Routine health information system in the health facilities in Yaoundé–Cameroon: assessing the gaps for strengthening

Quality health care delivery is a product of informed decision making which in turn is based on proper health information management [1]. The management of health data and its use for informed decision making remains one of the most challenging health sector aspects in developing countries [2, 3]. Many health information management sub-systems that function in a non-integrated and unstandardized manner characterise the routine health information system (RHIS). These sub-systems [4] include Community-based Health Information Systems (CBHIS), Civil Registration and Vital Statistics (CRVS), Electronic Health Management Information Systems (eHMIS), Financial Management Information System (FMIS), Human Resource Information System (HRIS), Logistics Management Information Systems (LMIS), and Surveillance Systems (SS). RHIS includes data collected at regular intervals at public, private, and community-level health facilities and institutions and health programs. The sources of these data generally include individual health records, records of services delivered, and records of health resources.

These sub-systems use physical tools (registers, paper and electronic data collection forms, etc.), and in most cases, there are no delegated persons in charge of statistics to ensure proper data management. Data are managed by clinical staff in addition to their daily tasks, thereby becoming overworked [5]. This results in the poor capture of health data at every level of the health pyramid, the non-analysis of the collected data at the given health pyramidal level before forwarding, the lack of sufficient feedback mechanisms, and the lack of public and private sectors collaboration in terms of information sharing [6]. Bottle-necks resulting from these include poor completeness and timeliness in information reporting, poor archiving, incoherence in both indicator denominators and numerators in the different databases, and the non-use of information for decision making at the given pyramidal level [1].

Though there is no outlined health-related Sustainable Development Goals (SDGs) target for HIS, the Universal Health Coverage (UHC) target is emphasised encompassing access to quality healthcare, essential drugs, and vaccines [7]. The importance of an efficient and harmonised RHIS cannot therefore be overlooked if health-related SDGs are to be met [8]. After strengthening the RHIS in some African countries, the MEASURE Evaluation project, funded by the United States Agency for International Development (USAID) with mission to strengthen health information systems (HIS) in low-resource settings, carried out assessments to measure the impact of the strengthening interventions. Significantly favourable results were obtained that showed improved data care in these countries. For example; in Mali, data quality (accuracy, completeness and timeliness) was improved after putting in place an enabling environment that permitted better data management by stakeholders [9]. In 2012 and 2018, performance assessments of the RHIS were also carried out using Performance of Routine Information System Management (PRISM) in Ivory Coast [10]. These assessments revealed that data reporting was improved, even though there still existed gaps especially with respect to data quality, data use, and data verification methods at the health facility (HF) level [10]. Also, in Uganda, completeness and timeliness in reporting were improved after one year of strengthening, even though there still existed the need to further enhance the system in order to improve its performance [11].

In order to meet the health-related SDGs, Cameroon is scaling up towards ensuring a UHC for all [3, 12]. In this light, the country identified and defined its 100 basic health indicators following the World Health Organisation (WHO) guidelines. The Ministry of Public Health (MOPH) has also standardized the RHIS by putting in place the second version of the District Health Information System (DHIS 2) for the management of aggregated HF data [3]. DHIS 2 is resolving problems encountered with the physical tools by ensuring the availability of routine health information (RHI) to every stakeholder. Individual client data management is so far not yet managed by DHIS 2; a persisting problem of the system [12].

Efforts are being made to ensure a properly functioning RHIS for the generation of quality RHI by the year 2027 [13]. The objective of the Health Sector Strategy (HSS) for the health information system (HIS) states: “By 2027, ensure the development of health research and the availability of quality health information system for evidence-based decision-making at all levels of the health pyramid” [13]. This objective is first priority for implementation, with a monthly activity reports (MAR) completeness of 80% expected to be met by 2027. The HSS aims at attaining 90% of health facilities having a well organised system of data management [12, 13].

It is not only important to ensure the availability of a RHIS but also its adequate performance through quality health information generation [1]. Evaluating the performance of the RHIS will ensure that gaps and weaknesses are identified and recommendations are made to strengthen the system [3]. Progress and performance tracking of health interventions to meet health-related SDGs, and HSS targets will be facilitated through an efficient RHIS, and the use of information for evidence-based decision-making and public health action [14, 15]. The objective of this study was to assess the RHIS in the HFs in Yaoundé in order to identify gaps and weaknesses, and to make proposals for strengthening.

The objective of this study was to assess the RHIS in the HFs in Yaoundé in order to identify gaps and weaknesses and to propose solutions for strengthening. This was fulfilled by assessing the RHIS domains and subdomains through a health facility-based cross-sectional mixed study in the six HDs and the Regional Office of the city of Yaoundé.

It has been evidenced that the HF should be paid more attention if the RHIS is to be strengthened successfully, since the HF is the point of data generation and entry into the information system [8, 9]. However, national, regional and district levels decision makers, administrative and coordination bodies cannot be neglected in the strengthening process. In light with this, we hoped to set the bases for programmatic RHIS strengthening interventions and for further extensive RHIS evaluations with emphasis at the HF level.

The 2016 to 2027 HSS outlines problems in the RHIS, some of which are: poor development of research in health, poor management of health information, non-informed decision, and insufficient dissemination of health information and research findings to all health pyramidal levels [13]. As such, the HSS objective for 2027 aimed at improving availability of quality information for decision making through: (i) the creation of a database accessible to all stakeholders, and (ii) the computerization of the National Health Information System. Data quality can be improved by assigning staff according to their competencies and posts [18, 19]. Most of the respondents in this study were clinical staff who performed additional functions as data managers and only 24 (21.6%) of them were statisticians. Staff trained specifically for this role are limited, and this could explain some of the bottle necks in data management. This points out the need to train and deploy statisticians at the health facility level to carry out this task [4].

From the overall results of the four domains, Data Collection and Processing scored highest for adequate functionality. However, several participants ignored the RHIS standards at the health facility level. A lot of communication and training is necessitated at this level, considering the fact that the HFs and the communities are the initiation points for data management. Data Collection and Processing (51%) and Data Analysis, Dissemination and Use (48%) were mostly recommended for strengthening. On the other hand, Data Collection and Processing was the most cited domain for adequate functionality (22%). This could be explained due to the fact that actors are getting familiar with this domain on a daily basis, especially after the introduction of DHIS 2 [3]. Efforts to harmonise tools and procedures for collection and forwarding may also account for these results [20].

The sub-domains of Collection and Management of Individual Client Data, and Collection and Management of Aggregated Facility Data showed encouraging results. These sub-domains registered a minimum score of 25% for adequate functionality, 65% and 50% respectively for needing strengthening, and less than 12% each for needing to be developed. The proportion of the ignorant for these two sub-domains is also very low (less than 6% each). On the other hand, in the same domain, Information and Communication Technology registered only 11% for adequate functionality and 42% who opted for strengthening. The importance of ICT cannot be over stressed here, considering that computerizing the national health information system is an HSS strategic objective. ICT framework and competence are still a major set-back to the proper functioning of the RHIS. Only 9% of responses acknowledged the presence of an overall framework and plan that includes equipment, acquisition and its use at all levels of the RHIS as well as internet coverage. So far, ICT (eHealth, mHealth) is mostly used only in active surveillance data collection and forwarding. However, these ICT methods could also be developed and integrated into the RHIS for client and aggregated data collection in remote areas. Although ICT is gradually being implemented across the national territory, ICT methods alone cannot improve much on the quality and availability of data for decision making [21]. Other strategies should be employed in combination with social media to ensure strengthening.

This study revealed that Data Demand and Use was stated to function adequately by a maximum of only 16%, and needs strengthening by 58% of participants. This finding is low compared to the PRISM assessment obtained in East Gojjam Zone, Northwest Ethiopia, which revealed that 45.8% of workers had good level of health information use [22]. Promoting a culture of demand and use of information greatly improves on its use for informed decision making, as well as influences on donor response [23]. However, this aspect is not felt by actors on the field (only 4% of adequate functionality, with 36% level of ignorance with respect to this culture).

Results per district provided orientation to specific programmatic strengthening of the RHIS in the various districts. For example, in Biyem-Assi, Data Decision and Support Needs presented the worst results (5% for adequate functionality, 55% for strengthening). In this domain, the components of surveillance mostly needed strengthening. Eighty-one percent (81%) recommended strengthening of the definitions of priority diseases under routine surveillance. A successfully strengthened RHIS will facilitated not just the surveillance of epidemic prone diseases, but also the surveillance of other back-ground potentially dangerous health issues due to routine data availability [24]. In Cité verte, the worst results were registered by the domain Data Analysis, Dissemination and Use (5% for adequate functionality and 51% for strengthening). Bulletins and annual reports should be produced regularly and disseminated to HDs, as well as ensuring regular feedback on the RHIS performance of the various districts. Social media has been found to improve on health information dissemination and thus can as well be exploited at the HDs to improve on data dissemination [25]. Coupled with staff empowerment in data analysis and dissemination, the use of data for decision making at the HF level will also be improve [4]. Disaster response preparedness will also be assured by an adequately functioning RHIS. This is due to the fact that there is available baseline information on health indicators (populations at risk, human resources) that can immediately be exploited for immediate response planning [26‐28].

One major limitation was that some respondents, though recommended by head of the HF, were neither in charge of statistics nor were responsible for the information system. This was due to the fact that most HFs did not have a RHIS staff. It is possible that this introduces bias in reporting based on the information each respondent provided. Efforts have been made to minimize this bias by ensuring that the respondent was the most qualified in the HF for any RHIS issue.

The domains and subdomains of the RHIS of the HFs in Yaoundé were functioning adequately at very low rates. While gearing up to meeting the health-related SGDs and the HSS objectives, it is imperative that district-specific strengthening actions should be implemented. In this light, the findings of this study have been communicated to the various HDs and HFs so as to facilitate strengthening at these levels. The gaps and weaknesses identified will help in strengthening the RHIS and improving the data at the district level, and indicate where resources should be invested to improve the system. The study design neither permitted an exploration of the factors associated to the poor performances, nor the understanding of the mechanisms of these associations. As such, a nation-wide assessment should be carried out in order to understand the determinants of these poor performances and to strengthen the national RHIS.