Health care providers, in particular, the performance monitoring team (PMT) is a team of multidisciplinary health workforce that is primarily responsible for improving data quality, using information regularly, monitoring the health progress, and improving the performance of health care delivery at all levels of the health care system. PMT members are selected health care providers who are involved in the collection, generation, and utilization of health information for decision making, and they serve as the focal persons in their departments/wards. PMT members in Ethiopia are prominent/selected health care providers who widely participate in using district health information system 2 (DHIS2) data for decision making. The commitment levels of the PMT members to their organizations and the use of health information for decision making is a topical issue that needs some attention in the delivery of quality health care.

Changing the culture of information use at each level of the health system is one of the transformation agendas of the Ministry of Health of Ethiopia. This cannot become real unless health care providers are committed to use locally collected data for evidence-based decision making. Health care providers’ level of commitment to use DHIS2 data could provide comprehensive and dependable information, which is the basis for better decision making [1-3]. This is because DHIS2 data consist of global initiatives by Sustainable Development Goals and Countdown to 2030 that emphasize its contribution to monitoring of service delivery by health care providers [4]. The DHIS2 is used in more than 60 countries, and most global initiatives are interested in using DHIS2 data for monitoring the health performance [5-7]. Facility-based data (DHIS2 data) is one of the major identified strategies to achieve sustainable development goals—especially for maternal mortality and neonatal mortality to reach a global average of only 70 per 100,000 live births by 2030 [2,8].

As per the World Health Organization (WHO), health care providers’ level of commitment has paramount influence on DHIS2 data utilization for decision making that will also be the basis for the provision of quality health service [9]. The WHO and the Institute for Health Metrics and Evaluation have stated that to improve the accuracy and utility of health information for decision making, the commitment levels of health care providers is the base [10]. This is because improving the quality of health service can be affected if health care providers are not responsible in using the highly generated medical data, which is but a mandatory step on the path to reaching the sustainable development goals and universal health coverage [11].

A study in Nigeria has identified that the commitment of health care providers to use health information should be taken into consideration, and currently, the level of commitment among health care providers in Nigeria is 60%-80% [1] A study conducted in Isfahan showed that the compliance of health care providers to use district health information was much lower than WHO standards (90%) and was limited to an average of 35.75% [12]. Another study conducted in Iran at hospitals proposed that health care providers’ level of commitment toward the use of health information was a worthy path that every health care worker needs to be dedicated to in using and implementing routine health information for decision making. Currently, the average score of health care providers’ level of commitment to use and implement routine health information, especially electronic medical records, has been achieved with an average of 74.7% [2]. Another study in Ghana indicated that health care providers are expected to have a sense of promoting responsibility to use health information and should feel committed to improving the health status of the target population. Factors such as punctuality at work, documentation of daily activities, and monitoring of data wisely have been associated with the level of commitment to use information. However, currently, the level of commitment among health care providers, specifically among senior managers, is 77.3% [13].

Studies have identified that health care providers need to be committed to using DHIS2 data, wherein over 90% of the available data have been generated within only 2 years [2,14]. In sub-Saharan Africa, the standard procedure for data use is poor and the measures of the health care performance are very low because of the inadequate commitment of health care providers [15]. The quality of health care depends on the dedication and commitment of health care service providers [2]. Being committed to using DHIS2 data will favor high-quality health systems, thereby ensuring relevant advancements toward achievement of sustainable development goals [2,14]. However, over the years, evidence for low commitment to use data have been less as decisions are not taken based on data [2]. Health information data show inconsistency and poor treatment responses because of the low levels of commitments of health care providers [16,17]. The government’s health facilities are not committed to reporting data on a regular basis, data are not used for setting target programs, and these facilities are unresponsive to timely decision making [2,14]. The WHO has stated that factors that affect the commitment to use DHIS2 data are critical in affecting the quality of health service provision [9,10]. Thus, quality of health care will improve when health managers are committed to the use of health information for decision making because quality in health care is a production of cooperation between the patient and the health care provider in a supportive environment [1]. High-quality routine health system data are highly relevant for monitoring advancement toward achievement of the Millennium Development Goals 4 and 5, which are twins to the Sustainable Development Goal 3. However, the main determinant to reach this stage is the level of commitment toward the utilization of routine health information systems. The evidence for the provision of good-quality health service is lacking due to the low commitment of health care providers toward the utilization of health information systems [2]. Low commitment toward the utilization of DHIS2 data results in the production of late diagnosis and treatment reports and distorts the consistency within data space, making the overall utilization of district health information system for decision making to be low [3].

In Ethiopia, the PMT is one of the major platforms to review the performance, data quality, and information use of the health system at each level. The level of commitment of health care providers (especially PMT members) has direct influence on DHIS2 data utilization for decision making [13,18]. Nevertheless, to the best of our knowledge, evidence is limited on PMT members’ level of commitment to use DHIS2 data and the factors that determine the extent of their commitment levels. Therefore, this study aimed to fill the evidence gap on PMT members’ level of commitment to use DHIS2 data for decision making and the factors that determine their commitment levels.

This study focused on the level of commitment of health care providers to use DHIS2 data and the factors that affect their levels of commitment. We found that the 45.8% (121/264, 95% CI 40.0%-52.8%) of the PMT members used DHIS2 data for decision making, which was higher than that reported in a study conducted in Iran (35.75%) [19]. This finding may be attributed to the fact that the government of Ethiopia has given special attention to the utilization of health information systems for decision making and the internal commitment of health care providers in Ethiopia to use these data has increased [20]. However, the proportion of PMT members committed to using DHIS2 data in this study was lower than that reported in a study conducted in Ghana (77.3%) [21] and Iran (74.7%) [22]. This might be because infrastructures and advancements in technology in Ghana are more developed than those in Ethiopia. The proportion of the committed PMT members in this study was also lower than that of the PMT members in a study conducted in Nigeria, wherein the proportion of professionals committed to use the routine health information system was 60%-80% [23]; however, the target for this proportion in 2010 was 90% [24]. The possible explanations for this variation could be the size of the study participants, their scope of roles, availability of infrastructure, and availability of resources such as internet connection and other related electronic devices. This result was supported by qualitative findings as follows:

PMT members competent in DHIS2 data tasks were 2.41 times more likely to have a higher level of commitment to use DHIS2 data for decision making than those incompetent in DHIS2 data tasks (AOR 2.41, 95% CI 1.27-4.55). This finding was in line with those reported in studies conducted in Ethiopia [25], Ghana [2], Nairobi, Kenya [26], and another study conducted at the health facilities in Kenya (P=.03) (AOR 4.32, 95% CI 2.34-7.98) [27]. However, this finding was inconsistent with that of a study conducted in Kenya, which indicated that competency in DHIS2 task has no association with the performance of the health information systems [28]. This result was supported by qualitative finding as follows:

This study revealed that feedback on DHIS2 data use was positively associated with PMT members’ commitment level to use DHIS2 data for their decision making in the Ilu Aba Bora zone health facilities (AOR 1.85, 95% CI 1.02-3.33), which was in line with the findings of the studies conducted in Ethiopia [12], Kenya [29], and Ghana (P=.04) [2]. However, this finding was inconsistent with the findings of a study conducted in Ghana [30].

The promotion of information use culture in health care providers would result in them being 1.92 times more likely to have higher levels of commitment to use DHIS2 data as compared to those who did not have a culture of information use (AOR 1.92, 95% CI 1.03-3.59). This result was supported by qualitative findings as follows:

As this study revealed, commitment levels to use DHIS2 data for decision making were based on health needs (AOR 3.96, 95% CI 2.11-7.41). However, this finding was inconsistent with that reported in a cross-sectional study conducted in Ghana, which showed that the commitment to use DHIS2 data for decision making does not depend on the health needs [2]. This result was supported by a qualitative finding as follows:

Regarding study participants’ motivation to use DHIS2 data, respondents with higher motivation were 1.80 times more likely to have higher levels of commitment when compared to those with lower motivation to use DHIS2 data for their decision making (AOR 1.80, 95% CI 1.00-3.25). This finding (P=.03) was in line with the findings of studies conducted in Ethiopia [25] and Ghana (P=.01) [2].

PMT members with regular supportive supervision visits were 2.84 times more likely to have a higher level of commitment than those who did not have regular supportive supervision (AOR 2.84, 95% CI 1.50-5.37). This result was similar to those reported in studies conducted in Ethiopia [12,25] and Ghana, which showed that the level of commitment to use DHIS2 data was directly associated with the daily managerial supervision (P=.04) [2].

This study attempted to reveal the commitment levels of health care providers to use DHIS2 data and the factors associated with their levels of commitment. The strength of this study lies in the attempt to cover the different types of health facilities such as health centers, primary hospitals, and referral hospitals. Moreover, our study used a mixed-methods approach and gives evidence on the commitment levels of PMT members to use DHIS2 data for decision making and the barriers in using it. However, our study has the following limitations. First, this study was a facility-based cross-sectional study; therefore, it could not provide the causal relationships with the factors. Second, this study was conducted at health facilities and might not be generalizable to all other administrative services in Ethiopia. In addition, this study did not include health care providers in private health care facilities.

In conclusion, less than half of the PMT members in this study were committed to using DHIS2 data for decision making. Based on WHO’s criteria for commitment to use health information and other studies found in the literatures, our proportion was low. The culture of information use, motivation to use DHIS2 data, competency in DHIS2 tasks, health needs, managerial supervision, and feedback on DHIS2 data use were the most important factors determining the commitment of health care providers to use DHIS2 data for decision making. Thus, we found significant factors that affect PMT members’ level of commitment to the use of DHIS2 data for their decision making. The findings of our study suggest that providing regular supportive supervision and feedback, increasing the motivation of health care providers, and changing their attitudes will help in bringing cultural transformation of data use for evidence-based decision making in health care.