Potential Bottlenecks in Implementing MCTS in Odisha.

Introduction

Mother and child tracking system (MCTS) is the online software used by the National Health Mission (NHM), formerly National Rural Health Mission (NRHM), for tele-monitoring Reproductive and Child Health (RCH) services delivered by the Government of India(1). It is an innovation of Health and Family Welfare (HFW) department supported by the National Health Mission(2). This software was conceived way back in 2008 to increase the coverage of RCH services. Left out and drop out beneficiaries for various services, including immunization, can be tracked name wise using this system. Using this software, beneficiary wise and even health unit wise relevant information can be retrieved from any location by any health or associated authority by logging on to the system using the username and password provided to him/her(3). It can greatly reduce the death rates of infant and mother and even reduce total fertility rates through an attempt to provide universal coverage of services.

The origin of the concept is linked to the tracking of ‘due’ beneficiaries in immunization sessions using the tracking bag(4) at the sub-center. The tracking bag consists of 14 pockets, of which 12 are meant for 12 months in the year and two more meant for children with complete and incomplete immunization status respectively. Due beneficiaries for a particular month are tracked using counterfoils which would be kept in the pockets for the particular month.

MCTS utilizes two formats for capturing data for new beneficiaries– Format I and Format II. The former one is meant for mothers and the latter is for children born of these mothers. Once a woman is detected to be pregnant, she is registered with the health system in the MCTS register so as to receive all the free health services and details are captured in the format I. The data are then sent every week, via the supervisors to the block level, for online data entry into the MCTS. The same is also done for all newborn babies using format II. Services received by the beneficiaries are supposed to be maintained in the Mother and Child Protection (MCP) card provided to the beneficiaries. Subsequently, every week sub-center wise work plan is generated from the MCTS and distributed through the supervisors to the sub-center Auxiliary Nurse Mid-Wife (ANM), for providing the services, updating the services received and tracking the beneficiaries who could not avail the services.

Work plans are generated for various kinds of services like registration of pregnant woman, antenatal care services, delivery services, post-natal care services for mother and neonatal child, child health services including immunization, family planning services, etc(2). In short the system perfectly tries to track the left out and drop out case wise, and ensure universal delivery of services(2)(5).

Presently MCTS is used throughout the state and lots of human resources have been deployed by NHM at block and district levels to enter, analyze and track the data for the mother and child services. As compared to the proportionate increase in the human resources and other investments, the service coverage has not increased substantially (for example immunization coverage). Even certain studies on mechanisms for tracking immunization in developing countries show similar results(6). There has been disparity during data validation exercises using health indicators from sources like Health Management and Information System (HMIS)(7) and MCTS. Even no assessment has been undertaken to review the bottlenecks of MCTS. Hence a study was planned to identify and provide suggestions for correcting the bottlenecks in the implementation of mother and child tracking services in the state of Odisha, if any existed.

Objectives of the study

1. To understand the process of implementation of Mother and Child Tracking Sytem in Odisha and identify the bottlenecks in the implementation process, if any.
2. To identify feasible solutions and suggest recommendations for the identified bottlenecks.

Method of study

The study was qualitative in nature. It was conducted in three UNICEF supported districts (all tribal predominant) of Odisha state (having 30 districts) from August 2013 to November 2013. In-depth interview (IDI) was the key tool for data collection. Key program implementers involved in the process were listed down along with their assumed roles and responsibilities (Table 1). Judgmental sampling method(8) was then used and IDI was done with identified key informants involved in the implementation of MCTS (block and district level managers and supervisors). A total of 15-24 in-depth interviews (IDI) were planned for the study (regarded as the stage of thematic and theoretical saturation)(8). The end point planned was the point when no new qualitative information was received(9).

Three blocks each of these districts were randomly selected and key informants were identified for IDIs. Consent was taken from the interviewers using WHO’s informed consent form for qualitative studies(10). Personal interviews were performed with a pre-determined and pre-tested tool with more often than not open ended and few close ended questions/ probes (Box 1). Along with that satisfaction level of the implementers was recorded using a continuous scale(11). Practically feasible solutions and suggestions as recommended by the informants were also noted along with bottlenecks. Data collection, cleaning and analysis was done simultaneously. Recorded data were transcribed independently by two researchers onto paper, translated to English and then manually analyzed. The qualitative content analysis method was employed(12)(13)(14) for analysis. Nine major heads were identified for the purpose- human resource issue, data generation issue, issues with skill, data entry issues, covering events, software issues, supervision, review and financial topics. All other findings were put under a tenth head. After data analysis, brainstorming sessions were carried with the RCH team of UNICEF Field office to put forth other recommendations for the issues noted.

Results

A total of 20 interviews were conducted in the study with six to seven interviews on an average from each district. Time for the interviews ranged from minimum of 25 minutes to a maximum of 40 minutes. Block level data managers and block program managers in charge of MCTS in the block were identified as the key informants at the block level. Lady health visitors (LHVs) and Health Supervisor (HS (M)) were likewise included in the process. Interviews were also conducted with District Data Managers (DDM) who was the supervisor of BDMs at the district level.

Interviews with the stakeholders revealed that there has been a lot of improvement in certain service delivery components. Some of these include availability of a definite work plan (also called due list) for the ANM and Accredited Social Health Activist (ASHA) every week, validation of HMIS data, entering data and assessing reports from any place using provided username and password, validation of incentives provided to beneficiaries and to ASHA for various activities, improvement in service delivery for various national health programs, etc.

“We are able to review the sectors based upon the MCTS data.” [LHV]

“Now, the health workers have realized the benefits and use of MCTS and are frequently asking for clarifications, when required”. [BPM]

It was observed that the work plan and reports passed through all the stakeholders of MCTS, including the supervisors. But the involvement in terms of understanding of the process and providing mentoring support was poor, as cited by a few. The reports were collected at the end of the HWF, who would submit reports to their sector level supervisors. Details of the flow mechanism of reports are shown in Fig. 1.

On an average satisfaction level regarding implementation of MCTS among block and district level stakeholders was found to be 7 out of 10 (range 4 to 9). Lack in the perfection of the implementation were many, some of which were analyzed and placed in Table 2. It was also noted that a BDM had to devote a great proportion of his time for data entry thus disturbing the equilibrium between personal and professional life. This was set up especially for those located in big blocks and universally for everyone roughly on an average 15 days (last week of a month and first week of the following month), at the time of report collection and entry. Verbatim of some of the important issues found during the interview are listed down under.

“Health workers collect their work plans on their own or in some indefinite process. But the collection of updated work plans from the workers is being done in sector meetings.”[LHV]

“We are facing problem in covering the beneficiaries in outreach areas due to seasonal and migration issues.” [LHV]

“The software needs to be improved.”[BPM]

“HMIS software is better than MCTS with respect to report generation and review & monitoring. The MCTS software is much slower than HMIS and needs high speed internet connectivity.”[BPM]

“Due to network connectivity issues, we often ask the BDMs to come to the district NRHM Office and do the data entry here.” [DDM]

Discussion and Recommendations

Tracking down beneficiaries to increase the coverage of services can definitely reduce the number of miss outs and drop outs for any services catered, and with stringent implementation as planned can definitely improve service delivery. Moreover the planning component of some of the health programs can be addressed in the process. But it was found that issues invariably did exist at all levels and all components of this naïve model.

A single register needs to be maintained integrating components of mother register and child register, which will reduce the workload of the health workers. The simple availability of logistics like paper and cartridge for printing can be some of the minor issues, which if addressed can bring out successful results. Similarly, engaging the data entry operators in the tasks they are meant for can provide quality inputs to the tracking system, not only in terms of improving the data quality, but also an effective plan generation, follow up and tracking of miss out and drop out cases and health review. It will provide a working environment and boost the motivation of these DEOs. Review of MCTS entry, analysis and tracking of follow up of instances should be done block wise with team effort rather than having any single individual accountable. Supervisors should take on an important part in offering mentoring support for tracking, record keeping and updating. An effective model of internal monitoring and/or mentoring system for underperforming sub-centers in MCTS implementation (eg. Using Lot Quality Assurance Sampling Method) is needed.

Own server can be set up at the state to solve server speed issues. More data entry staff at the block level is needed so as to reduce data entry load in large blocks with huge data load. More number of ANMs or support in the form of additional ANMs is needed in sub-centers with more population. This solution has also been cited in other studies of the same author(15). Data Entry Operators (DEOs) for Rashtriya Swasthya Bima Yojana (RSBY)(16) can be engaged in data entry activities wherever the data entry load is high. A proper operational research can throw light on the mechanism to identify blocks needing more human resources along with other financial support.

All services provided and recorded in MCP card should be fed into MCTS to make effective tracking possible. Customization of the software for integrating and validating data of other related programs like Home Based Newborn Care(17), Special Newborn Care Unit(18)(19), etc. can also be done. Adequate contingency provision in the NHM PIP should be made. Collaborating with mobile partners to develop SMS based portal for reporting details of a beneficiary can be done and this can also provide real time reporting. Similarly loading the data in a Geographic Information System (GIS) based maps can be used increase tracking mechanism one step further(20). Extra incentives for each additional work put to the BDMs, may be provided. Training pharmacists in ODMIS(21) can decrease the workload on BDM at the block level.

Conclusion

Mother and child tracking system is an innovative method of tracking down the beneficiaries name wise, with an objective to bring down the IMR, MMR and TFR. It can help the government to achieve universal coverage of services. Presently MCTS has helped the service providers to effectively manage miss outs and drop outs for various services like immunization, family planning, maternal and new-born care. Validation of HMIS and incentives (to beneficiaries and ASHA) is also being done using MCTS. In spite of all positive aspects, practical issues were found to exist and need to be sorted out. Review, in detail, can sort out many operational and financial issues. Needs of large blocks should be addressed specifically. Server issues need to be addressed along with a provision of SMS based reminders. Real time data entry can make things more convenient. Correct and complete entries in the MCP will help in appropriate utilisation of the software.

Acknowledgement:

The authors would like to thank program managers from National Health Mission and health staff of the state government for participating in the study and providing field realities. Dr. Ashish Kumar Sen, being supervisor of the team, had supported the study and provided relevant inputs is also acknowledged.

Competing interest:

This article was accepted and presented as a conference paper at the International Telemedicine Conference held at Jaipur in 2013.

References

1. Achievements of MDG Commitments Made Under NRHM [Internet]. Press Information Bureau, Government of India. 2012 [cited 2014 Nov 25]. Available from: http://pib.nic.in/newsite/erelease.aspx?relid=82520

2. Operational Manual: Mother and Child Tracking System [Internet]. National Rural Health Mission; 2010 [cited 2014 Nov 17]. Available from: https://nrhm-mis.nic.in/Home MCH Tracking System/User manual for MCH Tracking by NIC – PDF format.pdf

3. Ministry of Health and Family Welfare. Mother and Child Tracking System [Internet]. [cited 2014 Nov 17]. Available from: http://nrhm-mcts.nic.in/mch/

4. Immunization Handbook for Medical Officers. Department of Health and Family Welfare, Government of India; 2008. 197 p.

5. Operational plan for Mother and Child Tracking System [Internet]. Ministry of Health and Family Welfare; [cited 2014 Nov 17]. Available from: http://mohfw.nic.in/showfile.php?lid=421

6. Leach-Kemon K, Graves CM, Johnson EK, Lavado RF, Hanlon M, Haakenstad A. Vaccine resource tracking systems. BMC Health Serv Res. 2014;14:421.

7. Ministry of Health and Family Welfare. NHM Health Management Information System Portal [Internet]. [cited 2014 Nov 29]. Available from: https://nrhm-mis.nic.in/SitePages/Home.aspx

8. Marshall MN. Sampling for qualitative research. Fam Pract. 1996 Jan 1;13(6):522–6.

9. Baker SE, Edwards R. How many qualitative interviews is enough? [Internet]. National Center for Research Methods; [cited 2014 Nov 25]. Available from: http://eprints.ncrm.ac.uk/2273/4/how_many_interviews.pdf

10. WHO | Informed Consent Form Templates [Internet]. WHO. [cited 2014 Nov 25]. Available from: http://www.who.int/rpc/research_ethics/informed_consent/en/

11. What’s the best satisfaction survey scale? [Internet]. being CustomerSure – Proven advice from Business Rockstars. [cited 2014 Nov 25]. Available from: http://www.customersure.com/blog/best-satisfaction-survey-scale/

12. Kohlbacher F. The Use of Qualitative Content Analysis in Case Study Research. Forum Qual Sozialforschung Forum Qual Soc Res [Internet]. 2006 Jan 31 [cited 2014 Nov 25];7(1). Available from: http://www.qualitative-research.net/index.php/fqs/article/view/75

13. Thorne S. Data analysis in qualitative research. Evid Based Nurs. 2000 Jul 1;3(3):68–70.

14. Gläser J, Laudel G. Life With and Without Coding: Two Methods for Early-Stage Data Analysis in Qualitative Research Aiming at Causal Explanations. Forum Qual Sozialforschung Forum Qual Soc Res [Internet]. 2013 Mar 18 [cited 2014 Nov 25];14(2). Available from: http://www.qualitative-research.net/index.php/fqs/article/view/1886

15. Padhy G, Padhy R, Panigrahi S, Sarangi P, Das S. Bottlenecks identified in the Implementation of components of national health programmes at PHCs of Cuttack district of Odisha. Int J Med Public Health. 2013;3(4):271.

16. Ministry of Labor and Employment. Rashtriya Swasthya Bima Yojana [Internet]. [cited 2014 Dec 1]. Available from: http://www.rsby.gov.in/about_rsby.aspx

17. NHM Child Health Guidelines-Revised Home Based Newborn Care Operational Guidelines [Internet]. [cited 2014 Sep 30]. Available from: http://nrhm.gov.in/images/pdf/programmes/child-health/guidelines/Revised_Home_Based_New_Born_Care_Operational_Guidelines_2014.pdf

18. Neogi SB, Malhotra S, Zodpey S, Mohan P. Assessment of Special Care Newborn Units in India. J Health Popul Nutr. 2011 Oct;29(5):500–9.

19. Neogi SB, Malhotra S, Zodpey S, Mohan P. Challenges in scaling up of special care newborn units-lessons from India. Indian Pediatr. 2011;48(12):931–5.

20. Barau I, Zubairu M, Mwanza MN, Seaman VY. Improving polio vaccination coverage in Nigeria through the use of geographic information system technology. J Infect Dis. 2014 Nov 1;210 Suppl 1:S102–10.

21. Odisha Drug Inventory Management System [Internet]. [cited 2014 Nov 29]. Available from: http://dims.nrhmodisha.in/