Effects of primary healthcare reform on routine health information systems (RHISs): a mixed-methods study in Lesotho

Abstract

Background and objective: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement.

Methods and analysis: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR.

Results: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts.

Conclusion: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR.

Keywords: health services administration & management; international health services; organisation of health services; primary care.

Figure 1

Map of districts in Lesotho. Included are LPHCR pilot districts highlighted in colour and those not LPHCR in black ink. Three of the districts are conterminous, while Mohale’s Hoek is located in the southeast by itself. LPHCR, Lesotho National Primary Health Care Reform.

Figure 2

The Performance of Routine Information System Management framework was developed by MEASURE Evaluation to assess quality and utilisation of RHISs while examining possible gaps in the process related to behavioural, technical and organisational determinants. IT, information technology; RHISs, routine health information systems.

Figure 3

The WHO Data Quality Assurance framework was used to select key primary healthcare indicators for data completeness assessment. Here we used this framework to assess the average completion rate during the three study periods. We included two time segments referring to LPHCR and Test and Treat (TT) implementation. ANC, antenatal care; ART, antiretroviral therapy; LPHCR, Lesotho National Primary Health Care Reform; TB Tx, tuberculosis treatment.

Figure 4

Forest plot visualisation of unadjusted and adjusted regression results for the key WHO Data Quality Assurance indicators. ANC, antenatal care; LPHCR/TT, Lesotho National Primary Health Care Reform with Test and Treat; PNC, postnatal care.