Working papers in
Information Systems
AN INSTITUTIONAL PERSPECTIVE ON HEALTH
SECTOR REFORM AND THE PROCESS OF REFRAMING
HEALTH INFORMATION SYSTEMS: CASE STUDIES
FROM MOZAMBIQUE
Bruno Piotti, Baltazar Chilundo and Sundeep Sahay
WP 9/2005
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be quoted without the author(s)'s permission.
Information Systems group
University of Oslo
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P.O.Box 1080 Blindern
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http://www.ifi.uio.no/~systemarbeid
Piotti, Chilundo and Sahay
Copyright © with the author(s). The content of this material is to be considered
preliminary and are not to be quoted without the author(s)'s permission.
An Institutional Perspective on Health Sector Reform and the process of reframing
health information systems: Case Studies from Mozambique
Bruno Piotti
Baltazar Chilundo
Directorate of Cooperation and Planning
Ministry of Health
Mozambique
Department of Community Health
Faculty of Medicine
Eduardo Mondlane University
Mozambique
Sundeep Sahay
Dept. of informatics
University of Oslo
P.O. Box 1080 Blindern
0316 Oslo
Norway
<sundeeps@ifi.uio.no>
+47 2284 0073 (phone)
+47 2285 2401 (fax)
Abstract:
Global concerns about poverty, epidemics and new emergent diseases urges rich
countries to improve their development assistance, aid effectiveness, investments in
health systems, including the health information systems. Governments of low income
countries have embarked since about a decade ago on various health sector reforms that
have led to often contradictory but most often not so successful outcomes. Formally,
governments of rich and poor countries share the same goal: to increase coordination and
harmonization of relationships on aid, debt relief, trade, poverty reduction program and
health systems support. Mozambique, one of the poorest countries in the world and
also one of the largest recipient of loans, grants, and technical support, has gone through
multiple phases of reforms involving different kinds of partnership with donor countries,
and have experienced different degrees of successes, unfulfilled promises, unsuccessful
coordination attempts and duplications of intervention. The aim of this paper is to try to
unpack some of the complex institutional and organizational changes relating to these
attempts at health reform, and to understand alternative ways to approach them. We draw
upon an institutional perspective to understand this complexity, by historically examining
the formal and informal institutions in play, and the degree of overlap or not that exists,
and how these influence the reform processes. Further, we examine how these formal and
informal institutes relate to change processes - both planned and emergent. Empirically,
the analysis is grounded in two case studies from Mozambique of ongoing efforts to
reform. The first concerns the process of selection and design of national level indicators,
and the second relates to the integration of the multiple reporting systems of the
HIV/AIDS health program. We argue that in the first case where the overlap between the
formal and informal institutions is greater as compared to the second case, the degree of
success experienced in the reform effort is greater.
This leads us to three practical
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Piotti, Chilundo and Sahay
implications that can help support reform processes. The first concerns the key role of
participation of various stakeholders in the reform process. The second concerns the need
to adopt a "cultivation" rather than a "construction" approach to the reform process. And,
the third relates to the need for incorporating flexibility in the reform planning and
implementation process such that the space for emergent changes is not shut out.
Keywords: Health sector reforms, institutional changes, health indicators and integration
of health IS
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1. The challenge of health reform and organizational change in developing countries
In 2003, the Director of the World Health Organization (WHO), Grö Harlem Bruntland,
declared that “health is central to development” (Ruger, 2003, p. 678). In December 2001,
the WHO Commission on Macroeconomics and Health (CMH) report strongly
recommended to low and middle income countries that investing in health will be the
most effective way to overcome poverty, and urged them to increase their investments in
the health sector to help fight against economic deprivation (WHO-CMH, 2001a).
However, such investments need to be accompanied with a range of reforms, such as in
accounting and budgeting practices, in order to attract investors from the rich world. As
Ruger argues:
“Good health enables individuals to be active agents of change in the
development process, both within and outside the health sector. Increased
investment in health requires public action and mobilization of resources, but it
also brings individuals opportunities for social and political participation in
health-system ”. (Ruger, 2003, p. 678).
However, the assumption that health and socio-economic development are correlated is
not new. In 1978, the links between poverty, political commitment, economy and
community involvement were at the centre of the Alma-Ata Declaration (WHO, 1978, p.
49-51) on primary health care and in the WHO and United Nation’s program on ‘Health
for All by Year 2000’ endorsed by 134 countries (Mahler, 1988, WHO, 1988). This
program urged a radical switch from curative to preventive medicine and advocated for
community-based approaches to health care, publicly funded, and free for all at the point
of delivery (Werner & Sanders, 1997). At a global-level, after 27 years of the Alma Ata
declaration, the objective of "health for all" is far from being met, and today we have
millions of poor people who are still being denied access to basic healthcare, a problem
that continues to be magnified with time (Kvamme, Olesen and Samuelson, 2001;
Goorman and Berg, 2000).
In developing countries, the health care sector has historically been a target for different
kinds of reforms. At the beginning of the 1990’s, the Structural Adjustment Program
(SAP) was launched by the International Monetary Fund (IMF) and the World Bank in
several low and middle-income countries. Health reforms accompanied the SAP, which
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have over the years been subject to serious criticism. For example, Lown et al. have
argued:
The policies of structural adjustment, imposed on developing countries by the
World Bank and the International Monetary Fund, have emphasized debt
repayment based on maximizing exports at the expense of agricultural selfsufficiency and domestic social programs. These economic strictures have
curtailed the already small funding for health services, education, and the
environment. According to World Bank projections, by 2005 sub-Saharan Africa
will be back to levels of income per head that it had in the 1970s.7” (Lown et al.,
1998, p. S34).
What are the major features of the health reforms? A WHO (1995) document describes
Health sector reform is a sustained process of fundamental change and institutional
arrangements, guided by government, designed to improve the functioning and
performance of the health sector and ultimately the health status of the population”.
(WHO, 1997, p. 3).
Some key points of reforms are: improving civil service performance and Ministry of
Health functioning, decentralization of responsibility in healthcare management,
broadening financial options, introducing or widening the role of private health providers
in the health sector (Cassels, 1995, p. 11).
These goals have been translated into various national and regional level health reform
efforts, including prioritizing public sector resource allocation using cost-effectiveness
analysis, developing alternatives to public financing, integrating donor funding models,
building coordination mechanisms, the integration of development programs into the socalled Poverty Reduction Strategy Papers (PRSP), and the incorporation of ICTs to help
strengthen the informational basis by which health management decisions are taken.
The PRSP launched by World Bank and IMF in 1999, is a relatively recent socioeconomic program designed to have an impact on health systems. The PRSP provides
key founding principles to regulate two policies: the loan release conditionality and the
extension of debt relief to the highly indebted poor countries (Spanger and Wolff, 2003, p.
1). More recently, in 2000 all 191 UN members’ states signed the "Millennium
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Declaration", from which the Millennium development goals were derived, which are
mandated to be achieved by 2015. The goals include measurable, time-bound targets for
addressing challenges of poverty and hunger, education, maternal and child health, the
prevalence of diseases including HIV/AIDS, gender equality, the environment, debt,
trade justice and aid. It is becoming increasingly evident to policy makers in rich
countries that the heightened influx of migrants, ethnic and territorial wars, increasing
risk of epidemics and new emergent diseases represent threats to standards of life in
industrialized countries and provide compelling political and economic justification to act
globally, to increase investments in developing countries, especially in their health
sectors. “The notion of the goals as a compact between North and South was reaffirmed
at the international conference on financing development in Monterrey, Mexico, in 2002”
(Haines and Cassels, 2004, UN, 2002) . The G8 and OECD countries have repeatedly
stated their will (for example, MDG-2000, Genoa Summit 2001, Monterrey, 2002) to
increase their investments and their quota of GDP predetermined to the Official
Development Assistance (ODA). However, Labonte et al. document an appalling gap
between the volume of overall security investments against terrorism and the total
amount of ODA to low income countries (Labonte et al., 2004, p. XII). There is instead a
long list of promises given and largely unfulfilled or broken: African continent debt relief
or cancellation (Wintour, 2005); reaching the UN stated goal of 0.7% of rich country GNI
for aid to developing countries(Haines and Cassels, 2004, p. 396); significant increase of
ODA support to national health systems, e.g. for increasing the annual health budget per
capita from 7$7-10 per capita to $35-40 per capita (WHO-CMH, 2001b); increased
education coverage; and, corrections of trade unbalances (Labonte et al., 2004, p. 206209).
Despite the acknowledgement of the urgent need for health sector reforms, the results
emerging from efforts to date can be described as being fairly depressing. At a more
micro-level of particular countries, there have been numerous reports of how reform
efforts have not delivered to potential beneficiaries adequate services and in
strengthening the informational basis to support reform processes (Gilson, 1995, Heeks,
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1998, McLaughlin, 2001). The following statement from a former Zambian Minister of
Health emphasizes these continued failings:
Specific reform strategies and policies were not yet resulting in improvements
based on commonly used measures of service coverage. Thus, reform strategies
and policies must be inappropriate and should be revised. ‘The reformers were
unable to counter such a message because they had no data to back up their
strategies or progress expected as a result of reform…. (Extracted from
McLaughlin, 2001, p.2).
Brown (2001) provides a similar example of an ineffective reform effort on tuberculosis
control in Zambia:
The recent state of tuberculosis control in Zambia paints a bleak picture of a
health priority which is suffering from its integrated status. The National
Tuberculosis Review found that: (i) Tuberculosis focus has been lost and key
activities of tuberculosis control such as reporting and recording, patient follow
up and treatment outcome monitoring were not being performed in the majority of
districts; (ii) Technical capacities for tuberculosis diagnosis including laboratory
microscopy had dwindled both at central and district/peripheral levels; (iii)
Funding for tuberculosis control activities including drugs and laboratory
supplies was been inadequate… (p.9).
While it serves little purpose to provide examples of not so successful reform efforts, it is
more useful to try and understand the complexities that underlie these efforts, and
critically examine alternative ways to approach them. Unpacking this complexity in
particular contexts is important to understand the outcomes associated with different
reform efforts. This complexity can be seen to arise from a variety of sources. Firstly,
there are a multiplicity of levels involved, ranging from the global to the international, to
various administrative levels within the national health ministry (province, district, subdistrict), and to the community. These multiplicities of levels bring into the picture a
variety of actors (for example: donors, politicians, administrators, medical doctors, nurses,
health workers, educational institutions) with varying and often conflicting interests.
Secondly, there are various health programs serving particular needs or geographical
domains, which at some level and to some degree need to “speak to each other.” Thirdly,
developing countries are typically challenged by high disease burdens, for example
HIV/AIDS, Malaria, Tuberculosis, to name just a few. And fourthly, these countries are
faced with poverty and severe infrastructure constraints ranging from physical (roads,
transport), to ICT (connectivity, computers) and human related (numbers, educational
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background). The complexity in these contextual conditions make implementing health
reforms extremely challenging, an argument made by Gilson (1995) in her assessment of
the reform efforts in Tanzania. She writes:
The study’s findings suggest that health care reforms are needed to improve the
quality and efficiency of primary level care in Tanzania. However, current
patterns of performance are subject to many influences and …..(are) intertwined.
Understanding such complexities will facilitate the development of an integrated,
and so effective, policy and management response to existing problems. Health
sector reform package in Tanzania, as in other countries, must allow for
financing, organizational and management development (p. 708).
Information and Communication Technologies (ICTs) are increasingly being implicated
in health reform efforts, for example to strengthen the processes of decentralization of
health care delivery. ICT projects come in with their own particular challenges related to
the complexity of the technologies involved, the need for specialized infrastructure, the
requirements of trained manpower with specialized knowledge concerning programming
languages, software development methodologies, and design skills. Many ICT based
reforms have also over the years ended up as “partial” or “full” failures arising from an
imposed rationality and ‘hard design’ of imported devices which often conflict with the
local rationality (Avgerou, 2000, Heeks et al., 1999). In other cases, managers were
unable to manage effectively the processes of organizational change and consequences
resulting from ICT introduction and individuals and work group dynamics (Anderson et
al., 1994, p. 10-18), and in others, imported technology was unable to effectively trigger
development, human capacity building, reduction of digital divide under a schematic
duplication of exogenous models (Heeks and Kenny, 2002).
With or without ICT, a key actor in the formulation and implementation of health reform
efforts in developing countries is Government that is the Ministry of Health. They
directly or indirectly influence other actors in this domain such as the population who pay
and receives services, the financial intermediaries who collect funds and pay the
procedures, the providers of health services who can be public (National Health Services
- NHS), private non-profit (such as church related institutions), or private for profit
organizations and can operate at different levels of care (Mills, 2000, p. 6).
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In this paper, our focus in on the Ministry of Health in Mozambique and their attempts at
health sector reform. Mozambique is a Southern African Country classified by the 2004
United Nations Development Program Human Development Report as the seventh least
developed country in the world (UNDP, 2004). We seek to analyze some of the dynamics
that characterize the relation between ICT/information and organizational change
processes associated with health sector reform, and how can they be managed more
effectively. More specifically, this relationship is examined at two levels:
1.
The interaction between donors and national level health ministry: the empirical
arena for this interaction will concern the design and development of health
indicators. 2.
2.
The interaction between the national level and the point of health service delivery
around the ongoing efforts towards the integration of information systems of a
vertical disease-specific program.
The rest of the paper is structured as follows: In the next section, we discuss some key
notions from institutional theory which helps us to understand health reforms and change.
In section 3, the research method is described followed by two case studies from
Mozambique in section 4. Section 5 provides an analysis of the case, drawing upon the
theoretical notion presented earlier. Finally, some brief conclusions are presented in
section 6.
2. Theoretical perspective
The theoretical perspective that is drawn upon in our analysis of the reform related
processes in the health sector in Mozambique derives primarily from institutional theory.
A starting point in articulating this perspective is to clarify how we use the term
institution. The Nobel Prize winning economist Douglas North emphasizes the distinction
between organizations and institutions. He explains: “institutions are the rules of a game
in a society or, more formally, are the humanly derived constraints that shape human
interaction (North, 1990, p.3). Put simply, institutions represent the rules and norms that
individuals follow in their daily lives, the formal and informal constraints and their
enforcement characteristics. While institutions represent rules and norms, organizations
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can be conceptualized as structures that provide for human agency to be articulated and
expressed. These structures could be in terms of work tasks, control mechanisms, reward
systems, and ownership (Avgerou, 2002).
Given the above conceptualization, institutions can be seen to play three key and
interconnected roles. Firstly, institutions provide guidance by framing the behavior of
individuals, and as a consequence by also structuring the incentives those individuals face
in their everyday activities. Secondly, by guiding action, institutions facilitate social
action in our daily lives. As North explains, institutions are “a guide to human interaction,
so that when we wish to greet friends on the street, drive an automobile, buy oranges,
borrow money, form a business, bury our dead, or whatever, we know (or can learn easily)
how to perform those tasks….In the jargon of economists, institutions define and limit the
set of choices of individuals” (1990, p. 3-4). Thirdly, if follows from the earlier two roles,
that institutions reduce the uncertainty of social interaction by providing a structure
within which people can act and be understood.
Institutions can take the form of both formal and informal rules. Institutions can be
formal and explicit such as the national constitution, and can also be informal and
culturally agreed upon (but unwritten) such as the respect that is expressed to the elderly
in a particular community. The distinction between the formal and informal institutions is
described to be at the core of the economics of institutions because of the simple principle
that laws to enforce informal rules are much more costly than the formal. In situations
where there is little overlap between the formal and informal rules, and the formal
institutions can not be enforced adequately, the informal rules take priority. This makes
the enforcement of the informal rules difficult and costly. For example, Madon et al.
(2004) describe the formal and informal rules that shape the functioning of the property
tax institution in Bangalore, India. The informal rules, based on the interpersonal
relationship between the property owners and tax collectors were a more prevalent
mechanism for assessing property tax as compared to the formal calculation formulae for
assessment. This lack of overlap between the formal and informal institutions and the
dominance of the later made the process of introducing reforms into the property tax
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Piotti, Chilundo and Sahay
system extremely complex and time consuming nearly over a 20 year period. Sautet
(2005) provides a simple schematic to describe the relationship between the domains of
the formal and the informal (see Figure 1) which has implications for understanding
organizational change.
FORMAL RULES
FORMAL RULES
=
INFORMAL NORMS
INFORMAL NORMS
Figure 1 - The greater the overlap between the formal and informal,
organizational change will be easier to enable.
Source: Adapted from Saulet (2005)
Figure 1 The relationships between the domains of formal and the informal
A simplification that can be abstracted from this schematic is that the greater the overlap
between the formal and informal, organizational change will be easier to enable.
Interesting questions which thus arise are: what are the mechanisms for enabling these
changes?; how can the overlap between the formal and informal be increased?; and,
consequently how can the mismatch be reduced.
Drawing from Orlikowski and Hofman (1997), we argue that this process of alignment
between the formal and informal domains can be seen as a combination of three types of
improvisational change: anticipated, emergent and opportunity-based (see Figure 2).
Anticipated change concerns events that are planned for the future, for example
establishment of National Integrated Programs or strategic frameworks to guide health
policy. There are also two kinds of change, which arise spontaneously, as a result of the
experiences during implementation – opportunity-based and emergent kind of changes.
Opportunity-based change refers to those that occur without being planned in advance,
however, are deliberative with respect to taking advantage of an opportunity emerging
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Piotti, Chilundo and Sahay
during implementation. For example, Nilsson et al. (2001) describe a case of how a
discovery of an unexpected use of the technology was later capitalized to bring larger
scale changes in the work place where it was discovered. Emergent changes are those that
arise spontaneously from local innovation and were not originally anticipated or
deliberative as in the case of opportunity based changes. Such changes have also been
described by authors as drift, or improvisation (Ciborra, 2000).
The construction of the planned and opportunity-based kind of changes is particularly of
interest in this study as it is operated within the tandem of the formal and complex
organizations. This process, known as parallel learning structures of group-level change
interventions, has been described by Illes and Sutherland (2001, p.54) as follows:
Typically, a parallel learning structure consists of a steering committee (which
includes a top executive), and a number of working groups that study what
changes are needed, make recommendations for improvement, and monitor the
change efforts.(…) Parallel structures help people break free of the normal
constraints imposed by the organization, engage in genuine enquiry and
experimentation, and initiate needed changes… [They] are a vehicle for learning
how to change system, and then leading the change process.
Opportunity-Based
Change
Anticipated Change
Anticipated Change
Emergent
Change
Opportunity-Based
Change
Emergent Change
Figure 2 - An improvisational model of Organizational Change
Source: Orlik owsk i and Hofmann, 1997
Figure 2 Types of change from Orlikowski
As systems become increasingly complex, implying interconnection between parts and
also a greater speed of change, the potential for emergent impacts and “side effects”
(Hanseth et al., 2005) also increase. Given the complexity of the health sector in
developing countries, it becomes important to consider reforms as having (or not)
primarily anticipated effects, but also analyze the different kinds of emergent
consequences that arise. These three forms of change often co-exist over time and are
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Piotti, Chilundo and Sahay
linked to both intra-organizational and broader social contexts. Change is thus not a
straightforward, rational process but as a complex, analytical, and political process that is
historically situated (Walsham, 1993, p.53). Thus, the underlying rationality is mainly
due to cognitive human limitations imposed by given conditions (e.g. lack of human
skills) in the process of change. This situation described by Simon (1982) as situated
rationality represents ‘a style of human behavior that is appropriate to the achievement of
given goals, within the limits imposed by given conditions and constraints’ (p.408). For
example, one can argue that health reformers are limited by various constraints, including
the bureaucratic and political structures which primarily shape reforms as purely
economical rational decisions (efficiency oriented). Avgerou’s (2002) suggestion of a
‘contextualist position’ and ‘organizing regimes’ as key concepts to analyze the
rationality of organizing is helpful to explore the roles and influences of multiple actors
and interests on the reform process. She argues the need to acknowledge the existence of
rationalities that are historically developed, context dependent and emerging from
individuals’ situated enactments, and have resulted in modes of organizing which are
congruent with the rationalities (ibid, p. 93).
In summary, the theoretical perspective articulated has three founding principles. Firstly,
to view the NHS as an institution with formal and informal rules, both overlapping and
not. Secondly, the challenges inherent in the process of organizational change (planned
and emergent) can be analyzed with respect to the degree of overlap that exists between
the formal and informal domain and the enforcement characteristics to enhance (or not)
the overlap. Thirdly, to understand the different rationales behind this overlap (or not) we
need to analyze how these reforms have historically been formed, how they are limited by
the existing conditions and are embedded into different institutional settings, at the local,
national and international levels.
3. Research methods
This research is based on based on two interpretive case studies carried out in a public
health organization, i.e. the National Health System (NHS) of Mozambique. The
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Piotti, Chilundo and Sahay
interpretive perspective is based on the constructivist paradigm that social theory should
not be based solely on empirical observations stemming from general laws, but to
understand the social, one should analyze the reasons for the action of an actor (Walsham,
1993). In line with the interpretive approach, the case study presented in this research
‘assume that people create and associate their own subjective and inter-subjective
meanings as they interact with the world around them’ (Orlikowski and Baroudi, 1991,
p.15).
The Ministry of Health in Mozambique (called MISAU) has for several years been
attempting to implement various computer and paper based information systems to
strengthen the HMIS, for example to monitor the performance of health care and services
delivery, and to plan health interventions and resources. The NHS is comprised of
heterogeneous actors (for example, medical doctors, administrators, specialists, field level
workers etc), systems and programs (such as vertical programs for HIV, Malaria and TB)
that are organized in different interconnected levels of hierarchy (such as health facilities,
district, provincial and national directorates of health). The NHS can thus be viewed as a
complex
‘networked’ organization engaged in defining and implementing various
reforms, including decentralization and re-organization of health programs through
‘functional’ integration that also implies the need for information systems redesign.
Two researchers have conducted the data gathering process. One, guiding the first case
study as an ´involved observer’, engaged in the design of health indicators as an advisor
within the Ministry of Health. Two, guiding the second case study as an ‘outside
observer’, analyzing the challenges of health information systems integration across
different management levels from the health facility to the Ministry of Health
headquarters.
The first case study is based in the central headquarters of MISAU and involves the
consultative and participatory selection of national level indicators (in Portuguese, Lista
Nacional de Monitoria - LNM) to be used for monitoring and evaluating the
implementation of the key issues of the medium term plan of the health sector, i.e. the
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Piotti, Chilundo and Sahay
Strategic Health Sector Plan (locally known as PESS1). One of the authors of this paper
was actively engaged in this entire participatory process over the years 2001-2003. This
engagement involved periodic meetings of a small technical working group on
monitoring and evaluation (TWG-M&E) of 4-9 people representing MISAU and the
donor community. Periodic seminars of 1-2 days were held to discuss the indicators,
originating from the TWG meetings, and furthermore formal interviews were conducted
with relevant health program managers (20), health information officers and officials of
different Departments (15) at the MISAU headquarters. Regular meetings were held,
initially twice a month during the first nine months (March-November 2001), and then
followed by meetings in three other periods of two months each (May-June and
November-December 2002, and May-June 2003).
This TWG-M&E was an instrument of the Sector Wide Approach policy (SWAp)
development process, established between the MISAU and the Mozambican Government
on one part and donors and UN Agencies on the other part (2000). The TWG and its
proposed draft lists were accountable to the fortnightly regular forum meetings (SWAp
Working Group Forum, in PT, GT-SWAP Forum) established for the discussion of issues
of mutual interest over the year. The list of indicators was formally approved through
regular consultation meetings held by the Minister of Health and by the policy
coordination bi-annual meetings (in PT, Comité de Coordenação Sectorial-CCS) of the
Ministry and their aid partners, within the SWAp agreement framework (2001). A
number of documents were consulted to provide inputs into the process including the
reference documents for the SWAp policy, such as the Government Poverty Reduction
Plan (PARPA) (MPF, 2001), PESS document, Code of Conduct (2000, MISAU, 2001),
and the existing lists of indicators, e.g. SADC list (SADC-Committee, 1999), WHO
Catalogue of Indicators
(WHO, 1996), WHO World Report 2001 (WHO, 2001),
Millennium Development Goals Indicators(UN-MDG, 2000), UNGAS list (UNAIDS,
2002) and program specific indicator lists articulated in the annual operational reports.
The second research study involved the analysis of the attempts by the NHS to integrate
program specific information systems as mandated by the Directorate of Planning and
1
PESS is a Portuguese acronym of “Plano Estratégico do Sector de Saúde”
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Piotti, Chilundo and Sahay
Cooperation (DPC) of MISAU. This study was conducted through an in-depth review of
secondary data including official reports and registers used to document health related
data in the MISAU headquarters. In addition, primary data were collected through semistructured interviews with key informants (such as health workers, persons dealing with
statistics, health managers and planners) and observation of work practices surrounding
the collection, processing, use and transmission of data over five time periods: June to
July (2001), May to September (2002), March (2003), August to September (2003) and
October 2004. Data collection was conducted in two (out of eleven) provinces of
Mozambique, namely Gaza and Inhambane where computerization efforts at the district
and provincial levels were ongoing. Table 1 below provides a summary of the interviews
conducted. A research diary was maintained to document relevant notes and in some
cases, a tape recorder was also used after taking prior approval of the concerned
respondents. All interviews were conducted in Portuguese and subsequently translated
into English during the phase of analysis carried along with the third researchers who was
non-Portuguese speaking.
Table 1 Summary of interviews
Table 1 – Summary of interviewees in relation to their working places
Health
Staff
Managers
Working level
workers Responsible
for statistics
Inhambane Province
Maxixe health centre
5
1
2
Urbano health centre
3
1
1
Chicuque rural hospital
6
1
1
Other health facilities
8
2
1
Maxixe district office
2
1
Inhambane-city district
1
1
office
Provincial directorate of
3
5
health
Gaza Province
Chókwe-sede health centre
2
1
Chókwe rural hospital
4
1
1
Chicumbane rural hospital
5
1
1
Other health facilities
6
1
1
Chokwe district office
1
1
Xai-Xai district office
2
1
Provincial directorate of
2
6
health
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Total
8
5
8
11
3
2
8
3
6
7
8
2
3
8
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Piotti, Chilundo and Sahay
National Level
Total
39
1
21
5
28
6
88
In summary, the two case studies represents different ongoing reform efforts,
characteristic of similar ones going on in various other developing countries. While the
first one did not currently directly involve ICT, indicators can be viewed as important
information reflecting status with respect to different health services or diseases. These
indicators are in due course expected to be computerized. The second case study
explicitly concerns the health reform agenda related to information systems integration as
a basis to strengthen the delivery of health programs. Inputs gained from the comparative
analysis is useful to discern similarities and differences with respect to the role of ICT,
different organizational conditions, varying donor influences etc.
The formal and
informal institutions operating in these two cases thus have both similarities and
differences, which will help us to help us unpack the varying consequences of the
organizational change processes (in the two settings).
4. Case studies
In this section, we present the two case studies.
4.1 The process of designing health indicators
Mozambique is highly dependent on external funds and international aid. During the
Emergency and the transition periods (1990-1994), international aid to Mozambique was
one of the highest in Sub-Saharan Africa, amounting to $1.1 Billions, nearly 50% of the
GDP. (Hanlon, 1996, p. 16). This reflected a sharp increase from the pre-1985 period
where the international aid was about $14.7 million comprising 23.5% of the total
national budget of $62.6 millions. The multiplicity of sources of funding for the national
budget led to a proliferation of projects (nearly 450 in number) sponsored by different
agencies, and prompted a comment by the (World-Bank, 1990, p. 63) Minister of Health
in 1989 (during the emergency period) that the Ministry should move away from being
the Ministry of ‘health projects’ to a Ministry of ‘health services’ (Hanlon, 1996, p. 46).
During the years 1990-1994, international aid to the health sector was provided by the
IMF, World Bank, the African Development Bank (ADB), and a large donor community
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Piotti, Chilundo and Sahay
comprising of multilateral agencies such as UNICEF, UNDP, WHO, UNFPA, the
European Union, as well as bilateral aid, where the major actors were: the Swiss
Cooperation (from 1992 to 1998 was the leading donor to the health sector), France, Italy,
Spain, the Nordic group (Norway, Finland, Sweden and Denmark), followed by USAID,
Canada and the Netherlands. (Pavignani and Durão, 1999, p. 245).
The formal evaluation of the National Health Services (NHS) and MISAU activities
carried out in 1990 (MISAU-OMS et al., 1990) detected a divorce between the processes
of budget allocations and planning with adverse implications on the capacity of the
MISAU to control the allocations. In 1990, a common pooling of donor funds was
channeled to the provinces through a parallel, but shared budget. During the years of
transition from war to peace, the Swiss Cooperation was accepted as a ‘leading donor’ for
the health sector, with the responsibility to organize periodic meetings of the donors and
to coordinate interventions by ‘zones’. Every major donor was made responsible for a
geographical area in order to concentrate resources and reduce overall costs, thus trying
to make the use of funds more effective (Walt and et all, 1999, p. 274). In 1995, the
Health Sector Recovery Program was signed on one side by the Mozambican Ministry of
Planning and Finance (MPF) and MISAU, and on the other side by the World Bank and
some other donors. This program aiming at rebuilding the health facilities that had been
destroyed by the war, providing qualified human resources and the supply of drugs, and
to also create a ”common basket’ of funds (World-Bank, 1995).
This above program, including the previously mentioned donor coordination and other
institutional arrangements, e.g. about technical assistance were among the ‘building
blocks’ of a policy oriented to the SWAp2 (TAG et al., 1998, p. 1). At the end of the
1990’s the SWAp, was adopted in various sectors, e.g. Agriculture and Health, to
2
Sector Wide Approach policy (SWAp) is a sustained partnership led by national authorities, involving
different government institutions, groups in civil society, and one or more donor agencies. It includes an
appropriate institutional structure and process for negotiating strategic and management issues. It
accompanies institutional reforms and capacity building, relies on a collaborative program of work focused
on sectoral and multi-sectoral policies and strategies, medium-term plans, agreed common arrangements on
the areas of planning, financing and monitoring. Definition adapted from the booklet “Sector Policy
Review Tool”, Royal Tropical Institute (KIT), Amsterdam, The Netherlands, 2004, Part Two, Figure 1, p.
23
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Piotti, Chilundo and Sahay
stimulate the Government to allow the Ministry of Planning and Finance to play an
increased and lead role in taking and coordinating local action with other Ministries and
the donor community. This adoption was also expected to speed up public administration
reforms related to management, planning and financing. Currently, through a large pool
of donors (23 bilateral and 23 multilateral), Mozambique continues to receive more than
half a billion each year in development assistance representing about
69% of the
country’s GNI 3 (OECD) and half of the Government health budget. This makes the
Government of Mozambique as the recipient of the highest per capita Official
Development Assistance (ODA) in Africa (Aid-Harmonization-Alignment, 2004).
In 1999, MISAU signed a formal agreement (called Code of Conduct) with the main
representatives of the donor community (2000) that defined the development of new
institutional arrangements and shared objectives and targets to be achieved. There are
basically two key instruments of policy discussion and definition, aid coordination and
support on technical and operational activities. The first relates to two large gatherings of
the national joint committee (CCS), chaired by the Minister and Vice-Minister of Health,
where policy issues are deliberated or adopted and where the participants (about 80 to100
people) are the same as in the GT-SWAP Forum plus one Director of Provincial
Directorate (in rotation), other Ministry officers and NGO representatives. The second is
the above mentioned working group (GT-SWAP Forum) that meets regularly every 15
days and usually has a large representation (up to 30-50 people) including top managers
from MISAU (Minister, Vice Minister or Permanent Secretary, National Directors),
program managers, bilateral donors, and representatives from credit agencies and UN
Agencies such as WHO, UNICEF and UNFPA. This forum prepares the two annual CCS
and creates ad hoc small technical groups to assist the joint elaboration of technical
understandings, position papers and documents. One of these sub-groups was the TWGM&E set up to try and help rationalize the existing “common baskets” into one single
fund and the elaboration of the first common, strategic plan for the health sector (called
PESS). For the elaboration of the PESS document, MISAU organized over one year
3
Gross National Income (GNI) is the sum of value added by all resident producers in the economy plus any
product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income
from abroad. Extracted from Definitions, p. 271, HDR 2004, UNDP.
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Piotti, Chilundo and Sahay
(2000), several thematic working groups, comprising of Maputo based health
professionals, health and academic institutions, and the donor community. In some cases,
provincial level health staff and civil society representatives were also involved. The
PESS document approved in April 2001 (MISAU, 2001) served as a reference for
implementing the following SWAp goals:
1. A better management of services and an integrated planning process throughout the
different departments and levels of health care delivery,
2. Increasing the volume of grants and loans channeled through mechanisms of common
funds and Government budget transfer (in-budget), with a parallel reduction of the
earmarked and vertical funding.
3. More efficient accounting and increased transparency of financial management at
every level of health services,
4. The establishment of an integrated monitoring and evaluation system for assessing
results of plans and performance.
The major components of a sound SWAp process implies agreements between partners in
the health sector resting on three pillars (MISAU et al., 2002a, p. 1), as follows:
Table 2 Three major components of SWAp process
⇒
1. Agreed Sectoral Objectives
⇓
2. Agreed medium Term plans
based on medium term
expenditure framework
⇓
3. Agreed annual plans based
on funds available
⇓
SWAP
⇐
4. Agreed performance
5.
Agreed common financial
monitoring tools with annual
and accounting systems and
review
procedures.
Source: Report of First Joint Mission to evaluate the performance of the Mozambique Health Sector in
2001, p. 1, MISAU, September 2002.
Unfortunately, the final PESS document did not include quantified objectives and
relevant indicators. In March 2001 the technical working group (TWG-M&E) was
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Piotti, Chilundo and Sahay
created by the GT-SWAP Forum, including nine people: representatives of MISAU,
bilateral donors and UN agencies. This group’s mandate was to establish a commonly
agreed frame for periodic assessments of PESS implementation. The first draft of the list
was based on the health systems’ assessment indicators of the SADC4, Monitoring and
Evaluation Committee (1999) combined with performance assessment indicators
proposed by WHO in Geneva. From April to June 2001, the first draft was discussed with
respect to the relevance and value of specific indicators with all departments of MISAU
and identified adjustments, inclusions or cancellations were carried out. A large
workshop concluded this first consultative phase, where indicators were selected and
grouped in three categories (see Table 3 below).
Table 3 Conceptual Frame of the National List of PESS Indicators (approved in November 2001,
Maputo, MZ)
Key Issues PESS
Functions of the System
General and Impact
Access, equity and gender
Direction
Macro-economic
Quality of services and
priority programs
Financing
Absolute poverty
alleviation
Advocacy and individual and
collective strengthening
Resource allocation and
management
Population’s health status
Financing Strategy
Service provision
Institutional Development
Indicator selection and definition represented a long and complex process. The list was
expected to force different departments to monitor their performance with minimum data
in line with the program measurement objectives outlined in the PESS document. A
manager of the malaria program said: “how can you dare reduce the entire malaria
program assessment to a single indicator?”. The total number of indicators was
4
SADC stands for Southern African Development Community and was created in April 1980, following
the adoption of Lusaka (Zambia) Declaration: Towards Economic Liberation. Since August 1992
(Windhoek, Namibia) a Treaty signed by Heads of following States: Angola, Botswana, the democratic
Republic of Congo, Lesotho, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, United
Republic of Tanzania, Zambia and Zimbabwe commits the respective governments to act for a common
and regional development, well-being and improvement of standards of living and quality of life.
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Piotti, Chilundo and Sahay
continuously oscillating: from the initial number of 38 groups in April, to 45 in June, 60
in October and then back to 53 in November 2001.
These variations reflected an
intensive negotiation process between the TWG-M&E members, who tried at the same
time to reduce and simplify the list while covering all the main priorities and activities.
During the first workshop, consensus on the first draft was not reached, which led to the
opening of a second phase in order to verify every indicator proposed in the national list
against the most commonly used ones by the different programs and to then select again
the list. The formal list was approved by the CCS in November 2001.
At times the process seamed endless. Donors wanted clear dates for the approved list, as
it had to be used as a reference for disbursing funds. In November 2001 at the CCS, the
first official version of the list was approved, containing 53 groups of indicators
(equivalent to 95 single indicators), 44 to be collected annually and the remaining 9 every
2-5 years. Out of the total, 19 represented a ‘short list’ that included all core indicators
covering three subcategories: ‘macro-economic’, ‘absolute poverty alleviation’ and
‘population’s health status’. This conceptual frame is still unchanged until today.
After the approval, in December 2001, a detailed plan for data collection and inventory of
sources was prepared to implement the indicators. Before the first joint annual appraisal
(ACA-I) of the NHS performance carried out in July 2002, two officers, based at
MISAU-DPC, tried to gather data for the calculation of the indicators. In June after two
months of intensive work, only 50% of the total indicators (e.g. 26 groups) were
delivered to the evaluation team (MISAU-DIS, 2002). The main obstacles encountered
during the data collection and aggregation are reported as under:
•
Delay in the data submission from the Provincial Directorates.
•
Great difficulty to convey financial data from multiple sources into consolidated
and aggregated figures. Government budget was released by the Ministry of
Planning and Finance. Donor funds were channeled directly to MISAUheadquarters; and other common funds were in separate foreign accounts, e.g.
funds for drugs and for provincial support. This multiplicity of funding and
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Piotti, Chilundo and Sahay
banking arrangements contributed to various data flows and consequently
inefficient financial management overall.
•
There were delays and discrepancies between data received from parallel flows of
vertical programs and the data provided by provinces to the Department of Health
Information Systems (DIS).
•
Some data on quality of services was incomplete or not available despite this issue
being high priority for MISAU and among those earmarked for evaluation under
ACA-I.
•
As expected, the surveys used as sources for some of the impact indicators
identified (Table 3) were backdated, and figures available were only calculated
projections.
The final ACA-I report analysed in detail the list (MISAU et al., 2002b, p. 7-40) and
suggested significant changes to the LNM. The evaluation team suggested that the 53
indicators should be reviewed and reduced in number. In October 2002, after the ACA-I
Final Report publication, the GT-SWAP Forum instructed the TWG-M&E to perform the
revision of the LNM, through focusing consultations with several Departments, especially
with the Finance Directorate (DAG) at the HQ level. The DIS extended this revision to
the provincial officers of planning and cooperation by organizing a national workshop
(Namaacha-11-13 December 2002). The ‘short list’ of 19 indicators was discontinued,
and the total number reduced then to 36 groups, subdivided as before in three tables and
according to the same conceptual frame. Out of the total, 7 were to be collected every 2-5
years, 24 annually and 5 quarterly in order to monitor the execution of the operational
annual plan (POA 2003). The third version of the LNM was approved by the GT-SWAP
Forum and confirmed by the CCS in June 2003 and remains unchanged until today,
except for the addition in April 2005 of a few essential and internationally agreed
indicators on HIV/AIDS.
Given the difficulty in producing complete and timely indicators, this consultative
process can be considered very rich in terms of lessons learnt and crucial for triggering
further action towards the development of an improved Health Management Information
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Piotti, Chilundo and Sahay
System (HMIS). The point of view of many actors involved in this process of selection
can be considered as “minimalist,” implying a focus on identifying the minimum number
of most relevant issues. For instance, as a representative of donors said during a GTSWAP Forum meeting “the list of indicators should not be so complicated, it can be
reduced to 10-15 key ones to help assess the overall performance of MISAU and NHS, in
order to help the donors to decide whether or not to disburse the funds”. However, the
value of the LNM is not only limited to the donors. The LNM empowers Mozambican
managers to control their own monitoring, for example they have established when and
how to measure the quality aspects of programme such as emergency obstetric services,
TB, STI, AIDS treatment, with the their own definition of datasets and formulas.
Establishing periodic mechanisms for monitoring and evaluation contributes to the
building up of a sense of ownership on national instruments of negotiation between the
Mozambican government and their aid partners. The indicators calculated in the first year
represented useful ‘benchmarks’ to make the health sector more accountable towards the
Government and the donor community. These baseline indicators can be used for future
adjustments of the strategic development process. The long process of selection helped to
change the perspective in many health initiatives. SWAp and PESS strategies urged
complex programmes as the fight against HIV/AIDS, and administrative processes such
as ‘financing strategy’ or ‘better planning cycle’ to enhance the coordination of activities
and resources among different departments, aiming to achieve better results on equity and
efficiency. This enhanced coordinated action and the need to measure new indicators
demanded more coordination in every step of the information cycle (collection, flow, new
aggregation formats and analysis of data), challenging the historically existing
departmental borders and the barriers that hamper this cycle.
4.2 The case of integration of program specific information systems
As stated in the previous subsection, healthcare services in low income countries like
Mozambique are usually provided in collaboration between national authorities, foreign
aid agencies and NGOs. Mandatory requirements to demonstrate funding accountability
and short-term results have led donors to promote vertical (donor-driven) programs
operating, such as those centered on specific diseases (e.g. malaria, HIV/AIDS) or health
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Piotti, Chilundo and Sahay
problems (e.g. reproductive health) (Oliveira-Cruz et al., 2003). Such vertical programs,
which tend to oppose an integrated approach to health care delivery, have been reported
to contribute to a state of fragmentation and redundancy, and associated problems
(Hutton, 2002, Cassels and Janovsky, 1998).
The recognition of such problems has in recent years led national governments and some
aid organizations to try to promote broader health system development initiatives (e.g.
SWAp) so as to integrate specific vertical programs into routine health care delivery.
However, achieving this integration in practice is a complex undertaking (Oliveira-Cruz
et al., 2003), characterized by tensions between the ‘system designers’ (management and
planning specialists), who promote the overall operation of the health sector, and the
specific program managers, who are concerned with particular disease control strategies.
The situation is made more complex with a single vertical program being supported by
several bilateral and multilateral agencies, and comprised of a multiplicity of components,
including their information systems.
The analytical focus of this case is on the vertical program STI/HIV/AIDS 5 and the
ongoing dilemma of integrating existing reporting systems, both paper and ICT based,
within a broader framework of vertical program delivery. In Mozambique, the efforts of
national STI/HIV/AIDS program has centered on informing individuals and institutions
of a range of preventive measures and to improve care to infected people by enhancing
the availability and accessibility of anti-retroviral drugs, especially within the Prevention
of Mother-to-Child Transmission (PMTCT) component. Accessibility of drugs
significantly influence the politics of funding and contribute to debates over the rates of
growth of the disease (Barnett and Whiteside, 2002). In Mozambique, a number of
initiatives are currently ongoing such as the Global Fund for HIV, Malaria and TB; Bush
initiative, Clinton’s foundation, as well as through NGOs, government, NORAD
(Norwegian Agency of International Development) , the Center of Diseases Control,
Atlanta, PSI (Population Services International), DANIDA (Danish International
5
STI/HIV/AIDS – stands for Sexually Transmitted Infections/Human Immunodeficiency Virus/Acquired
Immuno-Deficiency Syndrome
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Piotti, Chilundo and Sahay
Development Agency), the WHO, UNDP, UNAIDS (the joint United Nations Programs
on HIV/AIDS) and USAID (United States Agency for International Development) to
name a few. Aiming to avoid the duplication of efforts and minimize fragmentation, all
the stakeholders have recently agreed on a platform called Three Ones Commitment
(DFID Health Systems Resource Centre, 2005).
The Three Ones Commitment include: (1) one agreed HIV/AIDS Action Framework that
provides the basis for coordinating the work of all partners; (2) one national AIDS
coordinating authority, with a broad based multi-sectoral mandate; and (3) one agreed
country level Monitoring and Evaluation system, including one integrated information
system for the program as a whole.
The need for integration of the disparate information systems was described by a Ministry
of Health official as follows:
Integration is one of the greatest preoccupation in the Ministry of
Health…Strategic creation of one single database seems desirable. We feel that
the introduction of SIS.D6 is the solution. All subsystems or components not
included in SIS.D can be designed and incorporated in this application as
Modules. For example the system for STI/HIV/AIDS…” Said the head of the
Department of Information for Health, October 2004.
Integration is also being planned through various other mechanisms, such as:
(a) To have a standardized collection system in place also in the provincial, regional
and central hospitals, as well as in the private sector by 2006;
(b) To have established electronic communication (e-mail and internet) and
reinforced ICT at the district and provincial directorates of health, including a web
page, LAN-WAN and intranet at the Ministry of Health headquarters;
(c) To allow for a thorough and progressive integration of all systems related to
resources (funds, staff, maintenance, etc.) and health care (volume of activities in
healthcare facilities).
6
SIS.D is a Portuguese acronym of Sistema de Informação de Saúde Distrital meaning “District Health
Information System”.
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Piotti, Chilundo and Sahay
Within this broader quest for integration, we describe the current context of the HIV
program with a focus on their information systems. A national strategic plan to fight
STI/HIV/AIDS-health sector 2004 to 2009 was recently launched (MISAU, 2003) which
establishes nationally 15 different components as well as 9 supporting services. Some key
components included in this are (i) promotion and distribution of condoms; (ii) diagnosis
and treatment of STI; (iii) Information, Education and Communication (IEC); (iv)
Voluntary, Counseling and Testing services (VCT); (v) Prevention of Mother-to-Child
Transmission (PMTCT); (vi) Treatment of Opportunistic Infections (OI) (including
tuberculosis); (vii) Control of Diarrheas (CD); (viii) Anti-Retroviral therapy (ART) and
(ix) Safe blood transfusions. Each of these components usually has its own coordinating
team which may be located in different departments in the directorates at the provincial
and national levels. For example: while the PMTCT is coordinated in the Community
Health Department, the ART and VCT components are coordinated by the Department of
Communicable Diseases and the component of Safe blood transfusions is by the Medical
Assistance Department. The overall coordination of these components is done by a
Technical Group of HIV/AIDS Monitoring and Evaluation, which meets every week.
This Technical Group is comprised by at least one key member of each component as
well as planners from the National Directorate of Planning and Cooperation of MISAU
and other funding agencies.
Monitoring &
Evaluation Group
National Directorate
of Health
Dissemination
twice a year
monthly
Provincial Department of
Planning and Cooperation
FEEDBACK
Component Managers Departments
of Community Health and Medical
Assistance/ Provincial Hospital
Production
of Reports
Program
Management
Partners
Data
Bank
Production of Reports
Program Management
National Directorate
of Planning &
Cooperation
monthly
monthly
District Directorate of
Health
Statistics Group
monthly
Health Area
Hospital
PMTCT, STI, TB, HAART,
OI, Laboratory, Bio-safety,
Safe Transfusion, Mental
Health
He alth C e nte r
PMTCT, STI,
TB, HAART,
OI
HBC, VCT,
YFHS
Note: NGOs report to the Hospital level and the Health Center level
Figure 3 - the ambitious routine "integrated" information system for ITS/HIV/AIDS
Source: MISAU-DPC (2004)
Figure 3 the ambitious routine “integrated” information system for ITS/HIV/AIDS
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Piotti, Chilundo and Sahay
In order to monitor and evaluate all these components, one plan has also been established
based on an ambitious “integrated” information system (MISAU DPC, 2004), as depicted
in Figure 3 above.
Notwithstanding its objectives of integration, the implementation of this model has
resulted in multiple compartmentalized information systems, representing “islands” with
an independent decision-making structure, an internal reporting system, resource and
information sharing (Figure 4). How this fragmentation works in practice is depicted
through Figure 4 below, and then the key characteristics are described.
National STI/HIV/AIDS
National Department of
National Blood
National Department of
Control Program
Communicable Diseases
Transfusion Programme
Health Information
Data computerized
Analysis, use
Province
Aggregation in
province hospital
Data computerized
Aggregation
Healt h
Facility
Aggregation in
district hospital
Monthly Reporting
District
Data collection
and collation
Data collection
and computerized?
Antenatal clinic
VCT Center
Infected Pregnant
women (PMTCT)
(1)
Data computerized
and used
Volunteers
(2)
Data comput erized
and used
Aggregation in
province hospital
Quarterly Reporting
Dat a computerized
and used
Monthly Reporting
National
Aggregation in
district hospital
Data collection
and collation
Blood Bank
(Safe transfusion)
Blood donors
(3)
Monthly Reporting
National Department of
Community Health
(PMTCT headquarters)
Data in paper
format, aggregated,
validated
Data
aggregation
Data analyzed
and used
Data
computerized
and validated
Data
aggregation
Data collection
AIDS cases,
STI, ART, OI
STI/HIV/AIDS
Patients
(4)
Figure 4: The "unruly mélange" of the existing information systems for STI/HIV/AIDS program in Mozambique
Source: Adapted from Chilundo and Aanestad (2004)
Figure 4 The "unruly mélange" of the existing information systems for STI/HIV/AIDS in
Mozambique
There are at least four parallel flows of data originating from Antenatal clinics (PMTCT),
VCTs, Blood Banks and inpatients in hospitals. Some key characteristics of the
information flows are described below:
(1) Data from PMTCT activities originating from health centers are sent on a monthly
basis upwards to the rural hospitals, then provincial hospitals and later on to the
PMTCT office in MISAU headquarters. This flow implies that data are shared
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Piotti, Chilundo and Sahay
minimally between the district and provincial managers. Planners at the National
Directorate of Planning can only access the data by requesting the PMTCT
component, located in the Community Health Department (part of the National
Directorate of Health).
(2) Routine system for reporting data from VCT centers is on a monthly basis. It is
operated directly by HIV/AIDS program together with NGOs.
(3) The routine system for reporting blood banks’ data is on a quarterly basis. HIV tests
of blood donors are reported by the blood bank channel at all levels with transfusion
facilities as part of the National Program of Blood Transfusion.
(4) Routine system for reporting on inpatients with AIDS is the responsibility of the
Department of Communicable Diseases operated together with the HIV/AIDS
program. The channel reports monthly data from infirmaries, both clinical AIDS
based on Bangui criteria and laboratory confirmed HIV cases. There is also another
“parallel” system that also reports AIDS cases as part of the district hospital reporting
system. As a result there is duplication of efforts in addition to important underreporting as reports are only sent from district hospitals while the majority of AIDS
patients are seen in the provincial and central hospitals. More recently another
subsystem has been established to report the number of HIV patients under ART and
those treated for opportunistic infections (OI) at the Day Hospitals. Finally, a routine
subsystem for reporting STI also exists. These data are mainly captured on adults and
Mother and Child consultations, and sent upwards on a monthly basis to the National
Department of Communicable Diseases.
The information system is thus comprised of several parallel and overlapping information
flows, which inhibits integrated analysis, and places a high burden of uncoordinated
components of the STI/HIV/AIDS program. This picture is aggravated by the historical
lack of horizontal data analysis at the facility, district and provincial levels. Also, the
overemphasis on data aggregation and reporting to the national levels masks the picture at
the disaggregated levels and inhibits focused intervention. The sheer inadequacy of the
human capacity both with respect to numbers and also quality, serves as a major
bottleneck at all levels of the health administration structure.
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Piotti, Chilundo and Sahay
5. Analysis and discussion
How we can understand the complexity and the interdependence surrounding the
organization of health sector institutions in Mozambique during the phase of
administrative and health reforms and external aid rationalization?
The two case studies presented in this paper try to respond to this question showing the
patterns of the change at different levels and the opportunities that these changes open to
the development of more effective health information system and the introduction of ICT.
In this section, we analyze both cases with respect to the following three questions:
What is the nature of the complexity that surrounds the relationship between the reform
effort and the organizational change?
What is the kind of organizational change that can be discerned with respect to
anticipated or emergent changes?
What implications can be drawn to make more effective the management of these change
processes?
5.1 What kind of complexity?
Complexity arises as a result of the interdependencies that exist within components of a
system and also on the kind of linkages that exist.
Hanseth et al (2005) describe
complexity relating to an Electronic Patient Record (EPR) system in the following
manner drawing upon Cillier’s (1998):
A complex system is made up of a large number of elements interacting in a
dynamic and non-linear fashion, forming loops and recurrent patterns which
involve both positive and negative feedback; it is open in the sense that it is
difficult to define the borders between it and other systems; it has “history”: its
past is co-responsible for its present as well as its future; and each element is
ignorant of the system as a whole, responding only to information available
locally. This broad definition will underlie our conceptualization of the systemic
nature of the EPR throughout the paper (p. 6).
Complexity is this thus shaped by the number and types of components, their inter
linkages, and the speed of change that influences these links. The notion of history is
important to understanding complexity as it shapes processes of path dependence, which
is described as a key facet of complexity (Urry, 2003). The notion of formal and informal
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Piotti, Chilundo and Sahay
institutions and the degree of their overlap helps us to further unpack the complexity in
the change processes studied.
5.5.1 Complexity in the process of design and selection of indicators
The indicators are basically the tools we use to convert day-to-day observations (e.g.
cases of the diseases, resources usage, services coverage, etc. as related to the size of
target population at risk of the event) into useful information for decision-making by
enabling comparison between different facilities or regions or countries. The value of a
health indicator relies upon the quality of the data used to calculate it (both the
observations and reliability of the population target in the community), the relevance of
the events that it intends to measure and their interpretations by health workers or
managers in the service of particular interests, purposes and population.
Indicators for the health sector have historically existed for decades in developing
countries (WHO, 1996) originating from the experiences and traditions of technical,
vertical programs and interventions. However, contemporary selection of health
indicators introduces a range of further challenges because the number of
‘global’
indicators is rapidly growing as M&E of programs and results oriented assessment
become more fashionable among credit agencies such as the World Bank and UN
agencies (including UNDP, UNICEF, UNFPA and others) (PARC, 2004) (UNDP, 2001).
This complexity is aggravated by the presence of multiple donors in Mozambique often
with heterogeneous agendas and priorities among them.
At each phase in the history of Mozambique, multiple donors have participated and
contributed to defining different modes and degree of coordination, and to the
harmonization of policies between the Government and aid partners. Due to the
heightened development assistance, the experience in experience in Mozambique has
shown that at each phase, for example ‘projects’, ‘zoning’, ‘common baskets’ and SWAp
- the modus operandi of donors have significantly influence the management and
financing of MISAU. These impacts are not limited to internal planning and management
in MISAU, but also to enhancing the heterogeneity in the donor efforts. The numerous
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Piotti, Chilundo and Sahay
office representations of bilateral and multilateral donors are still divided by the degree of
adherence and acceptance of SWAp. For example, the group of ‘pioneers’ such as the
Scandinavian countries and the Netherlands are keen to operate all interventions through
a single common fund, while other bilateral donors such as France and Italy prefer a dual
approach, while others such as USAID continues purely bilateral and promoting vertical
interventions. Also among credit agencies such as the World Bank and UN agencies,
there are significant differences in their adherence to the SWAp principles. The long and
sometimes difficult discussion for the selection of indicators reveals a power sharing
negotiation occurring within MISAU.
As a consequence, data collection and variables do not have an independent, internal
rationality, they rather reflect the vested interests of the multiple actors who have in
common the ‘stage’ of national list production, but continue to reflect their own
managerial habits, technical backgrounds and departmental influences. The negotiation
for the list among MISAU officers has shown that managers of predominant technical
programs tend to perpetuate their traditional functions of central organizers of service
delivery, advocating more indicators because this better protects their variety of technical
competence and prerogatives. On the other side, managers of supportive services,
financing and planning departments prefer fewer indicators more suited to measure the
cross-cutting functions and corporate coverage rates and outcomes. Despite the different
“agendas” of the multiple actors involved, a negotiation tool helped to diffuse some of
these differences by facilitating formal and informal negotiation among actors. The initial
formal commitments of all stakeholders determined to change their relationship under
SWAp was a driving force, but official documents did not provide enough power to
overtake preexisting norms, for example, such as existing multiple vertical program
indicators. While PESS strategies can be respected and observed formally, they are not
enough to deal with the internalized acceptance of authoritarian management styles, that
assign ‘directors’ with the prerogative of always being “right.”. The divergent and at
times contradictory donor vested interests coupled with the mélange of formal and
informal norms of Mozambican staff and donor representatives, required a forum and
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Piotti, Chilundo and Sahay
space for negotiation. While the SWAp process formally enabled this, informal
communication processed helped to solidify them and make it more effective.
5.1.2 The complexities of information systems’ integration
Typically, in the national health system, information systems are designed and
implemented to build health indicators. The calculation and presentation of indicators at
the national level is fundamentally dependent on what data is fed to it from the various
preceding levels including the province, districts and health facilities. The delay and
difficulty in receiving timely data and the positive contribution of provincial health staff
in the selection process reiterates the importance of considering the concrete capacity of
the health information system to channel data as the crucial reference and background of
any proposed monitoring system.
The ultimate end of establishing health information systems is specifically to collect
essential data at the facility and community levels to calculate the indicators which allows
the measurement of the performance of various programs. The baseline is thus the
community and the health facility levels where all health related events occur. The
‘bridges’ are the districts and provincial levels which are intermediaries between the
headquarters of MISAU and health workers on the ground. In the community and health
facilities, activity data are collected about special programs, routine services, and
epidemiological events in addition to semi-permanent data (i.e. data that change more
slowly) which comprise population, and administrative data. Activity data form the
numerator and population figures the denominator in the calculation of indicators.
For the health program in question in this study (STI/HIV/AIDS), the selected key
indicators (e.g. HIV prevalence rates among pregnant women, percentage of domiciliary
patients under ART, treatment dropout rates, mortality rates, etc) are presently
constructed through varying work practices surrounding the processes of data collection,
analysis (including the calculation of indicators) and their transmission to higher levels.
These processes are shaped by the social, political, economical and ethical context. Some
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Piotti, Chilundo and Sahay
examples are now provided. For example, these work practices are performed by health
workers who have the primary task of attending and treating patients. Due to the huge
shortage of staff (Economic Commission for Africa, 2003), the work burden on the
personnel is extremely high. The daily work is primarily patient focused, and the
registration and reporting is perceived as secondary tasks. The primacy given to patient
encounters adversely influences the data collecting procedures. For example, often
registering data on the number of patients seen or of condoms or drugs distributed are
through mere approximations at the end of the day after the patients have been seen
(Mosse and Sahay, 2003). The limited value attached to registering and reporting work is
reinforced by the widespread attitude that data is being registered, reported and collected
mainly for reasons of bureaucracy and not to support local action. The data collecting
activities thus become an institutionalized routine that must be performed as a part of the
job (Chilundo and Aanestad, 2004).
The divide between care and administration
becomes greater by the rapid increase of HIV/AIDS cases. In 2000 Mozambique had the
prevalence rate among adults (15 to 49 years of age) of 13.0% (INE et al., 2002) and in
2002 (INE et al., 2004) was 13.6%, which means more HIV/AIDS clients are
overwhelming the few health workers. This is then further taking away their attention
from performing the routine administrative tasks which in themselves are also increasing
as the data needs are becoming more extensive and sophisticated.
Because HIV/AIDS is a relatively a new phenomenon, the health network is being
adapted to increasingly respond to the new and increasing demands on both the clinical
and administrative fronts. The response has come through various reform efforts whereby
the STI/HIV/AIDS programs have established a number of services in terms of
components (15) which encompasses all the 98 mandatory indicators to be routinely
calculated, implying the introduction of a range of new data collection tools that must be
filled in by the already overburdened and inadequately trained health staff. At every
administrative level through which the data flows (from the health facility to the district
and to the provincial and national levels) there are complex and heterogeneous networks
in operation comprised of people, artifacts, values, work practices contingencies and
politics which shape the representation of what data gets captured and reported. For
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Piotti, Chilundo and Sahay
example, Chilundo et al. (2004a) report how at the national level, the managers of the
blood transfusion program add a 40% correction factor to the reported figures to
compensate the district underreporting.
In trying to situate the picture of the STI/HIV/AIDS program’s information systems
within the whole national health system, the influence of the complex historical context,
or what Avgerou (2002) calls as “organizing regime” can be interpreted. The existence of
multiple and uncoordinated information systems within the STI/HIV/AIDS program are
not an isolated situation within the Mozambican NHS but a historical reality. Another
study conducted by Chilundo et al. (2004) also reported that malaria data are being
reported through four different and compartmentalized channels that prevent the
construction of an overall picture of the disease prevalence in the country, with
significant adverse implications of the interventions targeted to fight this disease.
Largely unmindful or insensitive to this historical fragmentation and the reality of the
local work practices that surround the information systems, the health reformers (MISAU
officials and donor agencies) continue to make rather ambitious plans for the integration
of the information systems. The formal, technical and rather top down approach to this
reform effort represents a radical divorce from the informal practices that exist on the
ground. While the efforts to try and harmonize at the top through efforts like developing
national level indicators is a welcome step in the right direction, these are extremely
complex to implement on the ground because of this divorce. This implementation
requires political negotiations between the multiple donors, reformers, planners and
managers, to make explicit the various rationalities and tensions in play and to also try
and arrive on a consensus in where efforts need to be best directed, for example to build
up the information handling capacities of the health staff and to ease some of their work
pressures. Often the donors’ main interests are to ensure that the financial support being
given is well utilized and has a desirable impact which they seek to control through
budgetary mechanisms (Chilundo and Aanestad, 2004). Administrative aims of
controlling corruption and improving efficiencies often contribute to the promotion of
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Piotti, Chilundo and Sahay
individualized information systems rather than integrated and comprehensive ones best
suited to managing the disease.
INPUT 1
FORMAL RULES
CODE OF CONDUCT
STRATEGIC FRAMEWORK OF THE
HEALTH SECTOR (PESS)
GT-SWAP
SET OF VERTICAL PROGRAM'S INDICATORS
SECTORAL COORDINATION
COMMITTEE (CCS)
STRATEGIC PLAN OF HIV/AIDS
MULTIPLICITY OF INDICATORS' DEFINITIONS
INPUT 2
INFORMAL RULES
FORMAL & INFORMAL RULES
OUTPUT 1+2
NATIONAL LIST OF
MONITORING
MONITORING AND EVALUATION
OF HIV/AIDS
TWG-M&A
WORKSHOP & MEETING
INFORMAL NEGOTIATIONS
AUTHORITARIAN STYLE OF
MANAGEMENT
INFORMAL MEETINGS
DONORS' OWN AGENDA
CULTURAL DIVERSITY
TIME
Figure 5 - The overlap of formal and informal rules in the process of indicators' selection
Figure 5 The overlap of formal and informal rules in the process of indicators' selection
Figure 5 schematically depicts the selection of indicators as a process lasting over several
months. At the beginning, a series of official documents and commitments endorsed by
all stakeholders (formal rules) pushed towards a speedy production of a national list,
which was simultaneously challenged by the pre-existing set of indicators of the vertical
programs. The process was enabled by various multiple institutional arrangements like
the parallel structures and also the informal negotiations, and also inhibited by the
authoritarian style of management. These together produced an overlapping area of the
formal and informal institutional and negotiations arrangements that contributed to the
final approval and use of the LNM.
Figure 6 depicts a set of formal rules with respect to the information systems integration
case. This includes the monitoring and evaluation plan for HIV/AIDS, a management
information system design strategy for integration, and a set of information tools. These
formal rules and plans largely failed to take into account during the implementation, the
influences of various informal rules and norms historically existing due to conditions of
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Piotti, Chilundo and Sahay
donor influences, departmental ownership, individualized set of information tools and a
weak culture around data use and it s analysis. This resulted in a great divergence
between the formal and informal, and this lack of overlap, we argue, contributed to the
ineffective results in integrating the HIV/AIDS reporting systems. How this institutional
mismatch will be reduced in the future still remains an open and unsolved question.
However, the indicator selection process provides us with some insights to approach this
problem which we discuss in the final section on implications.
INPUT 1
OUTPUT 1
ONE MONITORING &
EVALUATION PLAN FOR HIV/AIDS
ONE INTEGRATED MANAGEMENT
INFORMATION SYSTEM DESIGN
STRATEGY
ONE SET OF INFORMATION TOOLS
SET OF PROCEDURES DEFINED
FORMAL RULES
INTEGRATED PLANNING
COMPROMISED
HARD TO CALCULATE
INDICATORS IN A
COMPREHENSIVE MANNER
COMPARTMENTALIZED
DECISIONS
OUTPUT 2
INPUT 2
DONOR DRIVEN INFLUENCE
DEPARTMENTAL OWNERSHIP
INDIVIDUALIZED SET OF
INFORMATION TOOLS
COMPARTMENTALIZED
COMPUTERIZATION EFFORTS
POOR HABIT OF DATA ANALYSIS
INFORMAL RULES
??
MULTIPLICITY
OF
REPORTING
SYSTEMS
HARD TO SHARE DATA
DUPLICATION OF EFFORTS
STAFF OVERWORK
DIVERSITY OF COLLATION TOOLS
POOR DATA QUALITY
TIME
Figure 6 - The lack of overlap between the formal and informal rules in the implementation
of information systems of the various components of the HIV/AIDS program
Figure 6 The lack of overlap between the formal and informal rules in the implementation of
information systems of the various components of the HIV/AIDS program
5.2 What is the nature of change?
Health sector reform is an ongoing process of reorganizing the public sector
administration by challenging the institutional bureaucracies in MISAU, challenging its
duties distribution, power balances and formal rules through the complex matter of
selecting health indicators. Change, both planned and emergent, guide these ongoing
processes of reform.
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Piotti, Chilundo and Sahay
The indicator definition case is guided by the SWAp framework which is pushing for
“planned change” calling upon new and formally agreed methods of performance
assessments which are expected to feed back into new forms of planning and financing.
As the relationships between the different stakeholders becomes more mature and
develops into a national and transparent agenda based on single channel of external funds
and regulated by common agreements on volume and duration, increasingly the
institutional rules tend to unravel themselves requiring transparency, measurable by
criteria of performance and accountability. New institutional enforcement mechanisms
and organizational forms of M&E (such as regular meetings, bi-annual seminars,
technical working groups, joint evaluations) help to implement the planned changes and
transform the old ways of managing resources and channeling funds among the different
departments of the MISAU at the central and provincial levels and subordinate health
institutions. The recent move of some donors, in Mozambique (called the ‘Group of 16’),
towards direct ‘budget support’ (direct disbursement of the external funds into the
Government budget) and increasing harmonization of donor initiatives (OECD, 2005) can
potentially further accelerate the transformation processes through formalization and
making more explicit the institutional rules such as through the definition of precise set of
measures defined uniformly on the basis of priorities, existing services and HIS capacity.
Nationally, incentives to implement these reforms is enhanced when the measurement of
health outcomes are in relation to a country’s own objectives and targets and not that of
the donors pushed unilaterally (Haines and Cassels, 2004, p. 395). Measuring the health
sector and the health outcomes of Mozambique through nationally established indicators
and mechanisms can better prepare the national actors in dealing with the international
rules.
The obstacles faced during the LNM exercise emphasize that parallel structures can be
created as part of the instrument of a steering committee to help plan changes in advance
and create the potential for opportunity-driven change. As argued by Illes and Sutherland
(2001, p. 54) they can overtake the inertia of large organizations, help to introduce
innovations. “In essence, parallel structures are a vehicle for learning how to change the
system, and then leading the change process” (Bushe and Shani, 1990).
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Piotti, Chilundo and Sahay
The consistent work of the TWG-M&E was extremely conducive for overtaking the
resistance of the vertical program managers, introducing an iterative process of short and
frequent meetings amongst them. These meetings allowed a more informal
communication in which technical issues could be debated without being trapped in
preconceived attitudes of acceptance or refusal of the change. The historical lack of
coordination, delay in submission and other obstacles to the satisfactory calculation of the
indicators in 2002, did not produce a collapse of the process. On the contrary, it produced
a positive streamline of the first version of the LNM, reducing it to a number of indicators
more adequate and manageable within the framework of the existing HIS. The official
role of accountability helped to enforce a process of continuous negotiation amongst the
Mozambican. This process contributed to improved quality of data and the revision of the
HIS through the upgrading of forms, procedures and coordination mechanisms. Emergent
changes help to diffuse the historically existing power struggles among departments
towards processes of compromise.
In the case of the integration of information systems for HIV/AIDS, we find an excessive
focus on top-down planned change based on a technical rationality that is divorce from
the local realities, and provides limited potential for emergent changes. For example,
while the plan presupposes data from all components to be integrated at district level by
an information officer, the emergent situation shows for instance VCT data being sent
directly to HIV/AIDS manager at the provincial and national levels, blood bank and
PMTCT data being sent upwards through immediate higher health facilities. Despite
SWAp’s agreed platform towards integration of the various vertical programs, as a way
to minimize the already significant degree of fragmentation, duplication and
inefficiencies, in practice these goals are far from being realized. The gap between the
formal plans to develop an integrated information system and the local reality is stark,
and the plans to not seriously take into consideration strategies to increase the overlap
between the formal and informal or how can this mismatch be reduced. This reflects that
managerial practices tend to be ‘reactive to events’ rather than forward looking in
anticipating needs.
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Piotti, Chilundo and Sahay
Table 4 helps to summarize the features of the planned versus emergent kind of changes
in the processes of indicators’ selection and implementation of information systems.
Table 4 Features of planned and emergent changes
Selection of indicators
Implementation of Health IS
Features of planned change
- One strategic
framework for the
health sector;
- Code of conduct;
- Terms of reference
for GT-SWAP form;
- WHO and SADC
indicators’ list
-
-
-
-
One strategic
framework for the
health sector;
One strategic
framework for
ITS/HIV/AIDS;
One list of essential
of indicators;
One information
system design
strategy
Revision of health
information tools
Features of emergent change
- Criticisms to the
preliminary list of
indicators from
Department and
Program managers;
- Resistance to a
corporate list from
Program managers;
- 2nd version of the list
streamlined and
consistent
Positive effects of
informal negotiations
-
-
-
Multiplicity of
reporting channels;
Heterogeneity of data
collection tools;
Unequal development
of computerized tool
among different
components;
Indicators hardly
calculated in a
comprehensive
manner
Increased
improvisation at
lower levels
5.3 What implications can be drawn?
At least three key implications can be drawn on how these reform processes can be
managed more effectively: increased participation; a cultivation approach; providing
space for flexibility and emergent changes.
Increased participation
The case of the indicator selection process emphasizes the positive contribution of
participation enforced through both formal and informal mechanisms. While the formal
mechanisms were provided through the framework of the SWAp, informal mechanisms
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Piotti, Chilundo and Sahay
were enabled through ongoing negotiations and discussions. An important feature of this
participatory process was the fact that it was broad-based, not restricted to particular
vertical programs, but including a whole set of stakeholders that aimed to create a
national level data set. Also important in this process was the fact that a good amount of
time was given to the process allowing development of a shared understanding and
facilitating the exchange of technical views among officials who are often busy and under
pressure. However, in the case of the integration, participation of staff from the subnational levels was negligible. The plan for integration was made top down and was
largely technical in orientation. For information systems to be effectively implemented, it
has been argued forcefully by various researchers, there is a need to understand local
work practices of the field workers who are involved in the ongoing processes of data
collection, analysis, use and transmission. The field staff was both geographically too far
and administratively too difficult to be included in this process.
Cultivation approach
Current research (for example, Aanestad 2002) in the domain of information
infrastructures has emphasized the importance of a cultivation approach in the design of
complex interconnected systems. The health information systems with its multiplicity of
levels, programs, and stakeholders can be conceptualized as such an infrastructure. Given
this interconnected nature, it becomes important not to be too ambitious and try to design
from scratch, but approach it in an incremental and evolutionary manner taking into
consideration history and what exists, i.e. an already installed national health information
system. The aim should be to try and cultivate in small steps, while making sure that what
is being changed does not radically influence the rest of the system. The indicator
selection process can be seen to reflect this cultivation strategy, where firstly by taking
the existing indicators as the starting point, the existing history was respected. Then
gradually through a process of negotiation, the list of indicators was iteratively modulated
and refined. In contrast, the integration case reflects the use of a construction approach
where there was the explicit assumption that an integrated system could be designed from
scratch not respect the power of the material, i.e. the installed base. However, the existing
situated rationalities arising from the work practices, donor influences, the particularity of
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Piotti, Chilundo and Sahay
the diseases reflected a strong installed base which could not be changed in a trivial
manner and demanded more respect.
Flexibility
Researchers like Aanestad, referred to earlier, have emphasized the need for flexibility in
the cultivation process. However, flexibility does not imply that “all things go,” but that
formal plans for standardization need to have inbuilt mechanisms for flexibility which
will allow actors to deal with situated contingencies and provide the space to improvise
and take advantage of opportunities as they arise. While both the indicator selection
process and information systems integration can be both seen as exercised in
standardization, the former can be seen to have greater amount of flexibility built into the
process. A starting point for this could be seen as the time given for this process which
allowed for a greater scope, for shared understandings to develop, and thus to enable
informal communication, something which is complex catch in more formal and
technical settings. The ongoing and regular meetings helped to iteratively discuss things,
and obtain consensus in a less threatening environment. However, the same cannot be
said of the integration case, where despite the formal mechanisms, and environment was
not enabled to provide for flexibility, and the space in which actors could leverage upon
the potential of opportunistic changes.
6. Concluding remarks
More effective management of health reform processes is a crying need for most low
income countries. This need becomes more urgent as the burden of diseases is rapidly
increasing, and resources to fight with these diseases more limited in relation to the
magnitude of the efforts required. However, strengthening these reform efforts is a nontrivial task given the complexity arising from the multiplicity of donors, the increasing
role of ICTs, high disease burdens, inadequate infrastructures, and institutions with
inadequate capacity and resources. We have argued in this paper that a starting point for
have more chance of succeeding in this task is to develop a deeper understanding of the
complexity that underlies the relation between reform and organizational change. To
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Piotti, Chilundo and Sahay
understand this complexity which is historically situated, and characterized by a
multiplicity of actors and interests, we have drawn upon an institutional perspective,
coupled with insights about ICT-mediated organizational change. By developing an
empirically grounded comparative analysis of two case studies from Mozambique we
have been able to theoretically and practically discern some of the things which work or
not. The implications of this analysis, we believe, are going beyond Mozambique, but
more broadly they can be considered for other low income countries involved in ongoing
processes of health reform.
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