In Mozambique, data quality continues to be a major challenge for many facility- and community-based programs. Often, facilities collect data from patients but don’t have a reliable system for ensuring this information is saved and used as a reference for future visits or compiled and reported to the national health information system. These challenges, coupled with a growing demand for expanded services to prevent and treat diseases like HIV, often lead to poor quality of care and gaps in service delivery.
Over the last four years, Dália Traça or “Pepe”, JSI’s project director for the USAID Strategic Information Project in Mozambique (M-SIP) has worked hand-in-hand with the Ministry of Health (MOH) to improve data quality for decision-making. Her goal is to help the MOH identify gaps in data collection and reporting so as to produce accurate, timely, and precise data. This is critical for health workers to make decisions about patient care and for broader health system actors to evaluate new and ongoing programs and ensure appropriate drug stocks.
Pepe recently talked to us about M-SIP’s impact and how they plan to transition the program to the MOH as the project draws to a close in late 2018.
Tell us a little bit about the M-SIP project?
This project came after MEASURE Evaluation closed in Mozambique so it’s a different type of approach to data quality, but it came out of the data quality and measurement mentality of MEASURE. The idea was to do data quality. Initially, we didn’t know if we should focus on strengthening the implementing partners like MEASURE did. As such, we started with more of an audit than an assessment. We launched an informal working group during the first week at a coffee shop with key partners including JSI, USAID, the Ministry of Health, CDC, and the University of California, San Francisco (they were doing similar work but funded through CDC). It was clear that the MOH did not see the project as a priority, primarily because previous data quality projects were focused on implementing partners. However, after we demonstrated to them that this was a totally participatory project that would focus on strengthening the MOH, they decided to fully own the process.
We co-developed our project indicators with the MOH and began preparing the tools. The focus was always on sustainability—in the sense that we needed to create something that could be left behind. Nothing too big, nothing too complicated, and nothing too expensive. The goal was always to leave something practical and doable.
What were some of the challenges that Mozambique was trying to overcome?
The MOH does annual supervision in the provinces to check data and quality. It was understood that there were significant problems within the HIV program. We just didn’t know how significant the challenges were. Health workers were entering wrong information, files were lost, there were 2–3 files per person, and nurses didn’t understand why updating the books was necessary. Some challenges were easily fixed and others were harder. For example, the registers the health workers used were difficult to use. We recently heard that the MOH is, in fact, changing the registers based on the findings and recommendation of our team.
What was JSI’s approach?
We figured if we could get through the first year—doing a full national round of data quality assessments—we could get a clear picture of the local context. After the first round, we presented the results to the MOH. It was after this presentation that we got their attention. The picture we got from our assessment showed horrible numbers and the clear need to act. We started working closer and closer with the MOH, always focusing on sustainability and transfer of knowledge and capacity. We had a full Mozambican team so everyone knew and was very much aware of the problems in the country. It’s not that expats can’t have that knowledge, but there was knowledge among our team of how you can’t always go in a straight line. Sometimes you have to go around.
How have you partnered with the MOH and other stakeholders?
It’s hard to work with the MOH in many countries especially when you’re asking them for change. What won them over was that our team was integrated with representatives from the MOH, the provinces, and the districts. Not only was it training, but this approach also ensured that the data we collected was viewed as valid and impartial. When we presented on the HIV program, at the end of the first year, people were horrified. There were deviations of 80 percent from what was collected in the field and what was reported at the central level. When we finished the presentation, there was silence in the room. The head of the HIV program said, “well, this is what we have, so what are we going to do?” and it sparked real ownership of this program from the MOH.
What did you do when you realized the scope of the data challenges?
Well, one of the problems our project has is that we go assess, we make the recommendation for what should happen, and then we leave. So over the past three years, the provinces have raised this issue—they need help to address the challenges. However, we don’t have the funds or the mandate to do the follow-up.
What were the biggest successes?
We supported a conference in the third year, led by the MOH, to stimulate healthy competition between the provinces. That’s when we realized we were doing way more than data quality; we were doing health systems strengthening. It occurred to me that the MOH was trying to improve the service delivery of the entire system not just the numbers of specific indicators. We were supposed to be HIV only, but then we were asked by the malaria, tuberculosis, and maternal and child health programs to do similar work for them. I think we got people thinking about data as a part of a system and not just a vertical area. Lastly, I’m most proud that this approach and this project are completely owned by the MOH. There is no other seal of approval better than that. We’re using simple, basic approaches that give an indication of a problem and at this point, that’s enough. We don’t need the specifics quite yet. We just need to understand the magnitude of the program and that’s enough. At this point, we’re providing technical assistance—we’re there helping out—which is what we want.
M-SIP’s long-term goal is to improve the capacity of PEPFAR Mozambique-funded implementing partners, local Mozambican community-based organizations, and select Government of Mozambique ministries at the national and sub-national level to collect, analyze, report, and most importantly, use data to scale-up and improve health programs in Mozambique.