In June 2012 communal violence broke out in Rakhine state in western Myanmar between the Buddhist Rakhine community and Muslim Rohingya. The violence displaced approximately 147,000 people into camps across the state. Since then the Rohingya – the world’s largest stateless population – have faced institutional discrimination, disenfranchisement from rights and services and stringent movement restrictions, including not being able to directly access state health care facilities. In Sittwe Township, where the majority of displacement camps are, non-governmental organisations (NGOs), both national and international, run clinics to provide primary health care to camp residents who cannot use state facilities.
The International Rescue Committee (IRC) has been running 22 health clinics across two townships, treating 43,000 patients a year. In 2016 the team developed a Health Geo-Spatial Information Management System using a combination of mobile technology and Geographical Information Science (GIS) software. By improving processes for documenting consultations within the camp clinics and improving data analysis, the system has enabled the team to make more evidence-based decisions to improve programming. The system was developed through the combined efforts of IRC’s clinical team, the Monitoring and Evaluation (M&E) Unit and GIS experts based in Rakhine State.
The need to innovate
Prior to 2016, the inability to track patient history was a significant issue within the clinics, especially given the high patient volume. With some clinics receiving over 100 patients per day, the resulting record-keeping burden was substantial. Consultations were documented on paper forms and stored in the clinics in locked filing cabinets. Data was aggregated and reported daily to the State Health Department (SHD) in hard copy to provide real-time data for the SHD’s surveillance reporting system. However, aggregating the data meant that the ability to track individual patient histories was lost.
Another factor contributing to difficulties in patient tracking is a lack of documentation. Specifically, anyone born before 1982, when the Myanmar Citizenship Law was passed, may not have official civil documentation. 1982 Myanmar Citizenship Law sets our different categories of citizenship and grants automatic citizenship to those who are a member of the recognized 135 “national races”, which does not include the Rohingya who need to apply under different (non-automatic) provisions. Documentation was also lost in the 2012 violence, when a significant number of Muslim homes and businesses were burnt down. As a result, patients often arrive at clinics with no form of personal identification.
Development and implementation
To meet the need for better tracking of patient histories, in 2016 the IRC developed a Patient Consultation Booklet (PCB), which from April has been distributed to all new patients when they register with community health workers (CHWs). IRC has distributed nearly 20,000 patient record books across our programme area. The front cover of each PCB has a unique ID number, but contains no other traceable information in order to protect patient confidentiality in the event they lose their book. Inside the booklet there are carbon copy pages of the clinical consultation form, which is filled in by a doctor or nurse during the consultation. Afterwards, one copy of the consultation form can be removed to facilitate further follow-up within the clinic (such as drug prescriptions) and then stored on site. A second carbon copy is kept in the book for the patient to take away. Each patient is asked to bring their book back for every consultation, allowing the clinical team easy access to the patient’s history the next time they visit.
All data, including PCB ID number, age, gender, village/camp name and shelter location, are recorded by CHWs on a tablet computer with a bespoke mobile application and saved on a password-protected Patient Record Database. The address system used in the camps means that it is possible to link the PCB ID to shelters, known locally as longhouses Distributions in the camps are often done longhouse by longhouse, so knowledge of shelter ID linked with a person or family’s name is common. (see Figure 1). The doctors and nurses in the clinics also use tablets to record clinical information in a Clinical Consultation Database, which records the same information as written on the carbon copy pages in the PCB. For every clinical consultation they record the PCB ID on the tablet version of the form, but not the patient’s name. This protects the identity of the patient while enabling a link to their location via the book’s ID. It is then possible to join the two datasets via a relational database to which only the IRC team has access.
The new system gives the clinical team direct access to patient histories via the PCB, meaning that clinicians do not have to waste time searching for past records. In addition, recording patients’ locations has improved understanding of the clinics’ catchment areas, enabling the team to map where people are coming from to access clinic services (see Figure 3), and to record people’s movements as they go about seeking care. It was found that a significant number of people from villages adjacent to the camps were also the using the clinics. This has informed programming in several ways, for example by allowing the team to adjust the number of CHWs assigned per area to account for the increased catchment area. CHW staffing ratio is 1:1,000 population: https://www.humanitarianresponse.info/en/applications/ir/indicator/h-a8 The system also makes it possible to map out common morbidities across the camps, such as diarrhea and infections stemming from cramped living conditions. The community health team can use these maps to inform and redirect their health education sessions and community awareness campaigns based on where common morbidities are coming from within the camps. By using clinical data, the IRC is connecting prevention activities in communities to the morbidities we are treating in our clinics. We also use the data for advocacy for shelter, WASH and health sector improvements in the camps with relevant humanitarian actors.
A review session was held with the clinical team and Programme Coordinator after the first seven months of implementation of the PCB and the new health information management system. The clinical team felt that having immediate access to patient records via the PCB was very useful in saving time trying to understand patient history from the patient. The Rohingya use a different language to the ethnic Rakhine and doctors and nurses come from the Rakhine population, so commonly doctors and nurses would have to use a translator to speak to the patient. The system also gave the clinical team better access to technical details about previous examinations. A significant number of returning patients brought their PCB with them to the clinic. Overall, the clinical team reported that the PCB positively supported the consultation process and had improved the quality of the health care provided.
As some double counting was taking place, the team also felt that the electronic version of the consultation form needed to be simplified by populating the PCB and the electronic version with similar data. Completing the full consultation sheet in the PCB was deemed more important when clinics were extremely busy, as this directly informs the care being given by the clinical team at that point. For example, nurses use the removed top page written on by the doctor to dispense the appropriate amount of drugs, whilst the data in the tablet is used to inform community health approaches and strategic programming, and is therefore less important during very busy periods.
The health team noted that the coding of the patient to their location (either to village/camp level or longhouse) was very beneficial as it allowed for the plotting of spatial variations in access to the clinics. It has also helped in understanding health-seeking behaviour and obstacles to access across the various camps. The team agreed that continuing to aggregate data to longhouses, which contain 40-80 people, was the appropriate method for patient confidentiality and protection and that a shorter electronic consultation form, recording just morbidity and longhouse ID, would help in targeting disease hotspots in the camps.
The team collectively agreed that continuing with the PCB methodology and simplifying the electronic form was the best way to generate data to facilitate well- informed consultations, in addition to providing the community health team with data to adapt its programme to observed health-seeking behaviours, blockages to health care and disease outbreaks.