TUGAS

REVIEW JURNAL
SISTEM INFORMASI KESEHATAN

DOSEN PENGAMPU:

Putu Eka Meiyana Erawan, S.KM., M.Kes

DISUSUN OLEH:

NAMA : ANDI RADYA TULMUAYADA BASIR

NIM : J1A120267
KELAS : REGULER E

FAKULTAS KESEHATAN MASYARAKAT

UNIVERSITAS HALUOLEO
KENDARI
2022
 REVIEW JURNAL
Menerapkan manajemen sistem informasi kesehatan baru di Uganda

1. Mengapa jurnal tersebut mengambil konsep SIK tersebut?

Karena , Kerangka kerja Sistem Informasi Kesehatan dapat memfasilitasi pengenalan inovasi
manajemen informasi di masa depan dan memungkinkan praktisi untuk menganggap pengenalan
mereka sebagai proses bertahap yang perlu dikelola. Implikasi untuk praktik diidentifikasi.

Pada penelitian ini menyelidiki proses implementasi sistem informasi kesehatan (SIK ) di Uganda,
yang dimana bagaimana memanfaatkan difusi inovasi dan model perubahan organisasi
keseimbangan dinamis. Tidak ada perspektif yang memandu proses pengembangan SIK. Sebaliknya,
masalah teknologi, alih-alih masalah organisasi yang lebih luas, mendominasi perubahan yang
direncanakan. Kebutuhan untuk mempertimbangkan konteks organisasi ketika mengubah sistem
informasi muncul karena prosesnya lebih kompleks daripada yang disadari oleh beberapa praktisi,
ketika mencoba memahami penyebab masalah manajemen informasi dan mengembangkan
manajemen SIK di negara-negara berpenghasilan rendah.

Secara khusus, pengembang sistem informasi belum mengakui bahwa mereka mempromosikan
pendekatan informa- tional untuk manajemen ketika mereka mempromosikan perubahan dari sistem
pelaporan terpusat ke HMIS yang mendukung penggunaan informasi pada tingkat pengumpulan.
Strategi untuk memfasilitasi pendekatan ini tidak dianjurkan.

Teori organisasi dapat berkontribusi pada difusi kerangka kerja inovasi. Ini telah menghasilkan
integrasi difusi rogers kerangka kerja inovasi dan konsep Leavitt tentang kekuatan organisasi dalam
keseimbangan. Kerangka kerja difusi menggambarkan prosesnya, tetapi model organisasi telah
memberikan konteks dan alasan untuk aspek-aspek proses. Model difusi tidak memprediksi apa yang
perlu diubah dalam organisasi ketika inovasi tertentu diperkenalkan, atau berapa banyak.
Penambahan model organisasi telah membantu.
 Hingga tahun 1993 Uganda memiliki sistem informasi kesehatan terpusat (SIK) yang
berfokus pada pelaporan morbiditas dan mortalitas, dengan data yang mengalir hanya dari unit
kesehatan individu ke tingkat kabupaten dan nasional. Sejak saat itu, Kementerian Kesehatan
(Kemenkes) menerapkan manajemen sistem informasi kesehatan (MSIK) yang menekankan
penggunaan informasi pada titik pengumpulan.

Banyak negara berpenghasilan rendah lainnya bergerak ke arah yang sama, dengan lebih banyak
keterampilan yang dituntut dari manajer perawatan kesehatan primer (PHC), termasuk penanganan
data dan informasi di semua tingkat sistem perawatan kesehatan (AKF 1993). Organisasi Kesehatan
Dunia (WHO) mengidentifikasi sistem informasi kesehatan yang berorientasi pada distrik sebagai
prioritas (WHO 1988) dan mencatat bahwa 'kelemahan dukungan informasi diakui- dipimpin oleh
sebagian besar negara anggota sebagai hambatan terus-menerus untuk manajemen yang kuat dan
objektif', dan bahwa 'upaya untuk memperkuat sistem informasi nasional seringkali menghasilkan
sedikit perbaikan dan kadang-kadang memperburuk masalah' (WHO 1994a).

Komisi Penelitian Kesehatan untuk Pembangunan (1990) mengidentifikasi perlunya penelitian

tentang pengembangan sistem informasi kesehatan praktis untuk memandu keputusan kebijakan dan
manajemen, dan perbaikan HIS diidentifikasi sebagai penting oleh negara-negara seperti Tanzania
(Research into Action 1999: 8) dan Karibia (Research into Action 2000: 5). Kemitraan internasional
telah memobilisasi dana dan dukungan teknis ketika perbaikan HIS dianjurkan sebagai bagian dari
peningkatan kesehatan di negara berpenghasilan rendah (Bank Dunia 1993). PerbaikanNYA di
banyak coun- try termasuk Peru (Bank Dunia 1999a), Kepulauan Solomon (Bank Dunia 1999b),
Honduras (Bank Dunia 2000b), Lesotho (Bank Dunia 2000a), Uttar Pradesh di India (Bank Dunia
2000b) dan Republik Kryragya (Bank Dunia 2001) didukung.

WHO telah memimpin dalam membantu negara-negara berpenghasilan rendah mengembangkan HIS
dengan memberikan dukungan teknis dan keuangan untuk menilai, merancang, dan mengembangkan
sistem tersebut. Tidak ada strategi pengembangan standar untuk dukungan WHO yang digunakan,
tetapi prinsip-prinsip khusus untuk membimbing pengembangan DAN kerja sama teknisNYA
didorong (WHO 2000a). Ulasan tentang dukungan telah dilakukan (WHO 1999) dan strategi untuk
mendukung perkembangan HIS di negara-negara anggota sedang didevel- oped (WHO 2000b,
2001a). Panduan tentang penilaian kebutuhan telah dirinci (Lippeveld et al. 2000; WHO 2000c) dan
pengalaman dalam perkembangan SIK dijelaskan (Lippeveld et al.2000).
 Pada penelitian ini Uganda dipilih karena sedang mengembangkan HMIS ketika dana
penelitian tersedia. Pendekatan kualitatif mengikuti Morse (1994), dengan strategi penelitian tidak
didasarkan pada pertimbangan sadar, sebelumnya dari pertanyaan filosofis, tetapi pada tujuan studi,
pertanyaan penelitian, keterampilan dan sumber daya yang tersedia: jika pertanyaan tersebut
menyangkut sifat fenomena, maka jawabannya paling baik diperoleh dengan menggunakan
etnografi.

Penelitian menggunakan observasi partisipan, wawancara, ujian dokumen resmi, catatan lapangan
tertulis dan buku harian. Dua kunjungan negara dilakukan oleh JG, menggunakan peran pengamat
periferal (Alder dan Alder 1994: 380) selama lokakarya 1 hari dan kemudian selama periode
pelatihan HMIS selama 9 minggu. Dua puluh sembilan wawancara mendalam, 47 pandangan
antarterstruktur semi-terstruktur dan 19 diskusi kelompok dengan unit kesehatan, pejabat kesehatan
tingkat kabupaten dan nasional, akademisi, pelatih manajemen distrik dan penyedia layanan
kesehatan lainnya melengkapi pekerjaan ini. Pengembangan tema dibantu oleh perangkat lunak
NUD.ist.
Dengan menggunakan klasifikasi hubungan Phillips dan Pugh (1994) tentang hubungan
antara teori dan bukti empiris, kami menggunakan teori hanya untuk menjelaskan dan
mengembangkan pemahaman lebih lanjut ketika menganalisis data empiris. Meskipun pengumpulan
dan analisis data awal tidak dipandu oleh teori yang ada, kami secara teor- sadar secara teologis
(Glaser dan Strauss 1967) sebelumnya.
Konstruksi teoretis dari sebagian besar nilai adalah difusi rogers (1995) dari kerangka kerja inovasi
dan gagasan Leavitt (1965) tentang sebuah organisasi sebagai kekuatan dalam keseimbangan
dinamis- rium, diuraikan oleh Leavitt et al. (1973), di mana organisasi memiliki kerangka kerja
semi-permanen, pengaturan proses, sumber daya material dan orang-orang dalam beberapa urutan
dan hierarki: perubahan di satu bagian mengarah pada perubahan di tempat lain.

Difusi kerangka kerja inovasi adalah pendekatan untuk mengidentifikasi masalah dan menentukan
solusi, atau mengidentifikasi terlebih dahulu masalah yang menghambat atau memfasilitasi adopsi
perubahan tekno- logis. Keputusan mengenai suatu inovasi terlihat sebagai proses pengembangan,
dan model bertahap, Proses Keputusan Inovasi, diusulkan. Implementasi tidak secara otomatis
mengikuti keputusan untuk mengadopsi inovasi – Rogers (1995) menggambarkan ini sebagai model
inovasi Proses Inovasi dalam organisasi.

2. Baik dan Buruknya konsep SIK yang dilakukan

 • Dampak baik dari konsep SIK yang dilakukan
 memahami kendala dalam pengambilan keputusan rasional di tingkat distrik di Ghana.
 Dengan dari konsep Sistem Informasi Kesehatan dapat mendukung manajemen distrik
dan unit kesehatandi Gnaha
 Dengan penearapan implementasi konsep SIK yang dilakukan dapat memantau
kesetaraan, cakupan, kualitas, dan efisiensi
 Memberikan gambaran perkembangan sistem informasi di Meksiko yang mereka yakini
berimplikasi pada negara-negara berpenghasilan rendah.
 Dengan Difusi inovasi dan model perubahan organisasi keseimbangan dinamis pada
konsep Sistem Informasi Kesehatan dapat mengenal strategi manajemen informasi baru
dan pendekatan pengelolaan di negara-negara berpenghasilan rendah.
 Dengan konsep Kerangka kerja ini dapat memfasilitasi praktik yang dimana
memperkenalkan inovasi tersebut dan memungkinkan praktisi untuk melihat pengenalan
inovasi sebagai proses bertahap yang akan dikelola

• Dampak Buruk dari konsep SIK yang dilakukan

Dari kasus penelitian diatas, dampak buruk dari implementasi konsep Sistem Informasi
Kesehatan ini tidak teridentifikasi, akan tetapi adanya kekurangan dari ini. Pengembang dan
pelaksana sistem informasi belum mengakui bahwa mereka mempromosikan pendekatan
informasi untuk manajemen dengan perubahan dari sistem pelaporan terpusat menjadi MIS
yang mendukung penggunaan informasi pada tingkat pengumpulan. Selain itu kurangnya
pertanyaan atau keputusan manage- ment yang terkait dengan data, dan tidak ada pelatihan
dalam alat manajemen

3. Masukkan dan saran untuk aplikasi/sistem informasi yang dilaksanakan

Hasil penelitian ini perlu adanya tindak lanjut yang dimana perlu menyediakan
kerangka konseptual untuk menghubungkan informasi, alat manajemen, dan manajemen
permasalahan bagaimana seseorang dapat merancang dan melakukan pelatihan yang secara
efektif meningkatkan penggunaan informasi yang sebenarnya untuk perencanaan dan
manajemen layanan kesehatan'. Selain itu dari hasil penelitian ini dapat menjadi bahan acuan
dalam memanfaatkan dan menggunakan konsep sistem informasi kesehatan dalam
pengumpulan data- data di Negara Negara yang berpenghasilan rendah
 HEALTH POLICY AND PLANNING; 18(2): 214–224 Health Policy and Planning 18(2), doi:
10.1093/heapol/czg026 © Oxford University Press 2003, all rights reserved.

Implementing a new health management information system in

Uganda
J GLADWIN,1 RA DIXON2 AND TD WILSON3
Health Services Research Unit, London School of Hygiene and Tropical Medicine, 2Sheffield Health and Social
1

Research Consortium and 3Department of Information Studies, University of Sheffield, UK

This paper reports on research investigating the health management information system (HMIS) implemen- tation process in
Uganda, utilizing the diffusion of innovation and dynamic equilibrium organizational change models. Neither perspective
guided the HMIS development process. Instead, technological issues, rather than wider organizational issues, dominated the

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planned change. The need to consider the organizational context when changing information systems arises because the
process is more complex than some prac- titioners have realized, when attempting to understand the causes of information
management problems and developing HMIS in low-income countries.

In particular, information system developers had not acknowledged that they were promoting an informa- tional approach to
management when they promoted a change from a centralized reporting system to a HMIS supporting use of information at
the level of collection. Strategies to facilitate this approach were not advocated.

Organizational theory can contribute to the diffusion of innovation framework. It has yielded an integration of Rogers‟s
diffusion of innovation framework and Leavitt‟s concept of organizational forces in equilibrium. The diffusion framework
describes the process, but the organizational model has given the context and reason for aspects of the process. The
diffusion model does not predict what needs to change within the organization when a particular innovation is introduced, or
how much. The addition of the organizational model has helped.

These frameworks can facilitate the introduction of future information management innovations and allow practitioners to
perceive their introduction as a staged process needing to be managed. Implications for prac- tice are identified.

Key words: health information, organisational change, diffusion of innovation, information use
by countries such as Tanzania (Research into Action 1999:
Introduction 8) and the Caribbean (Research into Action 2000: 5).
International partnerships have mobil- ized funds and technical
Until 1993 Uganda had a centralized health information support as HIS improvements were advocated as part of

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system (HIS) focusing on morbidity and mortality reporting, improving health in low-income coun- tries (World Bank
with data flowing only from individual health units to the 1993). HIS improvements in many coun- tries including Peru
district and national level. Since then, the Ministry of Health (World Bank 1999a), the Solomon Islands (World Bank
(MOH) implemented a health management information system 1999b), Honduras (World Bank 2000b), Lesotho (World Bank
(HMIS) that emphasizes use of information at the point of 2000a), Uttar Pradesh in India (World Bank 2000b) and Kryragya
collection. Republic (World Bank 2001) are supported.

Many other low-income countries are moving in the same WHO has taken a lead in helping low-income countries
direction, with more skills demanded of primary health care develop HIS by providing technical and financial support to
(PHC) managers, including data and information handling at all assess, design and develop such systems. No standard
levels of the health care system (AKF 1993). The World Health development strategy for WHO support is used, but specific
Organization (WHO) identified district-oriented health principles for guiding HIS development and technical cooperation
information systems as a priority (WHO 1988) and noted that are encouraged (WHO 2000a). A review of the
„weakness of information support is acknow- ledged by
most member states as a persistent obstacle to vigorous and
objective management‟, and that „efforts to strengthen
national information systems have often produced little
improvement and have sometimes made the problems worse‟
(WHO 1994a).
The Commission on Health Research for Development (1990)
identified a need for research on the development of practical
health information systems to guide policy and management
decisions, and HIS improvements were identified as essential
 215 Implementing a health Jmanagement Gladwin et al.information system
support has been undertaken (WHO 1999) and a strategy to
support HIS development in member states is being devel-
oped (WHO 2000b, 2001a). Guidance on needs assessments has
been detailed (Lippeveld et al. 2000; WHO 2000c) and
experiences in HIS development described (Lippeveld et al.
2000).
Developing and improving health information
systems
A detailed review of research and reports on information
management for health unit and district managers in low-
income countries found many problems (Gladwin 1999),
including: data collection and processing issues (Nabarro et al.
1988; Feacham et al. 1989; VanNorren et al. 1989; Robey and
Lee 1990; Foltz 1993; Jayasuriya 1993; Van Hartevelt 1993;
Sandiford 1994; WHO 1994b; Jayasuriya 1999;
Lippeveld et al. 2000); over-reliance on special purpose
surveys and epidemiological data (De-Kadt 1989; Keller
1991; Hussein et al. 1993; WHO 1994b, 2000a; Sapirie and
Orzeszyna 1995); poor information use (Smith et al. 1988;
Wilson et al. 1988; Feachem et al. 1989; Bekui 1991; Campos-
Outcalt 1991; Keller 1991; Finau 1994; Loevinsohn 1994; WHO
1994b, 1999; Sapirie and Orzeszyna 1995; Braa et al. 1997);
identifying information required at specific levels to monitor
equity, coverage, quality and efficiency (Smith et al. 1988; WHO
1994b); general organizational and management problems
(Newbrander et al. 1988; De-Kadt 1989; Robey and Lee 1990;
Sandiford et al. 1992; Foltz 1993; Husein et al. 1993; WHO
1994b, 2000a; Campbell et al. 1996; Braa et al. 1997; Azubuike
and Ehiri 1999); lack of an overall organizational information
strategy in low-income countries (Robey and Lee 1990; Van
Hartevelt 1993).
Many of these problems indicate a need for information that
could inform various aspects of operational managers‟ policy
implementation, monitoring, evaluation and planning role, rather
than contribute to profiling morbidity and mortality status for
national use, which was often the aim of central reporting HIS.
An underlying concept in many papers is the need for
information management strategies to promote an informational
approach to health unit and district level health
management.
Few publications describe the development of a new HMIS for
operational management in a low-income country, although
some describe the adoption of information tech- nology at
national or health unit level (Newbrander and Thomason 1988;
Singh et al. 1992; Jayasuriya 1999). Infor- mation system
developers in Ghana (Campbell et al. 1996) recognized the
scarcity of research describing the process of developing HMIS
for operational managers. Van Hartevelt (1993) discusses the
need for an information management approach when
strengthening information systems in Ghana.
215
Foltz (1993) describes technology transfer in Chad to
improve a national reporting system, apparently not devel- oped
for operational management of health services, but does not
measure success in such use of information. A case study of
information system development in Niger (Mock et al. 1993)
describes the change from a centralized reporting system to an
HMIS, but only MOH central management is facilitated.
Duran-Arenas et al. (1998) describe the develop- ment of an
information system in Mexico which they believe has
implications for low-income countries. Robey and Lee (1990),
describing the HIS redesign process in the Philip- pines,
identify useful lessons, as does Jayasuriya (1999) in
implementing a computerized information system. Heywood and
Campbell (1997) identify the need for critical appraisal of
determinants of success and failure of HMIS. WHO identifies the
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need to document common barriers to estab- lishing and
sustaining effective routine HMIS and identifies strategies to
minimize their effects (WHO 2001b).
This paper reports on a research study to understand the
information system implementation process in Uganda as it
moved from a centralized reporting HIS to a HMIS that
supports district and health unit management, using existing
theory and research to deepen our understanding.
c.oup.com/heapol/article/18/2/214/644250
Methodology
Uganda was chosen because it was developing the HMIS when
research funding was available. The qualitative approach
follows Morse (1994), with the research strategy based not on
conscious, prior consideration of philosophical questions, but
on study purpose, research question, skills and resources
available: if the question concerns the nature of the
phenomenon, then the answer is best obtained by using
ethnography.
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We used participant observation, interviews, official document
examination, written field-notes and diaries. Two country
visits were made by JG, using the peripheral observer
role (Alder and Alder 1994: 380) during a 1-day workshop and
later during a 9-week period of HMIS training. Twenty-nine in-
depth interviews, 47 semi-structured inter- views and 19 group
discussions with health unit, district level and national health
officials, academics, district management trainers and other
health service providers complemented this work. Theme
development was aided by NUD.ist software.
Using Phillips and Pugh‟s (1994) classification of relation-
ships between theory and empirical evidence, we use theory
only to elucidate and develop further understanding when
analyzing empirical data. Although initial data collection and
analysis were not guided by existing theory, we were theor-
etically aware (Glaser and Strauss 1967) beforehand.
The theoretical constructs of most value have been Rogers‟s
(1995) diffusion of innovation framework and Leavitt‟s
(1965) idea of an organization as forces in dynamic equilib-
216 Implementing a health Jmanagement Gladwin et al.information system
rium, elaborated by Leavitt et al. (1973), where organizations
have a semi-permanent framework, an arrangement of the
processes, material resources and people in some sequence and
hierarchy: change in one part leads to changes elsewhere.
The diffusion of innovation framework is an approach to
identify problems and specify a solution, or identify in
advance issues that inhibit or facilitate adoption of a techno-
logical change. The decision regarding an innovation is seen as a
developing process, and a staged model, the Innovation-
Decision Process, is proposed. Implementation does not
automatically follow the decision to adopt an innovation –
Rogers (1995) describes this as the Innovation-Process model of
innovations within organizations.
Background
Uganda‟s health sector reform was part of overall public
sector reform (Villadsen 1996), involving a form of decen-
tralization (Mills et al. 1990) called devolution (Jeppsson and
Okuonzi 2000). The district administration was strengthened
with some formal transfer of power to lower levels as well,
but, with insufficient financial means, the districts relied on
central government. The MOH expected the districts to
develop their own plans to reflect national polices and guide-
lines, but with district priorities and requirements (MOH
1993). Uganda had 45 districts in 1997, with no intermediate
level. Each district has counties, sub-counties, parishes and
villages.
Other major health policy changes taking place included
restoration of services to acceptable levels to match the
changing social, economic and political environment (MOH
1993b), and reorientation of health services to primary health
care (PHC).
There was a legacy of irregular and inadequate wages for
health workers and undue influence by international donors –
on health services and policy (Okuonzi and Macrae 1995) –
and by the nationally based vertical programmes. In 1987 a
new HIS was introduced by the Health Planning Unit of the
MOH; this was replaced by the HMIS in 1996/7.
The HIS was geared toward central planning to produce
information on health unit activity to support international
donors‟ reports to their headquarters. The information was
supplemented by ad hoc community-based surveys carried
out by non-government organizations. Unlike the HIS, the
HMIS information was to be for decision-making and
improving operational health services performance. All
health units (including non-government units) were to
collect, process and report routine data relevant both to
national policy and health programme objectives and to the
needs of health unit health professionals. The design
identified critical management questions that the infor-
mation should answer and, to identify appropriate data
collection, processing and analysis, utilized the systems
framework of inputs, procedures, outputs and outcomes for
216
immediate management, rather than awaiting higher-level
feedback. The system was to be integrated by having one
data source and set of forms in the health facility, so that all
existing health programme and general administrative infor-
mation would be brought together, instead of having parallel
and duplicate information.
Specified data and information flows included: the internal
flow of information amongst the health unit team; written
monthly reporting from the health unit to the District Health
Team (DHT); oral reporting of specific information to DHT
members on supervisory visits; and written feedback from
the DHT for comparison with other health facilities.
Data processing and analysis were intended to be primarily
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conducted by health unit staff, processed into summary values
to show changes over time, and provide performance indicators at
health facility, district and national level. Aggre- gation of data
only to the level where information could be produced for
decision-making was intended to make the data meaningful.
Graphs of routine information were to be produced by health units
for their own purposes.
The intended use of information in health units was not
always clear from the documentation, but implied: indicators of
low performance leading to examination of individual records to
provide insights into how to improve; collection of specific
information to trigger certain actions at health unit and district
level, such as specific disease notification leading to investigation;
service targets to be made using population information,
knowledge of attendance and available re- sources; and
information to be used to answer specific management questions
and plan future health unit services.
Information use at district level was intended to include:
formulation, monitoring and evaluation of annual workplans;
monitoring and improvement of health unit service delivery in
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coordination with support supervision visits; and reporting of
selected information to the District Health Committee for planning,
monitoring and evaluating progress towards district and
national objectives. Reports generated for various national
MOH and donor departments were to be used for national
planning and policy formulation.
Some features within the HMIS were not always made
explicit: certain management tools; the teaching and super-
vision role of the Extended DHT (EDHT); and the „infor-
mational approach‟ to decision-making, encompassing the
„rational health unit decision-maker‟.
The HMIS was initially designed and developed with ex-
patriate consultant help and input from the MOH and other health
care providers and donors. It was piloted in two districts and
extended gradually to all districts. Two devel- opers and 12
trainers trained the EDHT, who then trained in-charges and
senior health staff at health units.
 217 Implementing a health Jmanagement Gladwin et al.information system
Results: adoption of a HMIS innovation
The HMIS is viewed here as innovation diffusion, focusing on
the Implementation stage, when district personnel were trained.
Figure 1 illustrates our use of the Innovation-Process model with
concepts from the Innovation-Decision model. Leavitt‟s
dynamic equilibrium framework was essential to complete that
understanding, as indicated by the diamond shapes.
Redefining the innovation
Redefining the innovation to meet organizational needs and
structure took place as the HMIS definition and its purpose
varied. The developer and trainers did not adequately
Figure 1. Evidence for the Innovation-Process model: implementing HMIS
where the dynamic equilibrium model is relevant.
explain the Principles Knowledge embedded in the HMIS,
namely the anticipated new approach to management and
decision-making based on information. Examination of the
specified management questions was not in the classroom- based
curriculum for supervisors or in-charges. Trainers redefined the
HMIS by focusing their training not on health unit information use
but on data collection and processing for in-charges and by
leaving use of information and much processing for district-level
staff.
New definitions were probably dependent upon individual
ability and role. Health workers saw the HMIS as: new and
integrated, with fewer forms; new centres for holding infor-
mation; logistic and supplies data, morbidity data and data
produced through interaction with patients. The HMIS affected
data flows; monthly reports were going to district offices, and
duplicate reports were probably not sent to national level.
217
Health units did not process information as expected; many
health workers could not graph data and district staff did this.
Using information to inform decisions proved too difficult for
in-charges and often district or national level staff set targets
instead.
Innovation adoption at health units was only partial. The
HMIS was serving district needs more than health unit needs, so
redefining had taken place. One District Medical Officer said
he used the HMIS information “for the annual Workplan we are
doing now, for setting priorities, by knowing the most recurring
diseases, for resource calculations, to know the numbers of
patients. But I think the HMIS is of more benefit to the district
than to the health unit, especially with decentralization.” District
staff processed the data and new forms to varying degrees,
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though some found the work too difficult.
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indicates
Reasons for redefining
Previous practice contributed to redefining and included:
existing information management problems; the HIS infor-
mation management strategies; old ways of working;
concomitant changes; recent policy not enacted; manage-
ment problems at district and health unit level; excessive
influence of international donors; and organizational and
cultural practices. Other reasons, also identified by Rogers
(1995), included: adopters lacking full knowledge of the inno-
vation; the desire to simplify a complex and difficult to under-
stand innovation; and the innovation being an abstract
concept and tool. Other reasons, not identified by Rogers,
were: „inventors‟, change agents and aides lacked full know-
ledge of the innovation; lack of management tools to utilize the
innovation; and insufficient decision-making power.
218 Implementing a health Jmanagement Gladwin et al.information system
The innovation‟s perceived attributes and incompatibility
with management roles, ability, policy and organizational
situation were probably contributing to redefining. There was
a lack of tools to monitor and evaluate the innovation‟s
implementation and use, and a lack of understanding of
changes needed with the HMIS. The management tools,
power and attributes of the innovation were not aligned with the
HMIS in accordance with the dynamic equilibrium
concept.
Restructuring
Organizational restructuring occurred since the innovation was
introduced but not aligned, including: the role of the Medical
Records Officer (MRO) at district and health unit level; the
power structure within health units and district offices;
administrative procedures; additional contractual relationships;
and empowerment of some people to whom the HMIS training
brought extra finance.
Constraints on implementation
The hierarchy of power in health units and at district level
constrained HMIS implementation, as decentralization was
not fully enacted or understood. The previous hierarchy of
power placed the MRO in a lowly position, but the district
MRO was now expected to be an HMIS supervisor, even of
clinically trained staff, and fellow DHT members were
expected to produce reports the MRO could file, collate and
even interpret, which meant he had the right to demand
reports from these staff. While changes were expected in
health units, developers and trainers were unaware of these
constraints. Although face-to-face training of in-charges by
supervisors was probably an appropriate communications
strategy, insufficient time was allocated. Hence the social and
communication structures impeded diffusion.
Several constraints related to the HMIS‟s perceived attrib-
utes. The intended training approach was not always under-
taken and there was lack of understanding of changes needed
to accompany the innovation. Several unfounded assump-
tions were made about health unit staff and procedures when
identifying relevant information management strategies. For
example, HMIS data collection, processing and information
use assumes a certain level of general education and
specialist training amongst health workers, but this was not
available, especially in smaller health units. Too few support
supervision visits for HMIS training were made for health
unit personnel to grasp new skills, such as data processing,
compiling graphs and statistics. The trainers falsely assumed
that in-charges could easily be taught data processing
methods, but after 3 years many in-charges in pilot areas had
problems. Data collection was not always linked to diagnostic
ability as many health units did not have the equipment
and/or expertise to diagnose the diseases monitored. Many
nursing aides trained on-the-job had insufficient grasp of
218
English language concepts in the materials. Workers‟ skills
were not aligned with the HMIS.
Organizational changes intended to be in place before HMIS
implementation, including decentralization and the exten-
sion of managerial responsibilities for health unit clinicians,
were incomplete. Thus there was some incompatibility of
information management strategies with management roles,
ability, policy and organizational situation.
After 3 years of engaging with the HMIS, people were
seeking innovation knowledge of various kinds. The devel-
oper lacked faith in the usefulness of the HMIS, and there
were too few tools to monitor and evaluate the innovation‟s
implementation and use. These constraints may be due to the
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HMIS definition or to the management of information
system development. Classifying these as incompatibility of
perceived attributes deepens understanding, as Rogers
(1995) suggests, but it could be interpreted as the innovation
upsetting the dynamic equilibrium of the organization.
A key perception of the implementers was that international
donors had excessive influence over health unit data collec-
tion and, because they were interested in particular country-
wide programmes, national level MOH, rather than district or
health unit staff, often determined data collection.
The complexity of introducing the HMIS has been clarified after
developing a combined and expanded model from Rogers‟s two
models. Our findings on HMIS implementation do not fit neatly
into the classical Innovation-Decision Process model,
particularly because the implementation phase is too limiting.
The Innovation-Process model‟s redefining and restructuring
concepts offered clarification, as did many Innovation-
Decision model concepts, including: prior conditions affect- ing
44250 by guest on 31 May 2022
implementation, perceived attributes, and lack of knowledge
constraining implementation. Unlike Rogers‟s (1995) Innovation-
Decision model, it appears these concepts, which would usually
be important before the adoption decision, were important in
the implementation stage. Rein- vention of the innovation during
implementation is possible (Rogers 1995).
These two models do not entirely explain the evidence.
Rogers‟s (1995) concept of structural change within an
organization is too limited to understand how different
aspects of the organization change with innovation introduc- tion.
An adapted version of Leavitt‟s dynamic equilibrium model was
developed viewing the HMIS as the technology.
Figure 2 illustrates the dynamic equilibrium model, with
suggestions of where non-alignment occurred in health units. The
earlier description indicated management roles or in- charge
ability were not always appropriate to the information management
strategies, and vice versa. Management roles and the HMIS
were not „aligned‟; the HMIS assumes in- charges will be
managers, with monitoring, evaluating, controlling and planning
responsibilities, but these responsi- bilities have not been
completely devolved. In-charges do not have complete control
 219 Implementing a health Jmanagement Gladwin et al.information system
over drug supply, which the rational decision-maker idea assumes.
The patchy implementation of the cost-sharing policy and
incomplete financial decentral- ization illustrate lack of
alignment between structure and information management
strategies; cost analysis procedures were sometimes redundant. If
in-charges wanted to act as rational managers and take an
informational approach to decision-making, lack of power
prevented this.
The intended strategy of small health units is to provide
comprehensive PHC services with principles of equity and
community participation. In-charges have to monitor,
control and evaluate health centre services and resources, manage
staff and provide accommodation. For there to be alignment of
Structure, Individuals and Roles, or Management process
not incorporated into the HMIS: socioeconomic factors, access
to clean water and sanitation, and attitudes, practice and
knowledge of health-related behaviour – all components of
Comprehensive PHC (CPHC) vision.
Assuming management tools, procedures and style are an
additional organizational force (Scott Morton 1991), this case
study indicates non-alignment of health unit information
management strategies and this force. One key informant said
it was difficult to use information on the percentage of children
with protein-energy malnutrition “as there are no standardized
case definitions”, an essential management tool. Information
Figure 2. Application of dynamic equilibrium model of organizational change in health units: the HMIS is not aligned to Intended Strategy,
management strategies were not linked to health unit
decision rules, and there was non-alignment of strategy and
HMIS. „Individuals and Roles‟ appear to be non- aligned with
the HMIS, although some job changes were taking place to
facilitate alignment. Some administrative procedures and
information management strategies were not aligned.
Figure 3 illustrates the dynamic equilibrium model of
organizational change in understanding the district level. The
intended district level strategies were not aligned to the
HMIS. One District Medical Officer felt the HMIS needed to
incorporate extra information related to aspects of CPHC, in
particular, the idea of socioeconomic factors influencing health
status. As some in-charges were not able to carry out some
219
these two aspects, information to support the policy and roles is
needed, but this was often not the case. Non-alignment of
technology with organizational strategy arose, as the data to
monitor the strategies were lacking. Few data were collected
which could indicate which specific groups within the health
unit catchment area were in greater need or accessing more
services than other groups. Data collection or management
questions on the following were
unit type and staff ability; *Manage health unit staff Individuals and roles:
Key:
*Individuals not trained in using management
skills and tools;
*Role is often administration not management;
Downloaded from https://academic.oup.com/heapol/article/18/2/214/644250
*Job changes taking place
intended management activities, district managers were
undertaking these. The informational or rational management
approach was not fully utilized at district level as many DHT
members were unable to use the management tools, indicating
non-alignment. There was non-alignment of the HMIS and
supervisors‟ skills (Individuals and Roles), especially as
management training, teaching skills, improved data processing
skills and skills in using information are needed. Some DHT
management training was undertaken and as one DHT officer
said: “It’s only since the mid-level managers’ course that I
know the value of information for planning.” He had only just
realized the district MRO had useful information. Some
changes in the MRO role were also taking place; the technology
was pushing realignment of indi- viduals and roles.
Non-alignment of organizational structure with the HMIS was
apparent to the developer, who felt lack of district level financial
control inhibited information use. In a devolved situation,
international donors should negotiate with district and national
level personnel, yet when donors held a district meeting, they
by guest on 31 May 2022
merely gave information. It was also felt the organizational
structure prevented implementation in other ways. One District
Health Volunteer believed the HMIS needed a good
communication and referral system in order to work, but this
was lacking, especially during the rainy season. With
decentralization there had been some redistri- bution and
reinforcement of power at DHT level and District Medical
Officers became more powerful, but the team- working
220 Implementing a health Jmanagement Gladwin et al.information system 220

idea imposed by national and international agencies could Discussion

conflict with this.
The exploration of the change from the HIS to the HMIS,
within Leavitt‟s theoretical framework, reveals other changes
needed to ensure equilibrium and proper information system
functioning. It proved useful to change Task to Strategy and
add Management procedures, tools and style as an additional
force within the organization, though this organizational
change model has been useful only as an adjunct to the Inno-
vation-Process model. Dynamic equilibrium diamonds are
placed within the Redefining and Restructuring Stage
(Figure 1) in order to complete understanding of the process.
The diffusion framework describes the process, but the
*Decentralization incomplete
*Management and technical support role;
*Some changes taking place
*Lack of teaching skills
The need to consider the organizational context when
changing information systems suggests the process is more
complex than some practitioners have realized when
attempting to understand the causes of information manage-
ment problems and developing HMIS in low-income coun-
tries. Avgerou (1993) also criticizes national development
planning information-system developers for not seeing
organizational change as part of the systems development
process in low-income countries.
The extent of change needed to accompany the HMIS had
not been recognized and health workers were focusing upon
Indicates non-alignment

*HMIS is health unit based but

additional structure exists

Individuals and roles:

ministries?; *Some management trained;
*Enact conceptual framework *Lack of data processing skills; Key:

Figure 3. District level application of dynamic equilibrium model of organizational change: the HMIS is not aligned to intended Strategy, Structure,
Individuals and Roles, or Management processes
organizational model has given the context and reason for the small, rather than significant information system changes
aspects of that process. The diffusion model does not predict what in the absence of definitive information. Rogers (1995) did
needs to change within the organization when a particu- lar not discuss this, but others distinguish radical change from
innovation is introduced, or how much, but the addition of the incremental change (Kaluzny et al. 1977; Greer 1981;
organizational model has helped. Onstrud and Pinto 1991; Orlikowski 1993).
 221 Implementing a health Jmanagement Gladwin et al.information system
The issue of an innovation bringing concomitant changes or a
cluster of innovations is mentioned by Bonair et al. (1989)
who reviewed the transfer of medical technologies to low-
income countries: „Transfer of foreign medical technology to
developing countries means not only transfer of drugs and
equipment, but also transfer of a foreign cultural perception of
disease, the so-called western medical paradigm.‟ Foltz
(1993) recognizes the problem of defining the innovation,
a new MIS in Chad, when she says this is a complex
combination of organization and computer technology. The
developers and trainers did not fully recognize that the HMIS
was intended to promote an informational approach to
management. In Niger (Mock et al. 1993), information
system developers realized they were introducing not only
statistical techniques, but also a new management approach
with wider organizational consequences.
The diffusion of innovation framework, in its application to
organizations, is predicated on the following idea: „An
organization is a stable system of individuals who work
together to achieve common goals . . .‟ Rogers (1995: 403). This
idea was not borne out here. There was a conflict of interest
amongst individuals within the organization, as inter- national
donors requested extra data collection and process- ing to support
their headquarters‟ interest, rather than MOH information
management strategies. Using the diffusion of innovation
framework to deepen understanding of the adoption of new
information management strategies in a management-training
package, Gladwin et al. (2002) 1 identified that individuals
supporting the adoption were pursuing personal career goals in
addition to organizational ones. Mock et al. (1993) found
personal agendas affected implementation when new information
system strategies to reform the HMIS were introduced in Niger.
Greer (1977: 506) criticizes the diffusion of innovation frame-
work because it does not take into account political theory.
Themes of a political nature here were not explained within the
framework, but they have been displayed graphically as
additional issues in Figure 1. That civil servants pursue
personal rather than organizational goals, constraining rational
decision-making, is not a new concept (Montgomery 1987: 914;
Gyimah-Boadi and Rothchild 1990: 52). Wadding- ton (1992)
claims that recognizing differences between private and
publicly stated goals was crucial to understand- ing constraints to
rational decision-making at district level in Ghana.
The Innovation-Process model does not include the idea that after
the adoption decision, rejection or discontinuation could take
place during implementation, although this is recognized in the
Innovation-Decision Process. This research has shown the
relevance of the Innovation-Process model and that social
structure affects not only the decision to adopt (as the
Innovation-Decision process suggests) but also the
implementation process and consequences.
Information system developers and implementers had not
acknowledged they were promoting an informational approach
to management with the change from a centralized reporting
system to an MIS supporting use of information at the level of
221
collection. In Ghana, Campbell et al. (1996: 15), reporting on
HMIS development, acknowledge their desire to increase the
number of „informed decisions‟. They assumed that having
more objective, locally collected infor- mation would lead to
more effective and consistent health management, but they did
not acknowledge a different management approach was needed.
Although they acknow- ledge appropriate data analysis tools and
some management tools were necessary, there appears to be a
lack of manage- ment questions or decisions associated with the
data, and no training in management tools. They do not provide
the conceptual framework to link information, management
tools and management. Lippeveld et al. (2000) call for
research which identifies „how one could design and conduct
training that effectively improves the actual use of infor-
mation for health services planning and management‟.
Downloaded from
Downloaded
Conclusion
from https://academic.oup.com/heapol/article/18/2/214/644250
This case study followed the HMIS planning process and
explored the evidence by utilizing the diffusion of innovation and
https://academic.oup.com/heapol/article/18/2/214/644250
dynamic equilibrium organizational change model, which
guided previous research and practice. Neither perspective
guided HMIS development and implementation in Uganda.
Instead, technological issues rather than wider organizational
issues dominated the planned change to the HMIS.
The diffusion of innovation and dynamic equilibrium
organizational change models are applicable to the introduc- tion
of new information management strategies and manage- ment
approaches in low-income countries. Some refinements to the
models described by Rogers and Leavitt have been made, as
detailed by Gladwin (1999) and Gladwin and Wilson (2000).
These frameworks can facilitate the practice of introducing such
innovations and enable practitioners to see the introduction of
innovations as a staged process to be managed. Issues that may
facilitate or inhibit adoption may be identified in advance.
by guest on 31 May 2022
Some implications for practice from this study reinforce
existing guidelines while others are new. Rogers‟ (1995)
diffusion framework is relevant to the introduction of new
information management strategies and management
approaches, and his 87 generalizations with implications for
practice are also relevant. Table 1 identifies some of the
practical implications of this work; more detail is given in
Gladwin (1999). These ideas can also be used as part of needs
assessment and evaluation as well as introducing information
management innovations. This case study has documented
common barriers to establishing and sustaining effective
routine HMIS and strategies to minimize their effects, a
recent WHO aim (WHO 2001b).
Endnotes
1
This paper is a companion paper to the present one as it
follows the introduction of another information management inno-
vation; the two yield complementary implications for practice.
222 Implementing a health Jmanagement Gladwin et al.information system 222

Campos-Outcalt D. 1991. Microcomputers and health information in

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Table 1. Key implications for introducing information management innovations

Recommendation Strategies

Improve innovation definition Develop implied Meaning or Principle Knowledge before introduction and
introduce it before, or at the same time as, Awareness and How-to Knowledge
Clarify whether a radical change or natural extension is implied
Understand potential adopter‟s situation Be aware of organizational context and influencing factors Address
compatibility of innovation with existing practice
Understand IM innovations Ensure alignment of new IS technology by viewing introduction of IM involve organizational
change innovation as issue of organizational change and facilitate alignment of forces
within organization at all stages of process
Focus on information use as well as data collection and processing

by guest on 31 May 2022

Adopt conceptual frameworks
Utilize existing expertise and research in IS
Broad needs assessment,
evaluation
Training
Make explicit IM strategies to support informational management approach and put
support strategies in place
Diffusion of innovation framework and organizational change ideas will allow
practitioners to see innovation introduction as staged process to be managed
Efforts to improve HMIS should prioritize conceptual frameworks that describe health
workers‟ understanding of factors affecting health status and are utilized in planning
and monitoring
Clarify links between information, management tools and management
Apply an Information System Development Methodology: Soft Systems
Methodology developed by Checkland (1981), and ETHICS, developed by Mumford
(1983) identify techniques for dealing with issues, such as participation, bottom-up
development, stakeholder conflict and powerful stakeholder domination
Develop national Health Information Management Strategy
Needs assessment, evaluation and monitoring should focus upon data monitoring and
collection, processing and information use, skill levels and roles performed,
organizational structure, organizational strategies, management tools and management
processes in operation, and health workers‟ view of changes
All IM changes need to be monitored and evaluated; failure to adopt a particular IM
strategy may signal inappropriateness
Allow sufficient time for this long process, particularly at planning stage, as HMIS
implementation will proceed slowly, but chance of success will be higher
Health workers‟ training should focus on data processing, analysis and use
of information in their own written/spoken language
In-Charges and DHT must be trained in, and undertake their expected management role
at the same time, or before HMIS implementation
Teaching skills should be an integral part of supervisor‟s training
 223 Implementing a health Jmanagement Gladwin et al.information system 223

Adequate finance should be made available for support supervision including

Adopt staged process of innovation diffusion
Understand cultural issues
Develop appropriate IM strategies
transportation
Strategies to overcome lack of IM skills amongst less well-educated health workers
need to be developed, eg DHT may need to temporarily undertake data processing,
and provide newsletter
Change agents should be aware of adoption stage the organization is at to facilitate process
Opportunity to see the innovation in practice or clearly reported trial should accompany
innovation introduction
Innovation reinvention, redefining or adaptation occurs at different stages in diffusion
process; steps should be taken to facilitate or discourage this, depending upon the
change agents‟ aim
Innovations are introduced to individuals after organizational adoption; diffusion process
should be conducted accordingly
Consider various stakeholders‟ views, innovation facilitators personal
agendas, likely changes in status and power and other political factors when
designing, facilitating adoption and implementing IS
Conflicts between existing organizational culture and changes need to be carefully
negotiated
HMIS improvement should focus upon utilizing information as well as data and general

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features collection and processing
HMIS data and information is for operational management, not broader evaluation
Although some of that data may be of value for researchers, research will need
to conduct special surveys

IM = information management; IS = information system; HMIS = Health Management Information System; DHT = District Health Team.
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Acknowledgements
The researchers would like to express their thanks to MOH person- nel
and other health workers in Uganda for their time during this research.
We are also grateful to the British Council for funding the visit of one of
the researchers (JG) as part of a link programme for strengthening district
management.
by guest on 31 May 2022
Biographies
Jean Gladwin, PGCE, MSc, RPHNutr, Ph.D., completed her doctor- ate at
the Centre for Health Management Information Research, University of
Sheffield. The thesis (from which this case study is taken)
investigated the introduction of new information manage- ment strategies
intended to promote an informational approach to management at the
operational health service level in low-income countries. She is also a
Public Health Nutritionist having worked in Europe, East Africa and
South East Asia as a practitioner and researcher. She is presently
focusing on the use of death and mortal- ity information for management
and policy in the UK.
Robert A Dixon, BSc, Ph.D., is a NHS Research Manager and inde-
pendent consultant in International Health, formerly Senior Lecturer
in Public Health at the University of Sheffield. Doctoral work was on
local hospital and primary care health information systems. He has
worked in India, Indonesia, Cambodia and Bosnia, and is currently
evaluating the health programmes of Africa Inland Mission. [Address:
Sheffield Health and Social Research Consor- tium, Fulwood House,
Old Fulwood Road, Sheffield S10 3TH, UK]
Professor TD Wilson, Ph.D., is Professor Emeritus in Information
Management in the Department of Information Studies, University of
Sheffield, where he has been since 1972 and was Head of Depart- ment
for 15 years. He is also Visiting Professor at the Hogskolan I Boras,
 225 Implementing a health Jmanagement Gladwin et al.information system 225

Sweden and Academic Director of the International Centre for

Information Management Systems and Services at Nicholas Copernicus
University, Torun, Poland. His research interests are in information
behaviour, electronic scholarly communication, and the strategic aspects
of applications of information technology in organizations. [Address:
Department of Information Studies,
University of Sheffield, Western Bank, Sheffield S10 2TN, UK]

Correspondence: J Gladwin, HSRU, London School of Hygiene and

Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Email:
jean.gladwin@LSHTM.ac.uk