Implementation of pilot project

According to (Braa et al. 2002b) there are two main reasons why HISP’s cross-country adaptation is possible despite the major cultural and structural differences. First, the work of international agencies has established standard definitions of data elements and health services and procedures, like standard indicators for data reporting and HISs. Second, the IS design and development strategy is general in that it aims at the simple and achievable within the given context.

According to HISP’s software coordinator, the main reasons why HISP is suitable for the developing countries it has been introduced to so far, is that fundamentally they are struggling with similar problems:

• All countries have some kind of health sector reform going on, a central part of which is decentralization. All countries are struggling with similar questions, e.g. who decides on the budget and who decides on the service delivery. A lot of people in Malawi

complained about the top brass decentralizing the problems, but not the resources. This is archetypical, but still something all countries are grappling with. There has been a broad push from the WHO and most of these governments want to decentralize some how. Hence, there is a basic policy environment that is similar to some extent.

• All countries have been collecting huge amounts of data in the past, which generally is hardly ever used locally or centrally. Centrally

data typically has been used for pure descriptive and statistical purposes. Health workers regard reporting primarily as one way of showing that they are doing their work.

On the other hand, what is not similar is e.g. the different degrees of the drive towards decentralization. There are also problems, which are more technical in nature, arising from different administrative structures.

The Indian context is bureaucratic and hierarchical and the democratic and political ideology HISP presents was not always understood and appreciated by all participants. We had some challenges related to the social, cultural and political context (ref. section 7.3), and working with HISP in India has really proved the importance of a context sensitive approach.

Poor infrastructure

In Kuppam there were several problems because of infrastructural issues;

buildings were too poor to facilitate a computer, and the power cuts were a continuous problem. Lack of power slowed down the training process, as the field workers were not present at the primary health centres and could use the computer in between the power cuts. When the health workers finally had time to come, the power went down, and that did not motivate for further training. Poor infrastructure is a common problem in deprived areas, thus the need for computers only in a few primary health centres, is functional. Because of poor infrastructure in Kuppam, HISP could not scale, and their further strategy is to identify suitable primary health centres.

Starting to use computers - resistance to change

The resistance to organizational change amongst the Medical Officers can be cited in their refusal of letting the field workers use the computer and to attend training:

“Because of field work I am unable to learn about computers”

- Field worker in questionnaire The field workers are generally low in social and caste hierarchy, and less educated than the other health staff at the primary health centre. The fact that they would get equal access to the computer along with the Medical Officers may be seen as violating existing social norms and provokes further discussions. Tasks that only have been reserved the Medical Officers will now also be performed by the field workers. These issues interfere with the dynamics of knowledge, which depends on whom for what kind of knowledge.

The Joint Collector pointed out the importance of Medical Officers receiving the most computer training, since they were in charge of the

primary health centre. Giddens’ emphasis on the intended consequences of action can be used to represent the field workers getting more responsibility, while the unintended actions represent the relative disempowerment of Medical Officers.

Top down

The existing HIS in Kuppam, and the state generally, is of the top-down kind: people at the top with the power to make decisions, ask questions, while those at the bottom, health workers at the sub-centres and primary health centres, are persuaded to give answers. Some of the field workers said that they felt important doing their job when they reported to the District Medical and Health Officer, which is their supervisor. They did not appreciate the idea of reporting to someone with less authority.

I think this statement illustrates the focus of the previous data collection system; collecting data for the purpose of reporting to higher instances. In order to change the IS, regarding the IS as a social system provides a useful framework (ref. sub-section 2.1.2); relationship between people, work routines and perceptions will also need to change.

Targets

According to “Community Needs Assessment” targets should be set by health workers after doing surveys, to ascertain client needs. Looking at the targets set in the HMIS performance rating of primary health centres in sub-section 8.1.1, which are all the same for the different primary health centres, we have seen that this is not always the case. Workload, infrastructure, size of population etc. are not taken into account when setting the targets.

Targets are set to show the intended level of accomplishment, and tell the health workers what they need to achieve, by when, and to what degree (ref.

sub-section 3.3.3). Therefore, the targets need to be based on thoroughly investigation. They need to be set according to the size and needs of the population using a participatory process involving the local health staff.

Grading schemes

Another question concerns the grading scheme recently introduced (ref.

Table 8), and whether it provides advice to those primary health centres being identified with poor grades. The grading scheme should not only serve as a mechanism to reprimand poor primary health centres but as a source of suggestion for future actions to help improvement. Used just as a form of reprimand, the grading scheme can lead to manipulation of data, so that the health workers avoid being shamed in public, rather than to an improvement in service. The grading is useless unless it provides some incentives for those with “poor” grades. Reprimands alone are not helpful in improving the health status; the reason for the poor (grades) results must be

examined. If the reason is that they do not understand the data elements, getting a bad grade will not lead to any improvement.

One solution could be to organize the health workers in groups to evaluate each others’ performance. To be able to perform this kind of action, they would need guidance and assistance during the performance rating.

The grading schemes can also be linked to Giddens’ dimension of domination. When the grading schemes works as a form of reprimand, the IS works as a facility where the top-down social structures are reproduced by upper management.