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Information Systems

AN INSTITUTIONAL PERSPECTIVE ON HEALTH

SECTOR REFORM AND THE PROCESS OF REFRAMING

HEALTH INFORMATION SYSTEMS: CASE STUDIES

FROM MOZAMBIQUE

Bruno Piotti, Baltazar Chilundo and Sundeep Sahay WP 9/2005

Copyright © with the author(s). The content of this material is to be considered preliminary and are not to be quoted without the author(s)'s permission.

Information Systems group University of Oslo Gaustadalléen 23 P.O.Box 1080 Blindern N-0316 Oslo Norway http://www.ifi.uio.no/~systemarbeid

Piotti, Chilundo and Sahay

Number 9, 2005 http://www.ifi.uio.no/forskning/grupper/is/wp/092005.pdf

Copyright © with the author(s). The content of this material is to be considered

preliminary and are not to be quoted without the author(s)'s permission. An Institutional Perspective on Health Sector Reform and the process of reframing

health information systems: Case Studies from Mozambique

Bruno Piotti Directorate of Cooperation and Planning Ministry of Health Mozambique

Baltazar Chilundo Department of Community Health Faculty of Medicine Eduardo Mondlane University Mozambique

Sundeep Sahay Dept. of informatics University of Oslo P.O. Box 1080 Blindern 0316 Oslo Norway <[email protected]> +47 2284 0073 (phone) +47 2285 2401 (fax)

Abstract:

Global concerns about poverty, epidemics and new emergent diseases urges rich countries to improve their development assistance, aid effectiveness, investments in health systems, including the health information systems. Governments of low income countries have embarked since about a decade ago on various health sector reforms that have led to often contradictory but most often not so successful outcomes. Formally, governments of rich and poor countries share the same goal: to increase coordination and harmonization of relationships on aid, debt relief, trade, poverty reduction program and health systems support. Mozambique, one of the poorest countries in the world and also one of the largest recipient of loans, grants, and technical support, has gone through multiple phases of reforms involving different kinds of partnership with donor countries, and have experienced different degrees of successes, unfulfilled promises, unsuccessful coordination attempts and duplications of intervention. The aim of this paper is to try to unpack some of the complex institutional and organizational changes relating to these attempts at health reform, and to understand alternative ways to approach them. We draw upon an institutional perspective to understand this complexity, by historically examining the formal and informal institutions in play, and the degree of overlap or not that exists, and how these influence the reform processes. Further, we examine how these formal and informal institutes relate to change processes - both planned and emergent. Empirically, the analysis is grounded in two case studies from Mozambique of ongoing efforts to reform. The first concerns the process of selection and design of national level indicators, and the second relates to the integration of the multiple reporting systems of the HIV/AIDS health program. We argue that in the first case where the overlap between the formal and informal institutions is greater as compared to the second case, the degree of success experienced in the reform effort is greater. This leads us to three practical



implications that can help support reform processes. The first concerns the key role of participation of various stakeholders in the reform process. The second concerns the need to adopt a "cultivation" rather than a "construction" approach to the reform process. And, the third relates to the need for incorporating flexibility in the reform planning and implementation process such that the space for emergent changes is not shut out. Keywords: Health sector reforms, institutional changes, health indicators and integration

of health IS

Citation: http://www.ifi.uio.no/forskning/grupper/is/wp/092005.pdf



1. The challenge of health reform and organizational change in developing countries

In 2003, the Director of the World Health Organization (WHO), Grö Harlem Bruntland,

declared that “health is central to development” (Ruger, 2003, p. 678). In December 2001,

the WHO Commission on Macroeconomics and Health (CMH) report strongly

recommended to low and middle income countries that investing in health will be the

most effective way to overcome poverty, and urged them to increase their investments in

the health sector to help fight against economic deprivation (WHO-CMH, 2001a).

However, such investments need to be accompanied with a range of reforms, such as in

accounting and budgeting practices, in order to attract investors from the rich world. As

Ruger argues:

“Good health enables individuals to be active agents of change in the

development process, both within and outside the health sector. Increased

investment in health requires public action and mobilization of resources, but it

also brings individuals opportunities for social and political participation in

health-system ”. (Ruger, 2003, p. 678).

However, the assumption that health and socio-economic development are correlated is

not new. In 1978, the links between poverty, political commitment, economy and

community involvement were at the centre of the Alma-Ata Declaration (WHO, 1978, p.

49-51) on primary health care and in the WHO and United Nation’s program on ‘Health

for All by Year 2000’ endorsed by 134 countries (Mahler, 1988, WHO, 1988). This

program urged a radical switch from curative to preventive medicine and advocated for

community-based approaches to health care, publicly funded, and free for all at the point

of delivery (Werner & Sanders, 1997). At a global-level, after 27 years of the Alma Ata

declaration, the objective of "health for all" is far from being met, and today we have

millions of poor people who are still being denied access to basic healthcare, a problem

that continues to be magnified with time (Kvamme, Olesen and Samuelson, 2001;

Goorman and Berg, 2000).

In developing countries, the health care sector has historically been a target for different

kinds of reforms. At the beginning of the 1990’s, the Structural Adjustment Program

(SAP) was launched by the International Monetary Fund (IMF) and the World Bank in

several low and middle-income countries. Health reforms accompanied the SAP, which



have over the years been subject to serious criticism. For example, Lown et al. have

argued:

The policies of structural adjustment, imposed on developing countries by the

World Bank and the International Monetary Fund, have emphasized debt

repayment based on maximizing exports at the expense of agricultural self-

sufficiency and domestic social programs. These economic strictures have

curtailed the already small funding for health services, education, and the

environment. According to World Bank projections, by 2005 sub-Saharan Africa

will be back to levels of income per head that it had in the 1970s.7” (Lown et al.,

1998, p. S34).

What are the major features of the health reforms? A WHO (1995) document describes

Health sector reform is a sustained process of fundamental change and institutional

arrangements, guided by government, designed to improve the functioning and

performance of the health sector and ultimately the health status of the population”.

(WHO, 1997, p. 3).

Some key points of reforms are: improving civil service performance and Ministry of

Health functioning, decentralization of responsibility in healthcare management,

broadening financial options, introducing or widening the role of private health providers

in the health sector (Cassels, 1995, p. 11).

These goals have been translated into various national and regional level health reform

efforts, including prioritizing public sector resource allocation using cost-effectiveness

analysis, developing alternatives to public financing, integrating donor funding models,

building coordination mechanisms, the integration of development programs into the so-

called Poverty Reduction Strategy Papers (PRSP), and the incorporation of ICTs to help

strengthen the informational basis by which health management decisions are taken.

The PRSP launched by World Bank and IMF in 1999, is a relatively recent socio-

economic program designed to have an impact on health systems. The PRSP provides

key founding principles to regulate two policies: the loan release conditionality and the

extension of debt relief to the highly indebted poor countries (Spanger and Wolff, 2003, p.

1). More recently, in 2000 all 191 UN members’ states signed the "Millennium



Declaration", from which the Millennium development goals were derived, which are

mandated to be achieved by 2015. The goals include measurable, time-bound targets for

addressing challenges of poverty and hunger, education, maternal and child health, the

prevalence of diseases including HIV/AIDS, gender equality, the environment, debt,

trade justice and aid. It is becoming increasingly evident to policy makers in rich

countries that the heightened influx of migrants, ethnic and territorial wars, increasing

risk of epidemics and new emergent diseases represent threats to standards of life in

industrialized countries and provide compelling political and economic justification to act

globally, to increase investments in developing countries, especially in their health

sectors. “The notion of the goals as a compact between North and South was reaffirmed

at the international conference on financing development in Monterrey, Mexico, in 2002”

(Haines and Cassels, 2004, UN, 2002) . The G8 and OECD countries have repeatedly

stated their will (for example, MDG-2000, Genoa Summit 2001, Monterrey, 2002) to

increase their investments and their quota of GDP predetermined to the Official

Development Assistance (ODA). However, Labonte et al. document an appalling gap

between the volume of overall security investments against terrorism and the total

amount of ODA to low income countries (Labonte et al., 2004, p. XII). There is instead a

long list of promises given and largely unfulfilled or broken: African continent debt relief

or cancellation (Wintour, 2005); reaching the UN stated goal of 0.7% of rich country GNI

for aid to developing countries(Haines and Cassels, 2004, p. 396); significant increase of

ODA support to national health systems, e.g. for increasing the annual health budget per

capita from 7$7-10 per capita to $35-40 per capita (WHO-CMH, 2001b); increased

education coverage; and, corrections of trade unbalances (Labonte et al., 2004, p. 206-

209).

Despite the acknowledgement of the urgent need for health sector reforms, the results

emerging from efforts to date can be described as being fairly depressing. At a more

micro-level of particular countries, there have been numerous reports of how reform

efforts have not delivered to potential beneficiaries adequate services and in

strengthening the informational basis to support reform processes (Gilson, 1995, Heeks,



1998, McLaughlin, 2001). The following statement from a former Zambian Minister of

Health emphasizes these continued failings:

Specific reform strategies and policies were not yet resulting in improvements

based on commonly used measures of service coverage. Thus, reform strategies

and policies must be inappropriate and should be revised. ‘The reformers were

unable to counter such a message because they had no data to back up their

strategies or progress expected as a result of reform…. (Extracted from

McLaughlin, 2001, p.2).

Brown (2001) provides a similar example of an ineffective reform effort on tuberculosis

control in Zambia:

The recent state of tuberculosis control in Zambia paints a bleak picture of a

health priority which is suffering from its integrated status. The National

Tuberculosis Review found that: (i) Tuberculosis focus has been lost and key

activities of tuberculosis control such as reporting and recording, patient follow

up and treatment outcome monitoring were not being performed in the majority of

districts; (ii) Technical capacities for tuberculosis diagnosis including laboratory

microscopy had dwindled both at central and district/peripheral levels; (iii)

Funding for tuberculosis control activities including drugs and laboratory

supplies was been inadequate… (p.9).

While it serves little purpose to provide examples of not so successful reform efforts, it is

more useful to try and understand the complexities that underlie these efforts, and

critically examine alternative ways to approach them. Unpacking this complexity in

particular contexts is important to understand the outcomes associated with different

reform efforts. This complexity can be seen to arise from a variety of sources. Firstly,

there are a multiplicity of levels involved, ranging from the global to the international, to

various administrative levels within the national health ministry (province, district, sub-

district), and to the community. These multiplicities of levels bring into the picture a

variety of actors (for example: donors, politicians, administrators, medical doctors, nurses,

health workers, educational institutions) with varying and often conflicting interests.

Secondly, there are various health programs serving particular needs or geographical

domains, which at some level and to some degree need to “speak to each other.” Thirdly,

developing countries are typically challenged by high disease burdens, for example

HIV/AIDS, Malaria, Tuberculosis, to name just a few. And fourthly, these countries are

faced with poverty and severe infrastructure constraints ranging from physical (roads,

transport), to ICT (connectivity, computers) and human related (numbers, educational



background). The complexity in these contextual conditions make implementing health

reforms extremely challenging, an argument made by Gilson (1995) in her assessment of

the reform efforts in Tanzania. She writes:

The study’s findings suggest that health care reforms are needed to improve the

quality and efficiency of primary level care in Tanzania. However, current

patterns of performance are subject to many influences and …..(are) intertwined.

Understanding such complexities will facilitate the development of an integrated,

and so effective, policy and management response to existing problems. Health

sector reform package in Tanzania, as in other countries, must allow for

financing, organizational and management development (p. 708).

Information and Communication Technologies (ICTs) are increasingly being implicated

in health reform efforts, for example to strengthen the processes of decentralization of

health care delivery. ICT projects come in with their own particular challenges related to

the complexity of the technologies involved, the need for specialized infrastructure, the

requirements of trained manpower with specialized knowledge concerning programming

languages, software development methodologies, and design skills. Many ICT based

reforms have also over the years ended up as “partial” or “full” failures arising from an

imposed rationality and ‘hard design’ of imported devices which often conflict with the

local rationality (Avgerou, 2000, Heeks et al., 1999). In other cases, managers were

unable to manage effectively the processes of organizational change and consequences

resulting from ICT introduction and individuals and work group dynamics (Anderson et

al., 1994, p. 10-18), and in others, imported technology was unable to effectively trigger

development, human capacity building, reduction of digital divide under a schematic

duplication of exogenous models (Heeks and Kenny, 2002).

With or without ICT, a key actor in the formulation and implementation of health reform

efforts in developing countries is Government that is the Ministry of Health. They

directly or indirectly influence other actors in this domain such as the population who pay

and receives services, the financial intermediaries who collect funds and pay the

procedures, the providers of health services who can be public (National Health Services

- NHS), private non-profit (such as church related institutions), or private for profit

organizations and can operate at different levels of care (Mills, 2000, p. 6).



In this paper, our focus in on the Ministry of Health in Mozambique and their attempts at

health sector reform. Mozambique is a Southern African Country classified by the 2004

United Nations Development Program Human Development Report as the seventh least

developed country in the world (UNDP, 2004). We seek to analyze some of the dynamics

that characterize the relation between ICT/information and organizational change

processes associated with health sector reform, and how can they be managed more

effectively. More specifically, this relationship is examined at two levels:

1. The interaction between donors and national level health ministry: the empirical

arena for this interaction will concern the design and development of health

indicators. 2.

2. The interaction between the national level and the point of health service delivery

around the ongoing efforts towards the integration of information systems of a

vertical disease-specific program.

The rest of the paper is structured as follows: In the next section, we discuss some key

notions from institutional theory which helps us to understand health reforms and change.

In section 3, the research method is described followed by two case studies from

Mozambique in section 4. Section 5 provides an analysis of the case, drawing upon the

theoretical notion presented earlier. Finally, some brief conclusions are presented in

section 6.

2. Theoretical perspective

The theoretical perspective that is drawn upon in our analysis of the reform related

processes in the health sector in Mozambique derives primarily from institutional theory.

A starting point in articulating this perspective is to clarify how we use the term

institution. The Nobel Prize winning economist Douglas North emphasizes the distinction

between organizations and institutions. He explains: “institutions are the rules of a game

in a society or, more formally, are the humanly derived constraints that shape human

interaction (North, 1990, p.3). Put simply, institutions represent the rules and norms that

individuals follow in their daily lives, the formal and informal constraints and their

enforcement characteristics. While institutions represent rules and norms, organizations



can be conceptualized as structures that provide for human agency to be articulated and

expressed. These structures could be in terms of work tasks, control mechanisms, reward

systems, and ownership (Avgerou, 2002).

Given the above conceptualization, institutions can be seen to play three key and

interconnected roles. Firstly, institutions provide guidance by framing the behavior of

individuals, and as a consequence by also structuring the incentives those individuals face

in their everyday activities. Secondly, by guiding action, institutions facilitate social

action in our daily lives. As North explains, institutions are “a guide to human interaction,

so that when we wish to greet friends on the street, drive an automobile, buy oranges,

borrow money, form a business, bury our dead, or whatever, we know (or can learn easily)

how to perform those tasks….In the jargon of economists, institutions define and limit the

set of choices of individuals” (1990, p. 3-4). Thirdly, if follows from the earlier two roles,

that institutions reduce the uncertainty of social interaction by providing a structure

within which people can act and be understood.

Institutions can take the form of both formal and informal rules. Institutions can be

formal and explicit such as the national constitution, and can also be informal and

culturally agreed upon (but unwritten) such as the respect that is expressed to the elderly

in a particular community. The distinction between the formal and informal institutions is

described to be at the core of the economics of institutions because of the simple principle

that laws to enforce informal rules are much more costly than the formal. In situations

where there is little overlap between the formal and informal rules, and the formal

institutions can not be enforced adequately, the informal rules take priority. This makes

the enforcement of the informal rules difficult and costly. For example, Madon et al.

(2004) describe the formal and informal rules that shape the functioning of the property

tax institution in Bangalore, India. The informal rules, based on the interpersonal

relationship between the property owners and tax collectors were a more prevalent

mechanism for assessing property tax as compared to the formal calculation formulae for

assessment. This lack of overlap between the formal and informal institutions and the

dominance of the later made the process of introducing reforms into the property tax



system extremely complex and time consuming nearly over a 20 year period. Sautet

(2005) provides a simple schematic to describe the relationship between the domains of

the formal and the informal (see Figure 1) which has implications for understanding

organizational change.

INFORMAL NORMS

FORMAL RULES

=

INFORMAL NORMS

FORMAL RULES

Figure 1 - The greater the overlap between the formal and informal,

organizational change will be easier to enable.

Source: Adapted from Saulet (2005)

Figure 1 The relationships between the domains of formal and the informal

A simplification that can be abstracted from this schematic is that the greater the overlap

between the formal and informal, organizational change will be easier to enable.

Interesting questions which thus arise are: what are the mechanisms for enabling these

changes?; how can the overlap between the formal and informal be increased?; and,

consequently how can the mismatch be reduced.

Drawing from Orlikowski and Hofman (1997), we argue that this process of alignment

between the formal and informal domains can be seen as a combination of three types of

improvisational change: anticipated, emergent and opportunity-based (see Figure 2).

Anticipated change concerns events that are planned for the future, for example

establishment of National Integrated Programs or strategic frameworks to guide health

policy. There are also two kinds of change, which arise spontaneously, as a result of the

experiences during implementation – opportunity-based and emergent kind of changes.

Opportunity-based change refers to those that occur without being planned in advance,

however, are deliberative with respect to taking advantage of an opportunity emerging



during implementation. For example, Nilsson et al. (2001) describe a case of how a

discovery of an unexpected use of the technology was later capitalized to bring larger

scale changes in the work place where it was discovered. Emergent changes are those that

arise spontaneously from local innovation and were not originally anticipated or

deliberative as in the case of opportunity based changes. Such changes have also been

described by authors as drift, or improvisation (Ciborra, 2000).

The construction of the planned and opportunity-based kind of changes is particularly of

interest in this study as it is operated within the tandem of the formal and complex

organizations. This process, known as parallel learning structures of group-level change

interventions, has been described by Illes and Sutherland (2001, p.54) as follows:

Typically, a parallel learning structure consists of a steering committee (which

includes a top executive), and a number of working groups that study what

changes are needed, make recommendations for improvement, and monitor the

change efforts.(…) Parallel structures help people break free of the normal

constraints imposed by the organization, engage in genuine enquiry and

experimentation, and initiate needed changes… [They] are a vehicle for learning

how to change system, and then leading the change process.

Anticipated Change

Emergent Change

Opportunity-BasedChange

Anticipated Change

Opportunity-BasedChange

Emergent Change

Figure 2 - An improvisational model of Organizational ChangeSource: Orlikowsk i and Hofmann, 1997

Figure 2 Types of change from Orlikowski

As systems become increasingly complex, implying interconnection between parts and

also a greater speed of change, the potential for emergent impacts and “side effects”

(Hanseth et al., 2005) also increase. Given the complexity of the health sector in

developing countries, it becomes important to consider reforms as having (or not)

primarily anticipated effects, but also analyze the different kinds of emergent

consequences that arise. These three forms of change often co-exist over time and are



linked to both intra-organizational and broader social contexts. Change is thus not a

straightforward, rational process but as a complex, analytical, and political process that is

historically situated (Walsham, 1993, p.53). Thus, the underlying rationality is mainly

due to cognitive human limitations imposed by given conditions (e.g. lack of human

skills) in the process of change. This situation described by Simon (1982) as situated

rationality represents ‘a style of human behavior that is appropriate to the achievement of

given goals, within the limits imposed by given conditions and constraints’ (p.408). For

example, one can argue that health reformers are limited by various constraints, including

the bureaucratic and political structures which primarily shape reforms as purely

economical rational decisions (efficiency oriented). Avgerou’s (2002) suggestion of a

‘contextualist position’ and ‘organizing regimes’ as key concepts to analyze the

rationality of organizing is helpful to explore the roles and influences of multiple actors

and interests on the reform process. She argues the need to acknowledge the existence of

rationalities that are historically developed, context dependent and emerging from

individuals’ situated enactments, and have resulted in modes of organizing which are

congruent with the rationalities (ibid, p. 93).

In summary, the theoretical perspective articulated has three founding principles. Firstly,

to view the NHS as an institution with formal and informal rules, both overlapping and

not. Secondly, the challenges inherent in the process of organizational change (planned

and emergent) can be analyzed with respect to the degree of overlap that exists between

the formal and informal domain and the enforcement characteristics to enhance (or not)

the overlap. Thirdly, to understand the different rationales behind this overlap (or not) we

need to analyze how these reforms have historically been formed, how they are limited by

the existing conditions and are embedded into different institutional settings, at the local,

national and international levels.

3. Research methods

This research is based on based on two interpretive case studies carried out in a public

health organization, i.e. the National Health System (NHS) of Mozambique. The



interpretive perspective is based on the constructivist paradigm that social theory should

not be based solely on empirical observations stemming from general laws, but to

understand the social, one should analyze the reasons for the action of an actor (Walsham,

1993). In line with the interpretive approach, the case study presented in this research

‘assume that people create and associate their own subjective and inter-subjective

meanings as they interact with the world around them’ (Orlikowski and Baroudi, 1991,

p.15).

The Ministry of Health in Mozambique (called MISAU) has for several years been

attempting to implement various computer and paper based information systems to

strengthen the HMIS, for example to monitor the performance of health care and services

delivery, and to plan health interventions and resources. The NHS is comprised of

heterogeneous actors (for example, medical doctors, administrators, specialists, field level

workers etc), systems and programs (such as vertical programs for HIV, Malaria and TB)

that are organized in different interconnected levels of hierarchy (such as health facilities,

district, provincial and national directorates of health). The NHS can thus be viewed as a

complex ‘networked’ organization engaged in defining and implementing various

reforms, including decentralization and re-organization of health programs through

‘functional’ integration that also implies the need for information systems redesign.

Two researchers have conducted the data gathering process. One, guiding the first case

study as an ´involved observer’, engaged in the design of health indicators as an advisor

within the Ministry of Health. Two, guiding the second case study as an ‘outside

observer’, analyzing the challenges of health information systems integration across

different management levels from the health facility to the Ministry of Health

headquarters.

The first case study is based in the central headquarters of MISAU and involves the

consultative and participatory selection of national level indicators (in Portuguese, Lista

Nacional de Monitoria - LNM) to be used for monitoring and evaluating the

implementation of the key issues of the medium term plan of the health sector, i.e. the



Strategic Health Sector Plan (locally known as PESS1). One of the authors of this paper

was actively engaged in this entire participatory process over the years 2001-2003. This

engagement involved periodic meetings of a small technical working group on

monitoring and evaluation (TWG-M&E) of 4-9 people representing MISAU and the

donor community. Periodic seminars of 1-2 days were held to discuss the indicators,

originating from the TWG meetings, and furthermore formal interviews were conducted

with relevant health program managers (20), health information officers and officials of

different Departments (15) at the MISAU headquarters. Regular meetings were held,

initially twice a month during the first nine months (March-November 2001), and then

followed by meetings in three other periods of two months each (May-June and

November-December 2002, and May-June 2003).

This TWG-M&E was an instrument of the Sector Wide Approach policy (SWAp)

development process, established between the MISAU and the Mozambican Government

on one part and donors and UN Agencies on the other part (2000). The TWG and its

proposed draft lists were accountable to the fortnightly regular forum meetings (SWAp

Working Group Forum, in PT, GT-SWAP Forum) established for the discussion of issues

of mutual interest over the year. The list of indicators was formally approved through

regular consultation meetings held by the Minister of Health and by the policy

coordination bi-annual meetings (in PT, Comité de Coordenação Sectorial-CCS) of the

Ministry and their aid partners, within the SWAp agreement framework (2001). A

number of documents were consulted to provide inputs into the process including the

reference documents for the SWAp policy, such as the Government Poverty Reduction

Plan (PARPA) (MPF, 2001), PESS document, Code of Conduct (2000, MISAU, 2001),

and the existing lists of indicators, e.g. SADC list (SADC-Committee, 1999), WHO

Catalogue of Indicators (WHO, 1996), WHO World Report 2001 (WHO, 2001),

Millennium Development Goals Indicators(UN-MDG, 2000), UNGAS list (UNAIDS,

2002) and program specific indicator lists articulated in the annual operational reports.

The second research study involved the analysis of the attempts by the NHS to integrate

program specific information systems as mandated by the Directorate of Planning and

1 PESS is a Portuguese acronym of “Plano Estratégico do Sector de Saúde”



Cooperation (DPC) of MISAU. This study was conducted through an in-depth review of

secondary data including official reports and registers used to document health related

data in the MISAU headquarters. In addition, primary data were collected through semi-

structured interviews with key informants (such as health workers, persons dealing with

statistics, health managers and planners) and observation of work practices surrounding

the collection, processing, use and transmission of data over five time periods: June to

July (2001), May to September (2002), March (2003), August to September (2003) and

October 2004. Data collection was conducted in two (out of eleven) provinces of

Mozambique, namely Gaza and Inhambane where computerization efforts at the district

and provincial levels were ongoing. Table 1 below provides a summary of the interviews

conducted. A research diary was maintained to document relevant notes and in some

cases, a tape recorder was also used after taking prior approval of the concerned

respondents. All interviews were conducted in Portuguese and subsequently translated

into English during the phase of analysis carried along with the third researchers who was

non-Portuguese speaking.

Table 1 Summary of interviews

Table 1 – Summary of interviewees in relation to their working places

Working level

Health workers

Staff Responsible for statistics

Managers Total

Inhambane Province Maxixe health centre 5 1 2 8 Urbano health centre 3 1 1 5 Chicuque rural hospital 6 1 1 8 Other health facilities 8 2 1 11 Maxixe district office - 2 1 3 Inhambane-city district office

- 1 1 2

Provincial directorate of health

- 3 5 8

Gaza Province Chókwe-sede health centre 2 1 - 3 Chókwe rural hospital 4 1 1 6 Chicumbane rural hospital 5 1 1 7 Other health facilities 6 1 1 8 Chokwe district office - 1 1 2 Xai-Xai district office - 2 1 3 Provincial directorate of health

2 6 8



National Level 1 5 6

Total 39 21 28 88

In summary, the two case studies represents different ongoing reform efforts,

characteristic of similar ones going on in various other developing countries. While the

first one did not currently directly involve ICT, indicators can be viewed as important

information reflecting status with respect to different health services or diseases. These

indicators are in due course expected to be computerized. The second case study

explicitly concerns the health reform agenda related to information systems integration as

a basis to strengthen the delivery of health programs. Inputs gained from the comparative

analysis is useful to discern similarities and differences with respect to the role of ICT,

different organizational conditions, varying donor influences etc. The formal and

informal institutions operating in these two cases thus have both similarities and

differences, which will help us to help us unpack the varying consequences of the

organizational change processes (in the two settings).

4. Case studies

In this section, we present the two case studies. 4.1 The process of designing health indicators

Mozambique is highly dependent on external funds and international aid. During the

Emergency and the transition periods (1990-1994), international aid to Mozambique was

one of the highest in Sub-Saharan Africa, amounting to $1.1 Billions, nearly 50% of the

GDP. (Hanlon, 1996, p. 16). This reflected a sharp increase from the pre-1985 period

where the international aid was about $14.7 million comprising 23.5% of the total

national budget of $62.6 millions. The multiplicity of sources of funding for the national

budget led to a proliferation of projects (nearly 450 in number) sponsored by different

agencies, and prompted a comment by the (World-Bank, 1990, p. 63) Minister of Health

in 1989 (during the emergency period) that the Ministry should move away from being

the Ministry of ‘health projects’ to a Ministry of ‘health services’ (Hanlon, 1996, p. 46).

During the years 1990-1994, international aid to the health sector was provided by the

IMF, World Bank, the African Development Bank (ADB), and a large donor community



comprising of multilateral agencies such as UNICEF, UNDP, WHO, UNFPA, the

European Union, as well as bilateral aid, where the major actors were: the Swiss

Cooperation (from 1992 to 1998 was the leading donor to the health sector), France, Italy,

Spain, the Nordic group (Norway, Finland, Sweden and Denmark), followed by USAID,

Canada and the Netherlands. (Pavignani and Durão, 1999, p. 245).

The formal evaluation of the National Health Services (NHS) and MISAU activities

carried out in 1990 (MISAU-OMS et al., 1990) detected a divorce between the processes

of budget allocations and planning with adverse implications on the capacity of the

MISAU to control the allocations. In 1990, a common pooling of donor funds was

channeled to the provinces through a parallel, but shared budget. During the years of

transition from war to peace, the Swiss Cooperation was accepted as a ‘leading donor’ for

the health sector, with the responsibility to organize periodic meetings of the donors and

to coordinate interventions by ‘zones’. Every major donor was made responsible for a

geographical area in order to concentrate resources and reduce overall costs, thus trying

to make the use of funds more effective (Walt and et all, 1999, p. 274). In 1995, the

Health Sector Recovery Program was signed on one side by the Mozambican Ministry of

Planning and Finance (MPF) and MISAU, and on the other side by the World Bank and

some other donors. This program aiming at rebuilding the health facilities that had been

destroyed by the war, providing qualified human resources and the supply of drugs, and

to also create a ”common basket’ of funds (World-Bank, 1995).

This above program, including the previously mentioned donor coordination and other

institutional arrangements, e.g. about technical assistance were among the ‘building

blocks’ of a policy oriented to the SWAp2 (TAG et al., 1998, p. 1). At the end of the

1990’s the SWAp, was adopted in various sectors, e.g. Agriculture and Health, to

2 Sector Wide Approach policy (SWAp) is a sustained partnership led by national authorities, involving different government institutions, groups in civil society, and one or more donor agencies. It includes an appropriate institutional structure and process for negotiating strategic and management issues. It accompanies institutional reforms and capacity building, relies on a collaborative program of work focused on sectoral and multi-sectoral policies and strategies, medium-term plans, agreed common arrangements on the areas of planning, financing and monitoring. Definition adapted from the booklet “Sector Policy Review Tool”, Royal Tropical Institute (KIT), Amsterdam, The Netherlands, 2004, Part Two, Figure 1, p. 23



stimulate the Government to allow the Ministry of Planning and Finance to play an

increased and lead role in taking and coordinating local action with other Ministries and

the donor community. This adoption was also expected to speed up public administration

reforms related to management, planning and financing. Currently, through a large pool

of donors (23 bilateral and 23 multilateral), Mozambique continues to receive more than

half a billion each year in development assistance representing about 69% of the

country’s GNI 3 (OECD) and half of the Government health budget. This makes the

Government of Mozambique as the recipient of the highest per capita Official

Development Assistance (ODA) in Africa (Aid-Harmonization-Alignment, 2004).

In 1999, MISAU signed a formal agreement (called Code of Conduct) with the main

representatives of the donor community (2000) that defined the development of new

institutional arrangements and shared objectives and targets to be achieved. There are

basically two key instruments of policy discussion and definition, aid coordination and

support on technical and operational activities. The first relates to two large gatherings of

the national joint committee (CCS), chaired by the Minister and Vice-Minister of Health,

where policy issues are deliberated or adopted and where the participants (about 80 to100

people) are the same as in the GT-SWAP Forum plus one Director of Provincial

Directorate (in rotation), other Ministry officers and NGO representatives. The second is

the above mentioned working group (GT-SWAP Forum) that meets regularly every 15

days and usually has a large representation (up to 30-50 people) including top managers

from MISAU (Minister, Vice Minister or Permanent Secretary, National Directors),

program managers, bilateral donors, and representatives from credit agencies and UN

Agencies such as WHO, UNICEF and UNFPA. This forum prepares the two annual CCS

and creates ad hoc small technical groups to assist the joint elaboration of technical

understandings, position papers and documents. One of these sub-groups was the TWG-

M&E set up to try and help rationalize the existing “common baskets” into one single

fund and the elaboration of the first common, strategic plan for the health sector (called

PESS). For the elaboration of the PESS document, MISAU organized over one year

3 Gross National Income (GNI) is the sum of value added by all resident producers in the economy plus any product taxes (less subsidies) not included in the valuation of output plus net receipts of primary income from abroad. Extracted from Definitions, p. 271, HDR 2004, UNDP.



(2000), several thematic working groups, comprising of Maputo based health

professionals, health and academic institutions, and the donor community. In some cases,

provincial level health staff and civil society representatives were also involved. The

PESS document approved in April 2001 (MISAU, 2001) served as a reference for

implementing the following SWAp goals:

1. A better management of services and an integrated planning process throughout the

different departments and levels of health care delivery,

2. Increasing the volume of grants and loans channeled through mechanisms of common

funds and Government budget transfer (in-budget), with a parallel reduction of the

earmarked and vertical funding.

3. More efficient accounting and increased transparency of financial management at

every level of health services,

4. The establishment of an integrated monitoring and evaluation system for assessing

results of plans and performance.

The major components of a sound SWAp process implies agreements between partners in

the health sector resting on three pillars (MISAU et al., 2002a, p. 1), as follows:

Table 2 Three major components of SWAp process

1. Agreed Sectoral Objectives ⇓

2. Agreed medium Term plans based on medium term expenditure framework

⇓

3. Agreed annual plans based on funds available

⇓

⇒ SWAP ⇐ 4. Agreed performance monitoring tools with annual review

5. Agreed common financial and accounting systems and procedures.

Source: Report of First Joint Mission to evaluate the performance of the Mozambique Health Sector in 2001, p. 1, MISAU, September 2002.

Unfortunately, the final PESS document did not include quantified objectives and

relevant indicators. In March 2001 the technical working group (TWG-M&E) was



created by the GT-SWAP Forum, including nine people: representatives of MISAU,

bilateral donors and UN agencies. This group’s mandate was to establish a commonly

agreed frame for periodic assessments of PESS implementation. The first draft of the list

was based on the health systems’ assessment indicators of the SADC4, Monitoring and

Evaluation Committee (1999) combined with performance assessment indicators

proposed by WHO in Geneva. From April to June 2001, the first draft was discussed with

respect to the relevance and value of specific indicators with all departments of MISAU

and identified adjustments, inclusions or cancellations were carried out. A large

workshop concluded this first consultative phase, where indicators were selected and

grouped in three categories (see Table 3 below).

Table 3 Conceptual Frame of the National List of PESS Indicators (approved in November 2001,

Maputo, MZ)

Indicator selection and definition represented a long and complex process. The list was

expected to force different departments to monitor their performance with minimum data

in line with the program measurement objectives outlined in the PESS document. A

manager of the malaria program said: “how can you dare reduce the entire malaria

program assessment to a single indicator?”. The total number of indicators was

4 SADC stands for Southern African Development Community and was created in April 1980, following the adoption of Lusaka (Zambia) Declaration: Towards Economic Liberation. Since August 1992 (Windhoek, Namibia) a Treaty signed by Heads of following States: Angola, Botswana, the democratic Republic of Congo, Lesotho, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, United Republic of Tanzania, Zambia and Zimbabwe commits the respective governments to act for a common and regional development, well-being and improvement of standards of living and quality of life.

Key Issues PESS Functions of the System General and Impact

Access, equity and gender Quality of services and priority programs Advocacy and individual and collective strengthening Financing Strategy Institutional Development

Direction Financing Resource allocation and management Service provision

Macro-economic Absolute poverty alleviation Population’s health status



continuously oscillating: from the initial number of 38 groups in April, to 45 in June, 60

in October and then back to 53 in November 2001. These variations reflected an

intensive negotiation process between the TWG-M&E members, who tried at the same

time to reduce and simplify the list while covering all the main priorities and activities.

During the first workshop, consensus on the first draft was not reached, which led to the

opening of a second phase in order to verify every indicator proposed in the national list

against the most commonly used ones by the different programs and to then select again

the list. The formal list was approved by the CCS in November 2001.

At times the process seamed endless. Donors wanted clear dates for the approved list, as

it had to be used as a reference for disbursing funds. In November 2001 at the CCS, the

first official version of the list was approved, containing 53 groups of indicators

(equivalent to 95 single indicators), 44 to be collected annually and the remaining 9 every

2-5 years. Out of the total, 19 represented a ‘short list’ that included all core indicators

covering three subcategories: ‘macro-economic’, ‘absolute poverty alleviation’ and

‘population’s health status’. This conceptual frame is still unchanged until today.

After the approval, in December 2001, a detailed plan for data collection and inventory of

sources was prepared to implement the indicators. Before the first joint annual appraisal

(ACA-I) of the NHS performance carried out in July 2002, two officers, based at

MISAU-DPC, tried to gather data for the calculation of the indicators. In June after two

months of intensive work, only 50% of the total indicators (e.g. 26 groups) were

delivered to the evaluation team (MISAU-DIS, 2002). The main obstacles encountered

during the data collection and aggregation are reported as under:

• Delay in the data submission from the Provincial Directorates.

• Great difficulty to convey financial data from multiple sources into consolidated

and aggregated figures. Government budget was released by the Ministry of

Planning and Finance. Donor funds were channeled directly to MISAU-

headquarters; and other common funds were in separate foreign accounts, e.g.

funds for drugs and for provincial support. This multiplicity of funding and



banking arrangements contributed to various data flows and consequently

inefficient financial management overall.

• There were delays and discrepancies between data received from parallel flows of

vertical programs and the data provided by provinces to the Department of Health

Information Systems (DIS).

• Some data on quality of services was incomplete or not available despite this issue

being high priority for MISAU and among those earmarked for evaluation under

ACA-I.

• As expected, the surveys used as sources for some of the impact indicators

identified (Table 3) were backdated, and figures available were only calculated

projections.

The final ACA-I report analysed in detail the list (MISAU et al., 2002b, p. 7-40) and

suggested significant changes to the LNM. The evaluation team suggested that the 53

indicators should be reviewed and reduced in number. In October 2002, after the ACA-I

Final Report publication, the GT-SWAP Forum instructed the TWG-M&E to perform the

revision of the LNM, through focusing consultations with several Departments, especially

with the Finance Directorate (DAG) at the HQ level. The DIS extended this revision to

the provincial officers of planning and cooperation by organizing a national workshop

(Namaacha-11-13 December 2002). The ‘short list’ of 19 indicators was discontinued,

and the total number reduced then to 36 groups, subdivided as before in three tables and

according to the same conceptual frame. Out of the total, 7 were to be collected every 2-5

years, 24 annually and 5 quarterly in order to monitor the execution of the operational

annual plan (POA 2003). The third version of the LNM was approved by the GT-SWAP

Forum and confirmed by the CCS in June 2003 and remains unchanged until today,

except for the addition in April 2005 of a few essential and internationally agreed

indicators on HIV/AIDS.

Given the difficulty in producing complete and timely indicators, this consultative

process can be considered very rich in terms of lessons learnt and crucial for triggering

further action towards the development of an improved Health Management Information



System (HMIS). The point of view of many actors involved in this process of selection

can be considered as “minimalist,” implying a focus on identifying the minimum number

of most relevant issues. For instance, as a representative of donors said during a GT-

SWAP Forum meeting “the list of indicators should not be so complicated, it can be

reduced to 10-15 key ones to help assess the overall performance of MISAU and NHS, in

order to help the donors to decide whether or not to disburse the funds”. However, the

value of the LNM is not only limited to the donors. The LNM empowers Mozambican

managers to control their own monitoring, for example they have established when and

how to measure the quality aspects of programme such as emergency obstetric services,

TB, STI, AIDS treatment, with the their own definition of datasets and formulas.

Establishing periodic mechanisms for monitoring and evaluation contributes to the

building up of a sense of ownership on national instruments of negotiation between the

Mozambican government and their aid partners. The indicators calculated in the first year

represented useful ‘benchmarks’ to make the health sector more accountable towards the

Government and the donor community. These baseline indicators can be used for future

adjustments of the strategic development process. The long process of selection helped to

change the perspective in many health initiatives. SWAp and PESS strategies urged

complex programmes as the fight against HIV/AIDS, and administrative processes such

as ‘financing strategy’ or ‘better planning cycle’ to enhance the coordination of activities

and resources among different departments, aiming to achieve better results on equity and

efficiency. This enhanced coordinated action and the need to measure new indicators

demanded more coordination in every step of the information cycle (collection, flow, new

aggregation formats and analysis of data), challenging the historically existing

departmental borders and the barriers that hamper this cycle.

4.2 The case of integration of program specific information systems

As stated in the previous subsection, healthcare services in low income countries like

Mozambique are usually provided in collaboration between national authorities, foreign

aid agencies and NGOs. Mandatory requirements to demonstrate funding accountability

and short-term results have led donors to promote vertical (donor-driven) programs

operating, such as those centered on specific diseases (e.g. malaria, HIV/AIDS) or health



problems (e.g. reproductive health) (Oliveira-Cruz et al., 2003). Such vertical programs,

which tend to oppose an integrated approach to health care delivery, have been reported

to contribute to a state of fragmentation and redundancy, and associated problems

(Hutton, 2002, Cassels and Janovsky, 1998).

The recognition of such problems has in recent years led national governments and some

aid organizations to try to promote broader health system development initiatives (e.g.

SWAp) so as to integrate specific vertical programs into routine health care delivery.

However, achieving this integration in practice is a complex undertaking (Oliveira-Cruz

et al., 2003), characterized by tensions between the ‘system designers’ (management and

planning specialists), who promote the overall operation of the health sector, and the

specific program managers, who are concerned with particular disease control strategies.

The situation is made more complex with a single vertical program being supported by

several bilateral and multilateral agencies, and comprised of a multiplicity of components,

including their information systems.

The analytical focus of this case is on the vertical program STI/HIV/AIDS5 and the

ongoing dilemma of integrating existing reporting systems, both paper and ICT based,

within a broader framework of vertical program delivery. In Mozambique, the efforts of

national STI/HIV/AIDS program has centered on informing individuals and institutions

of a range of preventive measures and to improve care to infected people by enhancing

the availability and accessibility of anti-retroviral drugs, especially within the Prevention

of Mother-to-Child Transmission (PMTCT) component. Accessibility of drugs

significantly influence the politics of funding and contribute to debates over the rates of

growth of the disease (Barnett and Whiteside, 2002). In Mozambique, a number of

initiatives are currently ongoing such as the Global Fund for HIV, Malaria and TB; Bush

initiative, Clinton’s foundation, as well as through NGOs, government, NORAD

(Norwegian Agency of International Development) , the Center of Diseases Control,

Atlanta, PSI (Population Services International), DANIDA (Danish International

5 STI/HIV/AIDS – stands for Sexually Transmitted Infections/Human Immunodeficiency Virus/Acquired Immuno-Deficiency Syndrome



Development Agency), the WHO, UNDP, UNAIDS (the joint United Nations Programs

on HIV/AIDS) and USAID (United States Agency for International Development) to

name a few. Aiming to avoid the duplication of efforts and minimize fragmentation, all

the stakeholders have recently agreed on a platform called Three Ones Commitment

(DFID Health Systems Resource Centre, 2005).

The Three Ones Commitment include: (1) one agreed HIV/AIDS Action Framework that

provides the basis for coordinating the work of all partners; (2) one national AIDS

coordinating authority, with a broad based multi-sectoral mandate; and (3) one agreed

country level Monitoring and Evaluation system, including one integrated information

system for the program as a whole.

The need for integration of the disparate information systems was described by a Ministry

of Health official as follows:

Integration is one of the greatest preoccupation in the Ministry of

Health…Strategic creation of one single database seems desirable. We feel that

the introduction of SIS.D6 is the solution. All subsystems or components not

included in SIS.D can be designed and incorporated in this application as

Modules. For example the system for STI/HIV/AIDS…” Said the head of the

Department of Information for Health, October 2004.

Integration is also being planned through various other mechanisms, such as:

(a) To have a standardized collection system in place also in the provincial, regional

and central hospitals, as well as in the private sector by 2006;

(b) To have established electronic communication (e-mail and internet) and

reinforced ICT at the district and provincial directorates of health, including a web

page, LAN-WAN and intranet at the Ministry of Health headquarters;

(c) To allow for a thorough and progressive integration of all systems related to

resources (funds, staff, maintenance, etc.) and health care (volume of activities in

healthcare facilities).

6 SIS.D is a Portuguese acronym of Sistema de Informação de Saúde Distrital meaning “District Health Information System”.



Within this broader quest for integration, we describe the current context of the HIV

program with a focus on their information systems. A national strategic plan to fight

STI/HIV/AIDS-health sector 2004 to 2009 was recently launched (MISAU, 2003) which

establishes nationally 15 different components as well as 9 supporting services. Some key

components included in this are (i) promotion and distribution of condoms; (ii) diagnosis

and treatment of STI; (iii) Information, Education and Communication (IEC); (iv)

Voluntary, Counseling and Testing services (VCT); (v) Prevention of Mother-to-Child

Transmission (PMTCT); (vi) Treatment of Opportunistic Infections (OI) (including

tuberculosis); (vii) Control of Diarrheas (CD); (viii) Anti-Retroviral therapy (ART) and

(ix) Safe blood transfusions. Each of these components usually has its own coordinating

team which may be located in different departments in the directorates at the provincial

and national levels. For example: while the PMTCT is coordinated in the Community

Health Department, the ART and VCT components are coordinated by the Department of

Communicable Diseases and the component of Safe blood transfusions is by the Medical

Assistance Department. The overall coordination of these components is done by a

Technical Group of HIV/AIDS Monitoring and Evaluation, which meets every week.

This Technical Group is comprised by at least one key member of each component as

well as planners from the National Directorate of Planning and Cooperation of MISAU

and other funding agencies.

Monitoring &

Evaluation GroupNational Directorate

of Health

National Directorate

of Planning &

Cooperation

Production of ReportsProgram Management

Production

of Reports

Program

Management

DataBank

Dissemination

twice a year

Partn

ers

monthly

Provincial Department ofPlanning and Cooperation

Component Managers Departmentsof Community Health and MedicalAssistance/ Provincial Hospital

monthly

District Directorate ofHealth

Statistics Group

Hospital

PMTCT, STI, TB, HAART,OI, Laboratory, Bio-safety,Safe Transfusion, Mental

Health

monthly

Health Area

Health Center

PMTCT, STI,TB, HAART,

OI

HBC, VCT,YFHS

Note: NGOs report to the Hospital level and the Health Center level

Figure 3 - the ambitious routine "integrated" information system for ITS/HIV/AIDS

FEEDBACK

monthly

Source:MISAU-DPC (2004)

Figure 3 the ambitious routine “integrated” information system for ITS/HIV/AIDS



In order to monitor and evaluate all these components, one plan has also been established

based on an ambitious “integrated” information system (MISAU DPC, 2004), as depicted

in Figure 3 above.

Notwithstanding its objectives of integration, the implementation of this model has

resulted in multiple compartmentalized information systems, representing “islands” with

an independent decision-making structure, an internal reporting system, resource and

information sharing (Figure 4). How this fragmentation works in practice is depicted

through Figure 4 below, and then the key characteristics are described.

National

Province

District

Health

Facility

Antenatal clinic VCT CenterBlood Bank

(Safe transfusion)

AIDS cases,

STI, ART, OI

Data collectionand collation

Data collection

and computerized?

Data collectionand collation

Data collection

Aggregation indistrict hospital

Aggregation in

province hospital

Data computerized

and used

Monthly Reporting

Data computerized

Aggregation

Data computerized

Analysis, use

Aggregation indistrict hospital

Aggregation in

province hospital

Data computerized

and used

Dataaggregation

Dataaggregation

Data in paper

format, aggregated,

validated

Data

computerized

and validated

Data computerized

and used

Data analyzedand used

Infected Pregnantwomen (PMTCT)

VolunteersBlood donors STI/HIV/AIDS

Patients(1) (2) (3)

(4)

Monthly Reporting

Quarterly Reporting

Monthly Reporting

National Department ofCommunity Health(PMTCT headquarters)

National STI/HIV/AIDSControl Program

National BloodTransfusion Programme

National Department ofCommunicable Diseases

National Department ofHealth Information

Figure 4: The "unruly mélange" of the existing information systems for STI/HIV/AIDS program in MozambiqueSource: Adapted from Chilundo and Aanestad (2004)

Figure 4 The "unruly mélange" of the existing information systems for STI/HIV/AIDS in

Mozambique

There are at least four parallel flows of data originating from Antenatal clinics (PMTCT),

VCTs, Blood Banks and inpatients in hospitals. Some key characteristics of the

information flows are described below:

(1) Data from PMTCT activities originating from health centers are sent on a monthly

basis upwards to the rural hospitals, then provincial hospitals and later on to the

PMTCT office in MISAU headquarters. This flow implies that data are shared



minimally between the district and provincial managers. Planners at the National

Directorate of Planning can only access the data by requesting the PMTCT

component, located in the Community Health Department (part of the National

Directorate of Health).

(2) Routine system for reporting data from VCT centers is on a monthly basis. It is

operated directly by HIV/AIDS program together with NGOs.

(3) The routine system for reporting blood banks’ data is on a quarterly basis. HIV tests

of blood donors are reported by the blood bank channel at all levels with transfusion

facilities as part of the National Program of Blood Transfusion.

(4) Routine system for reporting on inpatients with AIDS is the responsibility of the

Department of Communicable Diseases operated together with the HIV/AIDS

program. The channel reports monthly data from infirmaries, both clinical AIDS

based on Bangui criteria and laboratory confirmed HIV cases. There is also another

“parallel” system that also reports AIDS cases as part of the district hospital reporting

system. As a result there is duplication of efforts in addition to important under-

reporting as reports are only sent from district hospitals while the majority of AIDS

patients are seen in the provincial and central hospitals. More recently another

subsystem has been established to report the number of HIV patients under ART and

those treated for opportunistic infections (OI) at the Day Hospitals. Finally, a routine

subsystem for reporting STI also exists. These data are mainly captured on adults and

Mother and Child consultations, and sent upwards on a monthly basis to the National

Department of Communicable Diseases.

The information system is thus comprised of several parallel and overlapping information

flows, which inhibits integrated analysis, and places a high burden of uncoordinated

components of the STI/HIV/AIDS program. This picture is aggravated by the historical

lack of horizontal data analysis at the facility, district and provincial levels. Also, the

overemphasis on data aggregation and reporting to the national levels masks the picture at

the disaggregated levels and inhibits focused intervention. The sheer inadequacy of the

human capacity both with respect to numbers and also quality, serves as a major

bottleneck at all levels of the health administration structure.



5. Analysis and discussion

How we can understand the complexity and the interdependence surrounding the

organization of health sector institutions in Mozambique during the phase of

administrative and health reforms and external aid rationalization?

The two case studies presented in this paper try to respond to this question showing the

patterns of the change at different levels and the opportunities that these changes open to

the development of more effective health information system and the introduction of ICT.

In this section, we analyze both cases with respect to the following three questions:

What is the nature of the complexity that surrounds the relationship between the reform effort and the organizational change? What is the kind of organizational change that can be discerned with respect to anticipated or emergent changes? What implications can be drawn to make more effective the management of these change processes?

5.1 What kind of complexity?

Complexity arises as a result of the interdependencies that exist within components of a

system and also on the kind of linkages that exist. Hanseth et al (2005) describe

complexity relating to an Electronic Patient Record (EPR) system in the following

manner drawing upon Cillier’s (1998):

A complex system is made up of a large number of elements interacting in a

dynamic and non-linear fashion, forming loops and recurrent patterns which

involve both positive and negative feedback; it is open in the sense that it is

difficult to define the borders between it and other systems; it has “history”: its

past is co-responsible for its present as well as its future; and each element is

ignorant of the system as a whole, responding only to information available

locally. This broad definition will underlie our conceptualization of the systemic

nature of the EPR throughout the paper (p. 6).

Complexity is this thus shaped by the number and types of components, their inter

linkages, and the speed of change that influences these links. The notion of history is

important to understanding complexity as it shapes processes of path dependence, which

is described as a key facet of complexity (Urry, 2003). The notion of formal and informal



institutions and the degree of their overlap helps us to further unpack the complexity in

the change processes studied.

5.5.1 Complexity in the process of design and selection of indicators

The indicators are basically the tools we use to convert day-to-day observations (e.g.

cases of the diseases, resources usage, services coverage, etc. as related to the size of

target population at risk of the event) into useful information for decision-making by

enabling comparison between different facilities or regions or countries. The value of a

health indicator relies upon the quality of the data used to calculate it (both the

observations and reliability of the population target in the community), the relevance of

the events that it intends to measure and their interpretations by health workers or

managers in the service of particular interests, purposes and population.

Indicators for the health sector have historically existed for decades in developing

countries (WHO, 1996) originating from the experiences and traditions of technical,

vertical programs and interventions. However, contemporary selection of health

indicators introduces a range of further challenges because the number of ‘global’

indicators is rapidly growing as M&E of programs and results oriented assessment

become more fashionable among credit agencies such as the World Bank and UN

agencies (including UNDP, UNICEF, UNFPA and others) (PARC, 2004) (UNDP, 2001).

This complexity is aggravated by the presence of multiple donors in Mozambique often

with heterogeneous agendas and priorities among them.

At each phase in the history of Mozambique, multiple donors have participated and

contributed to defining different modes and degree of coordination, and to the

harmonization of policies between the Government and aid partners. Due to the

heightened development assistance, the experience in experience in Mozambique has

shown that at each phase, for example ‘projects’, ‘zoning’, ‘common baskets’ and SWAp

- the modus operandi of donors have significantly influence the management and

financing of MISAU. These impacts are not limited to internal planning and management

in MISAU, but also to enhancing the heterogeneity in the donor efforts. The numerous



office representations of bilateral and multilateral donors are still divided by the degree of

adherence and acceptance of SWAp. For example, the group of ‘pioneers’ such as the

Scandinavian countries and the Netherlands are keen to operate all interventions through

a single common fund, while other bilateral donors such as France and Italy prefer a dual

approach, while others such as USAID continues purely bilateral and promoting vertical

interventions. Also among credit agencies such as the World Bank and UN agencies,

there are significant differences in their adherence to the SWAp principles. The long and

sometimes difficult discussion for the selection of indicators reveals a power sharing

negotiation occurring within MISAU.

As a consequence, data collection and variables do not have an independent, internal

rationality, they rather reflect the vested interests of the multiple actors who have in

common the ‘stage’ of national list production, but continue to reflect their own

managerial habits, technical backgrounds and departmental influences. The negotiation

for the list among MISAU officers has shown that managers of predominant technical

programs tend to perpetuate their traditional functions of central organizers of service

delivery, advocating more indicators because this better protects their variety of technical

competence and prerogatives. On the other side, managers of supportive services,

financing and planning departments prefer fewer indicators more suited to measure the

cross-cutting functions and corporate coverage rates and outcomes. Despite the different

“agendas” of the multiple actors involved, a negotiation tool helped to diffuse some of

these differences by facilitating formal and informal negotiation among actors. The initial

formal commitments of all stakeholders determined to change their relationship under

SWAp was a driving force, but official documents did not provide enough power to

overtake preexisting norms, for example, such as existing multiple vertical program

indicators. While PESS strategies can be respected and observed formally, they are not

enough to deal with the internalized acceptance of authoritarian management styles, that

assign ‘directors’ with the prerogative of always being “right.”. The divergent and at

times contradictory donor vested interests coupled with the mélange of formal and

informal norms of Mozambican staff and donor representatives, required a forum and



space for negotiation. While the SWAp process formally enabled this, informal

communication processed helped to solidify them and make it more effective.

5.1.2 The complexities of information systems’ integration

Typically, in the national health system, information systems are designed and

implemented to build health indicators. The calculation and presentation of indicators at

the national level is fundamentally dependent on what data is fed to it from the various

preceding levels including the province, districts and health facilities. The delay and

difficulty in receiving timely data and the positive contribution of provincial health staff

in the selection process reiterates the importance of considering the concrete capacity of

the health information system to channel data as the crucial reference and background of

any proposed monitoring system.

The ultimate end of establishing health information systems is specifically to collect

essential data at the facility and community levels to calculate the indicators which allows

the measurement of the performance of various programs. The baseline is thus the

community and the health facility levels where all health related events occur. The

‘bridges’ are the districts and provincial levels which are intermediaries between the

headquarters of MISAU and health workers on the ground. In the community and health

facilities, activity data are collected about special programs, routine services, and

epidemiological events in addition to semi-permanent data (i.e. data that change more

slowly) which comprise population, and administrative data. Activity data form the

numerator and population figures the denominator in the calculation of indicators.

For the health program in question in this study (STI/HIV/AIDS), the selected key

indicators (e.g. HIV prevalence rates among pregnant women, percentage of domiciliary

patients under ART, treatment dropout rates, mortality rates, etc) are presently

constructed through varying work practices surrounding the processes of data collection,

analysis (including the calculation of indicators) and their transmission to higher levels.

These processes are shaped by the social, political, economical and ethical context. Some



examples are now provided. For example, these work practices are performed by health

workers who have the primary task of attending and treating patients. Due to the huge

shortage of staff (Economic Commission for Africa, 2003), the work burden on the

personnel is extremely high. The daily work is primarily patient focused, and the

registration and reporting is perceived as secondary tasks. The primacy given to patient

encounters adversely influences the data collecting procedures. For example, often

registering data on the number of patients seen or of condoms or drugs distributed are

through mere approximations at the end of the day after the patients have been seen

(Mosse and Sahay, 2003). The limited value attached to registering and reporting work is

reinforced by the widespread attitude that data is being registered, reported and collected

mainly for reasons of bureaucracy and not to support local action. The data collecting

activities thus become an institutionalized routine that must be performed as a part of the

job (Chilundo and Aanestad, 2004). The divide between care and administration

becomes greater by the rapid increase of HIV/AIDS cases. In 2000 Mozambique had the

prevalence rate among adults (15 to 49 years of age) of 13.0% (INE et al., 2002) and in

2002 (INE et al., 2004) was 13.6%, which means more HIV/AIDS clients are

overwhelming the few health workers. This is then further taking away their attention

from performing the routine administrative tasks which in themselves are also increasing

as the data needs are becoming more extensive and sophisticated.

Because HIV/AIDS is a relatively a new phenomenon, the health network is being

adapted to increasingly respond to the new and increasing demands on both the clinical

and administrative fronts. The response has come through various reform efforts whereby

the STI/HIV/AIDS programs have established a number of services in terms of

components (15) which encompasses all the 98 mandatory indicators to be routinely

calculated, implying the introduction of a range of new data collection tools that must be

filled in by the already overburdened and inadequately trained health staff. At every

administrative level through which the data flows (from the health facility to the district

and to the provincial and national levels) there are complex and heterogeneous networks

in operation comprised of people, artifacts, values, work practices contingencies and

politics which shape the representation of what data gets captured and reported. For



example, Chilundo et al. (2004a) report how at the national level, the managers of the

blood transfusion program add a 40% correction factor to the reported figures to

compensate the district underreporting.

In trying to situate the picture of the STI/HIV/AIDS program’s information systems

within the whole national health system, the influence of the complex historical context,

or what Avgerou (2002) calls as “organizing regime” can be interpreted. The existence of

multiple and uncoordinated information systems within the STI/HIV/AIDS program are

not an isolated situation within the Mozambican NHS but a historical reality. Another

study conducted by Chilundo et al. (2004) also reported that malaria data are being

reported through four different and compartmentalized channels that prevent the

construction of an overall picture of the disease prevalence in the country, with

significant adverse implications of the interventions targeted to fight this disease.

Largely unmindful or insensitive to this historical fragmentation and the reality of the

local work practices that surround the information systems, the health reformers (MISAU

officials and donor agencies) continue to make rather ambitious plans for the integration

of the information systems. The formal, technical and rather top down approach to this

reform effort represents a radical divorce from the informal practices that exist on the

ground. While the efforts to try and harmonize at the top through efforts like developing

national level indicators is a welcome step in the right direction, these are extremely

complex to implement on the ground because of this divorce. This implementation

requires political negotiations between the multiple donors, reformers, planners and

managers, to make explicit the various rationalities and tensions in play and to also try

and arrive on a consensus in where efforts need to be best directed, for example to build

up the information handling capacities of the health staff and to ease some of their work

pressures. Often the donors’ main interests are to ensure that the financial support being

given is well utilized and has a desirable impact which they seek to control through

budgetary mechanisms (Chilundo and Aanestad, 2004). Administrative aims of

controlling corruption and improving efficiencies often contribute to the promotion of



individualized information systems rather than integrated and comprehensive ones best

suited to managing the disease.

CODE OF CONDUCT

STRATEGIC FRAMEWORK OF THE

HEALTH SECTOR (PESS)

GT-SWAP

SET OF VERTICAL PROGRAM'S INDICATORS

SECTORAL COORDINATION

COMMITTEE (CCS)

STRATEGIC PLAN OF HIV/AIDS

MULTIPLICITY OF INDICATORS' DEFINITIONS

INFORMAL NEGOTIATIONSAUTHORITARIAN STYLE OF

MANAGEMENTINFORMAL MEETINGSDONORS' OWN AGENDACULTURAL DIVERSITY

NATIONAL LIST OFMONITORINGMONITORING AND EVALUATION

OF HIV/AIDSTWG-M&AWORKSHOP & MEETING

TIME

FORMAL RULES

INFORMAL RULES

FORMAL & INFORMAL RULES

Figure 5 - The overlap of formal and informal rules in the process of indicators' selection

INPUT 1

INPUT 2

OUTPUT 1+2

Figure 5 The overlap of formal and informal rules in the process of indicators' selection

Figure 5 schematically depicts the selection of indicators as a process lasting over several

months. At the beginning, a series of official documents and commitments endorsed by

all stakeholders (formal rules) pushed towards a speedy production of a national list,

which was simultaneously challenged by the pre-existing set of indicators of the vertical

programs. The process was enabled by various multiple institutional arrangements like

the parallel structures and also the informal negotiations, and also inhibited by the

authoritarian style of management. These together produced an overlapping area of the

formal and informal institutional and negotiations arrangements that contributed to the

final approval and use of the LNM.

Figure 6 depicts a set of formal rules with respect to the information systems integration

case. This includes the monitoring and evaluation plan for HIV/AIDS, a management

information system design strategy for integration, and a set of information tools. These

formal rules and plans largely failed to take into account during the implementation, the

influences of various informal rules and norms historically existing due to conditions of



donor influences, departmental ownership, individualized set of information tools and a

weak culture around data use and it s analysis. This resulted in a great divergence

between the formal and informal, and this lack of overlap, we argue, contributed to the

ineffective results in integrating the HIV/AIDS reporting systems. How this institutional

mismatch will be reduced in the future still remains an open and unsolved question.

However, the indicator selection process provides us with some insights to approach this

problem which we discuss in the final section on implications.

ONE MONITORING & EVALUATION PLAN FOR HIV/AIDSONE INTEGRATED MANAGEMENTINFORMATION SYSTEM DESIGNSTRATEGYONE SET OF INFORMATION TOOLSSET OF PROCEDURES DEFINED

DONOR DRIVEN INFLUENCEDEPARTMENTAL OWNERSHIPINDIVIDUALIZED SET OFINFORMATION TOOLSCOMPARTMENTALIZEDCOMPUTERIZATION EFFORTSPOOR HABIT OF DATA ANALYSIS

FORMAL RULES

INFORMAL RULES

INTEGRATED PLANNINGCOMPROMISEDHARD TO CALCULATEINDICATORS IN ACOMPREHENSIVE MANNERCOMPARTMENTALIZEDDECISIONS

MULTIPLICITY OF REPORTING

SYSTEMS

HARD TO SHARE DATA

DUPLICATION OF EFFORTS

STAFF OVERWORK

DIVERSITY OF COLLATION TOOLS

POOR DATA QUALITY

INPUT 2 OUTPUT 2

INPUT 1 OUTPUT 1

TIME

??

Figure 6 - The lack of overlap between the formal and informal rules in the implementation of information systems of the various components of the HIV/AIDS program

Figure 6 The lack of overlap between the formal and informal rules in the implementation of

information systems of the various components of the HIV/AIDS program

5.2 What is the nature of change?

Health sector reform is an ongoing process of reorganizing the public sector

administration by challenging the institutional bureaucracies in MISAU, challenging its

duties distribution, power balances and formal rules through the complex matter of

selecting health indicators. Change, both planned and emergent, guide these ongoing

processes of reform.



The indicator definition case is guided by the SWAp framework which is pushing for

“planned change” calling upon new and formally agreed methods of performance

assessments which are expected to feed back into new forms of planning and financing.

As the relationships between the different stakeholders becomes more mature and

develops into a national and transparent agenda based on single channel of external funds

and regulated by common agreements on volume and duration, increasingly the

institutional rules tend to unravel themselves requiring transparency, measurable by

criteria of performance and accountability. New institutional enforcement mechanisms

and organizational forms of M&E (such as regular meetings, bi-annual seminars,

technical working groups, joint evaluations) help to implement the planned changes and

transform the old ways of managing resources and channeling funds among the different

departments of the MISAU at the central and provincial levels and subordinate health

institutions. The recent move of some donors, in Mozambique (called the ‘Group of 16’),

towards direct ‘budget support’ (direct disbursement of the external funds into the

Government budget) and increasing harmonization of donor initiatives (OECD, 2005) can

potentially further accelerate the transformation processes through formalization and

making more explicit the institutional rules such as through the definition of precise set of

measures defined uniformly on the basis of priorities, existing services and HIS capacity.

Nationally, incentives to implement these reforms is enhanced when the measurement of

health outcomes are in relation to a country’s own objectives and targets and not that of

the donors pushed unilaterally (Haines and Cassels, 2004, p. 395). Measuring the health

sector and the health outcomes of Mozambique through nationally established indicators

and mechanisms can better prepare the national actors in dealing with the international

rules.

The obstacles faced during the LNM exercise emphasize that parallel structures can be

created as part of the instrument of a steering committee to help plan changes in advance

and create the potential for opportunity-driven change. As argued by Illes and Sutherland

(2001, p. 54) they can overtake the inertia of large organizations, help to introduce

innovations. “In essence, parallel structures are a vehicle for learning how to change the

system, and then leading the change process” (Bushe and Shani, 1990).



The consistent work of the TWG-M&E was extremely conducive for overtaking the

resistance of the vertical program managers, introducing an iterative process of short and

frequent meetings amongst them. These meetings allowed a more informal

communication in which technical issues could be debated without being trapped in

preconceived attitudes of acceptance or refusal of the change. The historical lack of

coordination, delay in submission and other obstacles to the satisfactory calculation of the

indicators in 2002, did not produce a collapse of the process. On the contrary, it produced

a positive streamline of the first version of the LNM, reducing it to a number of indicators

more adequate and manageable within the framework of the existing HIS. The official

role of accountability helped to enforce a process of continuous negotiation amongst the

Mozambican. This process contributed to improved quality of data and the revision of the

HIS through the upgrading of forms, procedures and coordination mechanisms. Emergent

changes help to diffuse the historically existing power struggles among departments

towards processes of compromise.

In the case of the integration of information systems for HIV/AIDS, we find an excessive

focus on top-down planned change based on a technical rationality that is divorce from

the local realities, and provides limited potential for emergent changes. For example,

while the plan presupposes data from all components to be integrated at district level by

an information officer, the emergent situation shows for instance VCT data being sent

directly to HIV/AIDS manager at the provincial and national levels, blood bank and

PMTCT data being sent upwards through immediate higher health facilities. Despite

SWAp’s agreed platform towards integration of the various vertical programs, as a way

to minimize the already significant degree of fragmentation, duplication and

inefficiencies, in practice these goals are far from being realized. The gap between the

formal plans to develop an integrated information system and the local reality is stark,

and the plans to not seriously take into consideration strategies to increase the overlap

between the formal and informal or how can this mismatch be reduced. This reflects that

managerial practices tend to be ‘reactive to events’ rather than forward looking in

anticipating needs.



Table 4 helps to summarize the features of the planned versus emergent kind of changes

in the processes of indicators’ selection and implementation of information systems.

Table 4 Features of planned and emergent changes

Features of planned change Features of emergent change

Selection of indicators - One strategic framework for the health sector;

- Code of conduct; - Terms of reference

for GT-SWAP form; - WHO and SADC

indicators’ list

- Criticisms to the preliminary list of indicators from Department and Program managers;

- Resistance to a corporate list from Program managers;

- 2nd version of the list streamlined and consistent

- Positive effects of informal negotiations

Implementation of Health IS - One strategic framework for the health sector;

- One strategic framework for ITS/HIV/AIDS;

- One list of essential of indicators;

- One information system design strategy

- Revision of health information tools

- Multiplicity of reporting channels;

- Heterogeneity of data collection tools;

- Unequal development of computerized tool among different components;

- Indicators hardly calculated in a comprehensive manner

- Increased improvisation at lower levels

5.3 What implications can be drawn?

At least three key implications can be drawn on how these reform processes can be

managed more effectively: increased participation; a cultivation approach; providing

space for flexibility and emergent changes.

Increased participation

The case of the indicator selection process emphasizes the positive contribution of

participation enforced through both formal and informal mechanisms. While the formal

mechanisms were provided through the framework of the SWAp, informal mechanisms



were enabled through ongoing negotiations and discussions. An important feature of this

participatory process was the fact that it was broad-based, not restricted to particular

vertical programs, but including a whole set of stakeholders that aimed to create a

national level data set. Also important in this process was the fact that a good amount of

time was given to the process allowing development of a shared understanding and

facilitating the exchange of technical views among officials who are often busy and under

pressure. However, in the case of the integration, participation of staff from the sub-

national levels was negligible. The plan for integration was made top down and was

largely technical in orientation. For information systems to be effectively implemented, it

has been argued forcefully by various researchers, there is a need to understand local

work practices of the field workers who are involved in the ongoing processes of data

collection, analysis, use and transmission. The field staff was both geographically too far

and administratively too difficult to be included in this process.

Cultivation approach

Current research (for example, Aanestad 2002) in the domain of information

infrastructures has emphasized the importance of a cultivation approach in the design of

complex interconnected systems. The health information systems with its multiplicity of

levels, programs, and stakeholders can be conceptualized as such an infrastructure. Given

this interconnected nature, it becomes important not to be too ambitious and try to design

from scratch, but approach it in an incremental and evolutionary manner taking into

consideration history and what exists, i.e. an already installed national health information

system. The aim should be to try and cultivate in small steps, while making sure that what

is being changed does not radically influence the rest of the system. The indicator

selection process can be seen to reflect this cultivation strategy, where firstly by taking

the existing indicators as the starting point, the existing history was respected. Then

gradually through a process of negotiation, the list of indicators was iteratively modulated

and refined. In contrast, the integration case reflects the use of a construction approach

where there was the explicit assumption that an integrated system could be designed from

scratch not respect the power of the material, i.e. the installed base. However, the existing

situated rationalities arising from the work practices, donor influences, the particularity of



the diseases reflected a strong installed base which could not be changed in a trivial

manner and demanded more respect.

Flexibility

Researchers like Aanestad, referred to earlier, have emphasized the need for flexibility in

the cultivation process. However, flexibility does not imply that “all things go,” but that

formal plans for standardization need to have inbuilt mechanisms for flexibility which

will allow actors to deal with situated contingencies and provide the space to improvise

and take advantage of opportunities as they arise. While both the indicator selection

process and information systems integration can be both seen as exercised in

standardization, the former can be seen to have greater amount of flexibility built into the

process. A starting point for this could be seen as the time given for this process which

allowed for a greater scope, for shared understandings to develop, and thus to enable

informal communication, something which is complex catch in more formal and

technical settings. The ongoing and regular meetings helped to iteratively discuss things,

and obtain consensus in a less threatening environment. However, the same cannot be

said of the integration case, where despite the formal mechanisms, and environment was

not enabled to provide for flexibility, and the space in which actors could leverage upon

the potential of opportunistic changes.

6. Concluding remarks

More effective management of health reform processes is a crying need for most low

income countries. This need becomes more urgent as the burden of diseases is rapidly

increasing, and resources to fight with these diseases more limited in relation to the

magnitude of the efforts required. However, strengthening these reform efforts is a non-

trivial task given the complexity arising from the multiplicity of donors, the increasing

role of ICTs, high disease burdens, inadequate infrastructures, and institutions with

inadequate capacity and resources. We have argued in this paper that a starting point for

have more chance of succeeding in this task is to develop a deeper understanding of the

complexity that underlies the relation between reform and organizational change. To



understand this complexity which is historically situated, and characterized by a

multiplicity of actors and interests, we have drawn upon an institutional perspective,

coupled with insights about ICT-mediated organizational change. By developing an

empirically grounded comparative analysis of two case studies from Mozambique we

have been able to theoretically and practically discern some of the things which work or

not. The implications of this analysis, we believe, are going beyond Mozambique, but

more broadly they can be considered for other low income countries involved in ongoing

processes of health reform.

References

(2000) The Kaya Kwanga Commitment, A Code of Conduct to guide the partnership for health development in Mozambique. Agreement between Donor Community and MISAU.

(2001) Terms of Reference for the MISAU-Partners SWAP Working Group. Regulations and Procedures.

Aanestad, M. (2002) Cultivating Networks: Implementing Surgical Telemedicine, PhD Dissertation, Department of Informatics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo.

Aid-Harmonization-Alignment (2004) Initiatives for Mozambique: Country-Level Harmonization, http://www.aidharmonization.org/ah-cla/ah-browser/index-cnt=mz&bt, Available at [Last accessed in 5 December, 2004].

Anderson, J. G., Aydin, C. E. & Jay, S. J. (Eds.) (1994) Evaluating Health Care Information Systems: Methods and Applications, London, Sage Publications.

Avgerou, C. (2000) The Multiple Rationalities of Information Systems Development. In IFIP WG 9.4 Conference on Information Flows, Local Improvisations and Work Practices Cape Town, South Africa. May 24-26.

Avgerou, C. (2002) Information Systems and Global Diversity, Oxford University Press. Barnett, T. & Whiteside, A. (2002) AIDS in the Twenty-First Century: Disease and

Globalization, New York, Palgrave Macmillan. Bushe, G. & Shani, A. (1990) Parallel learning structure interventions in bureaucratic

organisations. IN PASMORE, W. & WOODMAN, R. (Eds.) Research in Organisation Change and Development. Greenwich, Conn, JAI Press.

Cassels, A. (1995) Health Sector Reform: Key Issues in Less developed Countries. Geneva, WHO

Cassels, A. & Janovsky, K. (1998) Better Health in Developing Countries: Are Sector-Wide Approaches the Way of the Future? Lancet, 352 (9142) pp. 777-1779.

Chilundo, B. & Aanestad, M. (2004) Negotiating Multiple Rationalities in the Process of Integrating the Information Systems of Disease-Specific Health Programmes. The Electronic Journal on Information Systems in Developing Countries, 20 (2) pp. 1-28.

Chilundo, B., Sundby, J. & Aanestad, M. (2004) Analysing the Quality of Routine Malaria Data in Mozambique. Malaria Journal, 3 (1) pp. 3.

Ciborra, C. (2000) From Control to Drift: The Dynamics of Corporate Information Infrastructures, Oxford University Press, UK.

DFID Health Systems Resource Centre (2005) The “Three Ones” in Action: Reaffirming and Strengthening Commitment, Discussion Paper Consultation on: ‘Making the Money



Work’ The Three Ones in Action, DFID, Available at http://www.dfid.gov.uk/news/files/aidsthreeones9mar05.pdf, [Last accessed in 21.04, 2005].

Economic Commission for Africa (2003) Commission on HIV/AIDS and Governance in Africa. Mozambique: The Challenge of HIV/AIDS Treatment and Care. Addis Abeba, Ethiopia, CHCA

Gilson, L. (1995) Management and Health Care Reform in Sub-Saharan Africa. Social Science & Medicine, 40 (5) pp. 695-710.

Haines, A. & Cassels, A. (2004) Can the millennium development goals be attained? BMJ, 329 pp. 394-397.

Hanlon, J. (1996) Peace without profit, London, Villiers Publications. Hanseth, O., Jacucci, E., Grisot, M. & Aanestad, M. (2005) Reflexive Standardization: Side-

effects and Complexity in Standard-making. University of Oslo. Working paper. Heeks, R. (1998) Information Systems and Public Sector Accountability, Information Systems for

Public Sector Management: Working Paper Series, Institute for Development Policy and Management, Available at http:/www.man.ac.uk/idpm/idpm_dp.htm#isps_wp, [Last accessed in 12th June, 2004].

Heeks, R. & Kenny, C. (2002) ICT's and Development: Convergence and Divergence from Developing Countries? In Proceedings on ICT and Development: New Opportunities, Perspectives and Challenges Bangalore, India. 29-31 May.

Heeks, R., Mundy, D. & Salazar, A. (1999) Why Health Care Information Systems Succeed or Fail, Manchester, UK, Inst. for Dev. Policy and Management, Manchester University.

Hutton, G. (2002) Issues in Integration of Vertical Health Programmes into Sector-Wide Approaches, Introductory test and bibliography for discussion group, Swiss Tropical Institute, Available at www.sti.ch/scih/swap.htm, [Last accessed in 20th March, 2003].

Iles, V. & Sutherland, K. (2001) Organisational Change: A Review for Health Care Managers, Professionals and Researchers, London, NCCSDO.

INE, MISAU, MPF, CEP, UEM, CNCS & MINED (2002) Demographic Impact of HIV/AIDS in Mozambique (update, year 2000). Maputo, Mozambique, Instituto Nacional de Estatística

INE, MISAU, MPF, CEP, UEM, CNCS & MINED (2004) Impacto Demográfico do HIV/SIDA em Moçambique (Actualização, ano 2002). Maputo, INE, MISAU

Labonte, R., Schrecker, T., Sanders, D. & Meeus, W. (2004) Fatal Indifference: The G8, Africa and Global Health, Cape Town and Ottawa, UCT Press.

Lown, B., Bukachi, F. & Xavier, R. (1998) Health information in the developing world. The Lancet, 352 (Supplement 2) pp. S34-S38.

Madon, S., Sahay, S. & Sahay, J. (2004) Implementing property tax reforms in Bangalore: an actor-network perspective. Information and Organization, 14 (4) pp. 269-296.

Mahler, H. (1988) Health for all-all for health! World Health Forum, 9 pp. 5-6. McLaughlin, J. (2001) Using Health Information to Sustain Support for Health Reform in Africa,

MEASURE Evaluation - RHINO, Available at http://www.cpc.unc.edu/measure/rhino/rhino2001/theme2/mclaughlin_paper.pdf, [Last accessed in 10th June, 2004].

Mills, A. (Ed.) (2000) Reforming Health Sectors, London, Kegan Paul. MISAU-DIS (2002) Rascunho sobre os Resultados do trabalho de recolha de dados para a LNM-

PESS. Maputo, MISAU, DPC, DIS MISAU-OMS, Noormahomed, A. R., Antonio C Cunha, Antonio V Sitoi, Herculano Bata &

Chomera, L. J. (1990) Organização e Funcionamento do Sistema Nacional de Saúde, Relatório da Avaliação Realizada, 2a Versão. Maputo, Ministério de Saúde, Grupo de Trabalho para Avaliação, OMS

MISAU (2001) Plano Estrategico do Sector da Saúde (PESS). Maputo, Ministério da Saúde



MISAU (2003) Plano Estratégico Nacional de Combate a ITS/HIV/SIDA Sector Saúde 2004-2008 Moçambique: 1º Rascunho. Maputo, Ministério da Saúde. Moçambique

MISAU, Singleton, G., Enemark, B., Nielsen, O. F. & Osorio, M. C. (2002a) Final Report of First Joint Mission to evaluate the performance of the Mozambique Health Sector Performance in 2001. Maputo, Ministry of Health (MISAU) & Donor Community: Joint Evaluation Team (4 external consultants & 2 internal officers)

MISAU, Singleton, G., Enemark, B., Nielsen, O. F. & Osorio, M. C. (2002b) Report of First Joint Mission to evaluate the performance of the Mozambique Health Sector in 2001. Maputo, Ministry of Health (MISAU) & Donor Community: Joint Evaluation Team (4 external consultants & 2 internal officers)

MISAU DPC (2004) Monitoring and Evaluation Plan of the PEN STI/HIV/AIDS - Health Sector 2004-2009. Maputo, Ministry of Health

Mosse, E. & Sahay, S. (2003) Counter Networks. In Proceedings of the IFIP TC8 & TC9 / WG8.2+9.4 Working Conference on Information Systems Perspectives and Challenges in the Context of Globalization Athens, Greece.

MPF (2001) Plano de Acção para Redução da Pobreza Absoluta (2001-2005), 4º Draft. Maputo, Ministério de Plano e Finança (MPF)

Nilsson, A., Josefsson, U. & Ranerup, A. (2001) Improvisational Change Management in the Public Sector. In Proceedings of the 34th Hawaii International Conference on System Sciences Hawaii.

North, D. (1990) Institutions, Institution Change and Economic Performance, Cambridge, Cambridge University Press.

OECD (2005) Paris declaration on Aid Effectiveness: Ownership, Harmonization, Alignment, Results and Mutual Accountability. Paris, OCED and High Level Forum

Oliveira-Cruz, V., Kurowski, C. & Mills, A. (2003) Delivery of Priority Health Services: Searching for Synergies within the Vertical versus Horizontal Debate. Journal of International Development, 15 pp. 67-86.

Orlikowski, W. J. & Baroudi, J. J. (1991) Studying Information Technology in Organizations: Research Approaches and Assumptions. Information Sistems Research, 2 (1) pp. 1-28.

Orlikowski, W. J. & Hofman, J. D. (1997) An Improvisational Model for Change Management: The Case of Groupware Technologies. Sloan Management Review.

PARC (2004) Meanings: basic concepts in the world of international development evaluation, http://www.parcinfo.org/meanings.asp, Available at [Last accessed in 12 December, 2004].

Pavignani, E. & Durão, J. R. (1999) Managing external resources in Mozambique: building new aid relationships on shifting sands? Health Policy and Planning, 14 (3) pp. 243-253.

Ruger, J. P. (2003) Health and development. The Lancet, 362 pp. 678. SADC-Committee (1999) Second Sub-Committee Report, 22-23 July, Series Editor, Series

Second Sub-Committee Report, 22-23 July,City, Institution. Sautet, F. (2005) The role of institutions in enterpreneaurship: implications for development

policy, George Mason University, Mercatus Center USA, Mercatus Policy Series. Simon, H. A. (1982) Models of Bounded Rationality: Behavioral Economics and Business

Organization, Manchester, The MIT Press. Spanger, H.-J. & Wolff, J. (2003) Poverty Reduction through Democratisation? PRSP:

Challenges of a New Development Assistance Strategy. Frankfurt, Peace Research Institute Frankfurt (PRIF)

TAG, Disch, A., Eeckhout, M., Kostermans, K., Ori, F. & Pavignani, E. (1998) Towards a Sector-Wide Approach to programming in the Health sector: Options for Dialogue and Action. Maputo, MISAU & Donor Community: Technical Advisory Group (TAG)



UN-MDG (2000) Monitoring progress towards the achievement of MDG, Department Economics & Social Affairs, Statistics-Division, Available at milleniumindicators.un.org/mi/mi_highlights.asp, [Last accessed in 16 April, 2003].

UN (2002) Report of the International Conference on Financing for Development. Monterrey, Mexico, United Nations Conference

UNAIDS (2002) Implementation of the Declaration of Commitment on HIV/AIDS: Core Indicators. New York, UN General Assembly Special Session on HIV/AIDS (UNGASS, June 2001), UNAIDS

UNDP (2001) Assessment of Development Results Paper. New York, UNDP, Evaluation Office (EO)

UNDP (2004) Human Development Report 2004: Cultural Liberty in Today’s Diverse World. New York, United Nations Development Programme

Urry, J. (2003) Global Complexity, Cambridge, Polity Press. Walsham, G. (1993) Interpreting Information Systems in Organizations, Cambridge, John Wiley

& Sons. Walt, G. & et all (1999) Managing external resources in the health sector: are there lessons for

SWAPs? Health Policy and Planning, 14 (3) pp. 273-284. WHO-CMH (2001a) Macroeconomics and Health: Investing in Health for Economic

Development. Executive Summary., World Health Organisation (WHO), Report of the Commission on Macroeconomics and Health (CMH), Available at [Last accessed in 30 January 2002, www.who.int/whosis/menu.cfm/cmh.english. 2002].

WHO-CMH (2001b) Macroeconomics and Health: Investing in Health for Economic Development. Executive Summary., World Health Organisation (WHO), Report of the Commission on Macroeconomics and Health (CMH)

WHO (1978) Les Soins de Santé Primaires. In Conference Internationale sur le Soins de Santé Primaires OMS, Serie Santé pour Tous Nº 1, Geneve, Alma-Ata, URSS. 6-12 Setembre.

WHO (1988) The Declaration of Alma-Ata (1978). Geneva, World Health 1988 WHO (1996) Catalogue of Health Indicators: A selection of important health indicators

recommended by WHO programmes. Geneva, World Health Organisation (WHO), Division of Health Situation and Trend Assessment

WHO (1997) Health Sector Reforms in Sub-Saharan Africa: a review of experiences, information gaps and research needs. Current Concerns.Geneva, World Health Organisation

WHO (2001) The World Health Report 2000 - Health systems: improving performance. Geneva, World Health Organisation

Wintour, P. (2005) Aid boost offered to Africa if corruption rooted out. The Guardian. London. World-Bank (1990) Mozambique: Population Health and Nutrition Sector Report. Maputo,

World Bank, Mozambican Office World-Bank (1995) Staff Appraisal Report-Health Sector Recovery Programme. Maputo, World

Bank, HROD, Southern Africa Department, Africa regional Offcie

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