Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

The burden of recording and reporting health data in primary health care facilities in five low- and lower-middle income countries.

BACKGROUND: Recording and reporting health data in facilities is the backbone of routine health information systems which provide data collected by health facility workers during service provision. Data is firstly collected in a register, to record patient health data and care process, and tallied into nationally designed reporting forms. While there is anecdotal evidence of large numbers of registers and reporting forms for primary health care (PHC) facilities, there are few systematic studies to document this potential burden on health workers. This multi-country study aimed to document the numbers of registers and reporting forms use at the PHC level and to estimate the time it requires for health workers to meet data demands. METHODS: In Cambodia, Ghana, Mozambique, Nigeria and Tanzania, a desk review was conducted to document registers and reporting forms mandated at the PHC level. In each country, visits to 16 randomly selected public PHC facilities followed to assess the time spent on paper-based recording and reporting. Information was collected through self-reports of estimated time use by health workers, and observation of 1360 provider-patient interactions. Data was primarily collected in outpatient care (OPD), antenatal care (ANC), immunization (EPI), family planning (FP), HIV and Tuberculosis (TB) services. RESULT: Cross-countries, the average number of registers was 34 (ranging between 16 and 48). Of those, 77% were verified in use and each register line had at least 20 cells to be completed per patient. The mean time spent on recording was about one-third the total consultation time for OPD, FP, ANC and EPI services combined. Cross-countries, the average number of monthly reporting forms was 35 (ranging between 19 and 52) of which 78% were verified in use. The estimated time to complete monthly reporting forms was 9 h (ranging between 4 to 15 h) per month per health worker. CONCLUSIONS: PHC facilities are mandated to use many registers and reporting forms pausing a considerable burden to health workers. Service delivery systems are expected to vary, however an imperative need remains to invest in international standards of facility-based registers and reporting forms, to ensure regular, comparable, quality-driven facility data collection and use.

Characteristics of Inpatient Hypertension Cases and Factors Associated with Admission Outcomes in Ashanti Region, Ghana: An Analytic Cross-Sectional Study.

BACKGROUND: Hypertension remains a cause of morbidity and mortality in the Ashanti Region of Ghana. It has been featured in the top ten causes of OPD attendance, admissions, and deaths since 2012. We investigated the sociodemographic characteristics and spatial distribution of inpatient hypertensives and factors associated with their admission outcomes. METHODS: A 2014 line list of 1715 inpatient HPT cases aged ≥25 years was used for the cross-sectional analytic study. Accounting for clustering, all analyses were performed using the "svy" command in Stata. Frequencies, Chi-square test, and logistic regression analysis were used in the analysis. Arc view Geographic Information System (ArcGIS) was used to map the density of cases by place of residence and reporting hospital. RESULTS: Mean age of cases was 58 (S.D 0.0068). Females constituted 67.6% of the cases. Age, gender, and NHIS status were significantly associated with admission outcomes. Cases were clustered in the regional capital and bordering districts. However, low case densities were recorded in the latter. CONCLUSION: Increasing NHIS access can potentially impact positively on hypertension admission outcomes. Health educational campaigns targeting men are recommended to address hypertension-related issues.