Abstract
Free and Open Source Software (FOSS) is increasingly being used as the basis for health information systems (HIS) of choice in health system strengthening efforts in Low and Middle Income Country (LMIC) contexts. However, empirical evidence from these efforts show less than optimal results due to various systemic causes. The personal motivation for this research was driven by my empirical experiences of observing repeated “failures” of several such implementation efforts in Sri Lanka, The theoretical motivation comes from the growth of discourses around Platform Ecosystems (PE) and the potential of FOSS to be treated as a candidate PE. Hence, the research question I pursue is: who are the actors and what are their inter-relationships comprising a PE around FOSS based HIS implementation in a LMIC setting?; what are the underlying governance modalities in such an ecosystem?; and, how does trust play out in the orchestration of such an ecosystem?
Contemporary FOSS business models focus on the development side, while the PE literature primarily considers the governance of commercial software platforms. This thesis argues a PE perspective helps analyse governance issues by combining concepts of ecosystem and FOSS business models to help better understand implementation dynamics. Due to the relatively independent nature of participating actors, governance is theorized as an orchestration, the nature of it is explored in this thesis, especially in the early phases of FOSS implementation. Given the absence of a strong commercial focus and the freedom that external stakeholders have access to in FOSS implementation, the governance dynamics are unique and have not been explored earlier in ICT4D literature. Further, notions of inter-organizational trust helps to develop further insights into PE orchestration.
The empirical basis to analyse the research questions posed comes from a longitudinal study over a five-year period (2012-2016) in the State health sector of Sri Lanka which focused on 3 cases. While one concerned an implementation of a hospital information system in various hospitals, the second was around the adoption of a FOSS applications for the primary health care sector. The third case study was pertaining to the establishment of a national governance body to regulate open source implementations in the State health sector. While all three cases were studied through an interpretive lens, I was also an involved insider also engaged in different kinds of action such as design, advocacy and capacity strengthening efforts.
This thesis identified inter-organisational trust as a vital component in the orchestration process governing multi-sector stakeholder networks. This finding extends the vendor focused orchestration of traditional PEs to open source, contributing through the development of the PE analytical lens. This perspective also helps to extend understanding of traditional buyer-seller relationships to theorize the influence of trust in FOSS implementation governance through orchestration. This understanding was the basis to synthesise the proposed FOSS governance framework, and to suggest strategies to overcome barriers to effective governance of HIS implementation projects.