Globally, health management information systems (HMIS) have been hailed as important tools for health reform (1). However, their implementation has become a major challenge for researchers and practitioners because of the significant proportion of failure of implementation efforts (2; 3). Researchers have attributed this significant failure of HMIS implementation, in part, to the complexity of meeting with and satisfying multiple (poorly understood) logics in the implementation process.This paper focuses on exploring the multiple logics, including how they may conflict and affect the HMIS implementation process. Particularly, I draw on an institutional logics perspective to analyze empirical findings from an action research project, which involved HMIS implementation in a state government Ministry of Health in (Northern) Nigeria. The analysis highlights the important HMIS institutional logics, where they conflict and how they are resolved.I argue for an expanded understanding of HMIS implementation that recognizes various institutional logics that participants bring to the implementation process, and how these are inscribed in the decision making process in ways that may be conflicting, and increasing the risk of failure. Furthermore, I propose that the resolution of conflicting logics can be conceptualized as involving deinstitutionalization, changeover resolution or dialectical resolution mechanisms. I conclude by suggesting that HMIS implementation can be improved by implementation strategies that are made based on an understanding of these conflicting logics.

ObjectiveTo assess the impact of mobile virtual reality (VR) simulations using electronic Helping Babies Breathe (eHBB) or video for the maintenance of neonatal resuscitation skills in healthcare workers in resource-scarce settings.DesignRandomised controlled trial with 6-month follow-up (2018–2020).SettingSecondary and tertiary healthcare facilities.Participants274 nurses and midwives assigned to labour and delivery, operating room and newborn care units were recruited from 20 healthcare facilities in Nigeria and Kenya and randomised to one of three groups: VR (eHBB+digital guide), video (video+digital guide) or control (digital guide only) groups before an in-person HBB course.Intervention(s)eHBB VR simulation or neonatal resuscitation video.Main outcome(s)Healthcare worker neonatal resuscitation skills using standardised checklists in a simulated setting at 1 month, 3 months and 6 months.ResultsNeonatal resuscitation skills pass rates were similar among the groups at 6-month follow-up for bag-and-mask ventilation (BMV) skills check (VR 28%, video 25%, control 22%, p=0.71), objective structured clinical examination (OSCE) A (VR 76%, video 76%, control 72%, p=0.78) and OSCE B (VR 62%, video 60%, control 49%, p=0.18). Relative to the immediate postcourse assessments, there was greater retention of BMV skills at 6 months in the VR group (−15% VR, p=0.10; −21% video, p<0.01, –27% control, p=0.001). OSCE B pass rates in the VR group were numerically higher at 3 months (+4%, p=0.64) and 6 months (+3%, p=0.74) and lower in the video (−21% at 3 months, p<0.001; −14% at 6 months, p=0.066) and control groups (−7% at 3 months, p=0.43; −14% at 6 months, p=0.10). On follow-up survey, 95% (n=65) of respondents in the VR group and 98% (n=82) in the video group would use their assigned intervention again.ConclusioneHBB VR training was highly acceptable to healthcare workers in low-income to middle-income countries and may provide additional support for neonatal resuscitation skills retention compared with other digital interventions.

In this article we describe and reflect on an ongoing project to develop an integrated health information system (HIS) in Sierra Leone. We emphasise the complexity of such an effort and on challenges faced with building a health information infrastructure in the context of a developing country. The main lesson of the paper is in the design of a change strategy towards an integrated HIS in Sierra Leone influenced by information infrastructure literature. The key elements of the strategy are 1) to facilitate a gradual change process building on the existing systems and practices (the installed base), 2) to bootstrap political will through quick wins and pilot projects, and 3) a flexible standardisation approach to integration to smoothen the change experience for users and stakeholders, and minimise resistance.

Health Management Information Systems (HMIS) in developing countries have yet to live up to expectations because of the significant proportion of implementation failures. Mobile health (mHealth) technologies are being adopted increasingly in Ministries of Health (MoHs) to address aspects of HMIS implementation failure, such as the timeliness and ease of data collection from the lowest levels of healthcare. However, networked technologies such as mobile technologies used in mHealth data collection can introduce a network logic into the organization. This network logic, which often favors open, non‐hierarchical modes of communication, must work with the traditional hierarchical bureaucratic logic of the HMIS and the MoH in which they become embedded. This paper conceptualizes the interaction between these two logics. It draws on succinct, empirical vignettes from two action‐research projects involving the use of mHealth technology to improve data collection for the HMIS in Nigeria. Based on these findings and an institutional logics lens, this paper argues that the interaction between these logics potentially leads to a conflict where the logic embedded in networked technologies (such as mHealth) disrupts and challenges the existing hierarchical logic in the bureaucracy (such as in the MoH). It threatens not only to unsettle existing practices and norms in the organization, but also to restructure (flatten) the organization, due to resistance, loss, or changes in some pre‐existing roles. Practitioners and implementation researchers need to be sensitive to potential hierarchical and network‐centric forces that are involved in implementing mHealth in traditional hierarchical settings, particularly with regards to the unintended side effects that may arise in the process.

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