‘The false reporter will get a praise and the one who reported truth will be discouraged’: a qualitative study on intentional data falsification by frontline maternal and newborn healthcare workers in two regions in Ethiopia

Abstract

IntroductionHealth Management Information Systems (HMIS) are vital to ensure accountability and for making decisions including for tracking the Sustainable Development Goals. The Ethiopia Health Sector Transformation Plan II includes preventing data falsification as a major strategic initiative and our study aimed to explore the reasons why healthcare providers intentionally falsify maternal and newborn health (MNH) data in two regions of Ethiopia.MethodsWe conducted a qualitative study in two hospitals, four health centres and their associated health posts in Oromia and Amhara regions. We conducted 45 in-depth interviews with health facility managers, quality improvement (QI) focal persons, health information technicians, MNH care providers, Health Extension Workers and QI mentors. Data were collected in local languages and transcribed in English. During analysis we repeatedly read the transcripts, coded them inductively using NVivo V.12, and categorised the codes into themes.ResultsParticipants were hesitant to report personal data falsification but many reported that falsification is common and that they had experienced it in other facilities or had been told about it by other health workers. Falsification was mostly inflating the number of services provided (such as deliveries). Decreasing the number of deaths or reclassifying neonatal death into stillbirths was also reported. An overarching theme was that the health system focuses on, and rewards, the number of services provided over any other metric. This focus led to both system and individual level incentives for falsification and disincentives for accurate reporting.ConclusionOur finding suggests that to reduce facility level data falsification policy makers might consider disentangling reward and punishments from the performance reports based on the routine HMIS data. Further studies examining the high-level drivers of falsification at regional, national and global levels and effective interventions to address the drivers of data falsification are needed.

Understanding maternity care providers’ use of data: A qualitative study in Southern Tanzania

“…The data was thus perceived as useless and consequently accountability was low. Other research from similar settings supports these findings: Numeric data was seen as owned by the management (5,44) and, similarly to our results, its completeness was valued over correctness (12). MCPs saw themselves as producers of data rather than users, feeling disempowered to apply their own data (4).…”

“…Research on the use of HMIS data including our own, suggests that MCPs need role models and support to develop a data perception that is led by accountability and transparency (4,8,22). In line with our findings, MCPs in Burkina Faso and Ethiopia reported managerial complacency with data modification (5,44). These experiences are likely to shape an organizational culture where data is used to safeguard social relationships as a coping mechanism within a complex environment.…”

“…Wendland depicts the apparent divide between seemingly neutral numeric indicators on one hand and how this evidence is contextually shaped on the other. Other authors report, how numeric data is modified by health care providers to counteract pressure from health management in Burkina Faso, Ethiopia and Tanzania (5,6,44). Our participants illustrated how HMIS data was adapted, and narrative documentation tweaked to construct a seemingly more trustworthy reality, with perceived control over work environment, managers' and public reactions to their performance.…”

Understanding maternity care providers’ use of data in Southern Tanzania

“…Estifanos et al take a health system focus and emphasise on managerial pressure as a main driver for data modification in Ethiopia, 46 but we argue, that healthcare data is part of a more complex social, organisational and individual concept of power, alienation, accountability and social integrity ( figure 4 ).…”

“…Previous research by our group from Southern Tanzania also described MCPs' accounts on how data in official HMIS registers was altered to satisfy official requirements. 4 Estifanos et al take a health system focus and emphasise on managerial pressure as a main driver for data modification in Ethiopia, 46 but we argue, that healthcare data is part of a more complex social, organisational and individual concept of power, alienation, accountability and social integrity (figure 4).…”