This case study presents some of the early experiences of the Maternal and Perinatal Death Review programme in incorporating maternal and neonatal death notification data into the District Health Information System (DHIS2). We hope to provide more insights as the programme progresses.
Over the past five years, the Ministry of Health and Family Welfare in Bangladesh has set as its priority the introduction of a web-based Health Management Information System (HMIS). In 2009, the HMIS was first transferred online under the coordination of the Directorate General of Health Services (DGHS). The web-based HMIS is seen as an opportunity to provide easy public access to data on key health indicators, including registration of pregnant women and coverage of antenatal and postnatal care.
In October 2013, the DGHS incorporated the web-based data collection software – District Health Information System (DHIS2) – into the HMIS. This software is an open source tool which enables users to collect, validate, analyse and present aggregated data related to HMIS activities. DHIS2 enabled routine data to be inputted directly into the HMIS at the district level from the government health facilities, rather than at the national level from paper- based reporting sent through email. As such, this functionality provided the scope for each maternal and neonatal death captured from each district to be inputted directly into the central HMIS system.
In light of this functionality, in October 2014, the Maternal and Perinatal Death Review (MPDR) programme undertook a pilot of incorporating maternal and neonatal death notification data into the DHIS2 in Netrokona district with support from UNICEF and the Centre for Injury Prevention and Research, Bangladesh (CIPRB). Before this pilot, death notification was inputted into the HMIS on a monthly basis from the district. This made it difficult to review progress from the national level.
The pilot began in Purbadhala Upazila in Netrokona District with maternal death data being entered each month into DHIS2 by sub-district statisticians from the Upazila Health Complex (Primary Health Care Centre). The statistician received notification of the deaths from field level health workers (e.g. Community Health Care Providers (CHCP)). The deaths were uploaded for each community clinic catchment area.
- The pilot set an example of how to incorporate MPDR into the existing HMIS system using the web-based DHIS2 system. Following the pilot, maternal and neonatal death data from the MPDR programme were uploaded into DHIS2 from three hard-to-reach districts of Bangladesh (Bandarban, Cox’s Bazar and Netrokona).
- The death registration data inputted into DHIS2 enabled, for the first time, district level maternal mortality ratios and neonatal mortality rates to be generated.
- Inputting maternal deaths into DHIS2 acted as a monitoring tool of the HMIS system. For example, the fact that not all maternal deaths reported into DHIS2 showed up as registered as pregnant demonstrated that not all pregnant women were being recorded in HMIS and that not all maternal care was being provided to women who needed it.
Key challenges and lessons learned:
The pilot has demonstrated that online notification of maternal and neonatal deaths is possible at the Upazila level. Nevertheless, there were challenges in implementing the pilot. For example, a lack of trained health care providers to enter data into the HMIS and DHIS2, and poor internet connection and limited electricity at hard to reach community clinics, which meant that deaths could not be inputted into the DHIS2 system by CHCPs.
These challenges were addressed by ensuring the training of CHCPs in MPDR and data entry, and having statisticians enter the deaths into the system at the Upazila Health Complex, rather than by the CHCPs at the community clinics. Moreover, having the statisticians enter the data into the system meant that any death that occurred outside the coverage area of the community clinic, which the CHCPs are responsible for, would still be entered into the system.
In light of the feasibility of the pilot, it is expected that by the end of 2015, DHIS2 will be used to collect data on maternal deaths in 10 MPDR-focused districts. It is hoped that linking MPDR and DHIS2 will ensure improved measurement and standardization of the health services through evidence-based quality data. This data will enable better support for decision making by local level managers and in developing evidence based plans at sub-district level.
The case study was written by Dr Animesh Biswas, Senior Scientist at the Reproductive and Child Health (RCH) unit of CIPRB with support and review by Dr Shukhrat Rakhimdjanov, Heath Manager (HSS), Dr Riad Mahmud, Health Specialist, UNICEF Bangladesh and Prof Abdul Halim, Director, RCH unit of CIPRB. Email: firstname.lastname@example.org, email@example.com
Photo credit: Todd Post
 Upazilas are sub-districts in Bangladesh