Public Sector Health Information Systems

eGovernment for Development
eHealth Case Study No.7: Design-Reality Gaps

Computerising a Central Asian Epidemiology Service

Case Study Authors

Valeriya Krasnikova and Richard Heeks


The national Epidemiology Service provides plans, reports and programmes about a variety of disease and public health issues.

Application Description

The application was the planned introduction of computers into the Epidemiology Service to replace the previously-manual processes of gathering, processing, storing and reporting disease and public health data. The main software was a series of packages for registration and analysis of various specific diseases and public health risks. These created a single common computer-based information system with local, regional and national databases that relied on common data items.

Application Drivers

Within the Epidemiology Service, there was a general awareness that the existing information systems did not allow the Service to monitor and analyse current health trends properly, or to make public health decisions in an effective and timely manner. Thus, top managers within the Service were a key driving force behind the application as they sought improvements in the Service's performance. There was also general external support for the programme, with the President wedded to modernisation of the public sector, and with citizens - becoming used to growing democratic processes in the country - voicing demands for better information and better health services more generally.


The project was initiated by senior managers of the Epidemiology Service, and agreed by staff of the Ministry of Health. Key users were most staff at all levels within the Epidemiology Service - managers, health specialists, statistical specialists, and (later) information systems personnel, and external users in various ministries, local authorities, research institutions and international organisations. Ordinary citizens were the ultimate source of much of the data, and also the ultimate intended beneficiaries of the project.

Design-Reality Gap Analysis

Design-reality gap analysis compares the assumptions/requirements within the application design with the reality pertaining just before that design was implemented along seven 'ITPOSMO' dimensions:

Design-Reality Gap Reductions During Implementation

A medium/33.5-score design-reality gap may well bring some problems for an e-health application (follow this link for further explanation of the score).

However, the Epidemiology Service took actions during the implementation process that helped to reduce the size of the gaps:

As a result, what was judged to be a medium design-reality gap at the start of the implementation process had been reduced to a small/medium design-reality gap later in the implementation process.

Evaluation: Failure or Success?

The overall computerisation project was largely successful, as might well be expected with a small/medium final design-reality gap implemented over two years.

The project was completed within time and within budget. All of the installed software systems are in frequent use within the Epidemiology Service itself, though usage rates by external users are lower. There has been a small but consistent and significant increase in usage of data provided by the Service. Perhaps most importantly, the system can be credited with a key role in disease control. For example, shortly after the system's introduction in 1997 a rise in diptheria cases was detected via the system. Coverage of the vaccination programme was strengthened, and revaccination was organised. By 2000, coverage levels had risen from an average 88% to 99%, and diptheria case levels had returned to their historical norm. Such actions were possible with the manual system, but automation reduced the decision-making period from 15 to 2 days, and also helped cut costs by allowing better prioritisation, planning and targetting of vaccination.

The only reported problems faced by the project have been constraints due to some rather outdated PCs being included in the installation, and conflicts that initially arose between health/epidemiological staff and IS staff, including conflicts at management level. Of course, those staff who were displaced from the statistical departments might well have a different opinion about the application, and not rate it as 'largely successful' from their perspective.

Recommendations: Reducing Design-Reality Gaps

One of the good practices of this project was that it was participative, ensuring that the design and implementation process involved a broad range of stakeholders. Information needs analysis covered managers, statistical officers, and external users to ensure a small gap between designed and actual information needs. The project was guided by a mixed team of epidemiological and information systems specialists, ensuring that design elements such as processes or skill requirements did not fall too far out of line with existing realities in the Epidemiology Service.

The project - if sensitised to the socio-technical rather than purely technical nature of information systems - could have anticipated some of the objectives/values problems. If so, it could have introduced from the start the improvisations introduced during implementation by the HR department.

Case Details

Author Data Sources/Role : Documents and Interviews; No Direct Role
Outcome : Largely Successful.
Region : Central Asia. Start Date : 1995. Submission Date : January 2003.

Last updated on 19 October, 2008.
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