Table 3 Summary of findings

 Type/goal(s)

Establishing and communicating goals is important for creating, and gaining buy-in to, a vision; and for measuring success. This was a challenge for all study systems, particularly due to diverse user bases.

 Perceived effectiveness

There was optimism regarding the potential for EHIS to ease workload of health staff. But challenges with development and deployment (as may be expected for high-tech systems in low-resource settings) raised concerns that early system glitches may compromise perceptions of reliability, ultimately undermining user buy-in.

 Financing

All study systems were reportedly highly dependent on external financing, though all have diversified funding beyond the initial investors. Many respondents perceived a high cost to maintain such a system, and a relatively low priority for the EHIS within national budgets. The burden of “donor dependence” and possible “mission creep” were also discussed.

 Training

Training has been a major component of all three systems. Respondents noted that full integration of EHIS into the health system may require widespread and appropriate training, including for all levels of managers to increase data use, and technical training to ensure maintenance of these complex systems.

 Local-level modifiability

System adaptability was associated with a number of implementation challenges. A centrally-designed system was criticized for its limited utility on-site. Flexible systems struggled to keep pace with users’ development requests, and the lack of standardization could slow software development and deployment.

 Donor-client interactions

Communication around EHIS support was reportedly positive, but implementing partners (and other development partners) frequently expressed a desire for more feedback, especially regarding organizational performance.

 Donor-community interactions

The community of system users generally perceived all three EHIS as Ministry-led activities, a strong reflection of institutionalization. Stakeholders noted a challenge around timing: if system users are engaged before the EHIS is robust, this could lead to disappointment and discontinuation of use.

 Project champion

The presence of a project champion was very often perceived to be important for sustainability. It was noted that championship could “trickle up” (from facility-based users) as well as “trickle down” (from central Ministries).

 Integration

All study countries had existing health data collection information systems, and all faced challenges in building synergies with the EHIS rather than duplication. The ongoing presence of (duplicative) paper-based data collection was an important frustration for system users in all three countries.

 Institutional strength/capacities

The importance of capacity was highlighted across many levels: in developing and maintaining the EHIS; in system implementation and scale-up; and in building momentum for EHIS as a national priority. Users’ computer literacy and technology infrastructure have impacted system (hardware and software) design and deployment.

 Concurrent projects/donor-supported activities

EHIS sustainability is strengthened by complementary activities, such as training on data use. Competing EHIS can undermine system standardization; in one example, failure to reach ex-ante consensus on national EHIS needs led to disagreements and a group who lobbied for introduction of an alternative EHIS.

 Community characteristics

Stakeholders widely expressed enthusiasm about the systems’ potential, and excitement to be a leader in new technology. Enthusiasm of downstream users (at the health facility level) depended on the system’s potential to lessen workload and reduce reporting requirements.

 Political, economic and cultural characteristics

All three countries’ health systems are largely dependent on public sector care delivery, and on financing from external donor sources. Importantly, worldwide trends in computing may lower local costs and increase the inevitability of introducing EHIS.