An analysis of approaches for developing national health information systems : a case study of two sub-Saharan African countries.
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Health information systems in sub-Saharan African countries are currently characterized by significant fragmentation, duplication and limited interoperability. Incorporating these disparate systems into a coherent national health information system has the potential to improve operational efficiencies, decision-making and planning across the health sector. In a recent study, Coiera analysed several mature national health information systems in high income countries and categorised a topology of the approaches for building them as: top-down, bottom-up or middle-out. Coeria gave compelling arguments for countries to adopt a middle-out approach. Building national health information systems in sub-Saharan African countries pose unique and complex challenges due to the substantial difference between the socio-economic, political and health landscapes of these countries and high income countries. Coiera’s analysis did not consider the unique challenges faced by sub-Saharan African countries in building their systems. Furthermore, there is currently no framework for analysing high-level approaches for building NHIS. This makes it difficult to establish the benefits and applicability of Coiera’s analysis for building NHIS in sub-Saharan African countries. The aim of this research was to develop and apply such a framework to determine which approach in Coiera’s topology, if any, showed signs of being the most sustainable approach for building effective national health information systems in sub-Saharan African countries. The framework was developed through a literature analysis and validated by applying it in case studies of the development of national health information systems in South Africa and Rwanda. The result of applying the framework to the case studies was a synthesis of the current evolution of these systems, and an assessment of how well each approach in Coiera’s topology supports key considerations for building them in typical sub-Saharan African countries. The study highlights the value of the framework for analysing sub-Saharan African countries in terms of Coiera’s topology, and concludes that, given the peculiar nature and evolution of national health information systems in sub-Saharan African countries, a middle-out approach can contribute significantly to building effective and sustainable systems in these countries, but its application in sub-Saharan African countries will differ significantly from its application in high income countries.