Strengthening health system through advancement of data quality, evidence generation and use in decision-making: case study from a Learning Site in Nepal

While Nepal’s 2015 constitutional provisions lay a strong foundation for improving health care by recognising it as a fundamental right, several challenges remain. The poor status of health information systems is one of those challenges, with negative effects resulting in poor quality of the data which is essential to informing policy and programme decisions. A municipality in Kapilvastu district, which is ReBUILD for Resilience’s Learning Site 1 (LS1) in Nepal, experiences such challenges, exacerbated by other contextual and capacity gaps. In this learning site, HERD International has been supporting the municipality, carrying out participatory research and working in partnership to build a resilient health system amid challenging conditions.

What problem is being addressed?

As Nepal navigates the complexities of federalism, effective and evidence-based planning at local levels is essential. With the increase in their decision spaces, local authorities must improve their evidence generation and usage capacities, and prioritise decisions grounded in high-quality evidence to manage limited resources effectively. As HERD International and municipality teams worked together, it emerged that the revision of the Health Management Information System (HMIS) tools [opens new tab] in 2019 led to health workers facing challenges in understanding this new recording and reporting system. This led to significant errors in data generation at the health facility level, especially in the absence of a robust monitoring and supervision system from the municipal authority. Consequently, erroneous data were reported, compromising the accuracy and reliability of health information. The low capacity of health workers to generate quality data emerged as a critical problem. In addition, although the municipality had access to secondary data from various sources, these were often under-utilised in planning and budget allocation.

What did we do?

Employing an embedded approach within the learning site, HERD International’s researchers provided technical support to local health stakeholders, helping to implement a co-created action plan. Based on the above observations, one of the plan’s objectives was to strengthen the capacity to generate and utilise quality data for effective planning through activities that are led by the municipality health section.

1. Workshop on health system resilience at the local level and the role of need-based planning

Participatory workshops using a group model building approach were organised with the health section team and health workers to reflect on evidence-based planning and the importance of data in decision making. Participants said that this was the first platform where they had discussed health issues and how local evidence could support planning processes. This collaboration led to the co-creation of an evidence-based, responsive action plan.

2. Institutionalisation of on-site coaching

With support from ReBUILD’s embedded researcher, the municipality health section developed a plan for providing on-site coaching to health workers, so that they could receive regular support sessions to discuss challenges and assistance in appropriate data recording and reporting practices. The onsite coaching has now been institutionalised, with an allocated budget from the municipality.

3. Skill enhancement through Public Health Analytics training

Public Health Analytics training, facilitated by HERD International and the Ministry of Health and Population team, has empowered health workers and the municipality health team with  skills in data generation, analysis and presentation. These skills are crucial for effectively communicating findings to various stakeholders, including policymakers, community leaders, organisations and individuals, and for fostering a better understanding of issues and prioritisation of need-based programmes. At each health facility two health workers with at least one female staff member (and totalling 24 health workers) received this three-day training course.

“In these three days, I learnt many new things. I didn’t know how to develop tables and graphs, but I learnt that in one hour.”
[Health worker]

4. Changes in the modality of monthly and review meetings

The municipality health section arranges health review meetings every month with the in-charges of all health facilities. After the Public Health Analytics training, there was a notable change in the way these meetings are conducted. They are now more organised, with health workers using computers and presentation slides to explain service utilisation data. Health workers support each other to develop their capacities, fostering a collaborative environment. A data verification sheet developed locally with support from the embedded researcher is used to identify and correct data errors. This practice has significantly reduced data errors compared to previous years, and health workers are now better equipped to justify discrepancies in the data.

5. Expansion of data quality assessment to all health facilities

While the Ministry of Health and Population mandates Routine Data Quality Assessments (RDQA) at the health facility level and provides tools for them, there is no budget provision under conditional grants for local governments to conduct them. Aided by ongoing technical support from HERD International, the municipality health section began allocating budget from internal sources to ensure regular data quality assessments and thus enhance data quality. Since last year, assessments have been expanded to all health facilities and showed improved data quality scores.

6. Initiatives for evidence generation

With technical support from the ReBUILD research team, the municipality in Kapilvastu District conducted a census, reaching 15,327 households and collecting data on the nutritional and immunisation status of children under two years of age residing in the municipality. The municipality allocated a budget for this survey, demonstrating commitment to generating quality evidence and enhancing the capacity of local health workers in data collection (45 health workers were trained in digital data collection techniques). The survey was instrumental in identifying several critical health issues requiring immediate action, including the prevalence of home deliveries (25.9% of childbirths) and malnutrition among children (10% had moderate acute malnutrition and 3% had severe acute malnutrition).

7. Ensuring gender, equity and justice in evidence generation and use

HERD International researchers have emphasised mainstreaming gender, equity and justice in capacity development and data quality improvement initiatives. The health section team encourages the participation of female and diverse cadres in meetings and training, ensuring an inclusive environment. They engaged with health facility and ward stakeholders to ensure that the voices of marginalised groups are considered and their access to health care is improved. Further, a gender, equity and justice lens is applied in data analysis and presentation, highlighting health disparities and informing targeted interventions for equitable planning.

Impact

The planning process of the municipality has become more evidence-based and inclusive. Health teams are increasingly integrating data into decision-making processes, particularly in planning for immunisation, nutrition and safe motherhood services to ensure equitable service delivery. The municipal executives have shown a strong interest and commitment for initiatives backed by relevant data, to ensure tailored interventions that meet specific community needs. For instance, to address the issue of home deliveries and ensure timely access of pregnant women to medical care, key municipal stakeholders, including the Mayor, Deputy Mayor, Chief Administrative Officer and health section team, decided to invest in an ambulance service to transport pregnant women to healthcare facilities.

Additionally, there has been a trend of increased budget allocation for health at ward levels over the last three fiscal years. This rise in the health budget reflects an increased priority for health among locally-elected representatives, aided by several workshops and capacity development activities conducted by ReBUILD researchers in Nepal.

“We used to focus more on how to complete the program or how to bring programs. But the important thing is data. We should make data a base for doing planning and implementation in coming days. If monitoring of the programs is done continuously, we can understand where we should improve, and it has been a lesson learnt for us.”
[Health section]

Further information

• Find more on this study and its outputs here.
• There are other ReBUILD for Resilience case studies here 

Image: Shophika Regmi of HERD leading a participatory action research workshop with stakeholders in Kapilvastu, Nepal