Today, many countries around the world focus on ensuring that all people can access health services of sufficient quality without experiencing financial hardship (i.e., universal health coverage). To measure progress towards this goal, countries need to build robust health information systems. Because countries need to root universal health coverage in primary healthcare, they also needs to sensitively anchor health information systems that support universal health coverage in existing routine health information systems. However, doing so involves significant challenges, which we study via empirically analyzing an Indian state's effort to implement a universal health coverage health information system in primary healthcare. Using a theoretical lens informed by institutional theory, we seek to answer the question: “What is required to develop institutions that support the use of new technologies and associated work processes that universal health coverage entails?”. We identify the contradictions that emerge when new systems clash with existing ones, and we discuss what implications such contradictions have in terms of system design, work processes, and institutions. We contribute to the literature by explaining inherent complexities in universal health coverage health information system design and implementation and providing system design guidelines.