|Subject Area="Health information systems."
||Objective="Performance monitoring to improve services."
|Details for Reform Option "Institutional Service Monitoring Report, Tamil Nadu"
There was no consistent reporting of institutional activity within Tamil Nadu’s health system, especially with regard to Primary Health Centres (PHCs), prior to 1999.
The implementation of an Institutional Service Monitoring Report (ISMR), funded initially by DANIDA. PHC staff are asked to fill in a computer-readable form every month which gives details of:
(i) outpatient and inpatient attendances,
(iv) minor surgery,
(v) laboratory investigations,
(vi) vaccines administered,
(vii) Indian system of medicine out patients etc.
The form was designed after careful consultations at all levels including PHCs and considerable effort was invested in sensitisation and training of all those concerned. These record forms have been produced as bound registers in different colours and numbered. Similar registers are also maintained at the Sub Centre and First Referral Unit (FRU) levels.
The form is filled out monthly and sent to the statistical section of the Public Health Directorate of the State Department of Health and Family Welfare for analysis.
They use an “Optimum Mark Reader” (OMR) which scans each form and permits, by means of a computer link, the tabulation, consolidation and analysis of a number of parameters.
The information is analysed for each level of the health care system: PHC, health unit district, health district and state.
By the 10th of the month, the data for the previous month is submitted by the districts to the statistical department.
By the 15th, it is scanned, consolidated and analysed and sent to the Chief Minister and to the Health Minister and his senior officials.
By the 20th of the month, feedback is provided to the District Collector and field level staff through the district.
The Institutional Service Monitoring Report (ISMR) has proved to be an excellent tool for constructive criticism leading to better service.
Since its introduction, there has been much greater awareness of performance levels which are discussed in review meetings at both district and PHC levels.
Substantial improvements in activity levels have been recorded which appear to be directly linked to the implementation of monitoring.
Between April 1999 and April 2004, the proportion of PHCs (out of 1,413) carrying out deliveries rose from 40% to nearly 90%.
Average daily outpatient attendances at PHCs rose from 68 to 116 (60% of this increase took place in the 8 months following the introduction of monitoring).
||Total Costs: INR 2,000,000 including:
Printing of OMR sheets: INR 100,000
Printing of registers: INR 700,000
Training of staff: INR 200,000
OMR scanning machine (a one-off cost) and annual maintenance cost: INR 1,000,000 (€17,915)
||Tamil Nadu. Autumn 1998 - December 2003 under the DANIDA project. This has since been continued by the State government and is now part of their regular reporting process.
||Formation of expert group to decide the selection of indicators: one month.
Proposal to funding agency: one month.
Proposal to government for getting orders: one month.
Discussion with stakeholders: one month.
Pre-testing forms: one month.
Printing of forms: two months.
Procurement of OMR equipment and computer accessories: one month.
Procurement of software for analysis: two months.
State level training of the use of forms: one month.
District level training: one month.
PHC level training: one month.
Simplicity: The monitoring forms are easy to fill in. The process at PHC level is manual so that no computer skills or equipment are needed. However, the forms are computer readable so even the analysis is very simple and easy to implement.
Speed: The system allows quick and comprehensive analysis and feedback. Shortfalls and lapses are highlighted and queries are raised. Reasons for good or bad performance are elicited through query and discussion.
Information: Knowledge of the workload has also permitted more rational allocation of staff.
Accuracy essential: As with any statistical system, the information obtained is only as good as the accuracy of the input. It is therefore important to monitor regularly the quality of the data recorded.
Increased workload: Possible opposition from PHC medical officers and district officers who may see this activity as an additional responsibility.
-- Funding support to sustain the activity.
-- Willingness of the department to internalise the activity.
-- Availability of trained personnel.
|Who needs to be consulted
District health managers.
State & district level staff.
PHC medical officers and statistical staff.
The Danida funding support was withdrawn from December 2003 onwards but the ISMR monitoring system was taken on by the Directorate of Public Health & Preventive medicine department from 2002.
Now ISMR is part of the regular reporting system of the directorate and functioning very well.
Based on its success, a PHC outreach services monitoring format (OSMR) is also being developed (August 2004) and is expected to become operational soon.
|Chances of Replication
This simple and effective system would appear to be easily replicable.
Andhra Pradesh also runs a Health Management Information System.
Securing ownership of the scheme through careful preparation of personnel at all levels is an important contributory factor to the success of the scheme.
Sara Joseph, ECTA, New Delhi. September 2004
||Registers filled in by the Village Health Nurse at sub-centre level