Many low-and middle-income countries have pluralistic health systems where private for-profit and not-for-profit sectors complement the public sector: data shared across sectors can provide information for local decision-making. The third article in a series of four on district decision-making for health in low-income settings, this study shows the untapped potential of existing data through documenting the nature and type of data collected by the public and private health systems, data flow and sharing, use and inter-sectoral linkages in India and Ethiopia. In two districts in each country, semi-structured interviews were conducted with administrators and data managers to understand the type of data maintained and linkages with other sectors in terms of data sharing, flow and use. We created a database of all data elements maintained at district level, categorized by form and according to the six World Health Organization health system blocks. We used content analysis to capture the type of data available for different health system levels. Data flow in the public health sectors of both counties is sequential, formal and systematic. Although multiple sources of data exist outside the public health system, there is little formal sharing of data between sectors. Though not fully operational, Ethiopia has better developed formal structures for data sharing than India. In the private and public sectors, health data in both countries are collected in all six health system categories, with greatest focus on service delivery data and limited focus on supplies, health workforce, governance and contextual information. In the Indian private sector, there is a better balance than in the public sector of data across the six categories. In both India and Ethiopia the majority of data collected relate to maternal and child health. Both countries have huge potential for increased use of health data to guide district decision-making.
In India, the central Government is mainly responsible for developing national standards, and sponsoring key programmes while health is a state subject and the state holds primary responsibility for healthcare delivery. The district acts as a link between the state and the local health centres, and is responsible for coordinating with state governments for programme implementation. The service delivery structure in a district comprises primary and community health centres at sub-district level and the sub-centre facility and community level workers at the community level. Through the health sector reform programme the National Rural Health Mission [later renamed the National Health Mission (NHM)] has sought to decentralize planning and increase community involvement, particularly planning and decision-making at district level. Accordingly, a District Programme Management Unit (DPMU) monitors and supports health programmes, collates data and makes plans and budgetary allocation (Ministry of Health and Family Welfare 2006). The NHM further aims to integrate district health plans with those of other sectors such as water, sanitation and nutrition, and to include partnership with non-governmental organizations and coordination with the private health sector (NRHM Division 2007; Ministry of Health and Family Welfare 2012; Prasad et al. 2013). The Ethiopian Government has also taken measures to decentralize the health care system (Earth Institute at Colombia University and Center for National Health Development in Ethiopia). The process of decision-making for health programme development and implementation is shared between the Federal Ministry of Health and the Regional Health Bureaus (RHBs), which also manage policy matters and provide technical support. Zonal Health Departments support the RHBs and District Health Offices in the management of health service delivery, while the District Health Offices are also tasked to manage and coordinate the operation of the primary health care services (Federal Ministry of Health, Ethiopia website). Health services at district level are delivered through Primary Health Care Units (PHCUs). Each PHCU is comprised of one health centre and five satellite health posts. These local health needs are determined through a district-based planning system where the objective is to meet the local health needs within the context of national targets. Health budgets are allocated by the governing body; the District Cabinet, which is responsible for dividing the district budget among different sectors including health, education and agriculture. The study was undertaken in Sitapur and Unnao districts in Uttar Pradesh, India and in Dendi district in Oromia region and Basso district in Amhara region in Ethiopia (IDEAS 2012a,b). Districts were selected in consultation with NHM representatives in India and Federal Ministry of Health and RHB representatives in Ethiopia, and based on variability in the functioning of health facilities and district health administration, which can have an effect on linkages with different sectors and also the nature and type of health data they maintained. We sought state (regional in the Ethiopian context) and zonal government support to facilitate visits to health facilities for meetings with key staff. We conducted an initial scoping visit to meet key informants in the public and private sectors in each district, identified on the basis of their role, knowledge and relevance in terms of managing health data. The team visited both strong and weak facilities, determined by the government representatives, at every level of service delivery, to solicit their cooperation. At this stage we outlined the structure of the health system, linkages between central, state (regional) and district levels and the various non-health departments and ministries in operation. After the scoping visit, data collection was conducted between June and September 2012. In India, we visited eight public health facilities at primary and secondary care levels and in Ethiopia we visited eight public health facilities at the primary care level. A complete listing of private sector organizations, both for-profit and not-for-profit, working on MCH in the selected districts was carried out and from that three private sector organizations in Ethiopia and four in India were included as case studies from the two countries. Private sector organizations were selected with the assistance of the district level health offices, using the selection criteria of having a district level office, a registered license to operate and a major presence in the community. At each selected facility we interviewed administrative heads and data managers, in all 35 respondents in Ethiopia and 18 respondents in India. Semi-structured interview guides were used to understand the structure and functions of the organizations, their activities and the type of data collected and maintained, the use of data for preparing district health plans, and linkages with the other sectors in terms of data sharing and flow. The team collected templates of all the data forms that the facility maintained, both article-based and online. Ethical approval for the study was obtained from the corresponding author’s institute, the Health Ministry Screening Committee in India, and the Science and Technology Ministry in Ethiopia. Verbal consent was obtained for the interviews. A Microsoft Access database was created of all the data forms that are maintained at district level by the public and private health sector. Each data form was given a unique number and was categorized based on its source, level of completion (within the health system) and frequency of reporting. The health system categories were adapted from the WHO framework of health system building blocks (WHO 2007). Thematic areas were first identified (e.g. immunization, human resources and expenditure) and sorted into one of the WHO health system categories. Each data element from the collected forms was then categorized according to thematic area (Table 1). Content analysis of the data elements in each form was conducted to capture the type of data available for different health system levels, the level of data sharing and the flow (Weber 1990). An in-depth analysis was done to understand the MCH service delivery data and distal services affecting MCH outcomes such as nutrition, water and sanitation, family planning and abortion care. Framework for health system data.
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