Leading directly from questions asked by our stakeholders, we have compiled this list of FAQs to support understanding of the research project.
Rationale for PHISICC
What is the basis of the PHISICC?
It is widely recognised that despite a lot of time and effort put towards the recording of patient data, there is very limited use of these data to provide immediate support to clinical, public health and managerial decision making. Rather, patient data are collected primarily for the purposes of reporting to higher levels within the system, where it is expected to inform managerial and strategic decisions, although this application is not always met.
PHISICC’s primary aim is to make better use of the data that are being collected at primary health care (PHC) facilities to support local health care workers in making the best decisions for their patients’ clinical care.
PHISICC is based on a global and local body of evidence on what works and how in health information systems (HIS) in LMIC.
What does the study aim to study?
PHISICC will examine whether having an enhanced paper-based health information system – one that focuses on helping health care workers to make good decisions – will result in improved data quality, work satisfaction and health outcomes at the primary health care level. We will also assess whether it is cost-effective.
Was a needs assessment conducted before new tool development?
In short, yes.
The need for improvements to be made to the HIS is indicated in the strategic policy documents in all three PHISICC countries (Côte d’Ivoire, Mozambique, Nigeria).
Globally, all countries are focused on continually improving their healthcare performance and health care data, and HIS are seen as having a central role in the delivery of equitable and high quality health services. The current paper-based systems have challenges but such systems will remain in place for the foreseeable future. At the same time, primary care is recognised as the keystone to strong health system performance. Taken together, there is a clear need and desire to build the evidence on effective strategies to support this level of care – PHISICC offers the potential for better health information tools to link data with decision making.
To ensure that PHISICC is targeting the most important needs, the team has carried out a characteristaion of the HIS in the three countries. Reports of these assessments (WS3 – Characterisation of Health Information Systems) can be found here.
The paper-based health information system is the mainstay of data management at the primary health care level so what does PHISICC have as additional advantage?
Paper-based HIS have been developed as programmatic needs emerged, rather than by careful design. This development has been guided by the need to capture information from health facilities in order to report it to higher levels of the system.
Whilst this approach meets certain reporting requirements, it is not supportive of better data use for decision making – neither clinical nor strategic. Instead, data and related indicators are more like a series of islands in the HIS rather than a joined-up network directed at providing clear insights for health workers and decision makers.
PHISICC is a research project and seeks to enable a connected, system-wide approach to primary health care decision making. Through the intentional design of paper-based tools, it seeks to identify the best tools to inform decision making. This project is about enabling better quality patient care, particularly for the most vulnerable populations. As a research project, it will provide new evidence for national and international researchers and policy makers.
Why not focus on digital?
The country HMIS is migrating to electronic data systems, is PHISICC not taking the nation back to where it is coming from?
It is true that there is some adoption of electronic systems; however, not all tiers and services across the whole health system are equally prepared in any country. Furthermore, most policy makers in the countries and researchers acknowledge that health facilities in many LMIC (and not few HIC) will continue to use a paper-based health information system because digital systems require long-term investment commitments, infrastructure, services, maintenance, renovation and troubleshooting, which are not widely available.
Westley (2016) explains this scenario well: “Despite the global shift toward digital data collection, there remain low–resource settings that are unable to support the infrastructure required for electronic register systems. For these settings, strengthening paper health register systems can bolster evidence–based decision–making in patient encounters, program planning and policy, and serve as a first step toward improving quality data in HIS as they shift toward electronic systems”. Further, in a technical brief authored by Measure Evaluation, it is shown that the transition from paper-based to electronic systems comprises five stages – the second of which focuses on the ‘optimization of paper systems through simplifying indicators and reducing duplication’.
PHISICC covers all of these areas and is essentially about seeing data as a tool for decision making.
How will the HMIS partners be engaged in the PHISICC project?
Partners have been engaged in all activities since inception. Contributions have been made to protocol development and research implementation and will continue through to the end of the project to encompass the dissemination of findings and policy uptake. There have already been several events, workshops and meetings to materialise these engagements.
Which entities are involved in this study?
In Mozambique, PHISICC has a Memorandum of Understanding with the MISAU (Ministry of Health, represented by Dra. Graça Matsinhe) and has established a partnership with the University of Lúrio (represented by Dr Artur Muloliwa).
In Nigeria, our counterparts are the NPCHDA (represented by Dr. Garba) and the University of Calabar (represented by Prof. Angela Oyo-Ita).
In Côte d’Ivoire, we are working with MSHP (represented by Prof Samba Mamadou) and the CSRS (represented by Dr Richard Yapi).
SwissTPH also has a national co-ordinator in each country: Sofia Mandjate (Mozambique); Dr Ngozi Njepuome (Nigeria); and Kouadio Dieu-Donné (Côte d’Ivoire). Many other stakeholders are also involved in different ways.
What is the perception of the FMOH (Nigeria) about the PHISICC project; is the FMOH involved?
Yes, the FMOH is also actively involved and part of the project partnership. Its views are taken into account and we are buidling a common understanding of the HIS problems and solutions.
Cost of scale-up
What will be the cost of the expansion, at the national scale, of the new intervention? Will it be sustainable?
We will not know this until we finalise the research but costs will certainly be measured and presented as part of the evidence generated from this research.
What happens to the plethora of printed child health registers when the PHISICC tools become available? Waste of resources?
PHISICC tools will only be implemented if the governmental health sector decides that it should be so, after having assessed the evidence produced in PHISICC. Replacement costs will have to be taken into account as for any occasion when systems are adapted or changed.
Managing content and tool use
How does PHISICC intend to contend with the 16 registers used in Nigeria for routine immunization and reflect the content of these registers in the new tool?
PHISICC aims to redress the current proliferation / redundancies of data items across the different registers for immunisation and all other primary health care areas. Current analyses confirm that there is a lot of room for simplification and reorganisation of data without losing its utility.
How will the PHISICC indicators align with the all indicators for immunization?
PHISICC will not change any of the indicators required at higher levels but will optimise the production and transmission of data from PHC.
Will the research include all components of health services?
PHISICC focuses on PHC and will cover all services delivered at PHC level.
Tools reproduction is a chronic challenge, how will the PHISICC project address this weakness?
The PHISICC tools will remain paper-based, so to some extent these chronic challenges may persist. However, it is hoped that the new tools will be simpler and as such, the requirements for reproduction reduced.
Is the intervention going to be a register or a form?
It can be anything! The hypothesis is that a piece of paper can change your behaviour – it’s about making ‘forms’ not just a place to write but to make a decision.
What is the usability of the new innovative tool?
The development of the new tools will be made through the PHISICC co-creation groups (CCG). The CCGs (one dedicated group in each country) will work directly with the design specialists to assess core requirements and create new designs so that they work as a best fit to the local conditions. Part of the CCGs role will be to run small pilot studies using the tools (development iterations) on site with local healthcare workers. It is hoped that this approach will foster greater usability before the trial is implemented and that monitoring and evaluation throughout the trial will also provide more insights on benefits / challenges around usability.
Training & implementation
There will be a need for training to use the new tools – how will this be managed?
We will provide training for both new and old tools. This will ensure that all sites selected (randomisation process) will be equally skilled for the start of the trial.
If we are going to introduce a new system for the trial – why then disrupt it again at the end of the trial?
Because we don’t know if it will work. Also, policy decisions are not based on a single study because every study has some bias. PHISICC will provide elementary evidence as a start and this will be considered alongside other evidence from other initiatives. Many other factors influence policy – the extent to which evidence shows concordance or conflict is just one of these. It’s about striking the right balance.
SwissTPH is covering all the technical parts – why not use in-country groups?
PHISICC heavily relies upon country groups in all workstreams.
Data reporting & management
How will data using the new intervention get transferred into the existing system?
Our focus is PHC and the district (or LGA) level will get what they need. We will have independent monitors to make sure data is not lost.
How can we ensure that reporting needs will be met?
Prior to embarking on any new tool designs we gathered and analysed the existing reporting needs for each country. Now that the design phase is underway, the whole team (i.e. public health, designers, co-creation groups) are continuously monitoring every development to ensure that the final intervention complies with country-specific information needs.
How will the intervention be evaluated? How do you know the difference that the format makes?
The intervention will be tested using a randomised controlled trial and because of this you will know that the only difference (if any) is due to the intervention.
Is a RCT the way forward? (an observation was made that in using a RCT there would be a need to compare health facilities with themselves as there are constant changes at this level and a real lack of uniformity. It would be good to have a mixed approach (e.g., a qualitative element))
We will consider the best experimental-comparative design for the intervention, and there are several ways to carry out trials. This requires further discussion with statisticians, trial specialists and country partners.
In how many and which Mozambican provinces will the study be performed?
One. In Manhiça province in this experimental phase. Later on, it will be the Government who may decide whether to scale up or not.
Considering the wide variation in health care services across the nation, the one site study site might not be representative of national picture (Mozambique)
This is a valid point and a limitation of any research study. PHISICC recognises the variation in services and has adopted what is currently the most robust approach for such heterogeneity – RCT design – for the intervention trial and three very different countries. We will also collect qualitative evidence that will help us to understand what works and how, and whether there are prospects of applying our findings to other geographical areas.
Funding & Ethics
What is the financial basis that the study has for the implementation? Is is approved by the Ministry?
The study is funded by the Bill & Melinda Gates Foundation and has already been approved by the Ministries of Health in each country. All partners comply with research best practices, including ethical reviews when required.
What is the timeline for the completion of this study?
Intervention design phase: Q3 2018; launch of trial: Q4 2018: trial duration: 2019; analyses of findings: Q1 2020
We aim to be responsive to this need throughout the project, so if there are any questions you would like answered, please contact us here.