• Step 1. Select a country for this assignment.

Zambia

• Step 2. Join the WhatsApp group for this country.

I have joined the Zambia What's up group

• Step 3. Identify the questions you want to answer about data flow, data tools, and the performance of your country’s monitoring system.

1. What mechanisms are in place to ensure that at each level data is verified by responsible officers and submitted timely? Do SOPs exist and are they clear for staff who handle data in order to ensure standards are followed?

2. Are the required data collection tools available in the required quantities?

3. Is data reviewed at the different levels by program managers to identify under-served or unserved populations?

• § How does data flow?

In Zambia, data flows from data collection at primary health care/ health facilities where it is collected at points of service onto activity sheets. At this point the information should first be entered into the relevant registers. For EPI these registers are under five registers.

From this point, the data are aggregated on monthly basis onto HIA2 summary which should be submitted to the district health information officer who is the M/E focal point person at the district level from the district health office.

The district aggregated data is then entered onto the web-based DHIS2. This is then viewed by Province Health Management Information Officer and then to the National Level Health Information Officers.

• § What are the different reporting layers (that is, who reports to whom) and what are the requirements for timeliness and reporting frequencies?

There are four layers in the reporting of the health management information system. At the primary data collection point where the data is paper based this function is carried out usually by the health provider; in many cases this function may be delegated to community health workers especially where there is high patient/client volume. From health facility the in-charge consolidates the reports and submits to the District Health Information officer. From district level the information officer enters data into DHIS2 platform; This is transmitted to the provincial health management officer and then onto the national level information officers.

• § Who first collects the data, prepares paper reports, enters data into electronic systems, receives and reviews reports?

The data is first collected by the health center staff by health workers in the various service delivery areas. For EPI, it is done by health workers in the MCH department. Data is collected onto paper base reports in the health facilities. The aggregation of the data too is on paper based. The aggregated reports are submitted by the health facility in-charge to the district information officer at the district level who then enters into the electronic DHIS2. Prior to this he should review the submitted reports. Review of data continues even when data has been entered onto the electronic platform.

• § What measures and procedures are in place for data verification, cleaning and feedback? What process is followed if data seems to be wrong?

Verification procedures at district level include review of paper based submission. On monthly basis, data is expected to be reviewed and cleaning at this level before the set deadline for the next level and corrective action taken if necessary. In the case of data issues encountered, a follow up is made by District Health information officer with the facility that submitted the reports to clarify and/or correct data. Data is not always cleaned before it is entered into DHIS2. This process also takes place even after data entry into DHIS2. The systems for reviewing and ensuring data is timely cleaned are not clear. This would be dependent on programs and if they use data frequently. It is unclear to me what systems exist to ensure that data is cleaned and reviewed before it is transmitted to the next level. What is noted that data issues may be noted even months after submissions in a number of cases. While data review meetings date place in a number of province, they do not do not review the data to the level that would identify bottlenecks.

• § Who are relevant players/stakeholders at each level? What do they do with the data (for example, collect, enter into electronic system, analyze, use to make decisions, etc.)?

What systems are put in plan ensure data is b]cleaned and/ or review data before it is transmitted to the next level?

The systems for ensuring that data is cleaned or reviewed before transmission for my country are not clear to me from the documents reviewed.

The relevant stakeholders at each level include the data collectors/ health workers at service delivery point, program managers at that level. In addition, for health facility level, the community; at districts level, partners, politicians and traditional leaders; at provincial level in addition to program managers relevant players include the line ministries, political leadership and at national level, the minister, partners.

The stakeholders use the data to assess performance and mobilise resources to support the program. In addition the data is used to map diseases or access of services provided by the facility, district, province and nation.

• Step 4. Identify and collect relevant background documents and other sources of information for your selected country.

§ Each SHARE must include a description. Summarize why you are sharing this document and how it useful.

Zambia Data Quality Audit 2012

An assessment was conducted on the quality of data in Zambia in 2012. In this report is embedded the issues identified related to data quality. The report highlights issues related to human resources handling health, the data tools, data system.

I am sharing this report even though it is old because many of the issues still remain relevant to today. At the time of the assessment, no improvement plan was developed and solutions to issues have been implemented either in pilot phase or in piecemeal.

Zambia Comprehensive Multi Year Plan 2017-2021

This document articulates the aspirations of the National Immunisation Programme following the review of immunisation performance including the performance of its various component and identification of gaps and targets set with benchmarks. The document prioritises key areas that will be considered for addressing in the lifespan of the plan, aligning then with regional and national priorities. Strategies and interventions have been articulated on how to achieve the targets set. All these are informed by data that is derived from DHIS2, Surveillance data and other reviews from the program.

I have shared this document because it has a section that is speaks to data quality and has some interventions to address the data quality gaps. This many have to be reviewed and updated and informed after the data quality review, assessment and improvement plan is done. The DQIP is planned to be completed in Q4 of 2018.

Zambia Comprehensive EPI and Surveillance Review

The document reported the immunisation system and surveillance system status in 2014. In this report the different immunisation components as well as the surveillance components were reviewed identifying the strengths and gaps with recommendation on what needed to be done to address them.

Even though the review is some time back the challenges are still relevant today. The highlights of which are quote ‘The country uses Web-based data base to collect information on health system information performance indicators including immunization, surveillance and reports timeliness and completeness. The system uses CSO data potentially leading to overestimates of coverage rates. The system also captures the data in newly introduced vaccine. Data base validation rules have not been built into the system and the data managers are not able to pick out data entry mistakes’. These findings would benefit from the lessons from this course as a data quality improvement plan is drawn up.

Zambia Integrated Disease Surveillance Guidelines (Upload failed)

Zambia has Technical guidelines for integrated disease surveillance that guide the details case definitions for each priority event, disease or condition and the need to review minimum data elements that facilities and other sources need to report. This guidelines states when this should be reported, to whom and how. It states which diseases or conditions should be reported immediately (whether by phone, form or voice) and often the required should be reported. It has samples of case-based investigation reporting forms, laboratory specimen based reporting form. Line lists for use in disease outbreaks and tables for summary totals for routine weekly reporting, routine month reporting, routine quarterly, graphs for time analysis of data, maps and charts for time and place analysis.

I am sharing this document because data derived from this system is used to triangulate Immunisation data and success of EPI through the surveillance of vaccine preventable diseases.

Zambia Measles Rubella Post Introduction Evaluation

This document reports findings on assess the overall impact of the introduction of Measles Rubella Vaccine on the national immunisation programme. The focus of the evaluation focused on the following: pre-implementation Planning and Vaccine Introduction Process, training, vaccine coverage, cold chain management, vaccine management, transport and logistics; waste management and Injection Safety, monitoring and supervision; adverse events following Immunisation; advocacy and communication and surveillance.

I am sharing this document because it has elements findings on data issues including availability of data tools; immunisation coverage reports which reveals the to some degree the status of data where the assessment was conducted.

Zambia Service Availability Readiness Assessment 2015

The SARA was conducted to assist the health sector assess accessibility of health services as well as service readiness and capacity at health facilities. The SARA study provides key information on the state of the health system with regards to accessibility of services. The assessment included density of health facilities, service provision and utilization, as well as the readiness of the facilities to provide an adequate level of service. Readiness was measured by the availability of trained staff, diagnostics, equipment and medicines, both for general health services and for specific key health interventions like obstetric and new-born health, HIV/AIDS, TB, malaria diagnosis and treatment.

I decided to share this information because it provides information concerning availability and readines of immunisation services in the selected sites. Records data on the percentage of health facilities that had tracer items for child immunization among those that indicated that they offered immunization by province and other background characteristics. In addition the reports provides information on data on Child immunization readiness in terms of requirements for a facility to offer a successful immunization service.

Zambia Restructuring Report and Zambia 2007 JOB DESCRIPTIONS AND SPECIFICATIONS

These two documents describe the struct of the Monitoring and evaluation unit at the Ministry of Health and the Restructuring report. In these documents are description of the Monitoring unit at MOH and the job descriptions for staff in the unit. 

I have shared these as they have a bearing on the exectuion of monitoring and evaluation duties carried out at the Ministry of Health

• Comprehensive Multi Year Plan 2017-2021 - Ministry of Health
• Zambia Service Availability Readiness Assessment (SARA) 2015 Report - Dr.Benson Droti et al
• Measles Rubella Post Introduction Evaluation Report 2018 - WHO
• Zambia Integrated Disease Surveillance Guidelines - MOH, WHO
• Zambia Comprehensive EPI and Surveillance Review - MOH
• Zambia Data Quality Audit 2012 - MOH
• Zambia Restructuring Report
• Zambia 2007 JOB DESCRIPTIONS AND SPECIFICATIONS

• Step 6. Perform a rapid review of these sources and evidence for data flow, tools, and performance of your country’s monitoring system.

Reliable sources (if they exist) that describe the data flow and data tools used in your country’s monitoring system and evidence that will help you identify strengths and gaps (through SWOT analysis) of the performance of your country’s monitoring system.

The review of the documents collected show that there are data challenges arising from inadequate supplies of data collection tools, denominator issues, no SOPs for data managers. Findings at service delivery level of the health information system found on the Data Quality Assessment in 2012 included poor recording and archiving, limited data use, while computerised archiving, reporting and demographic were on average good at roughly 80%. Accuracy ratios were generally low. In addition there was inadequate manpower to tally, enter and fill in all the various reporting forms at institutions visited. Staff at the institution were overwhelmed with service delivery duties while additional responsibilities of data collection, entry and processing of data are expected. The filing system and record-keeping were poor. Denominators issues were found to be a problem. Institutions often lacked reporting forms (especially for the very remote centres which may not easily access photocopying or printing services).

• Step 7. Summarize the quality of the available evidence.

The quality of findings are reliable. In terms of completeness, due to the passage of time, new issues in data quality have emerged particularly with the emphasis on reporting requirements related to data quality that may not have been raised in some of the reports. In addition, there was not much emphasis on the verification processes in reports nor was there emphasis on completeness and timeliness in the assessment.

From my personal experience in compiling data for reports I have noted many times data discrepancies for example for vaccines provided at the same visit, higher coverages for doses given later in the schedule as compared to doses for the same vaccine earlier in the schedule (higher OPV3 compared to OPV1), significant delays in submission of data reporting beyond the reporting timelines. Negative drop-out rates, higher than 100% coverage for a number of antigens. Discrepancies of administrative coverage compared to survey data. My review of the documents was not complete. There will be need to review the data for consistencies; timeliness and completeness. Data use is very rare as had been noted through the incomplete immunisation monitoring charts at all levels. Data review meetings are limited to aggregate coverages (FIC) only. There is need to review some analysis that have been conducted on the data though the process of Joint Reporting; data quality reviews. The review of the documentation does not provide information on whether data verified or how the cleaning process in does or who is responsible for that. There are no details on the availability of SOPS for the staff that handle data. The level of use is not described in the reports but has been noted through the Open Data Kit (ODK) supportive supervision process.

• What mechanisms are in place to ensure that at each level data is verified by responsible officers and submitted timely? Do SOPs exist and are they clear for staff who handle data in order to ensure standards are followed?

The mechanisms for verification by responsible persons is not very clear from the documents reviewed. 

• Are the required data collection tools available in the required quantities?

The required data collection tools are not available in the required amounts

• Is data reviewed at the different levels by program managers to identify under-served or unserved populations?

This is information was found to be weak.

• Step 8. Describe the data flow of your country.

Flow chart showing data flows and data tools being used across all levels

• Step 9. Make a SWOT analysis.

Make a SWOT analysis for the monitoring system in your country.

Analyze the Strengths, Weaknesses, Opportunities, and Threats.

• Step 10. Summarize what you learned from all of the other steps.

What I have learned from the steps above is that data processed through various ways. A system exists through different domains that need to be fully functional for quality to be assure. Gaps existing compromised the quality of data n the stsyem. Review of documents reveal gaps in the various aspects of the domains including human resources issues such as quantity, availability of tools for use, operating procedure and job descriptions, cldata flow and processing systems, 

Through the SWOT, I have noted that strengths, opportunities, weaknesses and threats are articulated to give a clearer picture of the status of data in as far as data quality is concerned.