View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by NORA - Norwegian Open Research Archives UNIVERSITY OF OSLO Department of informatics Implementing a health information system in India: Challenges and opportunities for scaling and sustainability Master thesis Jørgen Darre 12.02.2007 Abstract Abstract Health Information Systems (HIS) are used to collect and analyze health data in order to support the improvement of health care services. Public health care in third world countries are often based on a poor functioning HIS. Simply put, data collection processes tend to be extensive, often of poor quality and typically failing to be used for practical purposes such as for effectively allocat- ing resources. Thus, exploring ways of improving existing HIS is evidently a fruitful approach to strengthen public health care. As a part of health sector reform, governments in many developing countries are in the process of strengthening their HIS through the introduction of computer based systems. This thesis describes and discusses the implementation of the Health Informa- tion System Program (HISP) in the Indian state of Andhra Pradesh. The study was done using an action research approach over a five month period spread over two years. The challenges were to work with political, infrastructural, hu- man resources, geographical, and cultural issues to get the system developed, implemented and institutionalized. The results show that to institutionalize a HIS into the everyday working of the health department in Andhra Pradesh, it is important to recognise the interdependency between scaling and sustainabil- ity. Scaling indicates the need for the HIS to reach a certain geographic and functional scope so as to become of interest to the higher levels. Small pilot projects have problems in reaching such scale, and will therefore end up more as interesting academic exercises, unless they manage to reach a certain scope and scale. Theoretically, concepts from information infrastructure theory have been used to better analyze the complexities of scaling and sustainability, and their inter- dependencies. An important research focus has been to explore how the smaller scale project in India that was studied could be extended – scaled up – so as to become of interest to health managers at different levels, and thereby, eventu- ally, become institutionalised. Three key processes have been identified to achieve this goal of institutionalization. These are the processes of cultivation, the creation of gateways to enable integration between the “installed base” and the “new system”, and the choice relating to the level at which data-entry and report generation should take place. To achieve institutionalization, in addition to the above focus on these processes, equal emphasis needs to be also placed on obtaining political support, thus emphasizing the need to combine top- down and bottom-up strategies. iii Acknowledgments Acknowledgments I would especially like to thank Professor Sundeep Sahay and Professor Jørn Braa for their encouragement, guidance and great support in helping me write this thesis. Altogether, the experiences with the HISP team have been as fun as they have been educational. Special thanks also go to Maria Røhnebæk, Gunnar Bergersen and Nina Meland for great collaboration, useful discussions and overall moral support to help me finish this thesis. I also want to thank Bjarne Johannessen for proofreading and comments. In addition, I would like to thank all my friends for being supportive and under- standing throughout the process of writing this thesis. Finally I want to thank my mother, sister and my little niece Nora Emilie for making my life more pleasant. This thesis is to my father who I miss very much. Jørgen Darre Oslo, 12 February 2007 Parken forever! iv Table of Contents Table of Contents 1 INTRODUCTION............................................................................11 1.1 THE PROBLEM OF THE DIGITAL DIVIDE ..............................................................11 1.2 PROBLEMS ADDRESSED.......................................................................................13 1.2.1 Research question ............................................................................................13 1.2.2 Objectives.......................................................................................................13 1.3 MOTIVATION.....................................................................................................14 1.4 ROAD MAP OF THE THESIS..................................................................................14 2 HEALTH INFORMATION SYSTEMS IN DEVELOPING COUNTRIES.............................................................................................15 2.1 GLOBALIZATION, MARGINALIZATION AND ICTS................................................16 2.1.1 Health information and globalization ..............................................................17 2.2 INFORMATION SYSTEMS AND HEALTH INFORMATION SYSTEMS.........................18 2.2.1 Conceptualizing HIS as HII ............................................................................22 2.3 IMPLEMENTATION CHALLENGES: ISSUES OF SCALE AND SUSTAINABILITY............24 2.4 SUMMARY...........................................................................................................28 3 RESEARCH APPROACH..................................................................29 3.1 INTRODUCTION.................................................................................................29 3.1.1 HISP and action research ................................................................................29 3.1.2 HISP in India ................................................................................................31 3.2 RESEARCH SETTING............................................................................................31 3.3 DATA COLLECTION ............................................................................................32 3.3.1 Interviews.......................................................................................................33 3.3.2 Observations...................................................................................................33 3.3.3 Questionnaires................................................................................................34 3.3.4 Training ........................................................................................................34 3.3.5 Systems development........................................................................................35 3.4 DATA ANALYSIS ..................................................................................................35 4 A BACKGROUND ON HISP ...........................................................37 4.1 HISP – A BACKGROUND .....................................................................................37 4.1.1 Summary of development of HISP in key node countries ....................................38 4.1.2 DHIS – District Health Information System.....................................................41 4.2 ANALYSIS OF HISP’S STRATEGY ON SCALE AND SUSTAINABILITY.........................44 4.2.1 A different HIS...............................................................................................44 4.2.2 Technology and political alliances.....................................................................45 5 INDIA, ANDHRA PRADESH AND KUPPAM................................46 5.1 HEALTH CARE IN ANDHRA PRADESH..................................................................47 5.1.1 The health care system .....................................................................................47 5.1.2 The health information system .........................................................................48 5.2 WHY ANDHRA PRADESH?...................................................................................49 5.2.1 E-governance in Andhra Pradesh .....................................................................50 v Table of Contents 5.3 KUPPAM .............................................................................................................51 5.3.1 IT and initiatives in Kuppam..........................................................................52 6 FIELDWORK IN KUPPAM: CULTIVATING HISP .......................54 6.1 HISP IN KUPPAM ...............................................................................................54 6.1.1 Initiating the HISP pilot .................................................................................54 6.1.2 Description of the primary health centres...........................................................55 6.2 TRAINING ..........................................................................................................59 6.2.1 Classroom training..........................................................................................59 6.2.2 Training in the primary health centres..............................................................60 6.2.3 Local action group and reference group .............................................................61 6.3 LOCAL ADOPTIONS OF HISP ..............................................................................61 6.3.1 Initial stages ...................................................................................................62 6.3.2 Configuring DHIS..........................................................................................62