Contextual factors affecting health information system strengthening.

At the turn of the century, several major efforts were initiated to combat HIV/AIDS and other major epidemics affecting low- and middle-income countries (LMICs). They were accompanied by initiatives to enable recipient countries to collect and use data to guide their public health programmes. These health information systems (HIS) typify systems in that they have multiple interacting components, and they are embedded within larger systems. Components of a larger system act as the context for all lower-level systems. Their effects can be pervasive, and thus be taken for granted or regarded as unchangeable. We identify four contextual factors that affect efforts to strengthen HIS: hierarchical roles, aid funding, corruption, and competing priorities. We provide examples of each as experienced by those working to strengthen HIS in LMICs. Each of these contextual factors can seriously diminish the effectiveness of HIS strengthening efforts and their long-term sustainability. We propose research questions about each that would enable those engaged in HIS strengthening to work effectively and sustainably.