The institution of procurement: A key constraint to health management information systems reform

Key institutions that define HIS management are those concerned with the procurement and managing of IT services, and the IT service providers themselves. The rules that govern procurement and the organization that administers these rules tend to be extremely rigid with little scope for innovation. One set of problems relates to the fact that most rules have been developed for procurements where specifications are clear and it is relatively easier to ascertain delivery and make payments. Procurement of services is more complex, but essentially the principles in use are similar to those in use for any commodity. The bid is broken up into a technical and a financial part—and only those who qualify on the technical bid are considered for the financial bid. It is expected that if the technical capacity required is clearly and competently stated, low quality, and non-serious bids can always be eliminated. These tenders place certain entry barriers—like having done similar work before or having a minimum company size and revenue, ostensibly to eliminate low quality bids. Often these thresholds are so high that all but two or three large companies get eliminated. In particular, low budget resourceful open source-based firms and NGOs get excluded even from participation in such tenders, even though they may provide good quality technical solutions.

Procurement gives great importance to process and a very strict and literal adherence to rules. Two completely contradictory factors work to shape this. One is the fear that officers involved in making decisions are accused of being corrupt. The second is that there are various firms who are willing to pay bribes to secure contracts. The process is so rule-dense that it is easy to hold up files for one reason or another and without un-billed payments the files just do not move at all. But also necessarily some rules have to be overridden and few will take the risk without a monetary consideration. This also works to the advantage of the corporate healthcare IT vendor and against the small scale

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Case Study 6.2 Institutional Influences on HMIS Reform Process in Tajikistan

This case study (Sahay et al. 2010) examines the key institutions that challenge the introduction of ICT-based HMIS reforms in the context of a postSoviet economy—Tajikistan.

Tajikistan is unique in many respects. It is a Central Asian country about which little, if anything, has been published in the mainstream information systems and development literature. Gaining independence after the downfall of the Soviet Union in 1991, Tajikistan experienced an extremely rocky period, with a prolonged civil war and the loss of the supporting Soviet financial and social infrastructure. The country experiences an extreme climate, has a long and porous border with the war-ravaged Afghanistan, and has suffered a food and energy crisis of huge proportions. It has also seen the exodus of many trained people due to weak employment and decreasing social opportunities at home. Tajikistan faces urgent public health problems. The demise of the Soviet economic base, followed by civil war, has led to a surge in various communicable diseases in the last two decades, and this coupled with poor nutrition and polluted water has contributed to a drop in life expectancy among the population.

Acknowledging the key role that ICTs can play in development and public health management, the Asian Development Bank established the Health Sector Reform Project in 2005, with the aim of creating various reform initiatives, including those relating to HMIS. The reform process has been ongoing over the last decade, and has involved various donors and consultants, each focusing on particular aspects of HMIS reform including the definition of indicators, the redesign of the paper-based systems, the selection of software, customization, and pilot testing. This process of reform has been long and arduous, primarily because of the challenges related to countering the policies of the existing institutions left behind by the Soviet legacy, which favoured a large manual system based on a centralized planning model.

In the initial study of the existing situation of the HMIS in 2007, two dominant institutional logics were identified. The first related to central control of the HMIS under the medical statistics division (MedStat), which saw HMIS as the tool for generating annual statistics for their different principals, including the Parliament, the President’s Office, and the donor community. The central control of the statistics wing was a legacy from the Soviet rule that mandated the collection of large amounts of data and sending to the national level for making prospective five-year plans. The concept of data collection for supporting local-level action or providing feedback to lower levels was largely absent.

The software used for generating these statistics was based on the out-ofdate FoxPro platform, where data was entered on 37 reporting forms and generated for different categories of organization units, mostly on an annual basis. The software was not capable of generating any indicators (such as percentages or rates per thousand that required calculation with a numerator and denominator). Neither was the software capable of generating graphs and charts, and only statistical tables could be created. To develop graphical outputs, the statistics generated were manually fed into a separate programme, where indicators were generated, and manually uploaded into a national website.

The other dominant institutional influences came from the primacy of paper-based systems. These paper systems tried to include, at an extraordinary level of detail, all kinds of data which were also products of the Soviet legacy. For example, a data element still being collected in the routine HMIS was ‘airplane vibrations heard’, obviously an obscure legacy of the war times. There was a multiplicity of programmes, some electronic and some based on paper, but none could electronically speak to any other, despite all being under the control of the National Statistics division (called MedStat). Below the level of the 37 forms that corresponded to the different health programmes (with a great deal of overlap and redundancies) were another 367 recording forms used at the primary health facilities to record the provision of basic services. The reporting forms were poorly designed and comprised multiple subforms. For example, the form titled ‘Treatment Prophylactic Activity of Facility’ contained about 50 subforms, covering 1836 data elements and spanning 75 pages.

Given the huge amount of the data to be reported (about 30,000 data elements) on a routine basis, the extremely weak HMIS-related resources, and the view that reporting was an irrelevant exercise, data quality and use of information obviously suffered. These massive reams of paper could not provide the doctors with the data they immediately needed, which led to various local improvizations. For example, the Infectious Diseases Department at a central district created an ‘emergency form’ that listed eight essential diseases and this was used for local action.

Efforts to rationalize and computerize had to confront both these institutional legacies of central control and dominance of paper. The forms had multiple columns against a particular data element; for example the

‘Immunization’ section would have multiple age categories associated with it, and also a column for ‘totals’. Although officials were told that they did not need to manually enter the ‘total’ since the computer would automatically generate it, they continued to replicate the paper forms to the last detail. Similarly, there were logos on the paper which could not be modified at all in terms of placement, even though the reporting forms could be made to look more elegant with minor changes.

Computerization efforts thus struggled with dismantling the existing institutions and replacing them with new. It is only now, about seven to eight years after the reform process started that the systems have been redesigned, and the open source DHIS 2 has been used to deploy the revised systems at a national scale. However, creating institutions of local use of information will take many more years.

Source: data from Sahay S, S^bo JI, Mekonnen SM, and Gizaw, AA. Interplay of institutional logics and implications for deinstitutionalization: case study of HMIS implementation in Tajikistan. Information Technologies and International Development, Volume 6, Issue 3, pp. 19, Copyright © 2010 USC Annenberg School for Communication and Journalism.

service provider, who either does not have the resources or is often ideologically against bribes.

Procurement of ICT services for healthcare is challenging because of the difficulties in spelling out its requirements, which are extremely dynamic and keep changing, even as systems are being deployed. In addition, firms with high turnovers who get the contracts for public health work do not send their ‘A teams’ for implementation, because the volume of revenues is relatively small. Maintenance support and its cost are also difficult to estimate, and change management efforts are not easily quantifiable. Finally, as users become familiar, more users join and more needs arise, necessitating changes in software. Proprietary vendors tend to withdraw once their payment is made, and will wait for a new contract before responding to these necessary changes. A situation arises where the user is locked-in with a single vendor, and is forced to continue even with declining service quality.

There are also institutional challenges within the service provider. Most IT firms have limited public health skills, and work with the assumption that the customer can specify their needs accurately. In practice this does not happen. Often, because of the multiplicity of principals involved, the provider tends to be obliged to listen to the top player, even though he may not be primary for the design of the system. Usually the top player, the Secretary of Health, has a presumption of the information needs which are at variance with the ground realities. It is not common for this top player to be specifying requirements such as the need for automated correlations of deaths and causes, while the reality on the ground is for strengthening data management processes. This problem is exacerbated where the top player is a general civil servant—a bird of passage—who will move from the top position before any ICT project can become sustainable. The Punjab mHealth case demonstrates this transience which has adverse effects on the projects.

There are small start-up firms and niche firms which could take on a task that requires long-term maintenance, such as building and maintaining websites. But such firms would not meet the pre-qualification criteria set for the larger tenders. Very often, the complexities of procurement and the interests of donors add layers between the service provider and the user. In the almost inevitable stage of criticism and mutual recrimination, the service providers find it easier to tell the donor, who is the paymaster, that the problems of implementation lie in the national public health institutions, and deflect any criticisms from themselves.

Products based on open standards and open source principles where the source code is mandatorily made available lend themselves to evolution within the public health context. But large firms are less open to open source, as policy and their brand influence is such that their views prevail. Eligibility criteria for participation in bids are tweaked so as to remove many open source players, even though they are financially better placed, and also have ethical arguments associated with their bids.

Finally, this whole process of selection and retention is based on competition—both for getting the best price and the best product. However where there is so much uncertainty and change—reflected in the inability to freeze requirements—and with so much work required in capacity building, hand-holding, troubleshooting, and when products themselves have to be very dynamic, it raises the need for models that promote collaboration. A community of practice, where different IT firms working on different products could actually talk to each other and learn from each other could be very productive, but in an environment based on competition, and pregnant with information asymmetries, this is extremely difficult to achieve. The way forward rests on innovation at both ends—changing the rules of procurement of IT firms so they are better suited to the needs of the public health system, and changing the nature of the firm itself. Many funding agencies are beginning to see the logic of this, but for national governments, the task of bringing in these changes is much more complex.

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