The power of data: using routinely collected data to improve public health programmes and patient outcomes in low‐ and middle‐income countries

‘We are data rich, but information poor! ’ So said one of the senior Ministry of Health officials in Fiji when a team from the International Union Against Tuberculosis and Lung Disease and the University of Fiji was discussing the start of an operational research capacity building initiative in that country two years ago. This statement probably sums up the situation for many Ministries of Health and NonGovernmental Organizations (NGOs) in lowand middleincome countries (LMIC), where large amounts of data are regularly collected and collated from health facilities, filed away or shelved and never used, analysed or interpreted to drive improved performance of health services, the scale up of interventions or better outcomes for patients. This paradigm needs to change. Furthermore, such data could be used in the context of operational research to ask more farreaching questions about quality, coverage, safety and effectiveness of programmes or health systems. National tuberculosis control programmes (NTPs) throughout the world serve as a model for data collection. One of the essential components of the WHO Stop TB Strategy is a standardised monitoring, evaluation and reporting system to account for all TB cases diagnosed along with their treatment outcomes through cohort monitoring (WHO 2006). Within well-functioning NTPs, TB officers review patient data every three months in terms of who and how many are accessing treatment, whether treatment outcomes are satisfactory, and whether adverse outcomes such as death or loss to follow-up are being kept to a minimum. These data are used to assess programme performance, and they also serve as the foundation for district and national drug forecasting and procurement. The routine data can also form the basis of operational research, which we define as research into strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of the health system or disease programme in which the research is being conducted (Zachariah et al. 2009). Between 1996 and 2005, the Malawi NTP formally incorporated operational research into its routine activities, and a large number of research projects were undertaken to improve policy and practice and reduce morbidity and mortality of patients (WHO 1999). One particular example concerned high case-fatality rates in HIV-infected TB patients before the advent of antiretroviral therapy (ART). The country undertook a series of district-based operational research studies to determine whether it was feasible to offer a package of HIV testing and cotrimoxazole preventive therapy (CPT) to TB patients registered under routine programme conditions (Harries et al. 2011). Using routinely collected data, and paying particular attention during this time to ensuring that mortality data were reliable and complete, the studies showed a significant reduction in death rates of between 20–25%. This evidence persuaded the Malawi Ministry of Health to support the scale up of HIV testing and CPT countrywide for TB patients, and activities started soon after completion of the research in 2003. Between 2002 and 2008, routinely collected data showed a significant increase in HIV testing amongst TB patients with the majority of HIVpositive patients being started on CPT. Treatment outcomes in new smear-positive pulmonary TB patients