Designing Better Hospital Mortality Systems

Improving hospital systems in Mozambique ACHIEVEMENTS, CHALLENGES & OPPORTUNITIES

2006-2015

Dra Cidália Baloi, MOH

Dra. Esperança Nhagumbe, MOJ

Mr. Ivan Mabote, UEM-Moasis/Jembi

(on behalf of Dr. Alessandro Campione)

Ministério da Saude

CAIRO, EGYPT 2015

Ministério da Justiça

MOASIS is a non-profit organization of University Eduardo Mondlane, Living Lab created and

supported entirely by JEMBI with support of IDRC, CDC, WHO, Rockefeller and others ORG. We

aim to:

Strengthen HIS local capabilities involving the public, private and academic sectors

Reference and link between the MOH and public/private partners

Set up a South-South cooperation model

JEMBI/MOASIS model

Rationale

Before 2006: Mortality data collected through census/surveys and ad hoc studies

2006: pilot implementations of mortality and morbidity reporting using ICD-10

coding in 2 hospitals

MOH recognized the need for mortality statistics at hospital level and lacking of vital

statistics in the country

Strategy to address the need

MOH and partners revised entirely the national death registration system aiming to:

Strategic Priority: National level system for hospital mortality registration

Contribute to CRVS national reform (medium/long term)

Expansion to extra-hospital deaths in coordination with all CRVS stakeholders (Long

term)

Little pilot

Review of mortality system

In health sector

First ICD-10 Hospital Mortality System

Enhancement of electronic tool for

intra-hospital mortality register (SIS-ROH)

SIS-ROH expanding to all Mozambique

(till Sept 2015 = 44 sites, >100,000 records)

Strengthening of the whole

CRVS system and inter-institutional cooperation

Revision of Mortality registration System

2007

2008

2009

2013

2010

2015

Background (cont.)

CRVS COMPONENT

UEM-Moasis supported the creation Inter-institutional Group for Civil Registration and

Vital Statistics

Mozambique is one of the few African country that have this formalized and with a

Work Plan and is considered a best practice in the field of Mortality System

implementation.

Set up cooperation with Medical Research Council, WHO and STAT-SA

Promoted MoH as active member of WHO-FIC community

Constituted the Inter-institutional Vital Statistics Working Group (MoU) MOH, MOJ,

UEM/MOASIS, INE, MI.

Performed the In-depth assessment of CRVS and plan of action for CRVS Reform in

Mozambique

Participate to the CRVS reform

and working group

Visit to Stats SA

WHO-FIC

Conference

Cape Town

Planning stage (including the revision of the inquiry form for death registry

and cause of death)

Technical and financial support in the filed work (e.g. Boane)

Support and facilitated the consolidation meeting and training of the 2

components)

Support the draft, conclusion and approval from GITEV of the CRVS

operational plan

JEMBI-MOASIS active role in the CRVS in-depth

assessment

Mortality Registry System in Mozambique

- Analysis of death certification process - New national regulation - New death certificate

ICD-10 adopted as national standard FULL AND REDUCED LIST

2007 - 2008 2013-2015

• Expansion to 44 SITES

• extra-hospital deaths Expansion

• Update of analysis

• Report of Assessment of Death and Cause of Death Registration (CRVS Assessment)

• SIS-ROH APPLICATION VERSION 2.0 (web-based)

• 3rd National Mortality Data Analysis Report published

• Cuamba Rural Hospital Independent Mortality Data Analysis Report (Independent)

• Set up of ELECTRONIC Intra-hospital mortality register (SIS-ROH)

• Training >300 STAFF on ICD-10 and death registration

First national mortality analysis based on routinely collected data

2008 - 2013

-Expansion to 14 hospitals hospitals -New Death certificate approved

SIS-ROH official death registration of national health system

SUCCESS FACTORS

IT PROBLEM &

TECHNOLOGY

MANY FOCUS HERE

CLINIC/PUBLIC

HEALTH PROBLEM

NEED ASSESSMENT

PROJECT,

AGREEMENTS

FUNDRISING

COMMITMENT

REQUIREMENTS TRAINING

DEPLOYMENT

INTEGRATION

DATA QUALITY

PUBLICATION AND USE

MAINTENANCE

SUPPORT AND

SUSTAINABILITY

1. FOCUS ON THE WHOLE SYSTEM

CLINIC/PUBLIC

HEALTH PROBLEM

PROJECT,

AGREEMENTS

FUNDRISING

COMMITMENT

DEPLOYMENT

INTEGRATION

2. Institutional and Stakeholder support

Bottom-up approach

Start little, be pragmatic

Respond to needs of health workers first

Obtain concrete results and grow based on success

Local ownership and MOH commitment

Informatics solutions suitable to the country setting

basic computer technology

modular design, open source

minimum data set and introduction of standards

Creation of high level WG was a milestone to reach governmental

commitment to strengthen the overall CRVS

MOH/ UEM-MOASIS/JEMBI Collaboration for SIS-ROH

MOH has the ownership and provide overall direction and

supervision to all joint projects

UEM-MOASIS: UEM project design an all aspects, supports

development of system and software, implementation and

maintenance of all tools and training at the national level

Jembi: South African NGO, provides technical and financial

support to UEM-MOASIS

Institutional and Stakeholder support (cont.)

3. SIS-ROH SOFTWARE (success factor) Simple Individual based electronic register

• Registration of:

• Demographic data

• Data on hospitalization

• Causes of death (underlying and direct)

• Filing support

• Data used locally, in real time and highly accepted by users

• Data used at national level for health policy (yearly)

• Increasing geographical coverage with stable data quality

Data & standard

reports

available at

hospital and

national level

4. Country specific solutions

mICD SIS Compact

Station (Internet 3G) – Connectivity

issues mitigated, low virus

contamination, dedicated

to national HIS

ICD-10

Short list

5. IT In the Provinces

IT technicians supporting Health

facilities at the district and

provincial

Constant IT support and

maintenance, correction of bugs and

errors, helpdesk, troubleshooting to

ensure proper functioning of the HIS

and infrastructure at HF level

1 technician present in every

province of the country (MOH/DIS

with support from UEM-

MOASIS/JEMBI).

6. Quality Assurance

Mechanisms

Training:

At central and provincial level:

TOT on death certification and ICD-10

Training on SIS-ROH software for long term

maintenance

In each new implementation site:

Training on death certification and ICD-10 for clinical staff and Statistical unit staff

Training on SIS-ROH software for data management, filing, backup, maintenance

• SIS-ROH inbuilt data validations (cause of death coding according to age, gender, etc.)

• Routine data analyses, presentation/discussion and publication

• Data Quality assessments and supervision

Use of data at local and national level

OPPORTUNITIES &

FUTURE PROSPECTS

SIS-ROH VERSION 2.1

New Version of the Death

Registration system

Web-based

Standardized reports

Inclusion of maternal and foetal

deaths

Expansion to extra hospitals deaths

Expansion to the community

certification

Migration of SIS-ROH 2.1 into DHIS 2

platform – tracker module (testing)

Integration of SIS-ROH with other HIS

in Mozambique

Ongoing the SIS-ROH2 interoperability and

integration with some national HIS including

the greater national CRVS System, supported

by UEM-MOASIS/JEMBI including: • SIS-H = hospital IS based on short lists of ICD-10 for morbidity

reporting

• SIBI = patient based system for chronic patients

• SIS-MA = national M&E information system

Systems Integration & Interoperability

(CRVS)

CURRENT STATUS IN MOZAMBIQUE

Systems Integration & Interoperability

(CRVS) (cont.)

POSSIBILITIES FOR SYSTEMS INTEGRATION & INTEROPERABILITY

AMONG SYSTEMS & DATA SHARING

Mozambique CRVS Information Exchange Proposal

ACHIEVEMENTS AND IMPACT

SIS-ROH (Death Registration System)

Implemented in 44 sites (36 HF) at national level

(All Central & Provincial Hospitals, some rural

hospitals)

Training materials/IT support/on the job

training/Refresher by UEM-MOASIS/JEMBI

supporting MOH

Use of ICD-10 codes for causes of death (reduced

list at first, now full ICD-10 coding)

>300 staff trained

Expanded to Extra-hospital death

Increase in death

registration (2009-2013)

IMPACT

SIS-ROH

training

Before 2006, mortality data was acquired from

census and surveys

2009: Mozambique produced first data analysis

mortality report (extracted from SIS-ROH)

3 National reports to date have been produced

(The latest published data from 2009-2013)

Cuamba Rural Hospital Report (done by national

staff at own initiative)

>100.000 deaths registered

Data are also shared and used by INE for

specific epidemiological and statistical analyses

Regular use in Health Units for quality of care

and planning

DATA ANALYSIS, PUBLICATION AND USE AT NATIONAL AND

LOCAL LEVEL:

posters national and international, articles, regular

governmental statistic publications, specific study etc.

SIS-ROH NEW SIMPLIFIED DATA FLOW CYCLE PROCESS

250 copies reproduced and

distributed by the MOH to INE

(Body of National Statistics), to

the provincial levels (DPS), and

the national MOH Directorates.

THE LATEST PUBLISHED DATA FROM 2009 - 2013

0

2

4

6

8

10

12

14

16

18

Surgery Gyneco/Obst Medicine Orthopedics Pediatrics

2008 2009 2010 2011 2012 2013

Intra-hospital mortality rates in Central

Hospital of Maputo by department, 2008-

2013

Causes of death in the Paediatrics

department of Central Hospital of

Maputo, 2009-2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009 2010 2011 2012 2013

Intestinal infectious diseases

Protozoal diseases

Influenza and pneumonia

Malnutrition

Infections of the perinatalperiod

HIV disease

Respiratory and cardiovasculardisorders of the perinatalperiod

Intra-hospital deaths by type of admission

and level of referral hospital,

Mozambique, 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Central Hosp. ProvincialHosp.

General Hosp. Rural/DistrictHosp

Health Centre

Birth and outpatient Transfer from other HF Emergency

Mortality by cause of death, Mozambique

2009-2011 – Broad Category

Infectious

and parasitic

dis.

37%

Disorders

of perinatal

period

19%

Cardio-

vascular dis.

8%

External

causes

6%

Respiratory

dis.

5%

Neoplasms

5%

Endocrine and

metabolic dis.

4%

Nervous

system dis.

3%

Hematological

dis.

2%

Digestive dis.

2%

Pregnancy,

delivery,

puerp.

2% Other causes

7%

Mortality by cause of death

– Details per category: Infectious diseases

HIV/AIDS 73%

Malaria 10%

Infectious diarrea

5%

TB 6%

Other infectious diseases

6%

Mortality by cause of death

– Details per sub-category: HIV/AIDS

71,9%

11,2%

5,0%

4,2%

2,9%

2,5%

0,4% 0,2%

0,3%

1,1% 0,4%

HIV not specified

HIV + TB

HIV + multiple infections

HIV + encephalopathy

HIV + bacterial infections

HIV + Kaposi sarcoma

HIV + mycotic infections

HIV + Burkitt lynphoma

HIV + other malignantneoplasmHIV + pneumonia(pneumocystis)

Distribution of the causes of death by age

group or other demographic data

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000Outras causas

Causas externas

D. do sistemanervosoD. hematológicas eimunitáriasD. endócrinas enutricionaisNeoplasias

Sintomas, sinais eachados anormaisD. do aparelhocirculatórioD. do aparelhorespiratorioAfecções do períodoperinatalD. infecciosas

Causes of death: trends over time (>1

year, national level), 2010-2013

0

5000

10000

15000

20000

25000

2010 2011 2012 2013

All other causes HIV disease Malaria Tubersulosis

CHALLENGES

• Expansion to all Health Facilities, out of the Health System at

community level (cultural barriers, poor access to information, low

coverage health and civil registration services)

• Full implementation of Mother and child section of the SIS-ROH2 system

• Full integration in the national M&E system (SIS-MA)

• Full Connection and integration with the Civil Registration system

• Conduct regular training on death certification and ICD-10

• Ensure improvements in Data Quality

• Boost IT Infrastructure, other equipment and materials (ICD-10 manuals)

Kanimambo!

Obrigado!

Dra. Cidália Baloi

Dra. Esperança Nhagumbe

Mr. Ivan Mabote

Ministério da Saude

Ministério da Justiça