Knowledge Brief Health, Nutrition and Population Global Practice The Integrated Family Record System (SIFF), a Key Tool for Monitoring the Social Determinants of Health in Costa Rica Ana Lucia Rosado Valenzuela, Ashley Sheffel, Micaela Mussini, Ana Maria Lara Salinas, Laura Di Giorgio August 2023 KEY MESSAGES: • The family record, historically implemented at the primary health care level in Costa Rica, collects socioeconomic and health information and has become a key tool in the multisectoral strategy to address challenges that threaten the health of the population. • Recently, the digitization of family records into the Integrated Family Record System has boosted the benefits to the direct users of the tool, to the operation and administration of the Costa Rican Social Security Fund (CCSS), as well as to institutions of social interest in the country for the priority monitoring of vulnerable populations. • The integration of data collection through electronic tablets has allowed the georeferencing of the country's homes, an important step that will generate information on the concentration of epidemiological profiles and risk maps by communities and will facilitate the management of future epidemics and natural disasters. • This project was implemented quickly and achieved a high level of coverage in housing digitization prior to the COVID-19 pandemic. Barriers to implementation have been addressed through teamwork and institutional support and commitment. • The great benefits of SIFF are still incipient, as its immense potential through the georeferencing of dwellings will be fulfilled in the coming months. distribution in the national territory. It detects risk factors Introduction (social and health) in families and thus allows the early detection of vulnerable users, identifies groups that In a period of 7 years, Costa Rica achieved the require greater attention in terms of prevention and digitalization and automation of the Ficha Familiar, an facilitates their expeditious and safe referral to other instrument of the first level of care that provides levels of health care or other social services. At the same socioeconomic and health information of households and time, in operational terms, it made information records families in the country and that had been recorded on much more efficient by reducing paperwork and paper for almost four decades.(1) This technological tool, simplifying procedures, facilitating the monitoring of data now called Integrated Family Record System (SIFF, for its quality. name in Spanish, Sistema Integrado de Ficha Familiar), promotes the strengthening of Costa Rica's Universal SIFF's digital transformation was driven through the Health Insurance by providing real-time information on Program for Results (PforR), a World Bank financial the health of Costa Ricans. This allows to know the socio- instrument that incentivizes the achievement of strategic demographic characteristics of the population and its objectives and goals of programs in which governments Page 1 HNPGP Knowledge Brief seek to improve the use of general public expenditures or beginning of the 21st century to create digital files of improve their performance using their own processes these databases so that the Technical Primary Health and institutions. In Costa Rica, this program ran from Care Assistants (ATAP, for its name in Spanish, Asistentes 2016-2023 for the Strengthening of Universal Health Técnicos de Atención Primaria) could fill in the Insurance. Its initial objectives included modernizing and information in the Family Record on their return from strengthening the primary health care network, field visits. (5) This digitization of the information allowed improving the quality of services, increasing population a better analysis of the data at the local level, but they coverage, and making the network more capable of were isolated databases and lacked computer security. prevention, early diagnosis, and control of diseases relevant to the local, national, and regional epidemiological profile. In addition, the objective was also to improve the institutional and financial efficiency of the Costa Rican Social Security Fund (CCSS, for its name in Spanish, Caja Costarricense de Seguro Social), the main provider of health services in Costa Rica.(2) The World Bank's support not only made it possible for 100% of Costa Rican homes to be digitized in the family record information system, but has also been an important catalyst for the geo-referencing of more than Figure 1. ATAP in community. Credits: CCSS, 2022. (6) 60% of Costa Rican homes to date. This digital transformation success was also possible thanks to the The Integrated Family Record System digital transformation ecosystem that the CCSS is In 2015, SIFF progressed and was integrated into the experiencing. In addition to a great institutional Single Digital Health Record (EDUS, for its name in commitment and will that underpinned the necessary Spanish, Expediente Digital Único en Salud), an resources and transformation management at the institutional repository of patient data in digital format institutional level. It is also the result of an enormous that has enabled the security and interoperability of effort to overcome the barriers encountered in the information among the three levels of health care, implementation of a paradigm shift in the method of including that of SIFF. collecting information from the family records. Currently, there are two ways to enter information into This knowledge report, part of a broader series of SIFF; the computer version called SIFF Web, and the knowledge reports developed by the World Bank, seeks version for portable tablets known as SIFF Mobile (Figure to describe the main reasons for success, challenges and 2). The latter allows the portability and updating of key lessons learned during the digitization of the SIFF, information through an electronic tablet. Its main added with the objective of providing a roadmap for other value is georeferencing, a mechanism that generates an countries interested in implementing similar programs. identification number for each home according to its geographic coordinates. This allows the CCSS to better Background control and monitor the demographic and The identification of the health needs of the Costa Rican epidemiological profiles of the country, in addition to population at the community level has been present in facilitating the location of homes for future visits by the Costa Rica for more than thirty years.(3) In the 1990s, ATAPs.(7) rural health care assistants (4) visited their assigned The SIFF houses geographic, health, and social homes and collected indicators on the characteristics of determinants of health data. Specifically, housing the residences and the people assigned to their sectors, characteristics (e.g., condition and type of floors and these being the basis of the family record. The data walls), electrical equipment, basic services available, collected by the assistants served as input for the number of inhabitants in the dwelling, and the health creation of balance sheets and statistical reports on the status of each family member (e.g., vaccinations given, population in those territories. The recognition of the vital signs, weight, height, disability). The inclusion of relevance of this information, as well as the interest in these variables was obtained from the family files of the automating the process, led some health areas at the Page 2 HNPGP Knowledge Brief • 1990s and from governmental discussions on management of SIFF (e.g., information security and socioeconomic indicators of interest to reduce inequity follow-up of vulnerable patients). In addition, it monitors gaps. In turn, a Users' Committee (composed mainly of the registration and quality of information, with a SIFF coordinators at the national level) analyzes leadership and supervisory role in the activities of the institutional needs annually, as well as the ATAPs. socioeconomic, demographic and epidemiological In field implementation, the ATAPs are the link between context, for the updating and inclusion of new variables. the health system and the community. They visit all This review allows the data collected in SIFF to remain households in the country, including geographically adapted to current needs. inaccessible areas, using horses, boats, quadricycles, or long walks.(10) This has allowed an adequate approach and attention to the indigenous populations. During these home visits, the ATAP carries out health promotion and education activities and, together, records and updates the information in the Mobile SIFF. For their part, the nurses working in the community follow up on the scheduling and supervision of these home visits and provide ongoing training to the ATAPs. They also support the ATAPs with the care and referral of the most vulnerable patients and those with significant risk factors. EVIDENCE OF INTERVENTION SUCCESS Multiple facts demonstrate the success of the digitalization of the SIFF family file. Obviously, one of them is that 100% of Costa Rican households are currently integrated into the SIFF portal and nearly 67% are georeferenced. The different variables collected Figure 2. SIFF Mobile interface Credits: CCSS, 2019. (8) through the SIFF allow a prioritization at the three levels on the health risk of individuals and families in Costa Rica. SIFF planning and implementation (11) This means that, in theory, individuals can be visited The beginning of the implementation of the SIFF at the in their homes three, two, or once a year, according to national level was titanic, since training in the their level of risk. digitalization of family records was carried out with visits In addition, the information collected can be visualized to each of the health regions. With the arrival of EDUS through statistical cubes, which are the predetermined and its political and economic backing, a SIFF outputs of the data contained in the family files. These Massification Project was established. This included the cubes can be used at the institutional level for decision configuration of connectivity with cellular technology and making, or by specific areas, such as statistics and training and support for the Regional Directorates (7 epidemiology, for epidemiological surveillance, outbreak decentralized zones that provide local follow-up to the management, or emergencies. In due course, 105 health areas of the CCSS).(9)who were the managers georeferencing will allow the CCSS to generate an of the implementation in their territories.(1) This SIFF analysis of the data, relating it to time, place, and person. Massification Project was achieved with the donation of This will generate information on the concentration of 900 tablets and a projected average investment per year epidemiological profiles and risk maps by communities, of USD 300K to manage the software and mobile as well as facilitate the management of future epidemics connectivity. and natural disasters. The National Nursing Coordination is the technical body The value of the SIFF data is such that it even provides responsible for the SIFF program. This Coordination more updated information than the national population supports with the elaboration and validation of the censuses and has allowed other social institutions to regulations, as well as the guidelines on the regional Page 3 HNPGP Knowledge Brief benefit from and access the information, through the when the CCSS digital system suffered a cyberattack in signing of confidentiality and information security 2022, since the close relationship of the ATAPs with Costa agreements. Among them are the National Information Rican families made it possible to communicate the new System and Single Registry of State Beneficiaries security elements contained in the SIFF, so that people (SINIRUBE) and the Mixed Institute of Social Assistance could once again trust the system. (IMAS), which use the information to grant economic Committed and empowered nursing staff: The National assistance for the country's development. Nursing Coordination and its organizational distribution FACILITATORS at the regional level positioned the nursing staff as leaders in the implementation of the SIFF and the There are several enablers that together have driven accompaniment of the ATAPs. SIFF's digitization strategy. Political will and commitment: The potential of the data The expansion of the Single Digital Health Record: The contained in the SIFF has allowed the political will for the SIFF is integrated into the EDUS and as such, the growth project to grow. The potential of the information for strategy and implementation of this tool catalyzed the decision making and strategic plans of the CCSS has been expansion of digital family records. Therefore, the better appreciated.(14) necessary funding and resources, as well as the creation of infrastructure for internet connectivity, training and SIFF publicity campaign: The CCSS informed the change management implemented in the EDUS, population about the change to digitalization of the SIFF enhanced the digitization of the SIFF. and the added value this had for their health, through communication campaigns. This facilitated the A solid primary health care system and its Ficha Familiar acceptability of the use of the mobile SIFF in households. as a historical instrument: The various health promotion and prevention activities, implemented for decades in Being an objective of the PforR: The housing data entry community care in Costa Rica, allow the digital and georeferencing in the SIFF were part of the indicators introduction of the SIFF to be facilitated.(12, 13) In turn, promoted through the PforR, by common agreement the health care providers who now interact with the SIFF between the CCSS and the World Bank. This ensured that already knew the components to be collected within the the actions established were effective in achieving the family record, so the training and coaching focused projected goals and allowed the CCSS to commit and act exclusively on the use of the digital tool with computers swiftly to meet the objectives. and tablets and not on the explanation of the content of CHALLENGES ENCOUNTERED AND SOLUTIONS SIFF. APPLIED At the same time, several challenges have been encountered along the way that hinder effective implementation. Human resources gap: The number of ATAP and nursing personnel at the first level of care per 10,000 inhabitants is below what is necessary to cover the population's demand. Although the SIFF allows for stratification of families according to vulnerability risk, the limited number of ATAPs available in the country restricts home Figure 3. ATAP showing the SIFF Mobile to the patient at visits to once a year, instead of two or three visits home. Credits: CCSS, 2019. (8) according to the degree of vulnerability risk stratification. The ATAP as a local and reliable agent: The historical Despite this, the basic health care team (EBAIS) provides existence of the ATAPs, as well as their close relationship closer follow-up to these individuals by having them of trust with the families and their extensive knowledge identified in the SIFF.(15) Likewise, the CCSS is assessing of the communities they serve (an essential aspect in the the human resources needs at the first level of care. care of indigenous populations), has made the collection Based on these diagnoses, the aim is to increase the of information more efficient.(10) This element was key number of health personnel available to meet current Page 4 HNPGP Knowledge Brief • needs. purchase of new equipment. Balance in the management of ATAP activities: One of Resistance to digitalization: At the beginning, the ATAPs the main challenges has been the balance in time that did not know how to use computers or tablets management between data collection and follow-up of showed fear and resistance to their use. This was health promotion and prevention activities carried out by gradually reduced through training on the tool and the the ATAPs. For example, it is difficult to schedule the change management component (interventions duration of home visits, because there is variability in the implemented in the EDUS expansion to facilitate the number of family members to be followed up in the digital transformation process). homes. Another example responds to epidemiological COVID-19 pandemic: Social distancing restrictions, as emergencies, such as the response to the care of well as actions to address the COVID-19 pandemic imported measles cases during 2019, which paused data (COVID-19 vaccination), paused for two and a half years collection activities in the SIFF. Fortunately, the the home visit activities of the ATAPs, including geo- accompaniment and support to the ATAPs, by the nursing referencing of households. Recently, in February 2023, staff, has achieved a more effective balance between the the Medical Management of the CCSS instructed to management of their activities. resume home visits and related activities. THE ROAD AHEAD AND THE GAPS TO BE CLOSED The CCSS will continue to advance in the georeferencing of the country's housing. This will be achieved with the provision of tablets to areas served by third parties, with the requirement to be made in 2023. In total, about 1,600 tablets will be purchased, about double the first donation. This surplus of devices is intended to cover device replacements due to breakdown or loss. Figure 4. ATAP collecting vaccination card information in In addition to continuing to ensure the quality assurance SIFF Mobile. Credits: CCSS, 2019. (8) of the information, efforts will also be made to integrate Technological advances and computer equipment establishments that are not currently being explored by failures: Rapid technological advances have caused SIFF, such as schools, nursing homes and community portable tablets to become obsolete. In addition, there homes. have also been casualties in these equipment due to The future sustainability of the SIFF appears to be breakdowns in accidents or loss of the devices. To meet promising due to the richness of the universe of data it these challenges, a second purchase of tablets is being contains. This system will continue to prosper with the planned. Likewise, the CCSS is creating physical forms creation of the Directorate of Innovation and Digital compatible with the SIFF Mobile. These forms will be Health of the CCSS, which will implement projects to used to collect the information on paper, in the event of improve the use of the data contained in the digital any device cancellations. Together, the regional chiefs, ecosystem of the institution. The potential use of SIFF EDUS staff and the Nursing Coordination maintain data is much greater than what is currently used, so the constant communication and attend to failures in SIFF creation of dashboards, heat maps and other methods of through a WhatsApp group. analysis that take advantage of georeferencing to Attention through contracts with third parties: Six visualize, manage and improve the offer of prevention health areas were not included in the first supply of and care services of the CCSS is envisioned. electronic tablets, because they are served by contracts The family record is a fundamental tool for improving the with third parties through purchases of health services health of the Costa Rican population and the provision of made by the CCSS. The fact that these areas do not have CCSS services and can serve as an example for other SIFF Mobile (tablets) has prevented the georeferencing of countries (Box 1). Its digital transformation has benefited 180,000 families. Fortunately, this will soon be resolved the efficiency of data collection and analysis, as well as with the supply of devices to these areas through the the creation of an accurate diagnosis and timely follow- Page 5 HNPGP Knowledge Brief up of the main determinants of health in communities. Its improving the health of the population and reducing future development, together with the potential of inequity gaps in Costa Rica. georeferencing, will provide further inputs to continue Box 1. Lessons learned • Institutional backing and political will are necessary to generate investment, a regulatory framework and economic resources that transcend political cycles for the sustainability of the project over time. • Leadership and commitment to data collection in the field are indispensable to transform primary care. • The training of health personnel is vital for the proper implementation of the tool. • The population must be involved in the process and must be informed about the benefits of the project to be implemented. • From the beginning it is necessary to guarantee the security of the databases and the information contained in the system. • The SIFF was one of the objectives and intermediate indicators of the World Bank's Program for Results, which allowed the sector to focus its efforts and actions to meet the goals within the established timeframe. The World Bank's Health, Nutrition and Population Knowledge Briefs are a quick reference on key aspects of specific HNP-related topics that summarize new findings and information. They can highlight a problem and key interventions that have proven effective in improving health, or disseminate new knowledge and lessons learned from the regions. For more information on the topic, visit: www.worldbank.org/health. Generous funding support for this series of Knowledge Briefs was made possible by The Access Accelerated Trust Fund. Page 6 HNPGP Knowledge Brief • References 1. Barrantes Brenes G. Atención Primaria: Cómo Las Tecnologías Móviles Facilitan La Educación, Promoción En Salud Y La Prevención De Enfermedades En Costa Rica: RECAINSA; 2019 [Available from: https://recainsa.org/atencion-primaria-como-las-tecnologias-moviles-facilitan-la-educacion-promocion-en- salud-y-la-prevencion-de-enfermedades-en-costa-rica/. 2. The World Bank. 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