Results
In this section, we first present descriptive data on what falsification participants reported occurred. We then present five themes related to reasons data are falsified: ‘system’s focus on numbers’, ‘system level incentives to falsify data’, ‘system disincentives to report actual data’, ‘individual incentives to falsify data’ and ‘individual disincentives to report actual data’.
Data falsification
Most participants reported that there was no data falsification in their current facility. This was reported as a recent change and was often linked to the QI intervention as this included data verification, supervision from the mentors, being taught the importance of accurate data and using the data for decision making.
It [data falsification] has changed since the QI initiative …. Health professionals are encouraged to send the actual report [representing] the actual performance …. they started to report what they actually [have] done. I think we have seen a change after the QI initiative started. (ID07, nurse)
We noted some hesitancy talking about personal data falsification with many participants stating they are not liars or that falsification is not in their nature. One participant who reported that they had personally falsified data requested the tape recording be switched off highlighting that they viewed this as a sensitive topic. Despite reporting that it did not happen in their facility many participants reported that falsification was common and that they had seen it in other facilities or had been told about it by other workers:
… I never did like this [falsified data] in [my] history. I am not a liar in nature. If there is death, I always record the death …. However, my friends who work in other facilities tell me what they do [falsify data] when they are told to increase the number of deliveries …. (ID02, midwife)
The most commonly reported falsification was inflating the number of healthcare services provided, particularly deliveries, but there were also reports of decreasing the number of deaths or reclassifying neonatal deaths as stillbirths.
We don’t do such a thing [reclassifying neonatal death into stillbirth] … But sometimes it may occur. For example, a midwife may say it [the neonatal death] is stillbirth or IUFD [intra uterine fetal death] not to be reprimand or criminalized for a child who died because of poor follow up. Such practices are avoided after QI came to this hospital. (ID14, midwife)
Falsification was reported to be done by heath workers and by facility managers when they generate and submitted reports.
It was with guess that it [reporting form] was filled before. It was only the [manager] who filled this form. I [the manager] was filling this form alone. False reports were present … (ID06, health facility manager)
Reasons for data falsification
Although most participants did not report a practice of data falsification in their facilities they reported several reasons for data falsification in other facilities (figure 1). An overarching theme was that the health system focuses on, and rewards, the numbers of services provided over any other metric. This focus led to both system and individual level incentives for falsification and disincentives for accurate reporting. Incentives include praise and recognition of the facility or the individual, benefits for the facility such as increased power or material support and for the individual such as bribes or better educational opportunities. Disincentives included explicit pressure to falsify from those above you, this was from woreda officials at the system level and facility managers at the individual level, with a fear of a negative impact for those that did not comply. There was also a culture of blame for poor performance at facility and individual level, and a fear among individuals that they would be held accountable for poor clinical outcomes.
Figure 1Reasons for intentional data falsification by frontline maternal and newborn health care workers, Ethiopia.
System’s focus on numbers
A key theme was that there was a culture of falsification throughout the health system driven by the need to show high performance, which was judged by numbers, and was perceived to be desired by those above. Connected with this was a culture of blame for those who performed poorly.
Facilities exaggerate data because of the system, if the bosses are looking for high performance, the health professionals report high numbers to get appreciation from their bosses. Those who have reported false reports are appreciated and those who report lower numbers are blamed. So, this system encouraged the facilities [to] overreport their performance (ID07, nurse)
Even if I assist the delivery of a single woman they ask me to report it as ten [women] …. Once, I reported eight deliveries per month and the manager from health center and the woreda shouted at me and they say [to] me ‘you have some political problem’ (ID31, midwife)
System level incentives to falsify data
The number driven system led facilities and officials to exaggerate their performance so they would rank highly to create a positive image for their facilities compared with other facilities and to gain power or recognition, admiration, appreciation and praise for the facility.
Previously, to compete with other health center …. maybe to not lose their position; they tried to exaggerate the data. Due to these reasons they reported false reports (ID05, Health officer)
Sometimes they need power. Sometimes not to be insulted. And sometimes for example if we need to increase the name [improve the image] of our woreda, we overstate our data. This is to get our health center recognized. (ID11, HEW)
Exaggerated numbers could also lead to material gains such as receiving more ‘support’ or being eligible for a facility upgrade. For example, study participants from the hospitals identified the need to demonstrate high performance in relation to the number of services provided to upgrade the level of their hospital.
…; it is when there are a lot of cases or[we] provide services for many clients that the hospital gets support …. For example, it was said this hospital should upgrade to a referral hospital …. It was asked to present a report on the number of cases …. It is when they want to get support from the higher health bureau that they may exaggerate the numbers…. (ID12, midwife)
System level disincentives to report actual data
Study participants reported they had experienced, seen or heard about pressure being exerted on health workers to falsify data using terms such as ‘forced’, ‘pushed’ or ‘made’. Those exerting pressure were often described as ‘they’, but several participants clarified that they were referring to facility, woreda or zonal managers.
…. They push us to record what has not been done. For example, if there are 11 deliveries, they push us to record it as 21 deliveries. They push us to lie … (ID10, midwife)
Participants described a culture of blame where health workers and managers would be held accountable for ‘poor’ performance even when this was caused by factors outside of their control.
…. when it is said facility delivery has increased in other woredas, they say you are not performing well, but we are doing what we are supposed to do .…. (ID10, midwife)
Individual level incentives to falsify data
Incentives to falsify information at the individual level included appreciation and praise for false high performance, tangible benefits through bribes and greater transfer and educational opportunities.
Participants reported that health officials often praise/appreciate false high performance and sometimes pay money to ensure exaggerate performance.
… Let’s say two people were given ten works [tasks] each. But, in truth both of them did two out of ten, and one reported eight to be above 50% whereas the other reported exactly two; then your manager and people from the woreda blame you like you are not working, you are inefficient and such like, words that discourage you, despite your hard work to get even that two out of ten. So, the false reporter will get praise and the one who reported the truth will be discouraged …. (ID15, HEW)
… I know one health professional who quarreled with the [manager] of the woreda health office due to this [falsifying data]. He argued with him when he ordered him to increase the report. The other midwife received money and did what the [manager] said … (ID02, midwife)
Participants reported that healthcare workers who got education opportunity or transfer to a better health facility were those who manipulated the data to report high healthcare service provision performance.
… there was a summer education opportunity that was given to the health professional providing the most delivery services. Due to this, there was false recording of facility deliveries, even for mothers who had had home delivery …. (ID16, MCH focal person)
… If you do a good job, you get the chance of a transfer from one area to another area. They were thinking about these kinds of issues. That is why they reported the false report. (ID18, midwife)
Individual level disincentives to report actual data
At individual level there are different disincentives to report actual performance data including a desire not to be directly held accountable or blamed for poor performance, and not wanting to make their life difficult or fear of losing their job.
Participants stated that healthcare providers do not want to be blamed for low performance in provision of healthcare services and/or for reporting the actual high number of poor health outcomes. They also have a fear of being held directly accountable for poor clinical outcomes causing non-reporting or to misclassification of deaths.
…. It was eleven neonatal deaths [that were] reported in six months in this cluster, but what was reported was only six deaths. They have deducted five deaths because they want to exaggerate their performance. They do not want to be blamed. They hide information so as not to be blamed and insulted. It is the reason for false reporting; if there are a high number of deaths, the midwives will be blamed or insulted…. (ID04, HEW)
Some respondents mentioned fear of losing one’s job or stable income as a reason to falsify the MNH care service data.
… they are afraid of losing their job, so that, they tend to lie. The first reason for falsifying data is, to eat the available Enjera [Ethiopian flat bread] peacefully…. (ID19, QI mentor)
Many participants reported that most health workers do not want to lie, and have a responsibility not to do so, and sometimes argued with their peers and superiors about falsification, but did so in the context of a system that encouraged and rewarded falsification.