Koumamba et al.

BMC Med Inform Decis Mak (2021) 21:232

https://doi.org/10.1186/s12911-021-01597-5

RESEARCH ARTICLE Open Access

Health information systems in developing

countries: case of African countries
Aimé Patrice Koumamba1,2* , Ulrick Jolhy Bisvigou2, Edgard Brice Ngoungou2,3 and Gayo Diallo1

Abstract
Background: In developing countries, health information system (HIS) is experiencing more and more difficulties to
produce quality data. The lack of reliable health related information makes it difficult to develop effective health poli-
cies. In order to understand the organization of HIS in African countries, we undertook a literature review.
Methods: Our study was conducted using the PubMed and Scopus bibliographic search engines. The inclusion
criteria were: (i) all articles published between 2005 and 2019, (ii) articles including in their title the keywords "health",
"information", "systems", "system", "africa", "developing countries", "santé", "pays en développement", "Afrique", (iii) arti-
cles that are written in English or French, (iv) which deals with organizational and technical issues about HIS in African
countries.
Results: Fourteen retrieved articles out of 2492 were included in the study, of which 13 (92.9%) were qualitative. All
of them dealt with issues related to HIS in 12 African countries. All 12 countries (100.0%) had opted for a data ware-
house approach to improve their HIS. This approach, supported by the DHIS2 system, has enabled providing reliable
data. However, 11 out of the 12 countries (92.0%) frameworks were aligned with funding donors’ strategies and lacked
any national strategy.
Conclusion: This study suggests that the lack of a national health information management strategy will always be
a threat to HIS performance in African countries. Ideally, rigorous upstream thinking to strengthen HIS governance
should be undertaken by defining and proposing a coherent conceptual framework to analyze and guide the devel-
opment and integration of digital applications into HIS over the long term.
Keywords: Health information systems, Governance, Health data, Developing countries, Performance

Background of actions undertaken for health, epidemiological surveil-

The performance of a health system is strongly related lance [1]. It is on the basis for example, of quality health
to the quality of produced health information. Quality information that decision-makers not only have visibility
health information (credible, coherent, up to date, etc.) on the performance of their health system, but also have
allows the health system to be effective and efficient in the capacity to react more rapidly to health needs.
terms of decision-making by the health managers in Every year, for example, the World Health Organization
terms of resource planning, monitoring and evaluation (WHO) publishes figures on the world’s health situation
in order to measure member countries’ health outcomes.
That shows the importance of well-structured Health
*Correspondence: [email protected]; Information Systems (HIS). The latter properly produces,
[email protected]
1
analyses, stores and shares reliable and accurate informa-
Bordeaux Population Health (BPH), UMR1219, Applied Health
Informatics Research Team (ERIAS), Univ. Bordeaux, 33000 Bordeaux, tion for decision support at all levels of the healthcare
France system pyramid. Consequently, investing in the imple-
Full list of author information is available at the end of the article mentation of HIS has become a great challenge for health

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Koumamba et al. BMC Med Inform Decis Mak (2021) 21:232 Page 2 of 10

care systems in developing countries. Faced with these health services through better management at all of their
major health issues, coupled with the achievement of levels". The latter definition highlights the transversal
Sustainable Development Goals (SDGs), and focusing on nature of a HIS, in that it integrates the entire structural
its third goal, related to healthcare entitled "Healthcare dimension of a health organization.
and well-being", a highly-performed health information Looking at the HIS topic from the above approach, it
system could play a major role to enhance monitoring of is clear that no health system aspiring to be effective can
indicators. become effective without having a HIS capable of col-
lecting, processing, analyzing and making available reli-
Relationship between a health system and a health able and timely information for the purpose of planning,
information system monitoring and evaluating health actions.
To better establish the relationship between a health sys-
tem and a health information system, it was necessary Problem statement
for us to first of all understand what a health system is, Although having a HIS is a necessity for any health sys-
just as defined by the WHO. According to the WHO’s tems, many developing countries still have nowadays dif-
definition, a health system is defined as "all organizations, ficulties in obtaining reliable and accurate health related
individuals and actions whose primary purpose is to information. Due to that issue, they are unable to obtain
promote, restore or maintain health" [2]. To achieve this good health results. Consequently, their performance is
objective, the health system is founded on a conceptual far from meeting the needs of the population [2].
framework with six pillars outlined as follows. This literature review aims to provide an overview of
the factors that influence the optimal functioning of HIS
• Leadership and governance: involves the definition in limited settings and resources countries.
of national health policies, roles and responsibilities
of all the stakeholders; Methods of operation
• Health finance: implies having the necessary funds The study was carried out from February to July 2019
to finance expenditures related to the health needs in three stages: (i) relevant articles research, (ii) articles
of the people thereby enabling them to benefit from selection, performed by carrying out a complete analysis
services that effectively deliver needed services; of each article according to the publication dates and (iii)
• Health staff: implies that the health system must proceeding to the global analysis of all articles in a gen-
have a sufficient and qualified human resource in eral synthesis.
the healthcare domain, in order to sustain its perfor-
mance; Research strategy
• Essential medication and technologies: implies a For articles look-up, we used the Scopus and PubMed
more efficient health system, which requires proper databases and their research systems to conduct our
availability of medication and technologies; bibliographic search. To do so, we searched for relevant
• Service delivery: implies an organization of health articles dealing with national HIS performance (per-
service delivery that efficiently corresponds and formance is understood here as organizational, techni-
responds to the spatio-temporal health needs of pop- cal and behavioral determinants). In the bibliographic
ulations; research system of these databases, we used the follow-
• Health information: implies ensuring the availability ing keywords: "health", "information", "systems", "system",
of health information necessary for decision making. "africa", "developing countries", "Africa".
The necessity of reliable and accurate information Using the filters provided by the search engines (for
in order to plan, monitor and evaluate undertaken example the publication date), relevant articles were
activities or to take action so as to achieve the objec- selected on the basis of the criteria described in Table 1.
tives as defined in health policies. To lookup the databases, we exclusively relied on the
logical operator "OR", because the use of the logical oper-
The conceptual framework defined by the WHO clearly ator "AND" or the combination of both logical operators
demonstrates that the organization of any health system "OR" and "AND" enabled us to obtain a reduced number
must be perceived in a systemic approach by taking into of articles, which were unfortunately not relevant for our
consideration all its different stakeholders, including study. As a matter of fact, we found a limited set of arti-
those related to its information system. It is also defined cles dealing with information systems issues related to
by the WHO as "an organized system that integrates the specific diseases, such as malaria or cancer. As these arti-
collection, processing, communication and use of data cles do not comply with the initial objective of our study,
necessary to improve the effectiveness and efficiency of

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which was to examine articles dealing with the HIS at the study. The choice of PRISM was motivated, on one
large, in a systemic approach. hand, by the fact that all reviewers had been previously
By choosing to use only the logical operator "OR" in trained in this approach, on the other hand, it makes
our bibliographic search equation, our aim was to obtain it possible to evaluate the performance of a HIS on the
the maximum number of articles and later on select the basis of each of its three determinants, i.e., technical,
most relevant one. This strategy allowed to obtain few organizational and behavioral for the analysis of the
relevant articles that perfectly met the objective of the 14 articles selected in our study, we opted to examine
study, despite some false positives (many articles not only the organizational and technical determinants.
related to the study topic). The two search algorithm that The behavioral determinants were not examined, as
allowed us to select our articles is depicted respectively in they required the administration of a questionnaire to
Figs. 1 and 2. the various actors involved in the HIS. This was not
adapted to our study, whose approach was to review the
literature.
Selection of relevant articles
The selected articles were examined using a grid
All articles meeting the above inclusion criteria were
validated by all the reviewers. On that grid, the two
eligible for inclusion in the study. Firstly, on the basis of
selected determinants for the study were evaluated on
these criteria, we carefully reviewed each article title in
the specific aspects dealt with these articles, namely
order to reject articles whose title, although incorporat-
HIS governance (HIS legal framework, national HIS
ing some of the defined keywords, did not correspond to
strategies, etc.), data quality (data completeness, data
the objective of the literature review. In other words, not
reliability, data relevance, data accuracy, data timeli-
all the articles that focused on information systems spe-
ness, etc.), information technology (IT), data ware-
cific to certain health issues rather than the problems of
houses, HIS evaluation and DHIS digital solution
national HIS were eligible for our review.
(Fig. 5).
Secondly, we used the Performance of Routine Infor-
The analysis of these aspects related to the organi-
mation System Management (PRISM) approach from
zational and technical context of HIS, allowed to
the United States Agency for International Develop-
identify the strengths and weaknesses regarding the
ment (USAID) to review the 14 articles selected for

Table 1 Inclusion criteria

Inclusion criteria
Original articles written in English or French, peer-reviewed, published between 2005 and 2019
Research articles which addresses the performance factors of national HIS in developing countries

Fig. 1 Bibliographic research equation on the Scopus database

Fig. 2 Bibliographic search equation on the PubMed database

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Koumamba et al. BMC Med Inform Decis Mak (2021) 21:232 Page 4 of 10

Table 2 Some strengths and weaknesses of HIS in developing countries

Organizational issue Technical issue

Strengths Strengths
Definition and validation of the data to be collected by all stakeholders Possibility to contextualize and adapt DHIS to nationally validated models
Review and harmonization of data collection tools to avoid data overlap Consensus approach to a system
and duplication Removal of redundant data and improvement of data quality at the central
Definition of harmonized national indicators level
Validation of a national data warehouse, sometimes cohabiting with exist- Possibility to enter DHIS information from a mobile phone or a paper data
ing subsystems collection medium
Consensual choice of essential indicators by theme Storage and centralization of data in a single database
Creation of a HIS coordination unit housed at the level of the Ministry of Weaknesses
Health in some cases Design (of DHIS) taking insufficient account of the needs of data-producing
Weaknesses structures because the collection and transmission of aggregated data
HIS not sufficiently taken into account in national health policies, making more helps decision-making at the central level and not the local one
it difficult to ensure the sustainability of HIS at the end of projects Unable to collect primary data in DHIS (individual patient data)
Inadequate institutional management of HIS DHIS does not allow the linking of care data with those of other systems
Coherent conceptual frameworks insufficiently such as health insurance
defined
Dependency on external donors for HIS funding

implementation of HIS in developing countries at the A systematic review of the 14 resulted scientific
organizational and technical level (Table 2). articles enabled us to understand the state of health
information management in some African countries
Results in which such information had been subjected to peer
Based on the keywords selected to constitute the basis reviewed scientific publications (Fig. 4). These selected
of our bibliographic research, we identified a total articles dealt with issues related to the evaluation,
of 2492 articles: 624 identified in PubMed and 1868 organization, data quality, improvement or develop-
identified in Scopus. Among these articles, 2460 arti- ment of integrated information systems or data ware-
cles dealing with information systems specific only to house (Fig. 5).
certain health issues were excluded from the study. Four articles which focus on general HIS issues in
Thirty-two (32) articles were relevant according to the Africa [8, 12, 16, 20] and 10 others dealing with HIS-
selection criteria (full articles, written in English or specific issues from 12 countries were identified: South
French, peer reviewed and published between 2005 Africa [13, 14], Benin [9], Botswana [14, 15], Ghana
and 2019). Then, we carefully reviewed the titles and [15], Malawi [1, 5, 10], Mozambique [19], Rwanda [19],
abstracts of the 32 articles to check whether the techni- Sierra Leone [14, 18], Tanzania [19], Zambia [19], Zan-
cal and organizational aspects of the HIS on which our zibar [14, 17], Zimbabwe [15]. Although the literature
articles should be examined were taken into considera- on HIS in these countries has been limited, the analysis
tion. This step, selected 14 articles corresponding to the of the available literature enabled to identify the organi-
objectives of our study (Fig. 3). zational and technical structure of each of these HIS.
Faced with public health challenges, such as SDGs From the 14 selected articles, 13 (92.9%) were quali-
(e.g., by 2030, to reduce the global maternal mortality tative in nature. All 10 articles dealing with HIS issues
ratio to less than 70 per 100,000 live births), the essen- from 12 African countries address the topic of health
tial role of information in a health system is increas- data warehouses, 10/10 (100%).
ingly highlighted in all target countries [3]. Indeed,
reliable and solid health information facilitates, on one Insufficient integration of stakeholders and coordination
hand better monitoring of SDGs indicators and on the in the implementation of the HIS
other hand, the development of health policies based A health system, insofar as it involves several actors to
on established facts. Nowadays, unfortunately, due to achieve its objectives, should also proceed by involving
a lack of reliable data (i.e., updated, consistent, etc.), all these actors in the implementation of a reliable HIS
HIS in many countries are struggling to meet informa- strategy.
tion needs in order to monitor their health indicators, The review of the literature shows that taking into
such as the main reasons for hospital visits or the main account the needs of all stakeholders in the health sys-
causes of death [4]. tem is the common point between the countries identi-
fied in the study to set up HIS in Africa, although these
systems have been implemented in different ways.

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Fig. 3 PRISMA process diagram

Fig. 4 Places concerned by the information systems studied in our study

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Koumamba et al. BMC Med Inform Decis Mak (2021) 21:232 Page 6 of 10

Fig. 5 Themes covered in the 14 articles examined

The structuring of health systems can be seen as in place coherent strategies for the integrated manage-
follows: ment of their HIS [6]. However, it should be noted that
these strategies are generally short termed in nature,
often after the project is implemented [7]. Insufficiently
• the sub-system that we can call the public sector
asserted coordination supported with well-defined roles
which manages all the activities of the health struc-
and responsibilities also makes it more difficult to ensure
tures that belong to the government;
the sustainability of these integrated HIS, making them
• the sub-system that we can call the private sector
less and less effective with doubtful information qual-
which manages all the activities of health structures
ity. This situation tends to promote the fragmentation of
owned by individuals who, in their personal capacity
HIS within actors using specific information systems to
and under their personal responsibilities, carry out
collect the specific data they need. This fragmentation
activities of general interest in the health field;
of the HIS is sometimes encouraged by some funding
• the sub-system that could be referred as the para-
organizations that prioritize certain subsystem needs to
public sector, which manages all the activities of
the detriment of others and the global needs of the inte-
health structures for which the government and pri-
grated HIS [8]. Health programs collecting more spe-
vate individuals are all managers at the same time.
cific data to meet the objectives of their donor agencies
For example, health care facilities owned by private
have little involvement in more comprehensive strate-
individuals or companies, but receiving subsidies
gies for developing and managing more integrated HIS
from the state and the assignment of staff paid by the
[9]. This explains the fact that many HIS projects have
state funding.
experienced governance problems as a whole [10]. This
is why some countries such as Malawi have optimized
It is by drawing on their national health plans and the quality of their data by asserting their leadership,
involving all stakeholders, such as these different health including by implementing a national strategy. It has also
sectors (public, para-public and private), health insur- been observed that 11 of the 12 countries under study
ance companies, etc., that some countries have identi- (92%) did not have a national strategy, but rather strate-
fied the needs and defined all the aspects to be taken gies implemented under a specific project. Malawi is the
into account in the conceptual phase of their HIS [5]. only one that has a national strategy to which all actors,
Although the development of national HIS strategies including donors, must align. This strategy was accom-
has not been sufficiently highlighted, it has nevertheless panied by a procedural guide to facilitate the design of a
been noted in the literature that some countries that have HIS integrating all sub-systems [11].
taken into account the needs of all stakeholders have put

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Despite the implementation of coherent strategies it was intended to integrate all the paper forms of the
such as national health plans that integrate the develop- subsystems into the DHIS software without any prior
ment and management of HIS, it is clear that insufficient standardization, resulting in data overlap and duplica-
integration of all stakeholders and coordination of HIS is tion. Zanzibar and Sierra Leone, for their part, opted
not conducive to the production of comprehensive data. for a consensual (with all stakeholders) sorting of data
Indeed, collecting data from multiple non-harmonized from the different sources before their integration into
tools makes it difficult for managers to fill out various a unique DW. Although using the same approach in
paper or electronic forms at the same time for several standardizing data to be pre-integrated, their record-
programs [12]. As a consequence of the inadequacy and ing into the data warehouses was different in the two
reliability of data in regular HIS, some countries are countries. In Zanzibar, paper-based forms were used
forced to conduct ad hoc survey based on already vali- to collect data from health facilities and made avail-
dated data collection methodologies in order to have able to health districts, which were then filled in the
health information for decision support such as Service DW. To overcome the errors which may occur with a
Availability Readiness Assessment survey, demographic manual process associated with the use of paper forms,
and health survey, etc. to estimate certain necessary indi- the Zanzibar Ministry of Health had undertaken a pro-
cators [13]. ject to use the OpenMRS clinical management software
In 2007, the WHO, like many other partners working to at the health facility level for processing and recording
improve HIS established some mechanisms to align their data in the DHIS warehouse. However, this OpenMRS-
support with national strategies, policies and procedures based project is experiencing difficulties in its imple-
developed by partner countries [14]. In this perspective, mentation due to limited local technical capacity [17].
some countries have undertaken to assess and develop Sierra Leone has had an approach that takes into
their national HIS management policies. The fact that account the context of unequal distribution of technical
all the initiatives should be aligned to these agendas and infrastructures throughout the country. The adapted
policies for the identification and harmonization of indi- and validated digital DHIS solution served as a reposi-
cators is one of the first requirements of this approach tory for the national HIS at all levels of the health sys-
[15, 16]. tem. The adaptation of DHIS was done in such a way
that in areas with a digital infrastructure, this reposi-
tory exchanged data with a hospital management soft-
Organization of technical and infrastructural support ware (HMS), such as OpenMRS where the SDX-HD
for the implementation of HIS standard facilitates this data exchange. The DHIS solu-
To enable the considered countries to achieve better tion also provides the ability to enter data from paper
health outcomes, several funding agencies had advocated or mobile phones. It is therefore a model that allows
the integration of data into Data Warehouses. To mate- data to be recorded at all levels and aggregated in one
rialize this recommendation requires the commitment place [18]. This evolutionary approach, based on a col-
of all actors to the plans and strategies implemented by laborative architecture, has enabled Sierra Leone health
the countries. In this regard, some mechanisms to align system to have increasingly accurate health data that is
international efforts with national systems have been accepted by several organizations that use it.
set up, including the International Health Partnership Six other countries (Ghana, Mozambique, Rwanda,
(IHP+) and the Partnership for Statistics for Develop- Tanzania, Zambia and Mozambique) which received sup-
ment in the 21st Century (PARIS21). Some initiatives, in port from the International Health Partnership have used
line with this logic, have been undertaken with the Dis- the DHIS software to implement their HIS. In Zambia,
trict Health Information System (DHIS) software, among Rwanda and Tanzania for instance, the software has been
others, in South Africa, Sierra Leone, Zanzibar and Bot- adapted by standardizing and computerizing the various
swana [14]. registers to collect data on care delivery from the health
In South Africa, the approach had been to validate facilities. While Ghana and Mozambique have adapted
a standard model on which to build a data warehouse the software from the standardized tools collected. This,
(DW) based on the DHIS software. This DW operates in order to record aggregated data at the facilities, dis-
in parallel with other existing subsystems. It is noti- trict and regional levels [19]. For the majority of cases,
fied at all levels of the health pyramid and subsystems, initiatives to implement integrated HIS in the differ-
regardless of their specific needs. At the level of three ent targeted developing countries have been technically
other countries, the approach was to integrate all sub- supported by the use of the DHIS solution. This digital
systems into a single DW. In Botswana for instance, solution, with open source code, has enabled several
projects, even with various approaches, to digitize data

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management and analysis from the health district to the Information System Management (PRISM) tool [9, 10].
central level [20]. At the structural level, DHIS was either It appears that for most cases, these HIS implementa-
filled in from the paper-based supports which allowed tion projects are supported by external donors, with
the collection of care services, or by using an Extract, an involvement limited to a simple consensus between
Transform & Load (ETL) process that extracts data from actors without a regulatory coordination framework
the given HIS to transform them and load them into a at the country level [19]. Although stakeholders have
central DW. often been involved in the phase of identifying informa-
tion needs, harmonizing collection tools, defining data
Presentation of the common platform used in the HIS
to be collected and indicators, it is unfortunately worth
projects in Africa: DHIS 2
noting that the absence of a framework that is enforce-
DHIS 2 is an open source software platform for the inte- able against all does not always guarantee establishing an
gration, analysis and dissemination of routine health data integrated HIS in the long term [18]. The development
developed by the Health Information Systems Program of policies and strategies is an asset for the continuation
(HISP) with the support of the Department of Computer of an integrated HIS after the withdrawal of the external
Science at the University of Oslo in Norway. Initially donors, since the implementation of these HIS is based
designed and developed for data collection at the level of more on the policies of donor agencies often tailored to
basic health committees and community information sys- their own needs over national needs.
tems in health districts, the platform evolved into a web- Some countries that have set HIS projects up on the
based version in 2006 with an adaptation at the national basis of national strategies have sometimes had bet-
level, hence DHIS2 for version 2. It is oriented towards ter data [17]. However, overall, it can be observed that
the capture of aggregate data from health programs. The despite these few successes, a number of weaknesses per-
application has a specific module, the "tracker" that can sist, including those related to inadequate policies and
be configured to allow data to be recorded in the most insufficient data centralization, resulting in often incom-
granular way possible and facilitate automated compila- plete data. To maintain this momentum for improv-
tion. This module, which is far from playing the role of ing data quality, it is appropriate for the ministries in
an electronic patient record, is more oriented towards charge of health to assert their leadership by developing
data specific to certain health programs and almost not national information management policies and strategies
towards care services with more complex data. by defining the roles and responsibilities of the various
actors with coordination structures.
Discussion The use of information and communication technolo-
Main lessons learned
gies as a support for the HIS to collect, process and dis-
The implementation of an HIS must take into account seminate health information is widely observed in DC.
the process of data collection, analysis processing and The implementation of the context-specific DHIS solu-
transmission at all levels of the health pyramid. It must tion makes it easier than ever to collect and transmit
support decision-making in health planning, epide- information to central level to support decision-making
miological monitoring and evaluation of health actions. [20]. However, it is unfortunate that the non-systemic
This requires that the development of HIS be supported structure of this IT (Information technology) solution,
by sufficient governance with policies integrating HIS- which takes into account very little (if any) the health
related aspects, including harmonized indicators, forms related data at the structure level, undermines the latter
(electronic or paper-based) for integrated data collection, category of actors (local structures) who, in addition to
and databases that are easy to use and accepted by users. producing the data, are their first users.
Limitations of the study
From the conducted literature review, it mainly
emerges that governance, a crucial element for an effi- Our review, in addition to being less exhaustive in terms
cient HIS, has not been sufficiently taken into account in of representativeness of the countries whose HIS were
most of the projects to set HIS upin Developing Coun- analyzed in this study (12 out of 54 African countries),
tries. The weak involvement of all stakeholders, together has a low number of articles retained. In addition, out
with weak leadership expressed by States and insufficient of the 12 countries whose HIS issue were analyzed, 11
coordination of HIS actors are among the main factors were English-speaking countries. However, the reality of
that have often threatened the sustainability of these HIS HIS management in English-speaking countries may not
[10]. This is clearly highlighted by the results of some be the same as in French-speaking countries, even if the
HIS evaluations following the WHO Health Metrics Net- health problem remains similar. It is therefore relevant to
work (HMN) framework and the US Agency for Inter- deepen such an initiative at the level of French-speaking
national Development (USAID) Performance of Routine countries and establish differences if any.

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Conclusion benefits from project funding to support his work. However, in the design
of the study, data collection, analysis, interpretation of data and writing of
The implementation of an efficient and effective the manuscript, the project played no role. However, the results of this study
information system implies in its design a systemic were validated by the experts of the E-Gabon NHIS project for use in its
approach. This approach takes into account the global implementation.
consideration of the needs of stakeholders at all levels Availability of data and materials
of decision-making, including at the level of the health Not applicable.
care structure. Although not sufficiently implemented
in practice, because it is done in a consensual way with- Declarations
out an enforceable framework with coordination, it has
Ethics approval and consent to participate
been observed that most projects initiated in Africa to Not applicable
set up or improve HIS have integrated this systemic
approach by taking into account the needs of various Consent for publication
Not applicable.
actors. The main concern would be that this systemic
approach is often not supported by strong leadership Competing interests
from department in charge of the health sector. Nev- The authors declare that they have no competing interests.
ertheless, during the time of a project with a consensus Author details
between stakeholders, some countries have managed to 1
Bordeaux Population Health (BPH), UMR1219, Applied Health Informatics
obtain quality health data. This leaves an optimism that Research Team (ERIAS), Univ. Bordeaux, 33000 Bordeaux, France. 2 Research
Unit in Epidemiology of Chronic Diseases and Environmental Health (URE-
with a coherent and unified governance in terms of the MCSE), University of Health Sciences, BP 11587, Libreville, Gabon. 3 UMR 1094
management of state health information, better health Inserm parter IRD-Tropical Neuroepidemiology (NET), Faculty of Medicine
indicators can be achieved. In such a case, IT solutions of the University of Limoges, 87025 Limoges, France.
such as DHIS alone are not enough. It requires that Received: 7 January 2020 Accepted: 28 July 2021
during the development of any HIS, rigorous upstream
reflections on strengthening its governance should be
carried out by defining and proposing a coherent con-
ceptual framework. The latter will make it possible to References
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Abbreviations développement durable? Développement durable et territoires. Écono-
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