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Strengthening Health Information Infrastructures in Developing Countries
With the rapid proliferation of health information systems in low- and middle-income countries, there are ongoing efforts to incorporate architectural approaches to ensure interoperability and reduce fragmentation. A key component of this approach is a master facility list representing a standard list of health facilities. However, building and deploying mfl is a formidable challenge given the various socio-technical complexities. The theory of information infrastructures, which deal with large-scale, complex and distributed systems, provides guidance on how to approach such complexities. This paper suggests that Indian mfl has failed to create the heterogeneous socio-technical network around it, and been unsuccessful in creating value for initial group of users and subsequently building growth momentum. Also, it failed in making itself adaptable to different applications and use contexts. Three sets of recommendation for its improvement include enabling governance structure, adopting flexible design architecture and making active efforts to promote mfl use.
The authors acknowledge the reviewer at EPW for their suggestions for improvement.
The concept of geography is a crucial element of building effective public health interventions, for example, to know where a disease outbreak is occurring, or where scarce resources, such as medicines and nurses should be directed, and how to build geographical equity (Dummer 2008). In a health information system (HIS), this notion of geography is operationalised through the name and location of the “facility” from where health services are delivered to a catchment population, and includes other attributes, such as infrastructure, health services availability, and number and types of human resources deployed (Dixon et al 2014). For example, in India, the lowest level of public health facility is the sub-centre typically catering to about 5,000 persons spread over five to six villages run by one or two auxiliary nurse midwives (ANMs) and supported by a multipurpose health worker (MPW) in some states. At the village level, one accredited social health activist (ASHA) and a voluntary worker cater to around 500–1,000 persons in a village. A sub-centre is under the administrative jurisdiction of a primary health centre (PHC), which covers five to six sub-centres (MoHFW 2012). A PHC is under a community health centre, which is under the district hospital and then the state and national levels, respectively. The entire hierarchy of facilities from the national to the sub-centre level comprises the facility list. The master facility list (MFL) represents a “complete listing of health facilities in a country and is comprised of a set of administrative information and information that identifies each facility” (WHO 2012: 5) and the supporting information system is the health facility registry (HFR) (McFarlane et al 2016).
The MFL is crucial to enable data sharing across different HISs (Makinde et al 2016), for example, between the human resources and routine HIS, which can help to calculate cross-cutting indicators such as the percentage of births delivered by skilled birth attendants. A key challenge in national HIS strengthening efforts in a low- and middle-income country (LMIC) is the absence of an authenticated and government-verified MFL. The Government of India has recently announced a National Digital Health Mission (NDHM) and released a blueprint to facilitate its implementation (MoHFW 2019). This blueprint has identified an HFR as a core component of larger architectural design and suggests harmonisation of various legacy facility data sources to populate it. Global experiences indicate that the design, implementation, and evolution of a national HFR is a non-trivial challenge in LMICs, for both technical and institutional reasons (WHO 2018). Research into understanding these challenges tends to be limited to the technical issues of syntactic interoperability, ignoring semantic and organisational issues. Thus, a focus of this paper is to empirically investigate the research question of the nature of the socio-technical challenges in the design and implementation of an MFL and the approaches to address them.
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