Harmonized Reproductive Health Registry Communication Strategies: Using Health Data to Empower Women and Health Systems

This project aimed to demonstrate the feasibility and effectiveness of transitioning the health information system for maternal and child health in Palestine, from a traditional paper-based system, to a digital health registry - the maternal and child health eRegistry. eRegistries are used by the care provider at the point of care, and integrates multiple automated digital health interventions to optimize the use of data to better serve the women, their care providers, and the health systems managers. The main scientific objective was to undertake large scale cluster-randomized trials to generate evidence for the effectiveness of eRegistries, in improving quality of care and attendance to antenatal care services. Specifically, we aimed to test (I) digital checklists with clinical decision support vs pre-existing paper maternity records; (II) targeted client communications with SMS messaging individualized by eRegistry data vs no messaging; (III) quality improvement dashboards with feedback of performance indicators to care providers vs no feedback; and (IV) the potentially synergistic effectiveness of II + III. With synergistic funding from the European Research Council, the project developed the eRegistries in the free and open source DHIS2 software used by 72 low- and middle-income countries, and collecting health data on almost a third of the world population. The project succeeded in co-designing and implementing the DHIS2 eRegistry with Palestinian stakeholders, despite significant delays due to the need to develop multiple new software functionalities, as well as an Israeli ban on 3G technologies in Palestine that forced us to install fiber cables to clinics, and periods of war, civil unrest, and restriction of movements that slowed implementation progress. By the end of the project, eRegistries have adopted and deployed as the new national health information system across the West Bank and Gaza. Leading up to these trials (I-IV), we undertook formative research, including qualitative studies to co-design the eRegistry with the users, reporting on the scientific methodologies used to develop and implement the digital health interventions used in the trials. We performed analyses of both paper-based and eRegistries data to explore the most important health challenges and the biggest gaps in the quality and use of antenatal care in Palestine, as to design the digital health interventions specifically to counter them. We completed trial I to demonstrate both a significant improvement in quality of care, as measured in increases of effective coverage of essential interventions in pregnancy, and a significant reduction in the time spent by care providers in documenting and reporting data. We completed a non-inferiority sub-study of trial II with structured interviews of women demonstrating that targeted SMS messaging addressing risks in pregnancy and benefits of care did not create any adverse effects on women?s worries in pregnancy or their general satisfaction with care. We implemented Trials II-IV which were still ongoing when the Palestinian authorities declared the first lockdowns, including primary healthcare clinics, due to the COVID-19 pandemic in March 2020. The trials were forced to end with 85% of the sample size needed, we have completed the data collection, and analyses are ongoing. This project has demonstrated feasibility and effect of transitioning from paper-based health information to eRegistries. We developed the eRegistries in the free and open source DHIS2 Tracker software, and shared all methods, technologies, and comprehensive implementation guidance with the global community of health informatics professionals using DHIS2 (dhis2.org). As a result, DHIS2 eRegistries are now being deployed to support health systems in maternal and child health, immunization, tuberculosis, and child nutrition programs, and more, in multiple low- and middle-income countries, including Bangladesh, Ghana, Botswana and Rwanda.

The most important outcome of the project is not a singular finding, but the combination of our implementation reports, showing feasibility; our trials, showing effect; and our technology transfer with tools and implementation guidance for the global community of DHIS2 users. Scientifically, our trials will support the evidence underpinning WHO guidelines for digital health interventions. We have introduced a new paradigm for DHIS2 health information systems in low- and middle-income countries. The case study of the Palestinian eRegistries has become a core component of the curriculum of DHIS2 Expert Academies around the world. Large donors in global health, such as UNICEF, Gates Foundation, and GAVI, are specifically funding deployments of DHIS2 Tracker registries for e.g. immunization, maternal and child health, and child nutrition - built on the eRegistries technologies from the project.

A reproductive health registry (RHR) captures health outcomes and determinants, such as the coverage and content of essential interventions, and bridges the continuity from primary to facility-based care for women and children. The harmonized RHR Initiati ve, led by the Norwegian Institute of Public Health (NIPH) and the World Health Organization (WHO), have developed a framework and tool-kit to facilitate low and middle income country implementation to enhance data collection and use for the improvement o f reproductive health. Palestine is the first state to implement an RHR based on this framework, across all districts (both West Bank and Gaza), all levels of care, and all providers. The implementation is led by the Palestinian National Institute of Publ ic Health (PNIPH), in collaboration with the NIPH, WHO and the Health Information Systems Project (HISP) from the University of Oslo. This creates an opportunity for research where we will utilize a stepped, wedged cluster randomized controlled trial desi gn to undertake four trials of comparative effectiveness. We will test whether different communication strategies using data-driven automated electronic feedback from an RHR is effective in increasing healthy maternal self-care, care-seeking and demand be haviors, and improving the continuity and quality of care and guideline adherence by health providers in facility-based care for deliveries and newborns. Main outcomes include adherence to evidence-based WHO guidelines, enhanced quality and continuity of care, and improvement of health behaviors pertaining to self-care and care-seeking among women. The studies will have synergies with a sister project, funded by the European Research Council, studying effectiveness of the RHR in the setting of Primary He alth Centers of the Ministry of Health on the West Bank. Being the first state-wide RHR implementation based on this framework, the trials will have significant impact on future country implementation strategies.