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• clinical TB staff or nurses at facility level (n = 6) who had its benefits. Specifically, participants expressed fears over
experience using the paper TB registers and implementing reduction in data quality, uncertainty over changes to the
the TB module in TIER.Net in each facility, including status quo and, for some facility level staff, insecurity
capturing TB data into the electronic register regarding their ability to use an unfamiliar and electronic
• an implementing partner from the Anova Health Institute system. Participants referred to such challenges while
(n = 1) who provided extensive support to facility and describing positive experiences, such as significantly reduced
sub-district level staff during implementation in all three workloads, speed of accessing patient-level data and
pilot sites. click-of-a-button reporting. Our results report on three key
contextual factors emerging from our interviews that gave
To maintain their anonymity all manager-participants are rise to the conflicting sentiments that influenced the ease of
referred to as TB managers in the results regardless of their adopting the facility level electronic TB register: (1) the
position in the health system. Discussions were conducted position of TB programme and programme data, (2)
in participants’ preferred language by two bilingual perceptions about the new and old systems and (3) how
(Afrikaans and English) researchers using a semi-structured acceptance of the new system was facilitated.
discussion guide. Interviews were audio recorded and
ranged from 20 min to 90 min. Interview questions were Position of the tuberculosis programme and
about participants’ recollections of their experiences of tuberculosis programme data at the facility
TB programme data with the paper-based system, the The historically siloed nature of the TB programme and data
transition to an electronic system and their current flow in South Africa enabled TB clinicians and managers
experiences with the electronic system. The evaluation of
the pilot project was funded by the Anova Health Institute, careful control of programme data for surveillance purposes
which was the implementing partner at the time of the using paper-based registers. TB programme staff positioned
study. To mediate potential desirability bias in participants’ themselves as ‘TB champions’, that is, as custodians of
responses during interviews, the researchers conducting TB data, which they entered, tallied and then appropriated,
the interviews were external to the organisation. and this led to them having a vested interest in the status quo
of ‘their’ paper-based system. The transition to an electronic
in-facility register signalled a shift in how the TB programme
Data analysis
would be controlled, allowing more involvement of facility
Audio recordings were summarised and transcribed by the level staff in data entry and maintenance, and signalling a
researchers. An objective-driven thematic frame was used to loss of control as the data would be available to a much
explore the data – namely aspects of the health information broader audience. Excerpts from interviews illustrate the
system that could be influenced by transition from a paper- shift in power with introduction of the register:
based to an electronic TB patient register (e.g. resources, data
flows, decision-making and accountability) 14,15 , as well as ‘There is one person in the clinic who completes the [paper]
register; there is one person in the clinic who understands
contextual health systems factors that could influence TB data. And all of a sudden [with introduction of the electronic
transition to the electronic TB register. Key ideas from the TB register], the clerk must become involved, and more than one
data were grouped into: clerk, and more than one staff member.’ (Participant 19, female,
• contextual factors TB manager, 13 September 2016)
• process-related changes during the transition ‘In the olden days you felt like those old Sisters lording over
• recommendations for facilitating efficiency and everything – they can ask you anything, you know everything,
effectiveness. you understand everything. And [with the electronic TB register]
I don’t know it.’ (Participant 7, female, nurse, 09 September
These findings were discussed amongst the authors, who 2016)
drew on their experiences of implementing the TB programme
and health information systems to interpret the data. The electronic register would allow facilities to query and
clean their own data before submission in upward data flow,
Ethical �onsiderations with sub-district TB coordinators taking on a less hands-on
oversight role than they had before. This role change and the
Ethical clearance for this study was obtained from the
University of Stellenbosch’s Health Research Ethics perceived effects of the transition on data quality raised
Committee, and an informed consent process was followed anxieties:
with each participant (Ethical Clearance No. N16/02/024). ‘Eighty percent of [TB coordinators’] work was ETR, was TB data.
Data, data analysis, and data validation. Now we come and say
Results that there is a possibility that we’ll take the ETR away because
we want to do better patient management. That’s the anxiety –
Participants shared conflicting feelings about the transition what about us now? What is our role? They don’t understand,
to an electronic in-facility TB register, describing not only they’ll still have a role in data. The role just needs to be clarified.’
their anxieties around the transition but also acknowledging (Participant 20, male, TB manager, 15 September 2016)

http://www.sajhivmed.org.za 252 Open Access