Data for Decision Making: Using a Dashboard to Strengthen Routine Immunisation in Nigeria

"Our experience highlights the need for early and sustained advocacy to stakeholders in a decentralised health system to promote ownership and sustainability of a centrally coordinated systems strengthening initiative."

Following the adoption of District Health Information System version 2 (DHIS2) as a national electronic data management platform in Nigeria, the DHIS2 RI Dashboard Project was initiated to address the absence of some routine immunisation (RI)-specific indicators on DHIS2. The project was also intended to improve visibility and monitoring of RI indicators and to strengthen the broader national health management information system by promoting the use of routine data for decision making at all governance levels. This paper documents the process, challenges, and lessons learned in implementing the project in Nigeria.

The overarching purpose of the DHIS2 RI Dashboard Project was the improvement of data quality and use of data for decision making. Specific objectives were to: develop, pilot, and scale up an RI dashboard on DHIS2 for monitoring of key RI indicators; accelerate national deployment of DHIS2 for PHC data management and use; provide information for better targeting of enhanced supportive supervision; and improve use of good quality RI data for decision making at all levels. A multistakeholder technical working group developed an implementation framework with clear preimplementation, implementation, and postimplementation activities.

For example, given the fundamental changes this project would bring to RI data management system in Nigeria, it was necessary to secure the broadest stakeholder engagement possible prior to implementation. At the national level, these engagements were made through the existing working groups including the Routine Immunization Working Group and the Monitoring and Evaluation (M&E) Working Group. In order to translate this to subnational levels, multistakeholder advocacy and needs assessment missions were incorporated into preimplementation activities. These missions had the objective of securing commitments and promoting ownership and leadership by the states and local governments prior to any implementation activity. After the state-level meetings, a joint needs assessment visit with each state team was conducted to 4 local government areas (LGAs) and 4 health facilities (HFs) within each LGA. Two of the best-performing and 2 of the worst-performing LGAs were selected. Within each selected LGA, 2 high and 2 low patient-volume HFs were selected for assessment. The LGA and facility visits were necessary to tailor interventions to the needs of each state.

A pilot phase was conducted for the purpose of refining processes and providing evidence for advocacy to funders and stakeholders. For DHIS2 RI Dashboard Implementation Project, Kano State was selected for the pilot. Activities at the pilot included planning, logistics, development of a training module and a training of trainers. The Kano pilot was conducted between November 2014 and February 2015. The lessons learnt during the implementation of each component helped to improve the scale-up to other states.

As of the end of 2016, nearly 34,000 health workers of different categories and administrative levels had been trained on RI data tools and DHIS2 use. The project contributed to the improvement in completeness of reports on DHIS2 from 53% in first quarter 2014 to 81% in second quarter 2017. In the second half of 2014, only one state scored 80% or more on timeliness of reports and 14 states scoring 50%-80%. By the first half of 2017, 10 states scored 80% or more, while just 6 states scored below 50%. Regarding RI, the project led to a marked improvement in the availability of coverage data from HFs in every region of Nigeria. The national composite coverage reports for the third dose of pentavalent vaccine (Penta 3) improved from 56% in 2014 to 84% in 2017.

Furthermore, "The deployment of the DHIS2 RI Module has led to improved ownership of RI data by states and LGAs as they now have real-time access to their data...Use of RI data for decision making has also improved through regular monthly review of the DHIS2 RI dashboard, which summarises the performance of LGAs or HFs on selected indicators. The review helps managers prioritise HFs for supportive supervision and other support to improve overall performance."

The project faced challenges relating to primary healthcare governance structures at the subnational level, infrastructure (internet access), and human resource capacity. For instance, the transition meant that lines of authority were not always clear: There were problems around who made the decisions on who got trained and which agency of government would lead the process. This led to delays. Sustained high-level advocacy to the states ensured that these challenges were eventually resolved.

This experience highlights the need for early and sustained advocacy to and dialogue with stakeholders in a decentralised health system to promote ownership and sustainability of a centrally coordinated systems strengthening initiative. Going forward, it is important to ensure that all personnel appointed as monitoring and evaluation (M&E) officers are skilled in the use of computers.