Global Scaling of Health Information Infrastructures: Circulating Translations

Abstract

The aim of this thesis, and the research behind it, is to shed some light on the topic of scaling of IS, specifically scaling of Health Information Infrastructures (HII). There are both theoretical and practical motivations behind this. Theoretically, scaling has been treated as a linear process of expansion, though there remains little consensus about the directions, mechanisms, and content of scaling in the current literature. Practically, I have been motivated by the inability of many IS-projects that fail to scale, especially within the domain of health information systems. The motivation is thus to improve our understanding of phenomena of scaling, and how this can be utilized to improve the success of implementation.<br> Approaching the research theme, I have drawn upon IS literature that deals with scaling, and also the theoretical strand of technology transfer and associated topics. The work on technology translation have been particularly important, in that it deals with the mechanisms of appropriation of technology scaled from one context to another. Translation is the process where the local context shapes the technology and its use, and work in this field has been important for understanding mechanisms of scaling, and what process that then take place in a new context. Furthermore, I have drawn on theories on information infrastructures, and their evolution.<br> The thesis is based on a longitudinal and international action research project called the Health Information Systems Programme (HISP), engaged in HII strengthening in over 30 countries. With a focus on Botswana and Sierra Leone over the last 7 years, complemented with experiences globally including 2 years with the Health Metrics Network, Geneva, this thesis examines the mechanisms of scaling and translations based on empirical work I have myself been part of.<br> This thesis presents a theoretical model called “Circulating Translations” for analysing processes of global scaling of HII. Successful scaling of HII is seen as being embedded in a local context, while retaining the flexibility to scale to new contexts and be embedded therein. The focus is thus to explain how this embedding produce translations, through the mutual influence of infrastructure, software, practices, and ideas. These influences have different levels of materiality, and thus interpretive flexibility, with different impacts on scaling. These are termed as interaction effects, including processes of local appropriation, translation, and embedding. The local translations may in turn be disembedded, and scaled to new contexts, where they contribute to and also can be affected by local interaction effects. The mechanisms of this scaling to new contexts, called constellation effects, takes place through circulation of stories, material, people, documents, reports, etc, in short the circulation of any object carrying previous interaction effects. The level of materiality of these objects again determine how fast and at which cost they may circulate.<br> Together, interaction and constellation effects help to understand mechanisms of scaling, by showing how translations come about, and circulate. In these processes, there are elements of generification, and loss and gain. The software DHIS2, being used in over 30 countries by the HISP network, is becoming increasingly generic as it accumulates local translations and negotiates their generification. While the trend of development and progress of the software produces gains for the implementing actors, there are also losses involved, for example the reduction of inscriptions.<br> The articulated model has several implications towards the literature of scaling of information systems, technology transfer and translation. While technology transfer has treated scaling as linear and uni-directional, from one country to another, my model sees scaling instead as multidirectional, non-linear with potential to scale to other contexts. There are feed-back and feed-forward mechanisms, potentially allowing effects to initiate change in the original context. This thesis also provide some practical advice on HII strengthening, including how to manage increasing scale, and strategies for integration.