Analyse existing data flow, routines and systems

This section will describe how data is handled and reported in the health hierarchy in Chittoor. The health information flow in Andhra Pradesh was described in sub-section 6.2.1, so this section will focus on my findings in Kuppam.

The field worker fills out all her reports at the primary health centre. Last week of the month she gives it to the Multipurpose Health Extension Officer, which views and consolidates the data into one report. This job normally takes two days. Last day of the month the Multipurpose Health Extension Officer attends a meeting at the head quarter in Chittoor. The Statistical Officer gets the data before the meeting, and the Multipurpose Health Education Officer gets paid. The Statistical Officer consolidates the data for his district and sends it to the state (Hyderabad). The only feedback the health workers get is their salary or reprimands if they e.g. do not reach targets set (ref. section 8.1).

When HISP started in Kuppam, 30 – 40 existing data collection forms were in use. The goal was to reduce the number to one form at the sub-centre and one form at the primary health centres. The health worker would still carry a paper form in the field, and enter the data in the computer at the primary health centre.

During their survey in Kuppam, the HISP team had discovered several issues concerning the data handling:

• No analysis of data at sub-centre level.

• No analysis of data at primary health centre level except for immunization and tubectomy data.

• Analyzed data displayed as tables, no graphs used.

• No written feedback only verbal feedback in forms of “reprimands”

at monthly sectorial meetings.

• Duplication of data. The same data are reported at the primary health centre and the sub-centre.

• Reporting forms have no standard format, which lead to handwritten reports.

• Lack of correlation between multiple reporting formats.

The pictures below illustrate one of the registration forms.

Figure 12: Primary health centres review register

Figure 13: Sample of primary health centres review register showing erroneous and unreadable data. The number on the bottom line should be the sum of the column.

During our visits to the primary health centres we were allowed to study some of the data registration forms. I noticed several issues:

• Numbers were several times added wrong.

• Numbers had a habit of ending on zero, e.g. 10, 50, 60.

• Under-registration: fields in the form were left blank, without any explanation.

Just by looking at registration forms gave me an idea of the data handling.

Getting hold of population data

In addition to the census data, the field workers collect population data at the sub-centres, called the household register. We wanted to view the household data, but that was not an easy task. They were not kept in one central place, so we had to go around to the different primary health centres and get them ourselves. At the first primary health centre we visited the books and papers used for registration were kept in a closet, almost falling in your face when you opened the door. There was no system, and not even basic information was available. Only a few of the staff knew where different kind of information was, and simple data, e.g. population data, was not easily accessible. We were told that we had to wait for the field worker who was at work in a village, since she was the only one that possessed that kind of data. After several “she is coming tomorrow, come back then”, we went to her house to collect the population figures. The figures were written on a piece of paper that she carried with her in the field. She could not quite understand our eagerness in getting it right away, but was very happy to invite us in for tea and cookies.

Challenges with the data registration

The over/under reporting is caused by several reasons, and one of them is migration. In the health care system in India all patients can jump levels and walk in patients are received without being referred from another level.

Often women prefer to give birth at their mothers place. This information is not captured. Kuppam is situated close to two other states, Tamil Nadu and Karnataka. Rallabuduguru primary health centre is closely situated to Karnataka, and in serious cases, patients go to the hospital there. 10 of 40 pregnant women go to the hospital, and the rest prefer to give birth at home or at their mothers place. In the health system in India all patients can jump levels and walk in patients are received without a reference from another level. I was also told that it was common for people to go to a health centre in the town they were working in, which was often not the town they lived in. Some of the differences in number of patients across primary health centres are due to that some are very well equipped, and patients naturally prefer to go there. This will attract population belonging to other areas to the good primary health centres.

These findings show that there is need for improvement in the data handling and use. To investigate the quality of the health data collected further, I present a thorough analysis in chapter 8.