Grand Challenges of Public Health: How can Health Information
Systems Support Facing Them?
Objectives: Achieving Universal Health Coverage (UHC) and establishing robust Civil
Registration and Vital Statistics (CRVS) systems are two urgent priorities and grand
challenges of global health, especially in Low and Middle Income Countries (LMICs). It is
argued that addressing both these priorities requires strong supportive Health Information
Systems (HIS), which to date have been elusive to develop.
Methods: Two case studies are presented and discussed. The first concerns an Indian state's
effort to implement a UHC HIS in primary health care while the second relates to the efforts
of the Tajikistan national ministry to develop a HIS for CRVS.
Results: UHC and CRVS can benefit by learning from the domain of information systems
research and practice, especially relating to the design of large-scale and complex systems.
From this perspective, key areas of concern in strengthening UHC and CRVS include: the role
of primary health care, the role of existing systems and practices, and the fragility of
technical infrastructure in LMICs.
Conclusion: Implications for policymakers can be found on three levels: anchoring HIS in
primary health care, renewing what already exists, and adopting hybrid rather than fully
In this paper, from a policy perspective, we discuss two contemporary and grand challenges
facing global public health, and more specifically focus on approaches to strengthen their
associated health information systems. The first challenge concerns realizing the agenda of
Universal Health Coverage (UHC), which mandates providing financial risk protection to all in
accessing quality cost-effective health care. Its significance is emphasized by the WHO
Report from “MDGs to SDGs” which states that UHC cuts across all of the health-related
goals and is the linchpin of development in health and reflects the SDGs strong focus on
equity and reaching the poorest, most disadvantaged people everywhere . A strong
health information system is fundamental to realize the UHC agenda of providing data on
entire populations, their morbidities and mortalities, and monitoring of their costs of care.
The second challenge concerns the strengthening of Civil Registration and Vital Statistics
(CRVS) systems which represent the best source of continuous data on births and deaths.
Both the UHC and CRVS data is key to measuring progress to the SDG vision of ‘leaving no-
one behind’, and nearly one-third of the 120 SDG indicators require population data as
denominators for population-based targets. SDG3 which sets out to “Ensure healthy lives
and promote well-being for all at all ages,” emphasizes a new and key focus on non-
communicable diseases and the achievement of UHC. UHC is the substantial indicator that
health systems are trying to reach in the context of SDGs, while the CRVS represents a
measurement system of where we are in reaching the UHC goals. Both CRVS and UHC are
especially relevant to Low and Middle Income Countries (LMICs) where tackling these
challenges is particularly urgent to improve health outcomes.
The aim of this paper is to illuminate, discuss and draw policy implications related to the role
of health information systems in facing the grand challenges of UHC and CRVS. We are doing
so based on positioning UHC and CRVS HIS as large-scale and complex information systems
each having their particular information architecture problematic. In the next section, we
present existing knowledge on the information architecture problematic and how
researchers have identified challenges and approaches to deal with it. In the following
section 3, we present two (mini) case studies illustrating this problematic in the context of
UHC in an Indian state and CRVS in Tajikistan. Based on an analysis of these cases, we build
policy implications in section 4 before we conclude in section 5.
2. The information architecture problematic
We conceptualize the information challenges associated with both UHC and CRVS as the
health information architecture problematic, representing common characteristics
associated with large-scale and complex information systems (see e.g. [2,3]). Such systems
present unique challenges and also approaches to deal with them, which we discuss around
issues of integration, installed base, evolution and politics.
A common characteristic of large-scale and complex systems arise through the need to deal
with the existence of a multiplicity of systems which are fragmented, both technically and
institutionally. These different systems each have their own deeply embedded historical
legacies which make them difficult and risky  to change in responding to the novel
requirements that both UHC and CRVS demand. Because these installed bases comprised of
investments in technology , investments in user training, and institutionalized practices
, are deeply embedded and hard to change, development strategies need to take an
evolutionary path (see for example ) as changes can only be achieved in small steps .
Integration of fragmented health related information systems in the health care sector has
been discussed extensively in the literature concerning both developed [3, 7, 8, 9] and
developing countries [10, 11, 12]. The very idea of integration has been challenged due to
the rationalistic assumptions it inscribes, not accounting for the multiple rationalities and
truths that are typically involved. In addition, both UHC and CRVS bring particular integration
challenges of coordination, for example, across sectors and ministries, which are further
heightened when we consider the need to link these systems as required to measure
progress towards SDG3. Integration is thus not only, and often not primarily, a technical and
institutional challenge, but also political in terms of the implications of the resulting
functional architecture after integration  and the power relationships and existing
asymmetries between the different institutions involved and the value they each see in
ownership of data and information systems . Often integration is seen primarily as a
technical exercise of linking systems without adequately considering value add to the work
itself and not just adding more to the work .
UHC and CRVS systems, like many other health information systems in LMICs are faced with
challenges of poor and inadequate infrastructure, insufficient and unevenly distributed
resources, and lack of sufficient capacity to deal with the complexity they entail. It has been
further argued that the future trajectory of information systems tend to be indeterminate
making it difficult to plan for the now while keeping choices open to link with other existing
and emerging systems in the future, referred to as the challenge of change flexibility .
The future of UHC and CRVS systems are largely indeterminate in LMICs, being influenced by
the nature of diseases, technological changes, political agendas and various others.
While there is a significant body of knowledge around the design, use and evolution of large
scale and complex information systems, we argue that there are also additional and
particular challenges particular to UHC and CRVS systems, which require novel approaches.
We illustrate these challenges through two cases drawn from LMIC contexts of India and
3. Case studies
The information architecture problematic of UHC
The centrality of information in UHC is captured in this quote by Margaret Chan, Director-
General of the World Health Organization in 2007: “Without these fundamental health data,
we are working in the dark. We may also be shooting in the dark. Without these data, we
have no reliable way of knowing whether interventions are working, and whether
development aid is producing the desired health outcomes“.  In the Global Health 2035
report, the Lancet Commission on Investing in Health put forth an ambitious investment
framework for transforming global health through UHC by designing health service packages
and health financing systems . This framework provides little guidance on building the
supporting HIS .
UHC has a strong informational content, requiring robust supporting HIS, which we illustrate
through the following mini case study from India which one of the authors has been involved
in studying over the last 3 years.
Since UHC is a relatively new concept in India, many states are engaged in trying out pilots to
develop scalable models for delivery of UHC services, and also their supporting information
systems. This mini-case study is based on the study of efforts of a progressive north-Indian
state to build a UHC HIS through a large business organization under their CSR (Corporate
Social Responsibility) agenda. These efforts were located in a rural clinic (called PHC) and its
subsidiary centre (called a sub-centre – SC) which is responsible in providing both outreach
and clinic-based care to a 5000 population spread over 5-6 villages. There are 2 field nurses
(called ANM – Auxiliary Nurse Midwife) at the SC who provide various services, which
traditionally have related to maternal and child health. They record details of their activities
in field diaries, then transfer them to registers, summarise in monthly reports and send to
the PHC for computerization. The ANM manages about a dozen registers including for TB,
Malaria, and ANC, where patient wise details is entered for every service transacted.
In practice we saw the ANMs to be struggling both with the use of the pilot tablet and the
additional workload which UHC entailed. While the ANMs saw themselves to be competent
in using tablets, they struggled with technical support issues. We found one ANM’s tablet to
be non-functional for many months, despite her multiple requests for support. As a result,
she did all her entries on paper, to be later entered in the tablet. They also struggled with
bad network, and were often not able to log in. As it was difficult to use the tablet outdoors
due to sun glare, the ANMs did their outdoor work on paper, and later when indoors
entered into the tablet, causing duplication of data work. Due to internet constraints, sun
glare, and high workloads, often the ANM could not update the tablet after the screening of
a patient, and their data in the tablet rapidly got outdated. ANMs reported a significant
increase in their workload with the advent of the UHC HIS, requiring about 60 percent of
their time to be spent on data related activities, and consequently lesser on providing care.
Historically, ANMs were entering their data in multiple places, including: primary registers;
the HMIS (Health Management Information System) for aggregate reporting; and, the
Mother and Child Tracking System (MCTS) for tracking pregnant mothers and children by
names. The UHC HIS was the latest addition to their work, with none of the earlier systems
discontinued, and involving duplications of paper and tablet-based work. The result was an
exponential increase in workload.
In addition to the workload increasing in quantitative terms, the qualitative nature of work
with UHC was also expanded. Under UHC, the ANMs were required to screen the whole
population on 8 additional conditions (Diabetes, Hypertension, Oral Cancer, etc.), and record
details in existing registers and also the tablet. Identified patients at risk needed to be
electronically referred by the ANM to the PHC doctor’s system, which further needed to be
linked to the district hospital for advanced diagnostics. Both the hospital and PHC were also
expected to electronically back refer patients post-consultation to ANMs for follow up home
based care. At a PHC, we saw patients first going to the Pharmacist who maintained the
computer system and showing their health card. Subsequently, the doctor would examine
the patient, entering at the same time the details on his computer. The poor Internet
resulted in doctors requiring many minutes to log on, and case details were often noted on
paper due to electricity failure. Long power outages and continuous stream of patients
meant that the doctor could not enter transfer the patient details from paper to the
computer, contributing to a growing number of unrecorded cases. These constraints led to a
patient-doctor encounter taking about 10 minutes, leading one frustrated patient to say;
“doctor, why don’t you do your personal work on the computer later and first deal with me.”
The doctor often could not generate a print out because of the paucity of printing paper, and
manually noted the transaction details on paper, gave that to the patient, and also entered
the same in in a local register which he maintained. The Pharmacist would further note the
transaction details in the facility Outpatients register. When asked if work had become
simpler with computers, the doctor replied “no, it has become a torture.”
Doctors did not use the system functionality to view patient history, as search was
cumbersome record by record rather than as an aggregated profile. Important historical data
related to drugs was not normally available, as the doctors were mandated to prescribe only
certain medicines. If unavailable or if the doctor wanted to prescribe something out of this
list, they would write it on a slip, and not in the computer, to escape reprimand. This
absence of drug-related information in the patient record, adversely affected the continuity
of care. Continuity of care was also adversely affected by the technical inability of both the
tablet and PHC computer to generate referral linkages and synch data across systems, and a
poor existing culture of emphasizing follow-up care. For example, a doctor said he did not
use the available system functionality to schedule follow-up visits as it was the patients’
responsibility to come, and not theirs to follow up.
To summarize, both the ANMs and doctors saw no added value from the UHC HIS, as it was
introduced as “yet another system” without integration with and rationalization of existing
systems and processes. This added significantly to existing workload without adding value in
terms of strengthening care processes, such as of continuity of care. Infrastructural
constraints of electricity, internet and paper were significant, and the demands of the UHC
HIS could not be adequately addressed.
The information architecture problematic of CRVS
CRVS concerns the registration of vital events like births and deaths, and the generation of
vital statistics from these individual records. CRVS is based on four interrelated informational
functions: recording of the vital event; notification of the same to the relevant authority; the
legal registration of the event; and, the generation of vital statistics. An effective CRVS
information system should in particular help in strengthening mortality reporting (maternal,
neonatal, and infant) disaggregated by age, sex, social group and geography . These are
key measures of health systems outcomes and also the health related SDGs. Despite the
fundamental importance of mortality reporting, yet for most LMICs, this data is very weak
with limited mechanisms for data capture, with many gaps such as in reporting from
hospitals as well as for deaths at home, and ICD (International Classification of Diseases)
coding remains weak.
Building robust CRVS HIS requires multi-sectorial coordination mechanisms across
departments of health, civil registration, statistical offices, and the community. In many
nations, the health department is legally mandated to function as the civil registration
authority, hence necessitating coordination between different ministries. Another key
challenge is bringing about legal and regulatory changes needed to link CRVS improvements
with national identity management systems and the use of new ICTs such as mobiles for
registration and notification of an event.
Securing cooperation from the communities is crucial for improved recording and
notification of vital events, but is often difficult to establish as this will involve reaching out
to community leaders, funeral authorities, religious leaders, grassroots organisations, and
others. Building these linkages is as much a technical challenge as it is institutional. For
example, improving death registration requires the establishment of clear standard
operating procedures for certification with cause of death in different contexts – the home,
the hospital, where the doctor is available or not - and how this data is coded, shared,
analysed and presented while maintaining confidentiality. And there needs to be clear
strategies on how to trace and list unrecorded deaths. This requires widespread training of
doctors in PHC facilities on medical certification of death based on ICDs, including situations
where cause of death has to be defined retrospectively. ICT support is required across
functions (recording, notification, registration, generating of statistics), across levels (from
community to national level), and to facilitate interoperability across sectors.
In the case study presented below, we present how Tajikistan is trying to improve their CRVS
HIS, the challenges experienced and how attempts have been made to address them, with a
relative degree of success.
Till recently, Tajikistan had a well-established CRVS information system, though almost
totally without ICT support. Civil registration is handled by the Civil Registry Office (CRO)
which is located in all the 68 districts of the country, organized under the Ministry of Justice.
While being used as an example of strong routines and an institutionalized system, a
significant portion of neonatal deaths were not being recorded, as these typically happened
within the Ministry of Health facilities. Because the CRVS system relied mainly on paper
records, there was no easy way of accessing and sharing such data across health and justice
departments. There were also other challenges, like disincentives to report early deaths or
the payment requirements for citizens when interacting with the CRO, for example to get a
birth or death certificate.
At the municipality level, local government secretariats record vital events (births, deaths,
marriages etc.) for their catchment areas and on a monthly basis, and reported details to the
district CROs. Registration takes place based on citizens furnishing appropriate documents.
For example, health care institutions provide documents with proof of births and deaths.
Since the majority of Tajikistan’s population lives in rural areas, the bulk of data comes from
the municipalities. The State Statistics Agency (SSA), the official body for generating and
sharing public statistics, produces vital statistics such as censuses, household surveys,
demographic statistics and a wide range of economic statistics. The Statistical Office in the
capital city of Dushanbe receives consolidated and aggregated CR data along with copies of
the original records, where it is codified and aggregated reports generated. The SSA as the
official body for publishing national statistics can share demographic data with other
government and non-government organizations and make publications.
In 2013, the Government of Tajikistan, supported by European Union funds, started national
level computerization in two parallel streams: the national Health Management Information
System from the sub-district level; and, the CRVS system from the district level, interestingly,
both using the same open source software platform (DHIS2, see dhis2.org for more
information). While for HMIS, the aim was a national level implementation, the CRVS system
was to be piloted in one site at the district level. However, CRVS transactions with the public
took place at the level below – the Jamoat (municipality). In the pilot, the paper records
were brought from this level to the district for computer-based entry. The HMIS was made
fully operational nationally in 2016. Further, the proof of concept of the CRVS pilot was
successfully established at the district level, and in the next phase currently ongoing the
system is being decentralized to the next level of the Jamoat, to allow for direct entry of vital
events and the generating of certificates while interfacing with the public. To deal with
historical CRVS data, there is a plan to digitize the existing paper records, and assess the
national digital infrastructure required. The use of the DHIS2 platform for both HMIS and
CRVS has established the potential to share data across the two systems in the future.
The building of this CRVS system demonstrates the successful use of an incremental strategy.
First, the district level proof of concept was established, and then scaled to other districts,
before moving to the level below of the Jamoat to make it go live with real transactions. In
further phases, there are plans to digitize historical records, integrate CRVS with HMIS, and
strengthen mechanisms of sustainability.
In this section, we have discussed some of the informational needs and challenges
associated with UHC and CRVS HIS. This analysis helps us to understand how these systems
are large scale and complex, and reflect some of the issues discussed in section 2 which
characterize the information architecture problematic. Both these systems have the need to
integrate with others, like the HMIS in CRVS, and the hospital and primary care HIS in UHC.
Both systems have to contend with historically existing technical and institutional installed
base, like the historical records in the CRVS case, and the working practices and systems of
the PHC in the UHC case. The need for an evolutionary approach is exemplified in both cases,
demonstrated successfully through the CRVS case, while the absence of it contributing to the
relative failure of the UHC system. Addressing the political dimension is crucial, and the CRVS
system addresses it systematically by building collaborative coalitions in the CRVS case
between Ministries, the SSA and donors. Such political coalitions are conspicuous by their
absence in the UHC case.
While the CRVS and UHC system exhibit the characteristics of large scale and complex
systems, there are certain particularities which require us to also expand our
conceptualization of these systems. Achieving this both conceptually and practically,
represents our ‘grand challenge.’
4. Implications for Policy
A common characteristic of both UHC and CRVS is that they are primarily grounded in
Primary Health Care (PHC) based activities. UHC’s goal of providing financial risk protection
for all in accessing health care has necessarily to be grounded in PHC work which is the
entity primarily responsible for providing health care to all. Similarly, births and deaths take
place primarily in the community, and CRVS is also grounded in PHC work. An implication of
this characteristic in designing the supporting Health Information Systems (HIS) for both UHC
and CRVS is that they should build upon and extend existing routine facility information
systems which provide the existing backbone for PHC work. Our policy implications will be
anchored in this perspective.
Large scale and complex information systems are networks of interconnected components
belonging to and controlled by different actors. The design, implementation and
maintenance of these networks of systems must therefore be aligned with the interests,
often competing and conflicting, of a variety of actors and institutions involved in these
processes . As a starting point, UHC and CRVS must be acknowledged as comprising such
large scale and complex information systems. They cannot be built from scratch or changed
based on quick fixes, but requires substantial cross-institutional efforts over time. How
policy can be framed to face this complexity and the broad challenges relevant to both UHC
and CRVS described above, is now discussed.
A key learning from two decades of information systems research is that “airplanes don’t fly,
airlines do”, reflecting the interconnected nature of the technical and social domains, and
the need to align and nurture over time heterogeneous networks comprising of people,
technologies, institutions, work practices and more. This underlies the informational needs
and problematic, alluded to earlier, and addressing this lies at the core of strengthening the
information systems for CRVS and UHC. Illustrated by the cases above, we see three basic
implications related to the design of the supporting HIS necessary to deal with the
challenges of CRVS and UHC. We discuss each of these and how they relate to policy in the
Anchoring HIS within Primary Health Care – building upon what already exists
We have in this paper argued that both UHC and CRVS are anchored in PHC work. Designing
HIS must build upon and extend the existing facility HISs that already exist. Most LMICs have
multiple existing HIS with supporting infrastructure and human resources capacity. This
represents the installed base, which has its own inherent agency and capacity to shape the
trajectory of new initiatives. Policy should aim to encourage new UHC and CRVS initiatives to
leverage on this installed base, especially that which is found to work in practice, rather than
start on a new slate which runs the risk creating redundancies in resources and expanding
fragmentation. Important is for the new systems to not become one additional system
adding to the high work load of health staff, but using this opportunity to rationalize and
reduce redundancies. Relating to and building on what already exists will require changes in
small, incremental steps. By for example using prototypes, the viability of solution can be
tested on small scale before being scaled across functionality, populations and geographies.
The typical PHC based HIS is designed to support the local practices of health workers and
thus not likely to fully support CRVS and UHC work which is dispersed over a large
population, supporting continuity of care and the vital events throughout the lifetime of the
citizens and interlinking different levels of the health system and across different institutions.
To scale the prototypes and institutionalize its use across the larger population and
institutions, network effects and spill-overs within a growing user base can be pursued by
targeting motivated and knowledgeable users, choosing simple, non-critical, use areas and
use relatively cheap and well supported technical solutions typically based on free and open
source platforms . Both CRVS and UHC involve evolving work practices, both in volume
and type, and their supporting HIS should be designed to allow accommodating changes
over time. Thus, system specifications should include concrete requirements on flexibility
and openness for future changes and innovation.
Renewing what already exists – integration and rationalization
UHC and CRVS HIS add value by providing more granular information on people, vital events,
diseases, costs, all over time. This requires the HIS to be capable of providing clinical and civil
registration support, enabling the generation of aggregate reports, notification and
registration of vital events etc., and thus reducing the need for primary registers and
strengthening the follow up of individuals.
The multiple systems and data sources involved in UHC and CRVS, such as for surveys,
census, different health facilities and health programmes, requires integration at both the
technical and institutional levels. At the technical level, this involves building and
implementing syntactic and semantic standards , institutional integration requires
building mechanisms for multi-level and multi-sector coordination, and robust systems for
governance. UHC and CRVS fundamentally deal with individual level data, and its registration,
storage, cloud hosting, processing and transmission across levels and entities requires active
regulation such as related to data privacy, which typically is weak or non-existent in most
LMICs. Anchored in the health facilities, both UHC and CRVS require health workers to
record, track individuals and report data. If UHC and CRVS HIS is introduced without
integration and rationalization, this will increase the work burden of the health workers
significantly. With appropriate architectures and relevant integration of systems, old and
new, it is at the same time possible to support the health workers practices and reduce their
burden in terms of time spent on data entry and reporting, and add value to their ability to
take local action. For example, one of the reasons for the success of the CRVS system is its
ability to add value to civil registration work by providing functionalities to actually generate
birth and death certificates, which consequently reduces the manual burden of creating
these certificates. In contrast, in the case of the UHC HIS, no such clear value adds were
Standards provide the glue around which integrated systems can be designed for and
evolved over time. Standards need to be defined for both semantic (i.e. defining business
logic and nomenclature) and syntactic (i.e. technical protocols to exchange data across
systems) levels, supported by robust business level cooperation agreements. The
architecture must be based on key components and their underlying business relationships
and it must enable multiple uses of the different information flows. Information systems
research  warns that standards defined top down and parachuted down to organizations
users’ work settings will not work, and instead, they need to emerge from and evolve close
to practice. Such an approach helps to strike the right balance between stability and
flexibility in use and for change. Furthermore, standards need to represent a hierarchy with
senior administrators requiring more aggregated standards than the levels below. This will
require the definition of governance mechanisms clearly distinct from management,
providing appropriate mechanisms through which standardisation choices are made and
implemented. With the complexity of evolving health care practices, we cannot anticipate
the future fully, and thus need to assure that our architectural decisions are not blocking or
making irreversible certain paths in the future. Effective standards will go a long way in
addressing the integration challenge and lay the foundation for rationalization.
Lack of regulation may encourage innovation and the free flow of information across
hierarchies and institutions. But its lack also introduces significant risks in terms of the
potential repercussions and (perceived) consequences of future regulations. Policy should
encourage the initiation of processes towards regulating these voids. And regulation should
be balanced in supporting open data in the public domain and free flow of information
across institutions for the larger good, while at the same time ensuring privacy protection for
the individual. Many ministries are bound by regulations that health data should not leave
their national boundaries, and are not adequately informed on how to deal with the
technical and institutional issues as data is increasingly being hosted outside their
organization, i.e. in the cloud. At the organization level, policy should support eliminating the
many unknowns around contracts made for example by ministries of health and cloud
services providers. Appropriate regulation will support and encourage the flow of
information across institutions and institutional hierarchies. Establishing strong and flexible
linkages between the PHC based HIS with other systems will help enabling more
comprehensive UHC and CRVS.
Adopting hybrid rather than fully Internet dependent systems
Digitization should be pursued, but in communities where paper is the most viable solution
the focus should be on seamless integration between paper and the digital. Innovations
based on low-end technologies such as basic mobile phones (rather than smart phones)
should be encouraged. ICT tools are essential but not sufficient to overcome institutional
barriers as well as those related to organisational capacity and political prioritisation. They
need to meet the technical and institutional requirements of interoperability. This challenge
of infrastructure, especially relates to the need of building integrated systems in unevenly
resourced environments, for example settings (such as villages) with varying access to
electricity, Internet, computers and mobile phones.
Typically, HIS in PHCs of LMICs will be heavily constrained by lack of or fluctuating Internet
connectivity and electricity. System design therefore needs to be fundamentally hybrid,
providing for both online and offline data entry and access with the ability to synch both
forms. Further, mobile Internet should be considered as an option because it provides more
reliable connectivity than fixed Internet. By avoiding utopian infrastructure requirements,
such a design reduces data loss, minimizes work duplication whilst moving between paper
and the digital.
Universal Health Coverage (UHC) and Civil Registration and Vital Statistics (CRVS) are two
grand challenges facing global public health. We have in this paper discussed how
strengthening their respective PHC anchored supporting HISs can help in facing these
challenges. Positioned related to the information architecture problematic, we have
described three areas of policy implications which we believe can be a useful reference,
including: Anchoring HIS within PHC, Renewing what already exists and adopting hybrid
systems. While we in this paper have focused on HIS design, we have also pointed out other
challenges to be addressed to establish successful supporting HIS for UHC and CRVS such as
those related to legal regulations.
The authors are grateful for the support from the University of Oslo and the Research
Council of Norway.
 World Health Organization. (2015). Health in 2015: From MDGs, millennium development
goals to SDGs, sustainable development goals. World Health Organization.
 Hanseth O, Lyytinen. Design theory for dynamic complexity in information infrastructures:
the case of building internet. Journal of Information Technology 2010; 25:1–19.
 Williams R. Why is it difficult to achieve e-health systems at scale? Information,
Communication & Society 2016;19(4):540-550.
 Vikkelsø S. Subtle Redistribution of Work, Attention and Risks: Electronic Patient Records
and Organisational Consequences. Scandinavian Journal of Information Systems 2005;17(1):
 Lanzara GF. The Circulation of Agency in Judicial Proceedings: Designing for
Interoperability and Complexity. In F. Contini & G. F. Lanzara (Eds.), The Circulation of
Agency in E-Justice: Interoperability and Infrastructures for European Transborder Judicial
Proceedings, 2014:3-32. Dordrecht: Springer Netherlands.
 Karasti H, Baker KS, Millerand F. Infrastructure Time: Long-term Matters in Collaborative
Development. Computer Supported Cooperative Work (CSCW) 2010;19(3):377-415
 Aanestad M, Jensen TB. Building nation-wide information infrastructures in healthcare
through modular implementation strategies. The Journal of Strategic Information Systems
 Carlile PR. Transferring, Translating, and Transforming: An Integrative Framework for
Managing Knowledge Across Boundaries. Organization Science 2004;15(5):555-68.
 Fitzpatrick G, Ellingsen GA. Review of 25 Years of CSCW Research in Healthcare:
Contributions, Challenges and Future Agendas. Computer Supported Cooperative Work
 Braa J, Sahay S. (2012). Integrated Health Information Architecture: Power to the Users:
Design, Development and Use. Matrix Publishers.
 Nielsen P, Sæbø JI. Three strategies for functional architecting: cases from the health
systems of developing countries. Information Technology for Development 2016;22(1):134-
 Sahay S, Monteiro E, Aanestad M. Configurable Politics and Asymmetric Integration:
Health e-Infrastructures in India. Journal of the Association for Information Systems
 Sahay S, Sundararaman T, Braa J. Public Health Informatics: Designing for change - a
developing country perspective. 2017. Oxford, UK: Oxford University Press.
 Braa J, Hanseth O, Heywood A, Mohammed W, Shaw V. Developing Health Information
Systems in Developing Countries: The Flexible Standards Strategy. MIS
 Opening remarks at the Fourth Global Meeting of Heads of WHO Country Offices, Dr
Margaret Chan, Director-General of the World Health Organization, Fourth Global Meeting
of Heads of WHO Country Offices, Geneva, Switzerland; 12 November 2007
 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within
a generation. The Lancet 2013;382(9908):1898-1955.
 Wong A. Achieving Universal Health Coverage, WHO Bulletin 2015;93:663-664.
 World Health Organization. (2014). Improving Mortality Statistics through Civil
Registration and Vital Statistics Systems: Strategies for country and partner support. Report
from technical meeting, Geneva, 4-5 November 2014, World Health Organization.
 Hanseth O, Aanestad M. Design as Bootstrapping: On the Evolution of ICT Networks in
Health Care. Methods of Information in Medicine 2003;42:385-91.
 Ciborra C et al. From Control to Drift: the dynamics of corporate information
infrastructures. 2000. Oxford University press.