counting only treatments based on clinical diagnosis. However, there was no uniform understanding of this definition across different facilities. In some facilities all treatments (both clinical and lab-confirmed) were counted, while others counted clinical and confirmed malaria cases separately. It was also observed that in a few cases there was lack of common understanding on what ‘under age 5’ means, and whether it includes age 5 or not. In some, this was interpreted as inclusive of children who just turned age 5, while in others was considered not inclusive.

vi. Reporting guidelines

Though there were no written reporting instructions/guidelines on what, how and when to submit reports, it appeared to be widely known across facilities that reported should be submitted to the districts by 5th of every month. Overall, respondents in 33% of all the sample facilities reported that the HIS guidelines on what to report and how to submit the reports are not adequate (Figure 11). Regarding to whom and when to submit reports, about 25% of respondents indicated the guidelines to be inadequate. The graph also shows variation by facility level and ownership type. Almost half (45%) of private facility respondents indicated they were not provided with adequate reporting guidelines, while only 35% of lower-level government facilities, and about 25% of higher-level government and faith-based facilities reported the same. This

Figure 10: EPI Register with several pages lost to poor storage or handling

Figure 11: Indicators Definitions and Reporting Guidelines

suggests that data management and reporting guidelines are not uniformly supplied to facilities, particularly for private facilities.