Understanding the challenges associated with the use of data from routine health information systems in low- and middle-income countries: A systematic review.

BACKGROUND: Routine health information systems (RHISs) are crucial to informing decision-making at all levels of the health system. However, the use of RHIS data in low- and middle-income countries (LMICs) is limited due to concerns regarding quality, accuracy, timeliness, completeness and representativeness. OBJECTIVE: This study systematically reviewed technical, behavioural and organisational/environmental challenges that hinder the use of RHIS data in LMICs and strategies implemented to overcome these challenges. METHOD: Four electronic databases were searched for studies describing challenges associated with the use of RHIS data and/or strategies implemented to circumvent these challenges in LMICs. Identified articles were screened against inclusion and exclusion criteria by two independent reviewers. RESULTS: Sixty studies met the inclusion criteria and were included in this review, 55 of which described challenges in using RHIS data and 20 of which focused on strategies to address these challenges. Identified challenges and strategies were organised by their technical, behavioural and organisational/environmental determinants and by the core steps of the data process. Organisational/environmental challenges were the most commonly reported barriers to data use, while technical challenges were the most commonly addressed with strategies. CONCLUSION: Despite the known benefits of RHIS data for health system strengthening, numerous challenges continue to impede their use in practice. IMPLICATIONS: Additional research is needed to identify effective strategies for addressing the determinants of RHIS use, particularly given the disconnect identified between the type of challenge most commonly described in the literature and the type of challenge most commonly targeted for interventions.

Using routine health information data for research in low- and middle-income countries: a systematic review.

BACKGROUND: Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. METHODS: Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. RESULTS: We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. CONCLUSIONS: Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

An empirical evaluation of the performance of financial protection indicators for UHC monitoring: Evidence from Burkina Faso.

Achieving Universal Health Coverage (UHC) has been recognized as one of the Sustainable Development Goals (SDGs) and includes both ensuring access to health services and providing financial protection (FP) against using these services. Currently, progress towards achieving the FP component of UHC is assessed using the catastrophic health expenditure budget share indicator, which estimates the proportion of the population with health expenditures exceeding 10% of total income or consumption. Other indicators exist, however, and are widely used in the literature, yet few studies have compared the usefulness of these indicators for UHC monitoring. Using panel data from Burkina Faso, this paper seeks to evaluate the performance of common FP indicators based on three properties: (1) their ability to identify those most at risk of financial hardship (i.e. the poor), (2) their ability to detect households with health shocks, and (3) their sensitivity to seasonal variation. Our results indicate that, while some indicators perform better in certain conditions than others, none are without limitation. Indeed, despite being the best able to differentiate households who have experienced a health shock, the official SDG indicator performs the worst at identifying the poorest group of the population and is the most sensitive to seasonal variation. As such, more research is needed in order to improve the measurement of FP such that progress towards achieving UHC can be accurately monitored.

On the Measurement of Financial Protection: An Assessment of the Usefulness of the Catastrophic Health Expenditure Indicator to Monitor Progress Towards Universal Health Coverage.

Ensuring financial protection (FP) against health expenditures is a key component of Sustainable Development Goal (SDG) 3.8, which aims to achieve Universal Health Coverage (UHC). While the proportion of households with catastrophic health expenditures exceeding a proportion of their total income or consumption has been adopted as the official SDG indicator, other approaches exist and it is unclear how useful the official indicator is in tracking progress toward the FP sub-target across countries and across time. This paper evaluates the usefulness of the official SDG indicator to measure FP using the RACER framework and discusses how alternative indicators may improve upon the limitations of the official SDG indicator for global monitoring purposes. We find that while all FP indicators have some disadvantages, the official SDG indicator has some properties that severely limit its usefulness for global monitoring purposes. We recommend more research to understand how alternative indicators may enhance global monitoring, as well as improvements to the quality and quantity of underlying data to construct FP indicators in order to improve efforts to monitor progress toward UHC.

Promoting healthy beverage consumption habits among elementary school children: results of the Healthy Kids Community Challenge 'Water Does Wonders' interventions in London, Ontario.

INTERVENTION: This study examines the impact of London's Healthy Kids Community Challenge (HKCC) 'Water Does Wonders' interventions, which combined water infrastructure and education programs. RESEARCH QUESTION: How effective were the HKCC interventions at increasing water and decreasing sugar-sweetened beverage (SSB) consumption among grade 4-8 children in London, Ontario? METHODS: Non-randomized controlled trial. Children's knowledge and beverage intake were measured before and after the interventions were implemented during the 2016-2017 school year. Children at intervention schools (n = 521) received education programs (Growing Chefs or UTRCA [Upper Thames River Conservation Authority]) and water bottle filling stations. Children at control schools (n = 410) received filling stations only. Multivariable linear mixed-model ANCOVAs were used to compare water and SSB consumption and knowledge across intervention groups, accounting for school-level clustering. RESULTS: Children who received an education intervention and filling station compared with only a filling station consumed more water (ß = 2.18 (95% CI - 1.87, 6.22) for Growing Chefs and ß = 2.90 (95% CI - 0.23, 6.03) for UTRCA) and fewer SSBs (ß = - 1.17 (95% CI - 3.83, 1.49) for Growing Chefs and ß = - 2.56 (95% CI - 5.12, 0.001) for UTRCA) post-intervention, and had higher nutrition knowledge (ß = 1.57 (95% CI - 1.68, 4.83) for Growing Chefs and ß = 2.02 (95% CI - 0.35, 4.39) for UTRCA). These findings were not statistically significant. CONCLUSIONS: An intervention intended to promote healthy beverage consumption yielded effects in the expected direction; however, they were small and not statistically significant. This is likely because the educational interventions were not fully aligned with the goals of the 'Water Does Wonders' program, preventing them from evoking meaningful changes in dietary behaviours.

Conceptualising the effect of access to electricity on health in low- and middle-income countries: A systematic review.

Access to electricity is an important issue in low- and middle-income countries (LMICs) however its health implications are poorly understood. This paper systematically reviews the health effects of access to electricity and develops a conceptual model to summarise the pathways through which these effects may occur. The databases CINAHL, Embase, and MEDLINE were searched for studies examining the effects of access to electricity on health in LMICs. Thirty-three studies met the inclusion criteria: 23 focusing on electrification and 10 focusing on electricity reliability. Using a modified socio-ecological model, 4 main levels of influence were identified: (1) individual, (2) household, (3) community, and (4) institutional. Electrification was generally associated with positive health outcomes, such as reduced mortality, lower rates of disease, and improved quality of and access to care, while poor electricity reliability was associated with negative health outcomes, including increased morbidity and mortality, lower quality of care, and reduced utilisation of health services. Although the overall quality of the evidence was weak, given the many potential pathways through which electricity may affect health, efforts should be made not only to increase the number of connected households globally, but to improve the reliability of the electricity supply as well.

Effect of power outages on the use of maternal health services: evidence from Maharashtra, India.

INTRODUCTION: Electricity outages are common in low/middle-income countries and have been shown to adversely affect the operation of health facilities; however, little is known about the effect of outages on the utilisation of health services. METHODS: Using data from the 2015-2016 India Demographic Health Survey, combined with information on electricity outages as reported by the state electricity provider, we explore the associations between outage duration and frequency and delivery in an institution, skilled birth attendance, and caesarean section delivery in Maharashtra State, India. We employ multivariable logistic regression, adjusting for individual and household-level covariates as well as month and district-level fixed effects. RESULTS: Power outage frequency was associated with a significantly lower odds of delivering in an institution (OR 0.98; 95% CI 0.96 to 0.99), and the average number of 8.5 electricity interruptions per month was found to yield a 2.08% lower likelihood of delivering in a facility, which translates to an almost 18% increase in home births. Both power outage frequency and duration were associated with a significantly lower odds of skilled birth attendance (OR 0.97; 95% CI 0.95 to 0.99, and OR 0.99; 95% CI 0.992 to 0.999, respectively), while neither power outage frequency nor duration was a significant predictor of caesarean section delivery. CONCLUSION: Power outage frequency and duration are important determinants of maternal health service usage in Maharashtra State, India. Improving electricity services may lead to improved maternal and newborn health outcomes.

Assessing the relationship between water and nutrition knowledge and beverage consumption habits in children.

OBJECTIVE: To examine the relationship between knowledge and beverage consumption habits among children. DESIGN: Cross-sectional analysis. Linear regression was used to identify sociodemographic, dietary and behavioural determinants of beverage consumption and knowledge, and to describe the relationships between children's knowledge and water and sugar-sweetened beverage (SSB) consumption. SETTINGS: Seventeen elementary schools in London, Ontario, Canada. PARTICIPANTS: A total of 1049 children aged 8-14 years. RESULTS: Knowledge scores were low overall. Children with higher knowledge scores consumed significantly fewer SSB (ß = -0·33; 95 % CI -0·49, -0·18; P < 0·0001) and significantly more water (ß = 0·34; 95 % CI 0·16, 0·52; P = 0·0002). More frequent refillable water bottle use, lower junk food consumption, lower fruit and vegetable consumption, female sex, higher parental education, two-parent households and not participating in a milk programme were associated with a higher water consumption. Male sex, higher junk food consumption, single-parent households, lower parental education, participating in a milk programme, less frequent refillable water bottle use and permission to leave school grounds at lunchtime were associated with a higher SSB consumption. Water was the most frequently consumed beverage; however, 79 % of respondents reported consuming an SSB at least once daily and 50 % reported consuming an SSB three or more times daily. CONCLUSIONS: Elementary-school children have relatively low nutrition and water knowledge and consume high proportions of SSB. Higher knowledge is associated with increased water consumption and reduced SSB consumption. Interventions to increase knowledge may be effective at improving children's beverage consumption habits.