Designed for performance

Introduction

There is a fundamental truth in health information systems: “every system produces exactly the results it was designed to produce”. If your data is poor, if it goes unused, if frontline staff see it as a burden, these are not accidents. They are the predictable outcomes of a system designed for compliance, not for learning; for upward reporting, not for local action.

A strong Routine Health Information System, or RHIS, is more than a technical platform. It is also a human and organizational system. People need the skills and confidence to use data. Facilities need routines and authority to act on what the data show. Technology must be simple, reliable, and useful.

This chapter is about those design decisions. It is about shifting from a centralised, compliance-driven model to a decentralised, people-centred information culture. We will explore the PRISM framework, which teaches us that a successful RHIS is not just about technology. It is about balancing three dimensions: behavioural (the people), organizational (the structures and processes), and technical (the tools). Neglect anyone, and the system will fail.

The decisions you make as a manager, whether at facility, district, or national level, will shape the destiny of your RHIS. This chapter will guide you in making the choices that lead to a system that demands data use, empowers its users, and ultimately transforms the health of the community it serves.

The three pillars of performance: The PRISM framework

Why do so many RHIS fail, even when the technology is sophisticated and the data is plentiful? The answer lies in an imbalance. Most efforts focus almost exclusively on the technical components: digitising forms, buying hardware, building databases. They neglect the human and organizational dimensions that determine whether people will actually use the system.

The PRISM Framework (Performance of Routine Information System Management) provides a powerful lens for understanding these dimensions. It proposes that RHIS performance, defined as the production of quality data and its active use, is determined by the interplay of three factors:

Behavioural Determinants: The knowledge, skills, attitudes, and motivations of the people who collect, manage, and use data. This is about human capacity, curiosity, and leadership.

Organizational Determinants: The structures, processes, culture, and governance that shape how work is done. This includes decentralisation, clear roles, feedback loops, and institutionalised data use activities.

Technical Determinants: The hardware, software, data standards, and infrastructure that enable data collection, storage, and analysis.

For a RHIS to thrive, these three pillars must be in balance. A system with perfect technology but no skilled, motivated people to use it is an expensive museum piece. A system with enthusiastic staff but chaotic organizational structures and no clear decisionmaking authority will burn out its champions. A system with perfect organizational design but outdated, incompatible technology will be slow, frustrating, and ultimately abandoned.

The core design decision for any health system is this: How will we balance our investments across the behavioural, organizational, and technical dimensions to create a system that is not just functional, but relied on daily?

1. The human element: Behavioural determinants

At the base of the PRISM framework lies the most important component: people. Technology is a tool; data is a resource and organisation is about systems. But only people can ask questions, interpret findings, tell stories, and take action. The behavioural determinants are about building the human capacity to drive the information cycle.

1.1 The power of information champions

Every successful information culture needs champions: people with natural curiosity, a spirit of innovation, a passion for understanding what the data means and the ability to find interesting stories. They are not necessarily senior managers. They might be a nurse, a health inspector, or a data capturer who gets excited by a graph or spots a story in an indicator with unusual results.

Your job as a leader is to find, nurture, and empower these champions. Give them time, resources, and authority. Protect them from the daily grind of reporting so they can focus necessary time on analysis and storytelling. Recognise their contributions and create a career path for them. A single, passionate champion can transform an entire facility, just as you can change your district!

1.2 Building teams, not just assigning tasks

Most health staff are not naturally interested in data. They see it as an additional burden on top of their core work of caring for patients. Forcing them to become data analysts is a recipe for resistance.

The solution is teamwork. Create dedicated information teams: small groups of interested and curious staff who take responsibility for the RHIS. These teams should be led by the information champion and include representatives from different programmes (maternal health, TB, HIV, etc.). They handle the data analysis, prepare the self-assessment, and create the information products. Programme managers need to be the drivers of data use. They need to be upskilled and made responsible for the analysis, interpretation and understanding of their programme data, supported by the information officers.

The rest of the staff? Their job is to collect good data at the point of care and to participate in the discussions that the information team facilitates. They do not need to become data experts; they need to see that their data is being used to improve their work and their community’s health. Then they will become interested.

1.3 Capacity development: Learning by doing

Training is necessary, but it must be practical and continuous, ideally combined with supervision, mentorship and coaching. A one-off workshop will not create a data culture.

Effective capacity development uses a mix of approaches:

Targeted Needs Assessment: Before any training, assess who needs to know what. Do not waste time training clinical staff on data analysis if they are not interested and will never use it.

Distance Learning: There are many high quality online courses and modules that staff can access at their own pace.

On-the-job Mentorship: Information champions and supervisors working side-by-side with colleagues, coaching them through self-assessment, graphmaking, interpretation and storytelling.

Practical, Contextualised Curricula: Training should focus on the specific skills needed for local RHIS functions: making a facility profile, calculating KPIs, creating graphs, developing stories. It should use the facility’s own data as the training material.

1.4 Leadership: The non-negotiable ingredient

None of this happens without the committed leadership of information champions. Leaders at all levels must visibly use data at all possible occasions :

Constant data use: Use data in your own presentations, planning, and supervision. If leaders do not use data, no one else will.

Ensure resource availability.

Do everything in your power to ensure internet connectivity. The commonest preventable system failure is that health workers cannot access the internet.

The information team should get dedicated time to ensure the data follows the full information cycle. They should not have to work after hours to make good reports, provide feedback and prepare stories.

Supervision, training and mentorship are expensive. Shift to targeted supervision and distance learning to reduce costs. Allocate dedicated, ringfenced money or these vital functions will not be performed

Hold programme managers accountable: Programme managers (not information managers) should be responsible for the quality and use of their own programme’s data. They should check the technical accuracy, sign off on reports and present their data at meetings. The days of relying on information officers to be the programme “mouthpieces” must end.

Create space for curiosity: Give staff permission to explore data, to ask "why," and to propose innovative solutions. Celebrate double-loop learning and critical thinking, not just compliance.

2. The architecture of use: Organisational determinants

You can have the most skilled, motivated staff in the world, but if the institutional systems, structures and processes are working against them, they will fail. The organisational determinants are about designing a system that enables and demands data use.

2.1 Decentralisation: The driving force

A centralised RHIS will never be fully used. When all decisions are made at the top, local staff feel no ownership. They collect data because they are told to, not because they need it. They see no connection between their collection efforts and the management decisions that affect their work.

Decentralisation is not just a structure; it is a philosophy. It means:

Empowering local teams to analyse their own data and make decisions based on their local context.

Giving local managers authority to allocate resources, adjust programmes, and implement solutions based on what their data tells them.

Creating accountability at the local level. When a facility owns its data, it takes responsibility for its quality and for acting on its insights.

A decentralised system is more responsive, more innovative, and more sustainable. It unlocks the creativity and local knowledge that a centralised system can never access.

2.2 Governance and stewardship (see chapter 8)

Decentralisation must be supported by clear governance (Policies, Plans, Guidelines) that is implemented through local district stewardship.

Governance as a skeleton means:

A clear vision, mission, and objectives for the RHIS at every level. What are we trying to achieve? What will success look like?

Defined roles and responsibilities documented in job descriptions and standard operating procedures (SOPs).

Standardised protocols and job aids. User-friendly and relevant SOPs for data collection, reporting, feedback, and self-assessment ensure consistency and quality across the system.

Sustainable financing. A common mistake is to fund the initial setup of an RHIS but not its ongoing operation. WHO recommends that each year approximately 5% of health resources should be allocated to the health information system. This is not a lost cost; it is an investment in the intelligence (brain and CNS) that guides all other spending.

Stewardship

This is the decentralised district team empowered to put the people (muscles) in place to implement these rules, regulations and policies.

The DHMT needs to decide who will do what task and produce appropriate local job descriptions. Who is the information champion? Who is on the information team? Who is responsible for data quality for each programme? What is the role of programme managers? Information officers?

Programme managers are key to this RHIS stewardship. They should have the skills to be responsible for the use (and quality) of their programme data. Information officers can support analysis and reporting, but they should not be the people who present programme data.

3. The enablers: Technical determinants

Technology is necessary, but it must support people and processes. Good technology reduces workload, improves data quality, and makes analysis easier. The wrong technology can be a challenging barrier to overcome.

3.1 User-centric design

The golden rule of health information technology is: The user interface must be simple, even if the backend is complex. If a system is hard for a busy nurse or a community health worker to use, they will find ways to bypass it or will use it poorly.

A picture based CHW register

Design decisions should involve users from the beginning. Ask them: What is easy? What is hard? What would make your job easier?

A system designed by and for its users has a far higher chance of being adopted and sustained.

3.2 Interoperability and standards

Health workers should not have to enter the same patient data into five different systems (as happens all too often). Technical decisions must prioritise interoperability: the ability of different systems to exchange and use information.

This requires adopting common data standards and investing in integration platforms to reduce duplication and promote reliable exchange of data between the different parallel information systems (RHIS, laboratory, pharmacy, programmes etc.).

3.3 Infrastructure and support

Information and Communication Technology (ICT) depends on basic infrastructure and reliable support. This means:

Reliable electricity and internet connectivity (with monthly bundles), especially in rural areas.

Appropriate computers, routers, tablets and other hardware that is durable and suitable for local conditions.

Ongoing technical support, including help desks, regular system updates, and local IT support personnel. Facilities (and districts) should be able to call for help and get it promptly to ensure that the RHIS computers and software are functional.

Underinvesting in infrastructure and support is a false economy. A tablet without connectivity, or a computer without support, quickly becomes an expensive problem..

3.4 The promise of artificial intelligence

We stand on the cusp of a technological revolution that is going to revolutionise our lives for the foreseeable future. Artificial Intelligence (AI) has the potential to transform how we use health data. Imagine:

Predictive analytics that forecast outbreaks before they happen, based on climate data, population movements, and historical patterns.

Natural language interfaces that allow you to simply ask your data a question in plain language: "Show me the five facilities with the lowest immunisation coverage this quarter."

Automated anomaly detection that instantly flags unusual patterns (a spike in a notifiable disease, a sudden drop in reporting) and alerts the relevant manager.

Intelligent storytelling that analyses a dashboard and generates a first draft of a narrative report, highlighting key trends and suggesting possible interventions.

AI is not a replacement for human judgment. But it will become an increasingly powerful partner in making sense of complex data. Districts and facilities should begin exploring how to incorporate these new tools as they become available.

4 Strengthening the RHIS: Unified action by district and facility

In the RHIS, two levels determine success: the district and the facility. District stewardship connects national policies to local reality. The facility is where data is born and used. Neither works alone. When they share a vision, the RHIS becomes a tool for daily improvement. Here is how, using the PRISM framework (Technical, Organisational, Behavioural).

1. Technical: Simple Tools That Serve People

The journey starts with technology. The guiding principle is clear: technology must serve the people, never the other way around. The district chooses user-centric technology: simple, relevant, integrated. It provides power, storage, connectivity, and ongoing support. It also creates feedback channels so users can report problems and suggest fixes. The facility manager advocates for simple, flexible tools and speaks up for frontline workers. They build local skills through on-the-job training using real data. They celebrate small wins: faster data entry, clean reports, clear graphs.

A technical system that does not listen to its users is a system that will fail.

1. Organizational: Structures That Enable Action

Technology alone is empty. It needs a supportive stewardship structure.The district establishes clear leadership, accountability, and a voice for facilities. It invests in practical skills development (e.g., facility profiles, self-assessments, dashboards).

It fosters a data-use culture through review meetings, regular M&E feedback, and public recognition of improving teams.

The facility forms a dedicated information team where possible: staff who are curious and reliable. It defines clear roles: who checks data quality, who enters data, who prepares self-assessments. It also shares anonymised data with the community and uses local knowledge to design solutions.

1. Behavioural: Culture, Feedback, and Belonging

The most elegant technology and the clearest organizational chart will fail if people do not want to use the system. This is where behavior and culture take center stage. The district builds a daily culture of learning, not blame. M&E feedback is a teaching tool. Review meetings ask “What can we learn?” not “Who made a mistake?” Structured feedback loops ensure even remote workers know their reports are seen and acted upon.

This behavioural shift finds its true home at the facility that closes the feedback loop. No more letting data disappear into a black hole. Every data collector sees the results of their work. The manager shares graphs and stories: “Because you tracked fever cases, we restocked antimalarials early.” This turns data entry into a source of pride. The manager also celebrates improvements with shout-outs or thank-you notes. These small acts say: You belong. Your work matters.

The Hub and the Heart, Beating Together

When the district acts as a supportive hub (investing in governance, user-centric technology, and a culture of feedback) and the facility acts as an empowered heart (forming teams, defining roles, celebrating small wins, and speaking up for simplicity), the RHIS stops being a bureaucratic burden. It becomes a horizontal learning system. National policies and annual plans are no longer distant mandates but locally interpreted actions. Data reflects both problems and possibilities.

A system that listens, trains, and celebrates will always outperform one that only demands.

5. The Information Triangle: Another lens to view your information system:

To balance these three pillars, visualise your system as a triangle where the RHIS sits at the centre, supported by three critical constraints:

Data Detail (Demand): Resist the urge to collect everything. High demand for overly granular data often overwhelms staff and leads to system collapse. Start with essential, actionable indicators and expand only as capacity grows.

Staff Capacity: Match your data requirements to your team’s current skills. Overworked or undertrained staff cannot maintain high-quality data. Invest in continuous, practical training and mentorship rather than expecting immediate, high-level analysis.

Resources: A system is only as strong as its foundation. Inadequate office space, unstable power, or outdated technology will inevitably fail. You must align your data collection ambitions with the actual resources available: if you demand complex data, you must provide the sufficient equipment, stable infrastructure, and technical support to handle it.

Ultimately, remember that imbalance is the primary cause of system failure: high data demands cannot succeed without proportional investment in both skilled staff and the necessary physical resources. The RHIS is central, and has 3 support systems to keep it in balance.

4 Managing change: From vicious to virtuous cycle

Systems do not change themselves, they change because people change how they work, think, and make decisions. This chapter teaches that poor data quality and non-use are not accidents but predictable outcomes of how a system was designed. To get different results, we must deliberately redesign the behavioural, organisational, and technical pillars, not just buy new gadgets.

Without change management, well-intentioned initiatives continuously crash into the vicious cycle: staff submit poor data because they see no use for it, managers distrust the data, demands increase, resentment grows, and quality worsens.

Change management breaks this cycle by giving people a voice in designing the solution, which builds ownership and reduces resistance. It allows us to test small, low-risk pilots that teach us what works before we scale up to the whole system. It replaces top-down mandates with local learning and turns data from a burden into a tool for solving real problems.

The five-step process described below is not a bureaucratic checklist, it is a practical roadmap for shifting from compliance to curiosity. Because if we do not manage the change, the change will manage us, and we will end up with the same old results, just with newer tablets. As the chapter concludes, "design is destiny," and change management ensures we design for success, not frustration.

Transitioning from a centralised, compliance-driven system to a decentralised, people-centred culture is a profound change. It requires a deliberate change management process built around standard change management steps.

5 Conclusion: Design is destiny

The systems we build produce exactly the results they are designed to produce. If you are dissatisfied with the results of your RHIS, do not blame the data collectors or the technology. Look at the design.

Are you balancing the behavioural, organizational, and technical determinants?

Have you decentralised decision making?

Have you institutionalised data use?

Have you empowered your champions?

Have you communicated your vision and the details of the design?

The decisions you make today will shape the health of your community for years to come. Choose to design a system that demands to be used, and watch your data transform from a burden into your greatest asset.

CAPSTONE EXERCISE: The PRISM action plan

Task: You have been asked to present a 10-minute briefing to your district management team on "How We Can Strengthen Our RHIS Using PRISM."

Using what you have learned from this chapter, prepare a one-page briefing note that answers in one sentence each:

1. Diagnosis (LO1): Which of the three PRISM pillars is weakest in our district right now?
2. People (LO2): Who is our information champion? If we do not have one, how will we find one?
3. Processes (LO3): What one routine data use activity will we institutionalise first?
4. Authority (LO4): What one decision will we decentralise to facility level as a test?
5. Pilot (LO5): What small pilot will we run in the next 90 days to break a vicious cycle?

Then: Treat this briefing as a small test of your own. Present it to a colleague and ask: "If you heard this, would you support it?" Use their feedback to revise before presenting to management.

Output for Capstone: One page. No more.

References

1. Aqil, 2009
2. Kawakyu, 2023
3. Anwer Aqil, 2010
4. Global Health Learning Center, n.d.
5. Anwer Aqil, 2010
6. Trinidad and Tobago RHIS study, 2024
7. University of Nairobi, n.d.
8. World Health Organization, n.d.
9. Aqil, 2009
10. Anwer Aqil, 2010