Johan Ivar Sæbø

Comparing strategies to integrate health information systems following a data warehouse approach in four countries

This paper addresses one of the major obstacles of reaching the Millennium Development Goals (MDG): inefficient and unreliable information systems. Leading international organizations have called for integrated data warehouses as one of the solutions, but this remains hard to achieve. This paper presents four country cases of standardizing and integrating health data which are all following what is here termed a data warehouse approach; data from across different health programs are organized in one database framework – or data warehouse. In all countries, fragmentation of health information in different partly overlapping subsystems run by different vertical health programs represented a major problem for the efficient use of health information. While South Africa developed a new integrated system in addition to the existing fragmented subsystems, Zanzibar, Sierra Leone and Botswana all aimed to encompass all or most of the data from the existing systems. The three latter countries all followed slightly different approaches, more or less incremental in the approach to standardizing health data, and more or less strict in whether to include “all” data, and whether to solve all inconsistencies between the various data sets included early on. The four cases demonstrate that integration is as much, and maybe more, about aligning organizational-political actors as it is about technical solutions. The technical solutions are, however, important in aligning these actors and in enabling integration. We argue that “attractors,” technical solutions or standards that achieve a certain level of success and enable the building of momentum, are important in aligning the various political actors. In turn, these attractors need to evolve within the changing context of a growing health information system in order to achieve the scale needed to address the MDGs with full force.

Participatory health information systems development in Cuba: the challenge of addressing multiple levels in a centralized setting

This paper will address issues of user participation in a large centralistic organization. It is based on one year experience of developing a computerized health information system within the Cuban health services. Relevant literature suggests that participative methods may be less feasible in centralistic environments. This paper confirms this by describing how participation in Cuba is restricted by political and organizational constraints. There is however documented that participatory approaches may be very rewording where such constraints are overcome. Experiences from a broad range of health units and organizational levels in the Cuban project show a trend of weakening centralistic control with regard to hierarchical level and geographic distance, and thus more autonomous organizational units and participating individuals at lower level farther from Havana. The research reported is carried out within a framework of a larger network of similar health information projects being carried out in Africa and Asia, and the case of Cuba is being compared with experience from these countries.

Three Strategies for Functional Architecting: Cases from the Health Systems of Developing Countries

Health systems in developing countries are commonly struggling with multiple and overlapping information systems (IS). There is a need to move away from this to reduce the burden of parallel reporting it creates and enable coordinated information collection and sharing. However, this is not straightforward as it prompts intricate functional architecting activities across a range of IS domains including health staff, commodities, logistics, progress tracking, financing and health services information. This paper is based on a case study of a District Health Information Software and how it is involved in the current drive toward integrated systems. From focusing on aggregate health indicators for health management, it is becoming one component among others in larger architectures where it may take on many different roles. The aim of this paper is to strengthen our understanding of the opportunities and challenges related to functionally architecting integrated systems. Applying an information Infrastructure lens, we describe these processes as involving a range of different software components and actors not under any central control. We conceptualize functional architecting as activities performed by multiple actors to configure and re-configure the functional roles of independent software components. Based on the case study, we contribute by identifying three different architecting strategies and conceptualize them as connecting, encroaching, and charting.

Evaluation of a bottom-up action research approach in a centralised setting: HISP in Cuba

There has been a high rate of failure in the implementation of information systems in developing countries. Participative approaches have received a lot of attention as a way to ensure more appropriate systems with a greater rate of success. The authors of this paper spent 4 months working on designing and implementing a health information system as part of the health information system program (HISP) in the Cuban Ministry of Health using this type of approach. This paper describes the experiences there. The HISP has proven to be a relatively successful information system in India and in several African countries, aiming at empowering local health management and improving information use at the local level. The primary contribution to the current literature on participative approaches is the lessons learned in trying to use this approach in a highly centralized setting. General implications for system development and collaboration in Cuba are also discussed.

The Information Transparency Effects of Introducing League Tables in the Health System in Malawi

League tables are used to compare the performance of different entities in the health systems in developing countries. The aim of this paper is to study the implementation process and its effects related to a computerized league table application in Malawi. Focusing on the health district and using a field experiment research approach, the focus is on the implementation process and how it improves information transparency for health managers. Based on routine health data recording in the health management information system DHIS2, the introduced league table was used by the district health management teams in the pilot districts to rank and compare performance among their health facilities. While the introduction of the league tables was challenging, it also showed its potential through effects including improved visibility of information and accessibility for managers, better understanding of indicators, the identification of data quality issues, skills acquisition in computing and information use and improved communication and collaboration among stakeholders.

Challenges for Health Indicators in Developing Countries: Misconceptions and Lack of Population Data

Indicators are foundational for planning, monitoring and evaluating of health services in developing countries. Most health indicators use population-based data, to enable comparison across geographical areas and over time. This paper is based on an interpretative case study on health indicators and how they are calculated and used at health facilities in Cameroon. We found that health managers at different levels of health systems do not share the same understanding of health indicators and we observed a wide-spread absence of population data. We further observed that health managers derive alternative ways of calculating indicators in the absence of population data. This paper contributes by discussing the implications of a lack of a common understanding of health indicators and the absence of population data to calculate health coverage indicators. Though this study was limited to data and program managers at district and regional levels, the findings raise issues that have wider applicability in the implementation of electronic health information system as well as how indicators such as UHC goals are calculated.

The Role of Global Standardization Communities in Shaping National Health Information Architectures

Health sectors in developing countries are commonly struggling with disarrayed health information architectures, where multiple vertical, disease-specific programmes have implemented their isolated information systems. A consequence is parallel and overlapping systems where information is stored at different locations and in different formats. To address this, multiple global standardization efforts to harmonize health information architectures have been initiated. Still, there is only limited knowledge about the role of these global standardization communities in shaping national health information architectures. This article is based on a case study of the global Open Health Information Exchange (OpenHIE) standardization community. With an Information and Communications Technologies (ICT) ecosystem perspective, we aim to improve our understanding of the relationships between global standardization communities and national ICT ecosystems. Theoretically, we contribute with our conceptualization of national ICT ecosystems.

Integrating health information systems in Sierra Leone

This paper presents an ongoing project in Sierra Leone to integrate health information systems at district and national level through a novel approach. Employing solar-powered low-energy computers running Linux, a wide consortium of local and international actors have tried to counter the severe problems of electricity supply breakdowns and computer viruses. The paper discusses the experiences from this effort, as well as the integration process itself, and the corresponding capacity building strategies. The findings so far suggest that alternative technologies, namely solar power and open source software, can be fruitful to apply in such infrastructural settings as Sierra Leone presents. Furthermore, the technical solution to an intermediary step towards integration shows some promising results.

Usability for novices and experts: A layered design in a case study in Malawi

This paper presents initial findings from a project in Malawi to develop and implement a simple application for making league tables in the health sector. League tables, sometimes also called scorecards, are tables that compare various entities according to several indicators, and rank them from best to worst performers. Prior work in Malawi has suggested that these tables would be useful at both national and local levels, and should therefore be customizable so that different users can make their own tables, based on the health indicators of their choice. A main finding from this project is that usability and learnability for novice users must be balanced against the request for more advanced features from expert users. This was achieved through designing the app with a novice and an expert layer. The expert layer concerned configuration of the league tables. Configuration or customization is a general functionality in many applications and may thus be segregated in an expert layer.

Patchworks of Logistics Management Information Systems: Challenges or Solutions for Developing Countries?

Uninterrupted supply of health commodities is a prerequisite for a well-functioning healthcare system. Establishing and maintaining effective supply chains is at the same time challenging in developing countries. A key part of this chain and the focus of this paper are the information systems supporting the communication and distribution of commodities between national warehouses and health facilities. Such systems supporting storage, transportation, wastage reduction, forecasting, planning and avoiding commodity stock-outs are invariably called Logistics Management Information Systems (LMIS). However, the blurred boundaries between the various parts of the supply chain and the numerous information systems involved is reflected in the lack of a clear definition of LMIS. The main aim of this paper is to provide a better understanding of what an LMIS is, and how it interacts with other information systems. By presenting two case studies, from Tanzania and Uganda, we show that the landscape of LMIS consists of a patchwork of information systems, which often have tighter coupling with systems of other domains (such as patient management) than with the supply chain. This leads us to ask the following research question; what are appropriate information systems architectures for LMIS? Our response, main argument and contribution is that the nature of these supply chains favours the emergence of several independent information systems. This is particularly due to the variation in resources and capacities on the different levels of the health system and thus the supply chain. Interoperability between the different levels and other related information systems should then be considered, necessitating a scrutinous evaluation of what data needs to be shared with whom.