Summary of development of HISP in key node countries

South Africa, Norway, India and Mozambique. Norway supports these coun-tries in teaching, development and funding. Malawi, Tanzania and Cuba are

interesting examples on the issues of scale and sustainability within the network and are thus mentioned here. Ethiopia, Tanzania and Vietnam are also briefly mentioned.

South Africa

The background for South Africa is given in the section above, and thus a summary of the most important factors for scale and sustainability are given here. Up to now HISP has been successfully implemented and institutionalized in all South African provinces. The most important reason for this success is described as the success of HISP in a few districts, the failure of other HISs in other districts, and the domino-effect this created. Because the decision-makers in the non-HISP provinces had no other alternatives to promote, and that HISP had proved successful in other provinces, HISP was able to scale rea-sonably fast within the country. Furthermore, the rapid scaling led to a foot-hold for HISP, eventually in every province, and has made HISP sustain as a HIS actor in South Africa, for about 12 years now. Furthermore, the political benefits and standardization advantages that HISP gained through the “EDS recommendation” were valuable for scaling and sustainability. The grass root level approach scored valuable political points which also benefited HISP in terms of scale and sustainability.

Mozambique

Mozambique became the second node after South Africa in 1999 and created the international network. The initial aim in Mozambique was to develop a HIS in three pilot districts (see Braa et al. 2000). The key problems identified were related to poor reporting and poor data management systems, no feedback of information, and poor communication between district and province levels.

Another problem was the impossibility for health facilities and districts to make local decisions. As these problems were addressed in the three pilot districts, it soon became clear that development at district level needed “to be interlinked with action and capacity development at province level, since this level is both the receiver of the data and responsible for supporting the district. Data from only one out of 12-18 districts on a province is not useful for the provincial administration” (Braa et al. 2004). A DHIS database with data from all prov-inces in the country was presented to officials to highlight the importance of this. Braa et al. (2004) describe the complexity on how HISP has failed to achieve success in Mozambique, i.e. has not been able to scale sufficiently and be self-sustainable in the country.

The highly centralized government in Mozambique made it difficult for HISP to adapt to local needs. Although HISP had contractual commitments with the Ministry of Health (MISAU), the official support for the project was in reality poor. For example, a decision to change the HIS software would require a deci-sion from the central government, making it difficult for provinces and districts

to do their own development. The reason for little official support can addi-tionally be explained by the country’s donor dependent economy. Since the country is so economically poor, it is very much dependent on donors to spon-sor many of the pilot projects that are initiated in the country. The government is thus unable to turn down donors that bring money and other valuable re-sources into the country. The negative side of this, from HISP’s point of view, is that competing approaches from different donors are initiated simultane-ously, and culminate as a pilot project after some time. Furthermore, Braa et al.

(2004) describe how HISP, because of its status as a research project, was reluc-tant to get support. Most donors and MISAU focused on HIS in provinces, while HISP was perceived to explore and develop solutions for the district.

HISP was because of this little involved in planning province related issues.

Finally, it has been problematic to scale HISP in Mozambique because of the difference in available electricity from district to district.

The Ministry of Health selected DHIS as the database to use in future HISs, and thus relying on further support from HISP and a decision to implement DHIS nationally was made. However, since 2004 the project has made little progress and is currently at a halt in Andhra Pradesh.

Other nodes

Malawi is another node that has done reasonably well within the HISP net-work (see Braa et al. 2004). HISP was initiated in two pilot districts in 2001 after a request from the country’s health ministry, and implemented nationally in early 2002. The reasons for Malawi’s relative success can be described by four key reasons. First, the entry through the health ministry, with full support and devotion, speeded up the process compared to e.g. Mozambique where the entry was through university collaborations. Second, quarterly reporting, in-stead of the usual monthly reporting, gave more time to fine-tune the system.

Third, all district- and hospital information officers were given a two weeks course in HIS to improve understanding and use of HISP. Finally, sufficient funding and good support from South Africa has contributed significantly to the sustainability HISP has achieved in Malawi. It has to be noted that Malawi is one of the poorest countries in the world with a highly lacking educational and human capacity infrastructure. For HISP to scale to a nation-wide imple-mentation and stay sustainable for four years is impressive.

Tanzania had initially the same approach as Malawi, but the outcome is not so optimistic. In short, Tanzania have not had the same external and financial support as Malawi, and together with poor local support, this resulted in the project being halted. The project has been re-initiated through a university col-laboration, with the aim to develop and pilot a new HIS in two districts and later implement it in a city.

Cuba is another interesting node, even though HISP as a pilot project has been terminated. The major reason why the project was terminated was because of a change in the political climate in the country, and the political support was quickly lost. However, set aside the political reasons, Sæbø and Titlestad (2003) criticize how the (Scandinavian) user participatory approach was used in this country, arguing that the approach was misplaced in a country so far from democratic values.