1. 1 Implementation of HIS: Complexities and Challenges – A Case from India and Mozambique Dr.Zubeeda Quraishy University of Oslo

2. 2 Information Systems Can be best understood as Social systems Web of social and technical elements(Walsham et al,1990) Heterogeneous networks (Braa & Sorenson,1998) ``Information systems (IS) as systems of human and technical components that accept, store, process, adapt and transmit information. Can be any combination of human endeavours, paper based methods and IT.’’ (Heeks1998,p5) Information infrastructure (Hanseth, 2000) Contd…

3. 3 Information Systems as… Technological discrete artefacts (Technological determinism)(Kling et al,2000) Why technological determinism cannot be applicable in ISs is: Pure technological view on Information Systems Predefined and expected effects has not always been realised in practice. (Technological determinism cannot adequately account for the interactions between ICT, the people who design, implement and use them, and the social and organisational contexts in which the technologies and people are embedded.“ (Kling et al. 2000 p.49-50) Also, it has limited value in dynamic and complex situations that unfurls over longer periods of time.

4. 4 ISs–Using Concept of Web Models (Social Informatics) ISs can be studied using web models(Kling and Scacchi 1982 “Web models draw broad boundaries around the focal computer system and examine how its use depends upon a social context of complex social actions.

5. 5 ISs–Using Concept of Web Models (Social Informatics) And social context here refers to the social relations between the set of participants concerned with the information system, the infrastructure available for its support, and the previous history within the organisation of commitments made in developing and operating related computer-based technologies.” (Walsham 1993 p.55) Walsham G. 1993 “Interpreting Information Systems in Organizations” John Wiley & Sons Ltd

6. 6 ISs can be best understood as Organisational Informatics Organisational Informatics.... is concerned with IS and the organisation where it is implemented Social systems perspective demands a much more complex view on the processes of change involved and the interactions between the information system and the organisation (Walsham 1993). To analyze the social interactions between information systems and organisational contexts three theories have been put forward and they are: a. Structuration theory, b. Information infrastructures and c. IS & Politics,(Walsham 1993, Braa 1997, Puri and Sahay 2003).

7. 7 Brief definitions of the theories… Structuration theory allows for change, it puts forward the fact that organisational structure can change and human actors are able to cause this change(Giddens, 1984)because social structures are constructed by social action. Information Infrastructures encompasses a whole network of human, social and technical components. Information Infrastructure are described as shared, evolving, open, standardised and heterogeneous, and it is also referred to as Installed Base (Hanseth and Monteiro,1998).

8. 8 Brief definitions of the theories Information Systems and Politics: Politics of organisations are considered as an important elements in the IS development process (Feldman & March,1981). Political perspective has been used as part of an analytical framework for IS and organisational change(Walsham,1983). People with different political agendas create barriers to information sharing (Buchanan-Smith et al, 1994). Example( Information use and collection is seen as important for decision making, it has an important symbolic value in these organisations and their decision making processes).

9. 9 Health Information Systems….. ``..as a combination of people, equipment and proceedures organised to provide health information to health workers and others in a way that enables them to make informed decisions’’(Boerma,1991).

10. 10 Types of Health Information Systems A. Clinical Health Information Systems Clinical HISs are typically large and complex hospital information systems that focus on patient specific data. These sophisticated health information systems that are often large hospital systems have proven to be difficult to develop both in developed and developing countries, and about three quarters of these systems have failed (Littlejohn, Wyatt and Garvican 2003, Heeks and Bhatnagar 2001).

11. 11 b. Routine Health Information Systems “Information that is derived at regular intervals of a year or less through mechanisms designed to meet predictable information needs” Potomac Statement (RHINO 2002 p.2) Examples of routine health information systems are : Health service statistics for routine services reporting and special program reporting (malaria, TB, and HIV/AIDS), administrative data (revenue and costs, drugs, personnel, training, research, and documentation), epidemiological and surveillance data, data on community-based health actions, data on vital events (births, deaths and migrations ).

12. 12 b. Routine Health Information Systems An important strength of routine HISs is that decision makers and managers at all levels of the health system has direct access to data. Useful in health planning and management, Empowers practitioners and managers to identify problems as they arise and solve them (ibid.). *HISP will focus on Routine HIS at Primary Health Centres & District Based Health Information Systems.

13. 13 Why HIS? HIS is essential for strengthening the information management practices within the Primary Health Care (PHC) sector with the larger aim to improve processes concerning health care delivery for the rural community. To develop capacity of the health staff to better deal with computers, health information systems, and health indicators and targets. Development of this capacity will lead to better governance of the health sector and improved delivery of health care to the community.

14. 14 Why HIS in Developing Countries? To strengthen information management practices within the Primary Health Care (PHC) sector with the goal to improve more effective health delivery to the rural community. Rationalization of data collection, computerization of information flows from the PHCs to Districts & State

15. 15 Why HIS in Developing Countries? Developing tools for analysis, and training of health care workers, Medical Officers in PHCs; District Medical and Health Administration, State Health Department including Family Welfare To increase feedback leading to Decentralisation An opportunity to bridge the digital divide by using ICTs in HIS( Castells, 2001)

16. 16 Information Systems and Developing Countries To bring the developing countries on par with the developed countries agencies such as UN have stressed on ‘Technology Transfer’.

17. 17 What is Technology Transfer? Dore (1984) defines the process of technology transfer as the effort of getting knowledge that is only in the head of some foreigners to the practise of the nationals in developing countries. Odedra (1990) sees the process as transferring knowledge on how the system works, how to operate it, maintain it and assemble the different components of it.

18. 18 Different Perspectives Towards Technology Transfer Heeks (2002) states that the failure rate of IT projects in developing countries is higher than the 75% failure that is found in the western world, and this he attributes to ‘design-reality gaps’. Gaps can be of all kinds- culture, organisation, information use, power structures, knowledge level, infrastructure etc., or more likely, a combination of several of these.

19. 19 Different Perspectives Towards Technology Transfer Technology transfer is not neutral & value free (Sahay &Walsham,1997) TT even from South-South is not problem free (Kaasboll & Nhampossa,2002) as they need to be more sensitive to the social context and more adaptation is needed than just transferring ICT infrastructure or tools. “Technology is not just an isolated machinery or artefact, but involves the social and cultural context.

20. 20 Different Perspectives Towards Technology Transfer Technology cannot be transferred and put into use as initially planned as all users shape and adapt systems in ways which were not planned (Bijker and Law,1992). Technology transfer can be sustainable provided the local knowledge is sufficient to maintain the technology (hardware & software) (Castells,1996)

21. 21 What is Primary Health Care and District Health System Concept of PHC – initiated at the WHO and UNICEF conference in 1978. Introduction of PHC - shift in health focus from the larger hospitals to health centres and from curative to preventive health care. “ Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self- determination.

22. 22 What is Primary Health Care and District Health System It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. ” (WHO 1978 p.1)

23. 23 Health District System WHO (1995) lists some characteristics of the health district system: A defined administrative area with a population of approximately 50,000 – 3,00,000. A segment of the national health system. It comprises all facilities and individuals in the district who are involved in health care at the various intervention levels, including not only governmental, but also church, charity, and private health care providers. The vertical programmes (e.g. immunization, family planning or AIDS control) should be coordinated with the horizontal health services and integrated as far as possible, at least at the primary level.

24. 24 Deterioration of PHCs …. The functioning of the PHCs began to deteriorate as the countries were too large and the tasks too complex and expensive to manage centrally (WHO 1995). Top down approach Centralised No feedback Collection of large volumes of poor quality of data with little or no analysis at the cost of providing health services to the community.

25. 25 Health Information Systems Programme (HISP) HISP was initiated in South Africa to develop a health information system. Software - District Health Information System was developed and was used as the basis for the development of a health information system that focused on local health management.

26. 26 HISP: A Global R&D Network Other initiatives e.g. Nigeria Norway South Africa India Mozambique Tanzania Malawi Ethiopia Cuba Mongolia

27. 27 HISP in India In India Andhra Pradesh was selected –overall policies and practices on IT provided the favorable clime for HISP. Objectives: Strengthen health information management at district and community levels to support local analysis and use of data Empowerment of health workers through the use of ICTs – developing “knowledge workers.” Integrate HISP with ongoing e-governance initiatives in AP

28. 28 Flow Chart Depicting the Hierarchy Levels in Health Sector

29. 29 India

30. 30 Andhra Pradesh

31. 31 Chitoor District

32. 32 Kuppam Constituency

33. 33 Situation Anlaysis- HISP in AP December 2000-September 2001 : Systems study and developing of Minimum Data Sets (MDS). Phase1(Sept’01-Aug’02)Piloting in Kuppam,9 PHCs, placing of computers in PHCs and in DM&HO. Customization and adaptation of software. ”On-site” and ”Off-site” training programmes Implementation and modification of MDS Creating routine database from Jan 2001 Generation of various reports Presentation to CM: Instructions for extension Systems handover to district in July ’02 Stabilization of existing 9 Kuppam PHCs

34. 34 Situation analysis… (contd) Sep 2002 –Nov 2002: Development of AP Reports module(25-30 reports) Sept 2002- Project evaluated by CFWD Oct 2002-MoU signed for expansion to Madnapally- total 46 PHCs Nov’02 –Feb’03- Creation of Chittoor district database(84 PHCs & regular updation of the data base. Feb’03- July’03- Implementation of HISP in 46 PHCs Aug’03- Dec’03 – Stabilisation of HISP in PHCs & customisation of DHIS Jan’03 –Training of trainers on advanced knowledge in the health domain, Development of MM & IM rate web enabled data base.

35. 35 Situation Anlaysis (contd) Feb’04 till May ’04 – CFWD contracted HISP to create state level database for a period of one year(2003-’04) Web enabled the state data base ( www.aphealth.org ) Creating a HISP Spatial Analyst( integration of the routine data, indicators and infrastructure with village boundary maps, over layed also with population and road maps )* Local language translation ** Proposal for integration of DHIS and FHIMS***

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38. 38 Parallel System in AP – FHIMS Name based system for providing services at the community level based on the H.Hold level data. Piloted in Nalgonda DHIS and FHIMS are complementary Proposal to pilot the Integration of FHIMS &DHIS to reap the potential synergies

39. 39 Household level data for various services like immunization, disease statistics, etc. FHMIS Routine monthly data for SC, PHC, and district PHC profiles Target and indicators Population (census) Maps (Village boundaries, population, roads, etc.) HISP Integration Bridge Routine monthly reports to be sent from PHC to district Routine monthly reports to be sent from district to state Analysis reports of performance of respective targets and indicators for the facilities Local level reports for ANMs like scheduling Tracking reports for particular disease like TB Tracking reports for particular services like immunization All reports will be GIS enabled and also web enabled Outputs reports This program will take the export files from FHMIS, reformat the file into notepad text file, and then imported to HISP

40. 40 Value Added Features of Integration FHIMS name based functionality can support MPHA scheduling of work Tracking action on diseases like TB and HIV HISP can provide All facility based reports, different formats and levels Based on improved data collected through FHMIS Overall through integration Overall improved information support at all levels Cost effective solution, rapid implementation Can draw upon HISP network locally and globally

41. 41 Strategies used.... Evolutionary step by step strategy Building rapport at all levels Developing institutional capacity within the health sector in information management and use Participatory design & prototyping Continuous support and motivation

42. 42 Action Research…...is a social research carried out by a team of researchers or professionals from different disciplines and members of community to improve the existing situation in the health sector. … promotes broad participation in the research process and supports action leading to a more just or satisfying situation for stakeholders’’(Greenwood and Levin,1998)

43. 43 Action research... has helped in understanding of an immediate social situation assists in practical problem solving and expands scientific knowledge is performed collaboratively and enhances the competencies of the respective actors thus implying a process of participatory observation. primarily applicable for the understanding of change processes in social systems.

44. 44 Ongoing Challenges in India Top down approach by the government Change of governments Lack of decentralisation Collection of large volumes of duplicated data. Poor quality data –no validation, manipulation of data at all levels Limited usage of data Lack of standards Large data sets Little or no analysis

45. 45 (contd..)Ongoing Challenges Formal approvals are delayed Funding (e.g. from EU or World Bank) requires HISP to be ”state project” Lack of resources, state funds for HISP over two years is less than Rs. 4 lakhs Weak district support at Chittoor Infrastructure conditions in PHC areas Needs stronger institutionalization, e.g. setting up cadre of health information officers. Bureaucratic procedures cause long delays

46. 46 (Contd…)Ongoing Challenges. Transfers, technical limits, time pressures. Institutionalisation issues: parallel systems, building routines and creating information culture Social factors Political Complexities Parallel system developed by GoAP (FHIMS- a name based system). HISP treated as outside agency

47. 47 HISP in -Mozambique Computer based HIS (called SisProg) in 1992 in all its 11 provinces and the national level. Routine health data in the paper forms from the districts entered into SisProg at the province level. Aggregated data sent in electronic (floppy disks) or paper formats to the national level. Kinds of problems that exist with data quality, structures of reporting, and aspects related to non-use of data. SisProg though irrelevant in local decision –making still over the period got embedded in to the practices of the Ministry making it difficult to replace.

48. 48 Situation Analysis – Mozambique In 1999 a team comprising of staff and students from Ifi, UiO attempted to customise and implement DHIS in three selected provinces on a pilot basis. Customization of DHIS -2 categories: a. Global-standardized reports (like missing data), indicator generator, data mart, analysis tool, etc. Changes in global features were coordinated by the South African development team. b. Location Specific- language, data elements, indicators, local reports, lookup tables, procedures and definitions, such as reporting frequency, need to be adapted locally by the HISP team.

49. 49 Situation Analysis – Mozambique a. Language was a crucial issue as many in the health sector could not understand English. b. Translation from English to Portugese (DHIS and documentation was in English). c. Translation process could not be carried out on multiple machines as the team implementing HISP in Moz depended on S.Africa for creating the Set up CD.

50. 50 Challenges….. Initial constraint on translation resulted in poor training facility. Translating and customizing the DHIS. For example, there were many ambiguous data elements. Institutional and technical challenges in the process of populating the data base in the software No formal permission and financial resources from MoH Parallel systems existed.

51. 51 In spite of all the benefits why there are challenges in implementation of HISP in AP?? Political agenda Bureaucratic Structure Top down approach Large Funding from International funding agencies Limited global experiences in implementation of HIS Limited actors involved and Participatory design is not encouraged. Lack of committment both in training and in implementation Fear of transparency – Access to data should be curbed by outsiders.

52. 52 In spite of all the benefits why there are challenges in implementation of HISP in AP?? Lack of expertise and understanding at the higher echleons in health department both in Technical (IT)and Social domains (Process of Implementation). Ex: Wants DHIS reports without DHIS software 2 -3 day mass training of users on FHIMS(14 module) software. Repeating the exercise(developing reports etc using commercial companies-waste of time,efforts & resources)

53. 53 Reasons for facing these Challenges in India Limited resources Considered to be a research project Not funded by huge International funding agency Lack of support from health department at the higher level

54. 54 Tackling the political complexities …. By approaching the officials at the CMs office. Demonstrating the benefits of implementing the integrated softwares at less cost. Highlighting the flexibility, user compatability & other components of DHIS Highlighting the users capacity gained through DHIS to analyse and make decisions using health data.

55. 55 Tackling the political complexities …. Presenting different outputs generated through DHIS -Strength of DHIS Providing Continuous On-site training to the Users at the PHCs –’ increasing support & confidence’ at bottom level Building the demand from Users for DHIS