Kwale Kenya - The challenges of digital data collection at community level

The importance of data collection and monitoring is an ongoing debate in the healthcare field. This is compounded often with data collected at community level. Data is only as good as its seen to be relevant, timely and accurate.

In Kenya, with its national community health strategy, the collection of data using logbooks is an intrinsic part of the role of the community health workers and the Community Health Assistants/PHOs who are responsible for collating the data. However, the current system using large logbooks for data collection and ideally monthly visits in the home has many challenges as we have outlined before in previous articles and that have been documented in a lot of research done on community activity. The most glaring challenges are often connected to the lack of support and financial renumeration for health volunteers/workers, lack of resources and transport challenges in more remote areas. The educational capacity and training of community workers is another issue. In Kenya with its devolved health system, each county has its own agenda and addresses the Community Health Strategy challenges in different ways. Even on a national level, the training in Community Health is very varied and the training of Community Health Assistants in the field is not being implemented. Most CHAs at this point are public health officers without any further training and they already have a heavy work load, preventing them being able to support and effectively monitor the community health volunteers.

Data collection at community level is therefore rather sporadic and although effort is spent collecting data and uploading it into the national system, it is not consistent or timely and data is rarely looked at a sub county or facility level. It is only looked at nationally and even then, given the amount of data, much of it is not looked at. Community based data, in particular is not given a lot of time, even though it is an important part of the function of the community volunteers.

DHIS2 is one of the main tools used to collect data at a community level and has the possibility to aggregate a lot of potentially important data, including basic demographic information, sanitation information, health data on chronic disease, referrals, mother and child data and much more. The potential of this data giving good information about community issues on their health care situation is large. However its relevance is diminished if not looked at from a local perspective.

Our project has been using one DHIS2 tool called DHIS2 tracker, which allows us to take individualized data and potentially to be able to follow the health experiences of people at an individual level. It is one of a growing number of projects that are using digital tools like smart phones and tablets to collect digital health data and upload it immediately to the national system, making data more accurate, fast and reliable. Therefore, it has the potential to help the health workers at every level, and especially the CHAs and facility in charges to analyse the data that they are working with on a daily basis. This emphasis on the ownership of data is a crucial part of what a project like ours can inspire. If those working on the ground, who know what is happening, can analyse their own data, then there is much more “ownership” of the information, and potentially can be used to measure outcomes of their work. Furthermore, it can link the community to the facility in a much more intimate way, again allowing a more integrated approach to healthcare.

As the goal of Universal Health Coverage is being taken onboard once more, the understanding that community-based health data can greatly assist in this is being recognized. Not all resources should go to the facility/hospital structures. Some should be given to the community, where many of the important issues, including hygiene, clean water, nutrition, access to healthcare and more social issues can be better understood.

However, one of the challenges is that the government tools to collect data are changing, and more data elements are being added, making the community-based data less recognizable. In Kenya, a household registration tool called 513 is used every six months and then a monthly log book, called a 514 collects more specific data, ideally on a monthly level. This data is amalgamated into a summary book called a 515, which is done by the PHO/CHA on a monthly basis. Health data from the facility is added to this summary form, but recently another 45 facility-based indicators have been added to this form, creating more work and also making the form less usable for easy analysis. The community data threatens to be subsumed by all the other data being collected. Therefore, for now, we are keeping our community-based data separate from the national database even though we are now also looking to integrate it as a means of showing how our data can ideally take the place of the logbook data.

Also, there are still some design issues with the way the logbooks were created, making for confusion and some potential duplication of certain indicators. Therefore, we are communicating these concerns to the national Ministry of Health to see how these things can change. It is important that those who are using the tools are able to communicate back to the Ministry of Health and other parties that have initiated the decision to put certain data in the forms, what is working and what is not.

Our other concern at this point is how best to keep supporting the utilization of this digital system of data collection if the county Ministry of Health cannot fully support it. The initial financial outlay can seem large – in purchasing smart phones or tablets as well as maintaining the equipment and support needed, but when one looks at even the cost of replacing all the logbooks twice a year, it adds up to many thousands of dollars, and most of the time, the data is not being used. Therefore, we feel we can make a case that a good, well designed digital system can be both more efficient if well developed and supported, and also financially a viable option when looking at health expenditure at a community level. We are currently discussing this with the county Ministry of Health, to see if more funds can be allocated specifically for community strategy. This is particularly important in looking at sustainability issues for the project within the larger community strategy mandate.

Therefore, we are hopeful that as we enter the last stages of our project, we will be able to show how useful this system can be in optimising the data collection at community level and also generally enhancing the importance of the community health strategy in Kenya.

Richard Pitt