Challenges and approaches to the integration of HIS : case studies from Tanzania

This research falls under the area of design and implementation of information systems in developing countries. I have studied the health information systems in Tanzania using case studies in Ilala Municipal, situated in Dar es Salaam city, and Tabora Municipal in the Tabora region. The purpose of the research was to study the challenges encountered by the health workers at the local level with regard to information collection, use and reporting. The focus of this thesis is on problems of fragmentation and challenges of integration. These have been studied both with regard to the routine health information system (MTUHA) in general, and specifically for the programme for prevention of mother-to-child transmission of HIV/AIDS (called PMTCT), which is relatively new and was supposed to become fully integrated with the ordinary health service structures. The research had been carried out as part of the Health Information Systems Programme (HISP) initiative, an international research and development project based in the Informatics department of the University of Oslo. The empirical fieldwork was conducted between 1st of July 2004 and 18th of January 2005. The study employed qualitative research methods, including; ethnographic interviews, participation in workshops, document analysis in the health facilities, and hands-on experience with existing computer systems in the district. The empirical data were analysed using the principles of qualitative research, and the analysis was informed by my theoretical framework. My theoretical framework is based on a literature review that covers research from various fields, including literature on health information systems (HIS) in developing countries, research on information infrastructures and on integration of information systems. I argue that rather than seen as information systems, HIS should be conceptualised as larger systems consisting of human and non-human components, where the design of new information system is done by gradually extending the existing HIS, rather than from scratch. Developing an information system involves not only a technical solution but also social considerations, and a socio-technical approach is, therefore, appropriate. I draw upon the metaphor of installed base cultivation, and the emphasis on incremental and bottom-up approaches that this perspective entails. The findings indicated that the HIS performance is hindered by the fragmentation within and across the HIS. Fragmentation creates duplication of work and data, lack of information sharing, and poor quality of information, poor use of information and hindering of health care service provision. As an organising framework to describe the findings, I categorise them into four dimensions: fragmentation problems related to software, to data, to work practices and to institutional factors. At the system’s level, the problems are inflexible code, poor performance of the computerised system, and different software between programmes. At the level of specific data items, I identify a serious problem related to identification of clients to the PMTCT programme, with consequences for follow-up. The information integration with the rest of the MCH health care services was weak. In terms of work practices, the study revealed problems related to information sharing between PMTCT staff and other staff. At the institutional level, the problems of patients (or clients) attending several and different clinics is a challenge. The causes for the fragmentation problems include low priority for HIS work, information flow reflecting higher needs, and lack of participation in system development. However, the study also revealed some instances of emergence of local improvised tools designed by health workers at the facility level, which was also being spread horizontally and used by other facilities. These tools can resolve (at least partly) the dilemmas of integration, and they address the immediate information needs of the workers. Based on these findings and on insight gained from theory, I end by proposing some cultivation strategies for dealing with the challenges identified in the research. Bottom-up standardisation and “loose” integration are central aspects here