Monitoring and improving quality of health care in LMICs presents unique constraints, including increasing scale and scope of the health sector, poor use of monitoring data and delayed course correction. Enhanced supervision is estimated to have the highest potential impact of all health system interventions. The Health Network Quality Improvement System (HNQIS) is an electronic tablet-based application created by PSI to improve quality of health services in health networks and to effectively manage and reach health impact at scale. HNQIS is composed of four modules that support Quality Assurance Officers (QAOs) to (i) plan supportive supervision visits using a prioritization matrix that factors quality scores and patient volume, (ii) assess providers’ quality of care against clinical standards, (iii) improve providers’ quality of care using tailored feedback that includes videos, and (iv) monitor quality over time. HNQIS is in sync with District Health Information Software 2 (DHIS2) and allows Health System Managers at district and national level to (i) identify gaps and priority areas to intervene to improve services, and (ii) better target resources. Health System Managers use tailored DHIS2 dashboards to monitor Key Program Indicators (KPIs), prioritize interventions and sustain programmatic decision-making process. HNIQS integrates into existing supervision systems enabling focussed support and better prioritization of scarce resources. The possibility to overlay data on quality of care with other existing databases like disease surveillance, patient load and stock of commodities offers health system managers a 360-degree overview of health service provision. Launched in Kenya in 2015, HNQIS is active in 23 countries with more than 30,000 assessments conducted on 13 Health Areas at more than 8,000 outlets. The presentation aims to share lessons learned on the use of HNQIS data to inform programmatic decision-making and better manage health care networks at scale.

Automation of supply chain systems (LMIS) and health management information (HMIS) has received a lot of attention and support in developing countries particularly over the past decade. However, pharmaceutical regulatory systems have generally speaking received far less attention. The business case for automation of regulatory information systems in Ethiopia grew initially from work automating LMIS, and anticipated benefits to extending that to regulatory processes. The Ethiopian electronic Regulatory Information System (eRIS) platform was conceived as automating all the functions of the Ethiopian Food and Drug Administration (EFDA), but was implemented in a modular bottom up fashion with EFDA prioritizing immediate needs. Currently, two modules of a planned comprehensive eRIS are fully operational: i-Import which approves medicine importation, implemented in 2017, and i-Register for market authorization/registration, implemented in 2018. Both are locally developed, open source solutions and are fully interoperable with the LMIS. All MIS use the same master data, and import requests made in the LMIS- synch to i-Import, as do import approvals and denials back to Vitas. Both systems were deployed initially for medicines and then extended to all regulated items including medical devices and supplies. Actual importation has also been automated and linked to the import approval process. Inspection and quality assurance, among other functions, are planned to be automated in the coming years. The system benefits from linkages between the various modules. For example, import approval (items and quantities) is now linked to actual items imported. And, linkages between importation and authorization facilitate ensuing only authorized items are imported. Standardizing master data has been an important system benefit and facilitator of success. The system is interoperable with the logistics management information system (LMIS). The agile modular approach to system development and deployment reduced risk and ensured the system met user requirements.

We share lessons from the 6-year journey of piloting to nationally scaling an eLMIS system for Senegal called “Yeksi-Naa”. Since 2013, IntraHealth and Dimagi have partnered in Senegal to implement the Informed Push Model (IPM) with Senegal’s Ministry of Health and Social Action (MoHSA) and National Supply Pharmacy (PNA). Before Yeksi-Naa, local health facilities were tasked with procuring commodities from district warehouses (“pulling”), paying upfront and without training or information for accurate forecasting. Yeksi-Naa was able to transform the supply chain system in Senegal through improved system design by moving to sending commodities to facilities (“push”), outsourcing distribution from public to third party logisticians (3PLs), enhancing real-time data visibility using tablet based eLMIS (i.e. CommCare), and increasing financial viability by moving to post-consumption payments by health facilities. CommCare is used at national scale for distribution of 118 essential medicines at 1,446 supply points in the country, covering public supply chains, including Malaria, HIV, Tuberculosis among other essential medicines. The program plans to achieve full transition to the government by August 2019. The program started with an initial pilot testing the distribution of 40 family planning products. The pilot contributed to impressive success on key health indicators over a 5 year span between 2012 and 2017: - decreased unmet need for family planning products from 29% to 22%; - increased mCPR from 12% to 26%; - decreased average contraceptive stock out rates from 80% to 1.87%. This success led to IPM-Yeksi Naa and CommCare being nationally accepted by the MoHSA and PNA with support from national program partners. The program was expanded to include 118 essential medicines. Dimagi and IntraHealth have been engaged in co-designing a hand over to the government in order for Yeksi-Naa to be a fully nationally owned program.

Acute encephalitis syndrome (AES) is a constellation of clinical signs and/or symptoms which presents with acute fever, acute change in mental status and/or new onset of seizures which are caused due to inflammation of the brain. Due to its complex multiple etiologies, AES continues to be one of the most difficult syndromes due to its high morbidity and mortality rates in the Indian states. In 2018, Uttar Pradesh recorded 8% AES deaths and experienced AES outbreaks for a number of years. Delay in diagnosis and lack of skilled healthcare professionals at the primary healthcare facilities were identified as the major contributors to high case fatality rate. In rural Uttar Pradesh, most of the patients seek treatment from traditional healers as a first contact in the community causing significant delay in treatment. In 2015, the government of Uttar Pradesh upgraded 104 primary and secondary healthcare facilities to encephalitis treatment centers (ETCs) to provide basic health care and supportive management. On request from the government of Uttar Pradesh, PATH offered a technical solution to monitor health commodities at all the established ETCs. The solution comprises of a mobile app to capture availability of health commodities and essential logistics including trained health workforce at the facility level through an online dashboard. Healthcare personnel were trained and provided hands-on support to capture the data on a weekly basis for secondary healthcare facilities and fortnightly for primary healthcare facilities. Data was uploaded to a google spreadsheet linked to a Tableau online dashboard. The online dashboard was shared with key decision makers at sub-district, district and state level to understand real time status on the availability of different health commodities, equipment, key essential drugs and logistics, with a visual depiction of functionality status of the healthcare facilities, caseloads including availability of trained manpower and health outcomes.