The challenges and opportunities with the top-down

Several HIS pilot-projects have died in developing countries because of politi-cal and bureaucratic decisions (Braa et al. 2004). One challenge for HISP in Andhra Pradesh was to influence politicians and bureaucrats on the boundaries of the project, in terms of gaining more resources and geographical coverage.

As a start, HISP was given a small and remote rural area to pilot. For the deci-sion makers, the start-up of the project was relatively low cost, could poten-tially boost local political popularity, and might give the village a few extra re-sources e.g. through governmental programs and donors. However, as the pro-ject continued over time and more money was needed, both to continue in the village, and to diffuse, support was more difficult to gain. It was difficult to argue for continued support in the village because the top decision-makers

could not see the value of the project, as the health data collected was only from a few primary health centres and consequently had no real value at the state level. To collect health data over a larger area, or at a higher level, was just as difficult because this would increase expenses and human resources. In addi-tion, the Family and Welfare Department commissioner was more supportive of the competing FHIMS project, and a DM&HO who supported HISP re-signed, which further impede the scaling problem.

Bold and long term HIS projects are often initiated by politicians. However, many projects are often too bold and ambitions and the results are rather sub-ject to high costs, slow progress and corruption. Thus, these HIS prosub-jects most often fade away and die. The FHIMS case has shown that although political support is given from the top with computers in every primary health centre in the state, the HIS is still far from being fully institutionalized.

As mentioned in the previous section, one of HISP’s goals is to improve the infrastructure at the primary health centres. An improvement in infrastructure over a large geographical area poses challenges to scaling because new and dif-ferent problems arise as the system tries to scale. For example, the problem of human resources in Kuppam was partly overcome by tying up with a local internet café in the town that could support some hardware needs. HISP also hired a hardware technician that could fix some of the hardware problems.

However, in other areas, internet cafés might not be around, and it might be difficult to find a hardware technician that is willing to move to rural areas. So, new solutions to the same problems would have to be tinkered on as the system scales. If the infrastructure generally was better across the constituency or state, these problems would have been easier to overcome. The problems can how-ever to an extent be avoided by lifting the data registration from primary health centre level to the district level, where infrastructure is generally considered to be better (see strategies in next section). It is also important to note that HISP is a relatively small project. With a small budget, compared to large donors like World Bank and IMF, it is difficult for HISP to push through large organiza-tional changes.

Corruption can affect scaling processes because large scale implementation usu-ally means that more money is involved, and consequently leads to more brib-ing. An example is how FHIMS, created by a large and financially strong In-dian corporation, got a state-wide implementation without first having any significant results to present.

HISP had to constantly and simultaneously handle politics and bureaucracy in Hyderabad and Kuppam, struggle with the poor infrastructure and lack of hu-man resources in Kuppam, battle for support from donors and other NGOs, and tackle corruption. Interconnected, issues of politics and bureaucracy,

do-nors, infrastructure, geography, and corruption, all magnify the difficulties for scaling a HIS. Separately these issues create their own problems for scaling, and taken together they make scaling exponentially more complex. Politics and bu-reaucracy influence how and where HIS prototypes are to be initiated based on the availability of infrastructure and human resources in the area. Donors also influence how and where a project is to be initiated, often conflicting with the will of the politicians and bureaucrats. Corruption, an underlying and cultural iniquity in many third world countries, is often an overlaying influencing fac-tor. Because HIS are equally dependant on all these issues, complexity conse-quently increases with efforts to scale.

At the time of implementation, DHIS was not demonstrated as a complete and functioning system that could handle the accumulated data and the statistical analysis for the whole state. On one hand, this is negative because from the politicians’ viewpoint the project is not viewed as a complete system. On the other hand, it made HISP work with donors and other institutions to integrate the various systems. This was useful because it linked HISP with several other networks. Not only did it expand the network, it also showed politicians and bureaucrats the flexibility of the project.

HISP did eventually manage to get support for health data collection at each of the 13 district offices. Computers were set up and HISP team members started populating the database with monthly health and survey data. However, this was after the project had continued for several years and through political pres-sure from HISP’s high-level supporters. The health data collected was not used or reported further up in the health hierarchy, and the project remained un-institutionalized. Furthermore, when the Naidu government lost the election in 2004, HISP lost many of their political supporters in the government. New connections had to be made and HISP made several strides to get support from key political leaders in the new government, such as the new Principal Secre-tary of health. He was supportive of HISP, but by beginning of 2005 too much money had been invested in FHIMS, and made it a decision which was hard to reverse.

In summary, the challenges and opportunities with macro issues are mainly how politicians and bureaucrats are nurtured to support the HIS. The above describes how dependant HISP has been on the support from politicians and bureaucrats and demonstrates the rigid and hierarchical structures that exist in India. Without proper support from politicians and bureaucrats from all levels in the health hierarchy, it is difficult to achieve scaling and sustainability of the HIS. The rigid power structures in India make it particularly important to have support at the very top of the hierarchy, which probably can influence all levels below for better support of the HIS.