ICTworks

Everyone wants to talk about digital infrastructure. Unreliable electricity, spotty internet, inadequate hardware budgets. These are real problems, and I’ve watched countless digital health conferences devolve into hand-wringing about connectivity gaps and power shortages across sub-Saharan Africa.

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But a systematic review of 42 studies across Africa examining health information systems implementation reveals a more fundamental barrier that we consistently ignore: we have no idea how to manage the competing priorities of diverse stakeholders. And this failure pattern is so predictable that it borders on willful negligence.

Stakeholder Tower of Babel

The review, which screened 886 articles over a 10-year period, identified six critical themes for successful HIS implementation. Stakeholder perspectives ranked among the most significant, yet it’s the theme practitioners most consistently underestimate.

This explains why African countries host “e-chaos not eHealth” with 738 documented digital health interventions showing massive duplication and limited coordination.

Here’s what actually happens on the ground:

• National ministries of health want centralized reporting for disease surveillance.
• Provincial health departments need budget accountability and resource allocation data.
• District hospitals require clinical decision support for patient care.
• Community clinics want something, anything, that doesn’t add three hours to their workday.
• External donors demand their specific indicators tracked through their preferred systems.
• And software vendors have their own proprietary interests.

These aren’t complementary needs. They’re fundamentally contradictory, and we keep pretending a single health information system can satisfy all of them simultaneously.

When Good Intentions Meet Reality

Research examining HIS sustainability in Malawi, Zambia, and Zimbabwe documented this pattern. After PEPFAR invested heavily in electronic health information systems, researchers found great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems.

Translation: nobody trusted the new systems enough to abandon the old ones, so health workers maintained dual systems, doubling their workload. The study concluded that sustainable systems need clearly-defined goals around which stakeholders can rally. This hasn’t been achieved in the systems studied.

The problem isn’t technical.

A qualitative study in Malawi examining stakeholder engagement in health policy revealed that not all stakeholders were equal in the exercise of stakeholder engagement:

• Donors wielded disproportionate influence at the central government level.
• Civil society organizations had minimal power.
• District health officers, the people actually implementing these systems, reported that they are doing their own thing regardless of national coordination efforts.

What emerges is a clear hierarchy where those closest to implementation have the least influence over system design, while those furthest from daily operations make the critical decisions.

Success Stories Share One Pattern

Burkina Faso provides a rare counterexample. The country achieved national-scale deployment of a digital health initiative when most African nations remain stuck in pilot purgatory.

Research on this implementation attributed success to an extensive, time-consuming and tailored stakeholder strategy that engaged each actor group individually to showcase benefits and address resistance. Heads of health districts became so engaged they felt like creators rather than users.

When these officials rotated to new regions through national mobility programs, they became ambassadors requesting the tool’s deployment in their new locations. One director even raised community funding to purchase equipment and accelerate implementation.

This didn’t happen by accident. It required substantial resources spent on stakeholder engagement before, during, and after technical deployment.

Coordination Paradox

The systematic review identified coordination and collaboration as essential for realizing the full benefits of health information systems. Yet coordination requires significant time investment that donors and implementing partners consistently underestimate.

Studies across five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) found that the iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops.

Implementation highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement.

But here’s the paradox: the health systems most in need of coordination improvements are precisely those with the least capacity for extensive stakeholder engagement. Understaffed facilities, overworked health workers, and resource-constrained ministries struggle to dedicate time to consensus-building when immediate patient care needs are overwhelming.

What Actually Works

The systematic review proposes a conceptual framework emphasizing that stakeholder perspectives must inform organizational structure, which in turn shapes coordination and collaboration mechanisms. These elements collectively determine whether systems address data complexity and ensure accountability.

In practical terms, this means:

1. Map all stakeholder groups before selecting technology. Understand their distinct needs, power dynamics, and existing workflows. If you can’t articulate why a district medical officer would voluntarily use your system, you’ve already failed.
2. Invest as much time in stakeholder engagement as technical development. The Burkina Faso case demonstrates this isn’t optional for scale. Budget for it. Staff for it. Measure it.
3. Design systems that distribute rather than centralize power. When health workers at the community level see tangible benefits from data entry (better patient tracking, reduced stockouts, clearer referral pathways), they become advocates. When they only see additional reporting requirements serving distant bureaucrats, they resist.
4. Acknowledge that donor influence distorts stakeholder engagement. The Malawi research found policies developed “to appeal to donors rather than to affect and enforce the changes needed to improve the health and wellbeing of the people.” Until we address this dynamic openly, we’ll continue building systems that satisfy funders while failing users.

Uncomfortable Truth

A review of health information systems in African countries found persistent challenges including lack of standardization, poor interoperability, inadequate coordination and fragmentation of data. We keep treating these as separate technical problems requiring technical solutions.

They’re not. They’re symptoms of failed stakeholder coordination.

We know this because the successful implementations, however rare, all share one characteristic: they cracked the stakeholder engagement problem before optimizing the technology architecture.

The systematic review concludes that decentralized health information systems offer advantages specifically because they enable local, regional and national health care service needs in a well-coordinated and collaborative manner.

Decentralization isn’t primarily about technology architecture. It’s about matching governance structures to stakeholder realities.

We can keep blaming infrastructure constraints, or we can acknowledge that we’re consistently underinvesting in the human coordination work that determines whether our technical investments survive contact with implementation.

The evidence is clear about which approach works. The question is whether we’re willing to spend money and time on the messy, unglamorous work of stakeholder engagement, or whether we prefer to keep building elegant systems that nobody uses.