Ola Hodne Titlestad

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.

Networks of Open Source Health Care Action

This paper reports on an effort to create a network of both developers and users of a public health information system. Through an analysis of capacity, recruitment, and power in the network, issues related to choice of technologies, global-local tensions, and parameters of institutional collaboration, we illustrate a number of challenges. Comparing OSS principles to a “Networks of Action” approach, conditions for learning in organizing training and development of software with participants from Africa, Asia, and Europe, as well as the involvement of advanced students in such efforts are discussed.

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 Change Strategy towards an Integrated Health Information Infrastructure: Lessons from Sierra Leone

In this article we describe and reflect on an ongoing project to develop an integrated health information system (HIS) in Sierra Leone. We emphasise the complexity of such an effort and on challenges faced with building a health information infrastructure in the context of a developing country. The main lesson of the paper is in the design of a change strategy towards an integrated HIS in Sierra Leone influenced by information infrastructure literature. The key elements of the strategy are 1) to facilitate a gradual change process building on the existing systems and practices (the installed base), 2) to bootstrap political will through quick wins and pilot projects, and 3) a flexible standardisation approach to integration to smoothen the change experience for users and stakeholders, and minimise resistance.

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.