# Nexus between policy and practice in institutionalization of clinical information systems and knowledge management in developing health systems: Context of tertiary hospitals in Malawi

## TL;DR

Digital health systems in Malawi face challenges due to misalignment between policies and practice, requiring better stakeholder engagement and training.

## Contribution

The study identifies institutional barriers to digital health adoption in Malawi and emphasizes the need for policy-practice alignment and stakeholder involvement.

## Key findings

- Limited leadership engagement at health facilities hinders digital health adoption.
- Unclear guidelines and weak enforcement mechanisms contribute to poor uptake of digital systems.
- Stakeholder power dynamics and competing priorities influence digital health implementation.

## Abstract

In emerging economies, the widespread penetration and mainstreaming of Clinical Information Systems (CIS) and Knowledge Management (KM) practices are challenging and often hindered by fragmented regulatory environments, professional resistance, and cultural misalignment. Drawing on Scott’s institutional theory and its three pillars—regulative, normative, and cultural-cognitive—as an analytical framework, the study aims to inform both policy and practice, contributing to ongoing efforts to strengthen digital health implementation, governance, and institutional capacity in low and middle-income countries (LMIC). The study employed qualitative methods, including analysis of policy documents, key informant interviews, and institutional case study analysis. The findings revealed policy-practice misalignment in the institutionalization of CIS and KM. There is limited engagement of senior management at the facility level in the institutionalization process. Key actors—including government agencies, healthcare providers, regulatory bodies, development partners, and healthcare workers—were identified, along with their roles and responsibilities in shaping institutional outcomes. Application of digital health policies and strategies in Malawi is hindered by limited resources, unclear guidelines, and weak enforcement mechanisms. Consequently, stakeholder engagement is essential for the successful and effective use of technology. These findings suggest that policy–practice gaps are shaped not only by policy design, but also by institutional arrangements and power dynamics within the digital health ecosystem. Thus, successful integration of CIS and KM requires alignment between policy and practice, ongoing training, active participation in system design, and a willingness to integrate digital tools into clinical workflows.

Digital health systems are increasingly promoted as a way to improve healthcare in Malawi, but many of these systems are not fully used once they are introduced. Clinical Information Systems and Knowledge Management tools are often expected to support better decision-making and patient care, yet healthcare workers and facilities face many challenges in using them in daily practice.

In this study, we explored why national digital health policies in Malawi do not always translate into effective use of digital systems at health facility level. We reviewed policy documents and spoke with key people involved in digital health, including policymakers, regulators, development partners, and healthcare workers. We found that limited leadership involvement at health facilities, unclear guidance on how policies should be implemented, and weak enforcement contribute to poor uptake of digital systems. Power relationships and competing priorities among stakeholders also influence how digital health initiatives are carried out. Our findings show that technology alone is not enough to strengthen health systems in Malawi. For digital health investments to succeed, policies must be better aligned with everyday clinical work, healthcare workers need ongoing training and support, and leaders at all levels must actively engage in system design and implementation. These lessons can help improve future digital health planning and data use in Malawi.