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31 July 2018 -
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Daily Reflections
31 July 2018
Today we went to the Provincial Medical Directorate and listened to presentations by many directors of various projects and programs. To start, I have to say it was a long day, I wish we'd had lunch to separate the presentations a little more -- they said lunch was at 3:00, which we'd all though was a joke (it wasn't). Also there was a rooster crowing the entire day, but those are all side notes before I begin. (:
The first presentation we listened to was interesting, and talked about surveillance systems, specifically with Malaria. I thought it was interesting how they determined under control populations, pre-elimination populations, and elimination populations. Also, how they used passive patients to then find active patients and address an outbreak. We also got an overview of Matabeleland North as a province, and their progress in comparison to the rest of the country. Next, we received a presentation on the National Health Information System. The NHIS is the data collection system used to measure program impacts, facilitate research, inform and raise awareness to staff and communities on health issues, and more. In order to keep information straight, each entry has a unique identifying number (country, province, district, institution). The reporting of this data is done by health care workers by transporting hard copies, stated over telephone, through text message, the DHIS2 web based database, and line lists in the form of excel worksheets. First, I asked a lot of questions specifically about the reporting of data and seeing if all data is actually reported, which I will speak to in a moment. But, now that I'm thinking about this system again, I wonder what state the data is in when entered. Most likely, I'd guess, there are inconsistencies in how data is entered as many are not consistently trained due to low resources and funding. Data is already difficult to clean in organized data sets, so if there are any inconsistencies it would take a lot of skill and time to clean the data set into useable information.
Returning to the questions I asked during the presentation, I am still not convinced of the accuracy of the data, as in the FETP presentations, every presentation on surveillance system efficiency highlighted that data reporting is very low, making research additionally difficult. This inconsistency between presentations forces me to take the information today with a grain of salt. I asked what incentives they use to get health workers to report, and they cited accountability. However, I'd bet money an overworked nurse getting off a long shift may not report every case due to fatigue. I wonder if a worker would lose their job if they under reported?
The NHIS definitely is not a perfect system, however I think a lot of the inconsistencies would be improved with a digitized system, as medical records could be anonymized and directly reported to the NHIS without any extra work by health care providers. The challenges then through are lack of consistent electricity and wifi as well as the training necessary to make the system sustainable and well functioning. I would like to see up close this reporting process, I think it'd be really interesting to see the process in action!
Finally, we also received presentations on VIAC and EPI in Met North.
On our way home we stopped at Jairos Jiri, a craft shop in Bulawayo which sells art by disabled Zimbabweans. Then we also went to the shops along the road. This I think was my favorite part of the day -- I love the cultural lessons surrounding the artwork!
Addition: I am continuing to watch and learn, I want my learning to be as well rounded as possible, so I'm trying not to lean one way or another especially when I believe I haven't heard everything there is to hear. I believe I'll see and hear that in the next weeks!
The first presentation we listened to was interesting, and talked about surveillance systems, specifically with Malaria. I thought it was interesting how they determined under control populations, pre-elimination populations, and elimination populations. Also, how they used passive patients to then find active patients and address an outbreak. We also got an overview of Matabeleland North as a province, and their progress in comparison to the rest of the country. Next, we received a presentation on the National Health Information System. The NHIS is the data collection system used to measure program impacts, facilitate research, inform and raise awareness to staff and communities on health issues, and more. In order to keep information straight, each entry has a unique identifying number (country, province, district, institution). The reporting of this data is done by health care workers by transporting hard copies, stated over telephone, through text message, the DHIS2 web based database, and line lists in the form of excel worksheets. First, I asked a lot of questions specifically about the reporting of data and seeing if all data is actually reported, which I will speak to in a moment. But, now that I'm thinking about this system again, I wonder what state the data is in when entered. Most likely, I'd guess, there are inconsistencies in how data is entered as many are not consistently trained due to low resources and funding. Data is already difficult to clean in organized data sets, so if there are any inconsistencies it would take a lot of skill and time to clean the data set into useable information.
Returning to the questions I asked during the presentation, I am still not convinced of the accuracy of the data, as in the FETP presentations, every presentation on surveillance system efficiency highlighted that data reporting is very low, making research additionally difficult. This inconsistency between presentations forces me to take the information today with a grain of salt. I asked what incentives they use to get health workers to report, and they cited accountability. However, I'd bet money an overworked nurse getting off a long shift may not report every case due to fatigue. I wonder if a worker would lose their job if they under reported?
The NHIS definitely is not a perfect system, however I think a lot of the inconsistencies would be improved with a digitized system, as medical records could be anonymized and directly reported to the NHIS without any extra work by health care providers. The challenges then through are lack of consistent electricity and wifi as well as the training necessary to make the system sustainable and well functioning. I would like to see up close this reporting process, I think it'd be really interesting to see the process in action!
Finally, we also received presentations on VIAC and EPI in Met North.
On our way home we stopped at Jairos Jiri, a craft shop in Bulawayo which sells art by disabled Zimbabweans. Then we also went to the shops along the road. This I think was my favorite part of the day -- I love the cultural lessons surrounding the artwork!
Addition: I am continuing to watch and learn, I want my learning to be as well rounded as possible, so I'm trying not to lean one way or another especially when I believe I haven't heard everything there is to hear. I believe I'll see and hear that in the next weeks!
1 August 2018
Today we went to the Tsholotsho District Hospital (a two hour drive from Bulawayo). First, we received a presentation and had a discussion with Alfred and the rest of the PMD staff. The presentation was very data driven and spoke of challenges and where to improve upon. As I watched this presentation, I was thinking about my feelings towards the reporting system. Even if there are inconsistencies and reports not taking place or documents forgotten in the reporting process, there are most likely consistencies in where this lack of reporting takes place, and therefore the data can still be used to make decisions. Especially when seeing how much data drives decisions -- specifically in regards to funding all the down to the clinics -- I can see that the system does its purpose, even though its purpose may be better informed with an upgraded system. This observation was also a confirmed view of Alfred, where he stated that reporting would improve once they implemented a digitized system.
The funding of clinics I mentioned, is based on performance of the clinic. If it performs highly, it receives funding. If it doesn't, it loses funding. This system has been proved to work, but the piloting of this program in regards to Child and Maternal Health improvement was funded by donor programs, and with the expansion of this system to other programs there is not enough funding to support it. However, they have implemented the program non-the-less and have created the necessary competition to improve health care facilities. This improvement of health care also saves money down the road!
I also found their comments on international funding refreshing to hear, as there wasn't much criticism yesterday and I was a little worried they'd refrain from criticizing. However, today they spoke about how they wished donors would fund holistically rather than for a specific problem -- health care needs are different every year, and funding should be allocated accordingly, however when it's specified, money is sitting while it could be used to save lives in another health field.
Today, I became, again, impressed with how thought out their system is. If Zimbabwe wasn't underfunded, their system would thrive. Especially with the HIV/AIDS patient-centered care to improve adherence, as well as the expecting mothers stay, Zimbabwe has created innovative solutions with low resources.
I'm excited to see more parts of the reporting system tomorrow. I saw the room which they input records and it is filled with paper documents. This was really cool to see. I want to learn more about how it all works, and how they plan on making the transition to digitized records as smooth as possible.
The funding of clinics I mentioned, is based on performance of the clinic. If it performs highly, it receives funding. If it doesn't, it loses funding. This system has been proved to work, but the piloting of this program in regards to Child and Maternal Health improvement was funded by donor programs, and with the expansion of this system to other programs there is not enough funding to support it. However, they have implemented the program non-the-less and have created the necessary competition to improve health care facilities. This improvement of health care also saves money down the road!
I also found their comments on international funding refreshing to hear, as there wasn't much criticism yesterday and I was a little worried they'd refrain from criticizing. However, today they spoke about how they wished donors would fund holistically rather than for a specific problem -- health care needs are different every year, and funding should be allocated accordingly, however when it's specified, money is sitting while it could be used to save lives in another health field.
Today, I became, again, impressed with how thought out their system is. If Zimbabwe wasn't underfunded, their system would thrive. Especially with the HIV/AIDS patient-centered care to improve adherence, as well as the expecting mothers stay, Zimbabwe has created innovative solutions with low resources.
I'm excited to see more parts of the reporting system tomorrow. I saw the room which they input records and it is filled with paper documents. This was really cool to see. I want to learn more about how it all works, and how they plan on making the transition to digitized records as smooth as possible.
2 August 2018
Today we went back to the Provincial Medical Directorate for more presentations. We received presentations on the DHIS2 system, Nutrition, Rehabilitation, Pharmacy supply chain, and EPI. We also received a tour of the cold room where they keep the vaccines.
We started the day with the presentation on the DHIS2. This presentation was extremely beneficial for me because it really answered all my questions. Seeing the system online as well as the hard copy data records was really helpful in understanding the system. When we received our initial presentation on the data reporting system, there was not a clear indication of the hard copy system -- I didn't know how consistent the reporting methods were across districts, etc. The hard copies are used at every health care facility and are extremely self explanatory; they would be difficult to mess up. When inputted into the computer, the system is set up pretty well, and is pretty user friendly. Being shown once would allow someone to use the system effectively. Inputting data is easy as well, as the online system input is set up the same way as the hard copies; it's in the same order and looks the same on the screen. The online program also provides options of excel files as well as .csv files. The woman who was showing us the program said she doesn't use the .csv files, which makes sense. For making general to relatively advanced graphs, you can do that with just an excel file. However, more in depth analysis which requires the use of a programming environment, one would import the .csv file to utilize the data.
Overall, after seeing this presentation, I'm convinced the reporting, despite its challenges, is very well implemented. The distances and internet challenges of the country are very limiting, and I'm impressed with the quality of this system. I think another thing which has made me realize this is the drive to Tsholotsho in combination with todays presentation. I now actually understand how distance could be a real issue.
The only thing that was a little odd to see was the Not Secure warning on the webpage, as well the address missing an https:// which also indicates an unsecured network. I asked her if that was there always, and she said yes. When we got home I checked the webpage myself, and my phone warned me the connection was not secure as well. I don't know a lot about internet security, but I know that many websites which contain sensitive information pay for webpage security for usernames and passwords. I'm not sure about government websites, but I know this is true at least for social media sites, email sites, etc. Government websites may have a separate security system implemented. The other thing which could be a concern in regards to security is if individuals login under and open internet connection. When logged in under open internet, it's easy for an individual to remotely watch what they're doing and steal passwords and usernames. I'm not sure if this is a concern, as I'm not sure why someone would want to hack into the DHIS2 system, but it's something to think about.
The other presentations were interesting as well, but I definitely got the most benefit from the first!
We started the day with the presentation on the DHIS2. This presentation was extremely beneficial for me because it really answered all my questions. Seeing the system online as well as the hard copy data records was really helpful in understanding the system. When we received our initial presentation on the data reporting system, there was not a clear indication of the hard copy system -- I didn't know how consistent the reporting methods were across districts, etc. The hard copies are used at every health care facility and are extremely self explanatory; they would be difficult to mess up. When inputted into the computer, the system is set up pretty well, and is pretty user friendly. Being shown once would allow someone to use the system effectively. Inputting data is easy as well, as the online system input is set up the same way as the hard copies; it's in the same order and looks the same on the screen. The online program also provides options of excel files as well as .csv files. The woman who was showing us the program said she doesn't use the .csv files, which makes sense. For making general to relatively advanced graphs, you can do that with just an excel file. However, more in depth analysis which requires the use of a programming environment, one would import the .csv file to utilize the data.
Overall, after seeing this presentation, I'm convinced the reporting, despite its challenges, is very well implemented. The distances and internet challenges of the country are very limiting, and I'm impressed with the quality of this system. I think another thing which has made me realize this is the drive to Tsholotsho in combination with todays presentation. I now actually understand how distance could be a real issue.
The only thing that was a little odd to see was the Not Secure warning on the webpage, as well the address missing an https:// which also indicates an unsecured network. I asked her if that was there always, and she said yes. When we got home I checked the webpage myself, and my phone warned me the connection was not secure as well. I don't know a lot about internet security, but I know that many websites which contain sensitive information pay for webpage security for usernames and passwords. I'm not sure about government websites, but I know this is true at least for social media sites, email sites, etc. Government websites may have a separate security system implemented. The other thing which could be a concern in regards to security is if individuals login under and open internet connection. When logged in under open internet, it's easy for an individual to remotely watch what they're doing and steal passwords and usernames. I'm not sure if this is a concern, as I'm not sure why someone would want to hack into the DHIS2 system, but it's something to think about.
The other presentations were interesting as well, but I definitely got the most benefit from the first!