In search of the missing data. The case of maternal and child health data in Malawi

Abstract

Health reform initiatives in most developing countries include introduction of information and communication technologies (ICTs). Conventio nally, it is thought that the introduction of ICTs will also help to modernize traditiona l work practices around data is collection, processing and reporting. However, this is not necessarily the case in a setting where there is a duality of modern and traditiona l practices. The traditional practices are deeply embedded in the cultural, economic and social life of people, something which ‘computerization’ fails to overcome. The dilemma is that although a high percentage of preg nant women still utilise the traditional health sector for delivery and child care, most of this data is not collected and entered in the official health information systems (HIS). In Malawi, as in most sub-Saharan Africa in general, the majority of people (about 80%) reside in rural areas, with limited abilities to access or afford the modern health services, forcing them to rely on traditional health services. Despite this de mographic reality, most reform initiatives involving ICTs tend to focus on the health facilities (“modern” health sector) and not on the rural community (traditional health sector) whic h is majority of the population. In this thesis, I explore the challenges in rea lizing good data quality for HIS in this context. Socio-cultural conditions, governance issues, vari ous policies, and political realities, are all seen to (adversely) influence the quality of data, and this thesis explores the nature of these influences. The research also addresses wheth er the current HIS implementation, one that excludes those using traditional services, can pr ovide solutions to strengthening HIS data quality and support health impr ovement interventions. Empirical ly, I use case studies from Malawi, focusing on maternal and child-health-related data. An interpretive approach using qualitative methods was adopted in the study in or der to uncover the depth and breadth of the practices that leads to generation of maternal and child health data in both modern and traditional health sectors. Data was collected over a two-year period from June 2008 to July 2010. Theoretically, concepts from the community of practice (CoP) theory are used to establish an understanding of practices across the traditional and modern sectors of the Malawi health system, the flow of data, and nature of li nks within these networks. The thesis draws contributions to the information systems field, specifically HIS, and to the health domain. Theoretically, the study extends the CoP theory with weak link concept. Practices, knowledge, and data are shared acro ss the organization through CoPs linkages, and these links needs to be strengthened. If any of the links is weak, knowledge, practices, and data are not shared consistently and some data may be lost. Practical contributions include the following recommendations: i) From a political perspective, the formulation and implementation of policy decisions should be gu ided by consensual processes, involving participants from health sector at all levels, and not rely on the use of top-down approaches. ii) governance mechanisms needs to utilize existing structures and enhance existing practices to capture data - such as having a village chief record the data when community members reports a birth and/or death in their community. iii) There is need to introduce policies that enhance strong collaboration be tween modern and traditional health sectors, allowing births taking place out of modern health sector to be recorded in a health passport by a chief. iv) Knowledge and practices generated in the traditiona l sector need to be taken on board to assist in capturing data generated in that sector . Community health workers known as health surveillance assistants (HSAs) should act as knowledge brokers, and should be given hardbound note books for capturing data instead of loose forms. In areas where there is coverage, HSAs and chiefs should be given mobile phones for sharing data.