To make appropriate decisions regarding medical interventions and financial and human resource allocation in the public health sector, timely, valid and complete health data are important, as resources need to be allocated to the right parts of the health service in a coordinated effort. This is especially relevant for developing countries that experience an increasing burden of disease as well asstagnant or decreasing financial and human resources. However, the reality is that health data is often inaccessible, duplicated and delayed. A reason for this is a fragmented health information system,where different groups collect the information relevant for themselves without sharing data.
This thesis is a study of the efforts made to create an integrated health information system in the public health sector in Botswana. To do so the challenges of expanding, or scaling, the health information system to new locations, functionality and use-patterns have been investigated. Through an action research approach, the empirical data collection was conducted through three periods of field work adding up to three months, spanning over one year. Theoretically, the thesis builds upon concepts from structuration theory, theory of informationinfrastructures and complex adaptive systems. Scaling of the health information system, especially to achieve full geographical coverage, is presented as a necessary push to change the existing fragmentedstructures and work practice. I account for the heterogeneity of health information systems, and argue that scaling should be viewed as consisting of four different dimensions that are intrinsicallylinked; (1) social/organisational, (2) technical/functional, (3) users and (4) geography.
The case of Botswana has illustrated that changes in one dimensions lead to the need to alter all the other dimensions, thus leading to an alteration of complexity. Further, I argue that the process of scaling is challenging because it requires integration with the installed base in all dimensions. A strategy of “mindful scaling” and the use of attractors are proposed as a way to be able to scale information systems. In the case of Botswana, the discussion shows that “scaling down to scale up” - where a reduction in scope is made to free resources to facilitate geographical scaling - might be useful, as it can change the project complexity to one that can be handled by the existing project management.