ß The Author 2005.

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved.
doi:10.1093/heapol/czj003 Advance Access publication 30 November 2005

HMIS and decision-making in Zambia: re-thinking

information solutions for district health management
in decentralized health systems
RICHARD I MUTEMWA
Centre for AIDS Research, University of Southampton, UK

At the onset of health system decentralization as a primary health care strategy, which constituted
a key feature of health sector reforms across the developing world, efficient and effective health
management information systems (HMIS) were widely acknowledged and adopted as a critical
element of district health management strengthening programmes. The focal concern was about the
performance and long-term sustainability of decentralized district health systems. The underlying logic
was that effective and efficient HMIS would provide district health managers with the information
required to make effective strategic decisions that are the vehicle for district performance and
sustainability in these decentralized health systems.

However, this argument is rooted in normative management and decision theory without significant
unequivocal empirical corroboration. Indeed, extensive empirical evidence continues to indicate that
managers’ decision-making behaviour and the existence of other forms of information outside the
HMIS, within the organizational environment, suggest a far more tenuous relationship between the
presence of organizational management information systems (such as HMIS) and effective strategic
decision-making. This qualitative comparative case-study conducted in two districts of Zambia focused
on investigating the presence and behaviour of five formally identified, different information forms,
including that from HMIS, in the strategic decision-making process. The aim was to determine the
validity of current arguments for HMIS, and establish implications for current HMIS policies.

Evidence from the eight strategic decision-making processes traced in the study confirmed the
existence of different forms of information in the organizational environment, including that provided
by the conventional HMIS. These information forms attach themselves to various organizational
management processes and key aspects of organizational routine. The study results point to the need
for a radical re-think of district health management information solutions in ways that account for the
existence of other information forms outside the formal HMIS in the district health system.

Key words: HMIS, information forms, decentralization, strategic decision making, district health systems

Introduction authority and play its role in the reformed health

structure. Thus, there has been a deliberate movement
Since Alma-Ata in 1978, most developing countries have to strengthen the management capacity of district health
implemented health sector reforms. In almost every case, systems (for instance, Cassels and Janovsky 1996).
a central feature of the reform strategy has been a process
of structural decentralization: the aim being to vest greater One area of focus in district health management
decision-making responsibility in the district health strengthening programmes has been health management
systems. The underpinning primary health care notion is information systems (HMIS) at the district level (for
that decentralization thrives on the essential involvement instance, Acquah 1994; Ankrah and Djan 1996; Lippeveld
of primary-level health management units in the delivery et al. 1997; Bodart and Sapirie 1998). There are challenges
of health services (WHO 1978). Although the geo-politics in clearly defining what is meant by HMIS (Lippeveld
vary from country to country, the district tends to be the and Sauerborn 2000). In this study, HMIS is used to refer
last formal unit of local government and administration to the predominant concept of a formal and structured
(Mills 1990). Across the variations of decentralization in health information system set up to support and facilitate
developing health systems (Mills 1990; Vaughan 1990), health management decision-making at different levels
the success of decentralization has predominantly been of any health system (for instance, Ankrah and Djan 1996;
considered to rely significantly on the capability of the Danish Bilharziasis Laboratory 2002; Gladwin et al.
district health system to effectively exercise its assigned 2003). In that light, HMIS is designed to carry both
 Re-thinking information solutions 41

epidemiological information (health prevalence, incidence, This problem has to some extent been acknowledged in
mortality, morbidity statistics) and administrative existing literature. For instance, Liebenau and Backhouse
information (resource inputs and service utilization). (1990) have pointed out how little we understand about
what information is and how it affects us in organizations.
The rationale for HMIS has been that the availability of More fundamentally, March (1988) and Mintzberg (1975)
operational, effective and efficient health management noted the general gap that exists between findings of
information systems is an essential component of the research on decision-making and the assertions of classical
required district management capacity. The logic is that normative decision-making theory that underpins the
effective and efficient HMIS will provide district health current argument for information in organizations.
managers with the information required to make effective March (1988) argues that this gap is ‘partly attributable
strategic decisions that support district performance and to limitations in the theories, rather than limitations in the
sustainability in these decentralized health systems. (decision-maker) behaviour’.

However, the arguments for HMIS are not based on The implications of these critical observations for devel-
unequivocal empirical evidence, or tested theory, that the oping health systems ought to be appreciated sensitively.
information carried in HMIS makes a difference, but These are resource-poor economies where new technolo-
rather represents a normative view of management capac- gies should be continuously and rigorously evaluated
ity. A review of empirical literature reveals a prevalence in terms of value creation for the health system, for each
of HMIS failure problems across a range of country dollar invested. Yet, the theory-practice gap being flagged
situations in the developing world (Lippeveld et al. 1997), up by empirical literature on information and decision-
as well as in developed health systems (for instance, making presents potential problems for cost-benefit
Southon et al. 1999; Snyder-Halpern 2001). analysis in these developing health systems. With diver-
gent trajectories or outcome-projection functions, between
Other specific difficulties with far more conceptual theory and actual practice, there is an absence of the
implications pertain to the widely recognized problems necessary agreement on the measurement of benefits,
with the decision-making behaviour of managers in success or indeed failure. The result has been a landscape
organizations in general, at least when that behaviour replete with a plethora of frameworks for measuring
is set against normative theories of management and information system failure or success (Skok et al. 2001).
decision-making practice. For instance, empirical studies This condition has not been helpful to practitioners in
suggest managers use information for political capital, developing health systems. Developing health systems
using information to seek legitimacy for their decisions often set out to strengthen their HMIS based on
rather than to make or clarify those decisions (Feldman normative decision theory principles (Acquah 1994;
and March 1988; Guldner and Rifkin 1993). More Gladwin et al. 2003), but later have to deal with measuring
crucially, it is widely acknowledged that managers use theoretically unanticipated informational phenomena in
information other than that provided by formal organiza- evaluation stages of their HMIS programmes.
tional information systems such as HMIS; and this other
information may take verbal and observational forms, The theory-practice gap that constitutes the root of this
or may be embedded in the training and experiential problem is essentially defined by the way in which
background of managers (for instance, Mintzberg 1975). information is ‘problematic’ in the organizational environ-
ment. An expeditious review of literature on information
This paper, therefore, addresses the challenge of reconcil- and decision-making reveals three major forms of this
ing the rhetoric for HMIS in district health systems with ‘problematic’ presentation of information. These three
observed problems that contradict it, threaten its very forms of presentation are briefly outlined here.
integrity, or, at minimum, recognize its limitations in
relation to management tasks. The paper describes a
Functional versus symbolic use of information
comparative study of two district health systems in
Zambia, and its main intention is to highlight one major The principles of normative decision theory are predicated
implication of the study findings. The paper describes on the functional use of information by decision-makers
the core research problem, key objectives of the study, where, since the onset of Frederick Taylor’s (1911)
the methods and key findings. It then concludes with a ‘scientific management’ paradigm, decision-makers use
discussion of the major practical implication of the study information objectively in making rational decisions.
findings, for HMIS design in developing health systems. Yet, such works as those by Feldman and March (1981),
Feldman (1988), and Dean and Sharfman (1993) represent
now common knowledge that people distort and manip-
ulate information for their own goals, and that this is a
Background
pervasive phenomenon in organizational life. Information
The key research problem confronted by the study was is often used as a symbol of competence, or merely as a
that the interaction between theory and empirical evidence signal of appropriate decision-making to secure legitimacy
so far indicates that organizations, public or private, for decisions made. Guldner and Rifkin (1993) observed
still understand little about the nature and behaviour from their field observations in Vietnam that data were
of information within the organizational environment. being widely used to justify rather than clarify decisions.
42 Richard I Mutemwa

Thus, the symbolic use of information directly defies the been insignificant. This study focused particularly on this
traditional logic of the functional value of information third problematique, with a fairly confident theoretical
to the production process. From the perspective of health hunch that the informational phenomena presenting the
systems, information is hence manipulated for goals first two problems would still be explainable from this
not necessarily compatible with the explicit aspirations perspective that recognizes the existence of other forms of
of decentralization. information outside the formal HMIS.

Use versus non-use of information Study objectives

Embedded within the logic of normative decision theory The aim of the study was, first, to establish the presence
is the presumption that decision-makers actually do use of written, verbal, observational, experiential and training
information when it is made available, and they behave information forms in the strategic decision-making
that consistently towards it. However, for decades now process. The focus on the strategic decision-making process
it has been well acknowledged, from observations, that represents a major concern for the management capacity
decision-makers gather information and ignore it; they of decentralized district health management systems and
make decisions first and look for the relevant information their sustainability. Local strategic decisions are central to
afterwards (for instance, March 1982). A study by Finau the definition of district health management capacity and
(1994) in the South Pacific highlighted similar problematic the determination of district health system sustainability,
behavioural tendencies, that local decision-makers in decentralized health systems (Mutemwa 2001).
ignored installed formal health information systems and,
instead, preferred ‘ ‘‘gut feeling’’, hearsay and ad hocry’. Secondly, the study aimed to establish the nature of the
micro-processes through which the above five information
Again, this is a condition that poses HMIS evaluation forms influence the strategic decision-making process.
problems for the health system planner. How credible The third and final aim was to determine the implications
would any form of systemic performance attributions to of these findings for HMIS design and operational
the installed HMIS? considerations. However, this paper will not cover the
second objective due simply to the complexity of the
dynamics involved in the micro-processes. The subject of
Formal HMIS versus other forms of information micro-processes should be better examined in a dedicated,
Contemporary philosophy of organizational management separate paper. Yet, such exclusion does not at all
information systems (including HMIS) is centred on undermine the visibility of overall policy implications
formal structured information systems with, among others, from the study, in the findings presented in this paper.
specified formal encoding, transmission and decoding
rules that govern those structures (Liebenau and
Method
Backhouse 1990; Ward and Griffiths 1996; Boman et al.
1997). As Simon (1957) pointed out, formal information
Study design
systems are based on formal channels of information
which may be characterized by ‘hard’/paper and/or The study was exploratory. The study did not exclusively
electronic forms of transmission in the organization. set out to only search for the different forms of infor-
In the study, these forms were collectively referred to as mation identified in the objectives above, but rather the
the written form of transmission or information, which researcher set out with an ‘open mind’. The basic
includes HMIS. reasoning was that there was still the possibility of finding
other forms of information not yet identified in existing
However, other forms of information have been identified literature, or indeed discovering new interesting insights
in empirical literature as being present in the organiza- into the strategic decision-making process.
tional environment. In his study of managers, Mintzberg
(1975) found that apart from formal management The study was designed as a multi-level, qualitative
information systems, managers used ‘soft’ information comparative case study and was conducted in Zambia,
and favoured verbal over written information. The above- where health sector reforms have involved a significant
mentioned study by Finau (1994) points to similar delegation of decision-making responsibility to district
observations. Mintzberg’s study further indicated that health systems (Mutemwa 2001). In Zambia’s decentral-
managers also use observational information in their ized health system structure, there is separation of policy
work. Experiential and training forms of information are and executive functions in health service provision.
widely acknowledged in the literature as well (for instance, At decentralization, the Ministry of Health retained the
Simon 1976; Melone 1996). All these forms of information national-level sectoral strategic functions of health
are significantly recognized in naturalistic decision theory policy and planning, finance and budget, legislation,
(a perspective on how decision-making occurs in real advocacy and international co-operation (Bergman 1996;
world situations). Yet, there still remains conspicuous MOH 1996).
ignorance of how these information forms operate within
the organizational environment. Hence, presently, their The government then created a parastatal, the Central
practical recognition in HMIS design considerations has Board of Health (CBOH), and delegated to it all the
 Re-thinking information solutions 43

executive functions of service provision: commissioning The second and primary level of comparative cases
health services in the sector, performance support, was the strategic decision-making processes sampled
monitoring and evaluation, national human resource from within the two districts selected for fieldwork.
development, and national health facilities planning The strategic decision-making processes or cases were
(Bergman 1996). Responsibility over actual delivery of compared within each district to establish the degree of
services was further delegated to district health systems, intra-district consistency, and across the two districts
which were re-constituted into District Health Boards to determine the degree of inter-district variation in the
(DHBs). DHBs are legal entities established under the behaviour of information.
Zambia National Health Services Act of 1995 (MOH
1995). They operate on an annual contractual relationship Data collection
with the CBOH, and annual service delivery benchmarks
are evaluated and reviewed each year-end, against which Ethical clearance
funding is negotiated and allocated (MOH 1992, 1996). Ethical clearance was obtained from the national ethical
DHBs have extensive strategic and operational decision- clearance committee, and administrative clearance
making discretion at that primary level, including the obtained from the Central Board of Health acting on
legal mandate to raise and manage their own resources. behalf of the Ministry of Health in Zambia, to conduct
A district can engage in profitable investment activities the study. Consent was also sought and granted by the
that it may deem beneficial; plan, recruit and manage selected districts to conduct the study and access written,
its human resources; and engage in any activities that verbal and observational data sources. Consent to access
may aid the sustainability and prosperity of the district data sources was also a continuous part of the research
health system. process, and was obtained both institutionally, whenever
necessary, and from individuals whose personal insight
For the study, the first level of comparative cases was the on specific issues was sought through interviews from
district health system context. Zambia’s district health time to time.
system profile consists of two main types of district
groups: rural district health systems, and urban district Selecting district cases
health systems. A rural district health system in Zambia One urban district, Lusaka, and one rural district, Monze,
has a district health service structure that serves were purposively sampled from the national sampling
a considerable urban population of the district town, frame of 72 districts in Zambia. The selection process
and further extends to rural village communities situated involved several progressive rounds of scoring all the
outside the town but still falling within the geo-political districts in the country on the basis of: whether a district
boundary of the district. A rural district health service had a functional District Health Management Team
will typically comprise a district health office, a referral (DHMT) and DHB; whether the district was willing to
hospital, at least one urban clinic, and a considerable be hospitable to the study; the final two districts had to
number of rural health centres and community be located in different provinces to control for regional
health posts distributed among the village and farming cultural bias; and a district could not have more than one
communities. donor-funded project running during the time scheduled
for the study, to control for interference from artificial
Conversely, an urban district health system in Zambia human and financial resource capacities that accompany
carries a district health service structure that serves an such health programmes. Donor programmes were
urban community only. An urban district health service considered not a reliable indicator for long-term district
will typically comprise a district health office, one or health system sustainability for two main reasons: first,
more referral hospitals, and a significant number of the short-term and definite life-span nature of inter-
urban health centres distributed among the urban and national development aid; and secondly, the characteristi-
peri-urban communities. cally indeterminate nature of outcome possibilities of
development assistance.
These two groups of district health systems experience
distinct epidemiological and health management problems On the basis of these four criteria, the list was eventually
and challenges, set within their equally varied respective reduced to the two districts. Lusaka is the capital city of
local socio-economies. Based on the understanding that Zambia; while Monze is a rural district in Southern
a number of strategic decision-making processes were to Province, about 200 miles south of Lusaka.
be studied from each district case selected, the researcher
estimated that two district health system cases would be Selecting strategic decision cases
sufficiently representative for the study: one rural district The strategic decision cases were also purposively sampled
and one urban district. These, it was felt, were sufficient to in a process that was closely guided by the methodology
provide empirical insights into how the rural and urban chosen for collecting data on the decision processes.
contexts differentially affect managerial decision-making By design, it had been decided that data on the strategic
and decision-making processes, particularly in terms of decision-making processes were to be collected using the
information variety and volume, and decision-making tracer methodology (Mutemwa 2001). Tracers are con-
activity. cerned with the elucidation of processes and are generally
44 Richard I Mutemwa

associated with the description of activities over time Prospective tracing of on-going or concurrent strategic
(Barnard et al. 1980; Hornby and Symon 1994). Basically, decision processes was done through unstructured
all the strategic decision processes selected for study in-depth interviews, review of organizational documenta-
were going to be traced, from beginning to end, for each tion, and direct observation of decision-making business
decision-making process. Tracing can be done retro- in the district health office. Observation notes were
spectively on decision cases that have already occurred, recorded in field notebooks and a diary. Direct observa-
or prospectively on decision cases that are concurrent tion took the form of participant observation, the
with the study. In retrospective tracing the researcher is researcher attending and witnessing decision-making
often guaranteed complete decision processes that have sessions without taking active part, but with his status
beginnings and ends, while in prospective tracing it is as a researcher known to the actors. To facilitate
never assured that a decision process being traced will participant observation, the researcher negotiated for
have resolved before the research project winds up its office space within the district health office and focused
fieldwork. The particular advantage with prospective data collection in each district for 6 months each; that is
tracing is that the researcher is able to witness the decision 12 months in all.
process as it unfolds, evolves and develops, which offers
a different and more intimate experience of decision Data analysis
process reality from that of recalled eye-witness reports
or experiential accounts in retrospective tracing. Thus, Data analysis was multi-stage. In the initial stage, data
to optimize the richness of data collected in each district, on each traced strategic decision were brought together
it was felt some of the strategic decision cases selected to reconstruct the story of the strategic decision-making
for the study were to be historical, for retrospective process, bringing out, as much as the data could allow,
tracing; while others were to be concurrent with the study, the reality and chronology of its mechanics. The process
for prospective tracing. of data interrogation to reconstruct decision process
stories started as part of data collection, in many instances
Three criteria were invoked for selection of strategic shaping follow-up interviews, documentary reviews and
decision cases in the two districts. A decision process observations. These reconstructed decision process stories
case had to have evidence of availability and reliability of were then verified with key informants for validation, and
information sources on it; in the case of historical decision any inconsistencies or misrepresentations corrected.
processes, there had to be evidence of the process having
reached some form of end or resolution; and, the district In the second stage, the eight constructed decision process
health office had to give full consent to the study of stories were structured. The search for structure was
a selected decision case. To succeed on these criteria, the a search for a common regularity in the decision process
exercise of selecting strategic decision cases for study in cases, which would enable cross-case comparison and
the two districts was deliberately participatory. DHMT meaningful subsequent abstraction. To educe a common
members, as executive custodians of strategic decision- structure of the decision process from the eight decision
making at district level, were involved in the discursive case stories, the emergent theme approach (Mintzberg
process of recalling, suggesting and listing strategic et al. 1976; Nutt 1984) and critical events principle
decision-making processes, historical and on-going, (Poole and Baldwin 1996) were deployed. Decision
which would be traced in each district. The three selection process stories were examined using the emergent theme
criteria served as a backdrop to the participatory process. approach, with intuition used to organize the stories
A total of eight strategic decision-making processes were into patterns that describe the nature and sequence of
selected for tracing in the study, four from each district. key phases and within-phase steps. The critical events
In each district, two of the decision cases were historical, principle helped identify key milestones or turning points
the other two current or concurrent with the study. in the decision case stories, which were used for
constructing the frame of the structure.
Collecting the data The last stage of data analysis involved individually
Retrospective tracing of historical strategic decision breaking down the structured decision stories for, among
processes was done through unstructured in-depth inter- other aspects: the presence of written, verbal, observa-
views and review of organizational documentation. tional, experiential, training and any other information
Unstructured in-depth interviews were conducted with forms; the source of the present information forms and
key informants on each strategic decision case traced. channels through which the information forms entered
Key informants were mainly those members of the the decision process.
DHMT or of the broader district health office that had
participated in the process. In addition, organizational
Results
documentation relating directly and indirectly to the
decision process was requested and reviewed. This involved
Strategic decision-making processes selected for study
meeting minutes, memos, letters, personal notes, strategic
and operational plans, reports and policies. Validation of As Table 1 shows, a total of eight strategic decision-
data was achieved through multi-informant and methodo- making processes were traced in the two district health
logical triangulation (Pettigrew 1990; Mutemwa 2001). systems. All the four decision processes from Monze were
 Re-thinking information solutions 45

Table 1. The eight strategic decision-making processes in the study, presenting problem situation and identifying the problem
by type and district that they then adopted for targeting.
District General management Health programmes Total Investigation
Monze 4 0 4 An investigation stage emerged as the second stage of
Lusaka 2 2 4 the decision-making process. It covers activities through
Total 6 2 8 which the managers get to understand the root cause
of the problem, and how much the problem may have
impacted on their organization or other aspect of their
service. Here, managers or their assigned proxies actively
about addressing administrative or general management searched for information relating to those aspects of the
strategic problems, and none were about addressing problem. The investigation stage typically ended at the
(epidemiological) health problems. Whereas, in Lusaka, point where the managers had gained full or part answers
two of the decision processes were about addressing on those aspects and they had some general conceptual
general management problems, and the other two were ideas about the attributes of the ideal solution to the
about (epidemiological) health problems. problem. These ideal-solution attributes then provided
a reference ‘blueprint’ for the next and final stage of
There appears to be no other immediate explanation for ‘solution development’.
this distribution in the nature of traced decision processes,
apart from the apparent inter-play between the tight Solution development
decision process selection criteria, coincidence and the
timing of the study. For instance, the decision process Solution development is the third and last stage of the
distribution for Monze does not necessarily imply that decision-making process. It covers activities about the
there were no health problems in the district at the time development of a solution, which in some decision cases
of the study. Major decisions worthy of study had been came in the form of a relatively complex programme
made and health programmes were already running at the design in bound hardcopy print. In other cases, the
time of the study, but these decisions did not exactly solution was nothing more than a simple list of inter-
satisfy the selection criteria. Moreover, it is significant related intervention activities on a one-page internal
that, in fact, the administrative or general management memo on file (or even listed in meeting minutes as recom-
decision processes traced in both districts either directly mendations for action). It is significant that, according
or indirectly, as would be reasonably expected, pertained to the study findings, solution development does not
to health programmes set up to address (epidemiological) include implementation of the solution because it was felt
health problems. ‘implementation’ posed a different set of questions.

Structure of the strategic decision-making process A few empirical observations should be made about the
three stages of the decision-making process delineated
All the eight strategic decision-making processes traced in above. First, the structure also recognizes the transitional
the study exhibited an identical developmental structure. linkages between the stages, and the activities that
However, detailed elucidation of how the decision-making constitute these linkages. These transitional activities
process structure operates can only be the subject of perform specific functions that ensure the relationships
a dedicated, separate paper. What will be attempted between the stages, and hence provide continuity to the
here is to delineate the form of the decision process structure.
structure only as far as it serves as the basic backdrop
to the subsequent presentation of data on presence of Secondly, each of the stages is amenable to analysis as
information, the focal subject of this paper. an episode with a distinctive set of activities that differ-
entiate it from the other stages in the process. This was
Thus, basically, the strategic decision-making process particularly useful to the task of breaking down the
structure that emerged from the data has three stages individual decision-making processes in the search for
around which activities in each decision-making process information in its various forms.
seemed to cluster, from beginning to end. The stages
are: problem recognition, investigation and solution
development. Presence of information in the strategic
decision-making process
Problem recognition
Firstly, all the five forms of information discussed earlier
Problem recognition emerged as the first stage of the were found to exist in the strategic decision-making
decision-making process. It covers dynamics by which process: written, verbal, observational, experiential and
the decision process is triggered, including the ensuing training. District health managers referred to a variety
activities up to the point where the managers arrive at of information forms in the course of strategic decision-
some definition or understanding of what the real or basic making. Table 2 shows, in a comprehensive manner,
problem behind the indicators is. In this stage, managers the information profile across the three decision-
tended to be pre-occupied with making sense of the making process stages for each of the eight strategic
46 Richard I Mutemwa

Table 2. Information profiles of the eight strategic decision-making processes across the three stages of the decision-making process

Decision process case Problem recognition Investigation Solution development

Transport policy 1. Written (HIS, AIS) 1. Written (HIS, AIS) 1. Written (HIS, AIS)
2. Verbal 2. Observational 2. Verbal
3. Experiential 3. Experiential
4. Training 4. Training
SEATS 1. Written (HIS 1) 1. Verbal (1) 1. Written (pilot)
2. Written (HIS 2) 2. Verbal (2) 2. Experiential
3. Training
De-linkage of outpatients department 1. Written (AIS) 1. Experiential (1) still in process
2. Experiential 2. Experiential (2)
3. Written (AIS)
Fuel 1. Written (AIS) (corrupted) (corrupted)
2. Verbal:
formal
informal
Health centre in-charge post 1. Observational 1. Experiential (1) 1. Written (AIS)
2. Verbal 2. Experiential (2) 2. Training
3. Written (AIS) 3. Experiential
4. Intuition
Strategic environmental health plan 1. Written (HIS) 1. Written (Research 1) 1. Written (Research)
2. Training 2. Written (Research 2) 2. Verbal
3. Experiential 3. Experiential
Health centre staff recruitment programme 1. Verbal 1. Experiential 1. Written (AIS)
2. Observational 2. Written (AIS) 2. Experiential
3. Written (AIS)
4. Experiential
Human resource policy 1. Observational 1. Experiential still in process
2. Experiential 2. Experiential

Notes: AIS ¼ administrative information system; HIS ¼ health information system; SEATS ¼ Service Expansion and Technical Support;
still in process ¼ unresolved by end of data collection.

decision-making processes traced in the study. For experience and professional expertize were pooled and
instance, in the ‘transport policy’ decision case, the district shared, and then applied to understand the transport
managers used verbal, written, experiential and training problem being discussed. This information in manage-
information to recognize the ‘transport’ problem in the ment meetings was pooled and shared in verbal form.
district. The managers then used written and observa- Note that, in all decision cases, the exact dynamics of this
tional information to investigate the problem and arrive at pooling and sharing of information was a subject beyond
some understanding of what the ideal solution to the the remit of the study.
problem would be. Finally, to develop the ‘transport
policy’ as the solution to the problem, the managers again Similarly, Tables 4 and 5 present the sources of informa-
used written, verbal, experiential and training informa- tion identified in Table 2 under, respectively, the
tion. Note that although the set of information forms used ‘investigation’ and ‘solution development’ stages of the
in the ‘problem recognition’ and ‘solution development’ decision process, for each decision case.
stages seem identical, their particular contents were
different due to the different goals targeted at these Secondly, there was no regular pattern in the presence of
stages. For instance, the written information used in the these information forms, either across decision-making
problem recognition stage was different in content to the processes or across the stages within each strategic
written information used in the solution development decision-making process, as illustrated in Table 2. Each
stage. Both are identified as ‘written’ for the reason that decision-making process was informationally distinct;
both of the information pieces were obtained from written as was each decision-making stage within a process.
paper and electronic documents. Thus, as the decision-making process progressed, infor-
mation in its various forms entered the process for a
Tables 3, 4 and 5 present the sources of the information specific purpose, and exited the process as soon as the
forms identified at each of the three decision process purpose was achieved.
stages in Table 2, for each decision case. For the ‘transport
policy’ decision case, Table 3 indicates that, in the problem In Table 2, the ‘Fuel’ decision process case is listed
recognition stage, the managers obtained written informa- as having ‘corrupted ’ following its first stage, to illustrate
tion from the HMIS, whereas verbal, training and the fact that the decision process lost its initial formal
experiential information were obtained through manage- focus in the subsequent stages due to political conflict that
ment meetings. What this simply means is that manage- emerged and preoccupied the process. Thus, the original
ment meetings served as arenas in which previous problem which the ‘Fuel’ decision case set out to address
Table 3. Routines associated with information types in the problem recognition stage, across the eight studied strategic decision cases

Decision case Information type

Experiential Intuition Observational Training Verbal Written

Transport policy Shared by DHMT – – Shared by Admin. Supervisory visits: HMIS: HIS and AIS
members in meetings Man. in meetings meetings with

Re-thinking information solutions

health centre staff

SEATS – – – – – HMIS: HIS

De-linkage of outpatients Shared by DHMT – – – – HMIS: AIS
department members in meetings
Fuel – – – – 1. Formal reports HMIS: AIS
2. Informal reports
Health centre in-charge – By DHMT members Supervisory visits: – Supervisory visits: HMIS: AIS
programme in sense-making observation of meetings with local routine quarterly reports,
meetings staff behaviour community members special reports
in health centres directly from
communities
Strategic environmental Shared by DHMT – – Shared by some – HMIS: HIS
health plan members in meetings DHMT members
in meetings
Health centre staff Shared by DHMT – Supervisory visits: – Supervisory visits: HMIS: AIS
recruitment programme members in meetings observation of meetings with
service provision health centre staff
in health centres
Human resource policy Shared by DHMT – DHMT observation – – –
members in meetings of administrative
practice

Notes: HMIS ¼ health management information system; AIS ¼ administrative information system; HIS ¼ health information system; DHMT ¼ District Health Management Team;
SEATS ¼ Service Expansion and Technical Support.

47
 48
Table 4. Routines associated with information types in the investigation stage, across the eight studied strategic decision cases

Decision case Information type

Experiential Intuition Observational Training Verbal Written

Transport policy – – Observational Shared by Admin. – HMIS: HIS and AIS

investigation Man. in meetings
conducted by
DHMT
SEATS – – – – Consultative –
meetings of
‘response team’
with NGOs and
youth
De-linkage of outpatients department Shared by DHMT members in meetings – – – – HMIS: AIS
Fuel Corrupted Corrupted Corrupted Corrupted Corrupted Corrupted
Health centre in-charge programme Shared by DHMT members in meetings – – – – –
Strategic environmental health plan – – – – – HMIS: AIS (research)
Health centre staff recruitment Shared by DHMT members in meetings – – – – HMIS: AIS
programme
Human resource policy Shared by task team in meetings – – – – –

Richard I Mutemwa
Notes: HMIS ¼ health management information system; AIS ¼ administrative information system; HIS ¼ health information system; SEATS ¼ Service Expansion and Technical Support;
DHMT ¼ District Health Management Team.

Table 5. Routines associated with information types in the solution development stage, across the eight studied strategic decision cases

Decision case Information type

Experiential Intuition Observational Training Verbal Written

Transport policy Shared by DHMT – – Shared by Admin. Consultative meetings HMIS: AIS
members in meetings Man. in meetings with health centres,
WaterAid, filling
station, other staff at
district health office
SEATS Shared by FHSTF – – Shared by FHSTF in – HMIS: HIS and AIS (pilot)
in meetings meetings
De-linkage of outpatients department – – – – – –
Fuel Corrupted Corrupted Corrupted Corrupted Corrupted Corrupted
Health centre in-charge programme Shared by DHMT – – Shared by DHMT – HMIS: AIS
members in meetings members in meetings
Strategic environmental health plan Shared by task team in – – – Shared by task team in HMIS: AIS (research)
planning workshop planning workshop
Health centre staff recruitment Shared by DHMT – – – Supervisory visits: HMIS: AIS
programme members in meetings meetings with health
centre staff
Human resource policy – – – – – –

Notes: HMIS ¼ health management information system; AIS ¼ administrative information system; HIS ¼ health information system; SEATS ¼ Service Expansion and Technical Support;
DHMT ¼ District Health Management Team; FHSTF ¼ Friendly Health Services Task Force.
 Re-thinking information solutions 49

Table 6. Contribution to the eight decision process cases, per information type

Decision case Information type

Written Written Verbal Observational Experiential Training Intuition Total of

HMIS Non-HMIS information
types

Transport policy 3 – 2 1 2 2 – 10
SEATS 2 1 2 – 1 1 – 7
De-linkage of outpatients department 2 – – – 3 – – 5
Fuel 1 – 1 – – – – 2
Health centre in-charge programme 2 – 1 1 3 1 1 9
Strategic environmental health plan 1 3 1 – 2 1 – 8
Health centre staff recruitment programme 3 – 1 1 3 – – 8
Human resource policy – – – 1 3 – – 4
Total per information type 14 4 8 4 17 5 1 53

Notes: HMIS ¼ health management information system; SEATS ¼ Service Expansion and Technical Support.

remained unresolved by end of the decision-making between the researcher and the District Administrative
process. Manager during an interview:

Thirdly, as Tables 2, 3, 4 and 5 indicate, written informa- Administrative Manager: ‘‘. . . sometimes we used to get
tion was either from routine HMIS or occasionally the information from (junior) health centre staff that
commissioned formal investigative research or enquiry transport is being misused.’’
report documents that are in circulation within the
district health office. For instance, in the ‘Strategic Researcher: ‘‘Verbal reports?’’
Environmental Health Plan’ decision case, managers
engaged investigative research in the investigation and Administrative Manager: ‘‘Yeah. Verbal reports. Some
solution development stages to gain required information. of them personal reports to me, that I should consider
The solution development stage of the ‘SEATS’ case private and in confidence.’’
involved a pilot study. In some of the traced decision
processes, written information took the form of formal Experiential and training information existed in the
one-off letters or informal anonymous notes, as in the memory stores of the district managers making the
following quote from an interview with the District decisions. This information was typically ‘downloaded’
Administrative Manager on the ‘Transport Policy’ and shared in management meetings, during moments
decision case: of reflecting upon or analyzing the problem at hand.
Whereas, observational information reached the managers
‘‘. . .Sometimes somebody would just come and push through direct or vicarious observation or witnessing
a note under the door to say transport is not being used of organizational activity related to the problem being
as meant for. In fact, not only from the health centre addressed. In vicarious observation, management typically
staff but sometimes also from the community. They used assigned a member of staff within the district health office
to come with a letter to say he (EHT) takes it to to conduct the observation on their behalf.
Mapanza where he comes from . . . So we had to decide to
put up a measure.’’ Fourthly, Table 6 shows the number of times each
information form was used in each of the strategic
Again, in this study, routine HMIS was taken to con- decision-making processes for a specific process activity
stitute two components: routine epidemiological health or purpose. At the bottom of the table are the
information and routine administrative information. corresponding crude totals of the information types,
indicating their respective contributions to the combined
Verbal information equally had formal and informal information profile of all the decision cases in the study.
attributes. Verbal information tended to be shared in Note that, although these figures cannot be taken beyond
formal gatherings, mostly as spoken reports to managers the eight decision cases in the study, information from
during formal supervisory visits to health centres and formal HMIS was not the top contributor to the traced
visits to local communities. Other formal verbal informa- decision process cases. HMIS was certainly a commonly
tion reached district managers through consultative used source of information, but the most common basis
meetings with affected constituencies and/or stakeholder for a decision was experiential information.
organizations during the process of decision making.
Informal verbal information was reported to be mostly Further, there was no ‘observed’ or detected difference,
in the form of informal intimacies about the problem between the two studied districts in the way information
situation; for instance, consider the following interchange behaved in the strategic decision-making process.
50 Richard I Mutemwa

Finally, no new significant information form was written, verbal, observational, experiential and training
discovered in the study. information.

It is worth noting that the labels of written and verbal

information relate to the formats in which information
Discussion and conclusion was delivered or exchanged, while observational, experi-
From the perspective of health system decentralization, ential and training pertain to the method or way by which
this study has shown that decentralized district health information was gained. Yet, these hints represent some
systems do engage in decisional activity on matters that of the fundamental aspects of any information system:
affect their long-term survival or performance as health collection and delivery of information to the users
system organizations at that primary level. The study has (Finlay 1994; Ward and Griffiths 1996; Boman et al. 1997).
also demonstrated that different forms of information Here, then, it becomes evident that the actual health
are brought to bear, in district decision-making, through management information system for a decentralized
different channels and from a variety of sources in the district health system is by far more integrated and
district health system. HMIS is only one of those channels complex than the formal HMIS, and carries organization-
or sources. The study has confirmed the presence of wide implications. The study results suggest that the
written, verbal, observational, experiential and training actual health management information system involves all
information forms in managerial decision-making, just aspects of organization: human resources, management/
as extant decision-making literature has insisted for organizational processes, organizational structure, and
decades. Yet, this study has gone further to locate these organizational systems. The HMIS is only one of the
various information forms within the process of decision systems in a typical organization (Hardy 1996). In this
making, and establish how they tend to be distributed study, therefore, the realistic informational status of the
over the decision process space and time. formal HMIS within the district health office has been
revealed.
Probably of most significance for policy is the indication
from the study that information in the district health One immediate practical implication is that when deciding
system exists not only in formal HMIS, but is also on installing a new HMIS, diagnosing problems in
embedded in and is brought into the decision-making a troubled existing HMIS, or indeed merely evaluating
process through the whole process of management and key the performance of an established HMIS, practitioners
aspects of organizational routine. In both Lusaka ought to take into account the informational contribution
and Monze districts, information also flowed through of existing human resources, management/organizational
other channels apart from the HMIS. For instance, routine processes and the organizational structure to the total
and other management decision-making meetings were information profile in circulation within the district health
fora for recalling and sharing experiential and training office or system. The study findings suggest that each of
information. Routine supervisory visits to health centres these three organizational elements must be appreciated
provided a channel for gaining verbal and written as a source and/or conveyor of information. HMIS will
information. Routine and specially commissioned moni- not likely succeed in supporting district performance,
toring of activity provided the channel for observational irrespective of success in adoption rate, if these other
information in the district. In addition, task forces specially components of the organization are not strengthened
convened for the decision process also became channels for and aligned for their informational contribution. The very
not only pooling information from various stakeholder design of HMIS must take into consideration the nature
experiences and expert knowledge, but also served as entry of the information ‘gap’ it is coming to fill in the district
points for that information into the decision-making health organization, and not only future interactions
process. Commissioned investigative research and pilot with prospective users – as predominant practice currently
testing of prototype solution designs were channels stands. Thus, sponsors of HMIS in district health systems
for more written information. For some of the should be concerned not only about technology adoption,
decision processes, consultative meetings with as has been the tradition, but also about successful
stakeholders and routine communication activities with technology ‘docking’ into the complex system that the
local communities also provided channels for verbal district health organization is, informationally.
information.
Note that the notion of technology ‘docking’ should not
Thus, information entered the strategic decision-making be confused with the systems approach to technology
process through people (district health managers/staff adoption already argued in the literature (for instance,
directly participating in the decision process); management/ Gladwin et al. 2003). Technology ‘docking’ relies on the
organizational processes (management meetings, super- identified information gap to be filled by the HMIS in
visory visits, task forces, consultation and communication the district health system, and hence necessarily views the
with local communities); organizational structure other key aspects of the organization as components of
(which legitimizes informational contributions); and the broader management information system. This in
the HMIS (as currently conceptualized). From itself suggests a need for a radical re-think of the concept
this collective of aspects of organization emerged and practice of ‘HMIS’.
 Re-thinking information solutions 51

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52 Richard I Mutemwa

The opinions expressed in this paper are those of the author alone in the Centre for AIDS Research. He is also Co-ordinator for the
and do not necessarily reflect formal views of the institutions Community Involvement Group on the Microbicide Development
mentioned. Programme Phase III Clinical Trial (in four African countries)
which is funded by DfID through the UK Medical Research Council
(MRC), and administered by the MRC Clinical Trials Unit (CTU)
and Imperial College in London. His research interests further
Biography include health systems, health economics and organizations.
Richard I Mutemwa is a Research Fellow, Southampton Social
Statistics Research Institute, University of Southampton, United Correspondence: Richard I Mutemwa, Centre for AIDS Research,
Kingdom. He holds a health management MBA and PhD, and has University of Southampton, Highfield, Southampton, SO17 1BJ,
additional previous experience in health and nutrition education and UK. Tel: þ44 2380 597988; Fax: þ44 2380 593846; E-mail:
communication mainly in Zambia. Dr Mutemwa is currently based [email protected]