As in many developing countries, lack of reliable data and grossly inadequate appreciation and use of available information in planning and management of health services were two main weaknesses of the health information systems in Malawi. Malawi began strengthening its health management information system with an analysis of the strengths and weaknesses of existing information systems, sharing findings with all stakeholders. All were agreed on the need for reformation of various, vertical programme-specific information systems into a comprehensive, integrated, decentralized and action-oriented simple system. As a first step towards conceptualization and design of the system, a minimum set of indicators was identified and a strategy was formulated for establishing a system in the country. The design focused only on the use of information in planning, management and the improvement of quality and coverage of services. All health and support personnel were trained, employing a training of trainers cascade approach. Information management and use was incorporated into the pre-service training curriculum and the job description of all health workers and support personnel. Quarterly feedback, supportive supervision visits and annual reviews were institutionalized. Civil society organizations were involved in monitoring coverage of health services at local levels. A mid-term review of the achievements of the health information system judged it to be one of the best in Africa. For the first time in Malawi, the health sector has information by facility by month. Yet very little improvement has been noted in use of information in rationalizing decisions. The conclusion is that, no matter how good the design of an information system, it will not be effective unless there is internal desire, dedication and commitment of leadership to have an effective and efficient health service management system.

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League tables are used to compare the performance of different entities in the health systems in developing countries. The aim of this paper is to study the implementation process and its effects related to a computerized league table application in Malawi. Focusing on the health district and using a field experiment research approach, the focus is on the implementation process and how it improves information transparency for health managers. Based on routine health data recording in the health management information system DHIS2, the introduced league table was used by the district health management teams in the pilot districts to rank and compare performance among their health facilities. While the introduction of the league tables was challenging, it also showed its potential through effects including improved visibility of information and accessibility for managers, better understanding of indicators, the identification of data quality issues, skills acquisition in computing and information use and improved communication and collaboration among stakeholders.

This journey would not have been successfully completed without the support and contributions from many different people.I would like to sincerely thank my supervisors: Associate Professor Petter Nielsen, Professor Jens Kaasbøll and Professor Sundeep Sahay for their guidance, encouragement and support; and for consistently advising me to challenge myself throughout the process of study. You were always there for me when I needed you most. Thanks to the research team of Johan, Marte, Kristoffer and Martin for designing and testing the prototype performance league table.I would like to extend my thanks to the Malawi Ministry of Health, the District Health Officers and health facility in-charges, as well as the health workers for allowing and participating in the study. My colleagues at the