″Implementing a policy is something else″: Governance of complex health information systems in Tanzania

Introduction: Health management information systems are crucial for a country′s health service planning and monitoring. Research indicates that generated data is often of low quality or not used for decision-making in low-resource settings. Digitalization potentially alleviates these problems, but scale-up in these countries is hampered by unreliable availability of resources. We aimed to understand how health policymakers perceive and experience working with data, data systems and the introduction of digital technology related to the governance of health management information systems in Tanzania. Methods: We conducted 16 interviews with national, regional and district health care managers experienced in using health information systems in Tanzania. Reflexive thematic analysis was used. Themes were developed underpinned by complexity theory and M. Lipsky′s theory of street-level bureaucracy. Results: Health care managers experienced challenges in health management information system governance in an unpredictable environment. Different power practices for system governance and implementation were used: Institutional power was applied to areas with existing international guidance and strategic examples. Subnational managers contextualized implementation through discretionary power practices where uncertainties prevailed. This led to transformed agendas in some cases, but also allowed for innovations to make policies work. Conclusions: Acknowledging the complexity of health management information system governance with constant adaptation can allow policymakers and senior managers to direct discretionary power where policy implementation would otherwise fail in the Tanzanian context. This can be achieved by identifying a set of social values around data processes that resonates with all actor groups and may support governance of this complex system.