title: Sustainability of health information systems: a three-country qualitative study in southern Africa.
abstract: Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems. As many donor-driven programs are increasing their focus on country ownership, sustainability of these investments is a key concern. This analysis explores the potential sustainability of EHIS investments in Malawi, Zambia and Zimbabwe, originally supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR).
  
  
  
  Using a framework based on sustainability theories from the health systems literature, this analysis employs a qualitative case study methodology to highlight factors that may increase the likelihood that donor-supported initiatives will continue after the original support is modified or ends.
  
  
  
  Findings highlight commonalities around possible determinants of sustainability. The study found that there is great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems. Full stakeholder engagement is likely to be crucial for sustainability, as well as integration with other activities within the health system and those funded by development partners. The literature suggests that a sustainable system has clearly-defined goals around which stakeholders can rally, but this has not been achieved in the systems studied. The study also found that technical resource constraints - affecting system usage, maintenance, upgrades and repairs - may limit EHIS sustainability even if these other pillars were addressed.
  
  
  
  The sustainability of EHIS faces many challenges, which could be addressed through systems' technical design, stakeholder coordination, and the building of organizational capacity to maintain and enhance such systems. All of this requires time and attention, but is likely to enhance long-term outcomes.
authors.affiliation: Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, 650 Charles Young Drive South, Los Angeles, CA, 90095, USA. cmoucheraud@ucla.edu.
authors.forename: Corrina
authors.identifier: 0000-0001-7862-7928
authors.initials: C
authors.lastname: Moucheraud
authors.affiliation: Centers for Disease Control and Prevention, Maseru, Lesotho.
authors.forename: Amee
authors.initials: A
authors.lastname: Schwitters
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Chantelle
authors.initials: C
authors.lastname: Boudreaux
authors.affiliation: Centers for Disease Control and Prevention, Maputo, Mozambique.
authors.forename: Denise
authors.initials: D
authors.lastname: Giles
authors.affiliation: Centers for Disease Control and Prevention Zimbabwe, Harare, Zimbabwe.|Division of Global HIV and TB, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, USA.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Kilmarx
authors.affiliation: JSI Research and Training Institute, Inc, Lilongwe, Malawi.
authors.forename: Ntolo
authors.initials: N
authors.lastname: Ntolo
authors.affiliation: Centers for Disease Control and Prevention Zimbabwe, Harare, Zimbabwe.
authors.forename: Zwashe
authors.initials: Z
authors.lastname: Bangani
authors.affiliation: Division of Global HIV and TB, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, USA.
authors.forename: Michael E
authors.initials: ME
authors.lastname: St Louis
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Bossert
mesh_terms: D015658:HIV Infections / Q000628:therapy; D063005:Health Information Systems / Q000191:economics* / Q000458:organization & administration; D006295:Health Resources; D006801:Humans; D007391:International Cooperation; D007407:Interviews as Topic; D008295:Malawi; D036301:Qualitative Research; D014481:United States; D015024:Zambia; D015030:Zimbabwe
keywords: Development assistance; Electronic medical record system; Health information systems; PEPFAR; Sustainability