This thesis investigates the challenges of scaling and standardizing Health Information Systems (HISs) in the context of developing countries. This investigation is based on case studies and action research interventions aimed at improving the existing HIS in two regions of Ethiopia (Addis Ababa and Oromia). The study has been carried out as a part of the Health Information Systems Program (HISP) initiative, an international research and development project based in the Informatics department of the University of Oslo.
The study was informed by qualitative methods, and carried out within an action research framework. We employed a comparative case study design to help firstly understand deeply and in a context specific manner what constitutes the challenges of scaling and standardizing,and secondly, to develop inter-case comparisons to identify similarities and differences, and what are the contextual influences contributing to these processes.
Theoretically, we build on the Information Infrastructure (II) perspective, which enables us to view the challenges related to HIS in a broader and more holistic manner than what is allowed through a more traditional lens of Information System (IS). Accordingly, we conceptualise HIS as a Health Information Infrastructure (HII) as it is composed of heterogeneous social and technical components. Specifically, the concepts of installed base and cultivation from IItheory provide us with the analytical leverage to understand both the challenges to scaling and standardizing, and also how they can be addressed in practical settings. We define the scope of the standardising effort to include; data set, data collectinginstruments, software system and work practices, and the scope of scaling to include; geographic, functional, learning and experience, and level of use. Through our empirical workin the two regions of Ethiopia; Addis Ababa and Oromia, various challenges to the standardizing and scaling processes were identified.
The challenges for standardizing were;
a)lack of national level involvement, b) poor culture of information use, c) inadequate publichealth inputs in the HISP team d) time and logistics constraints e) large geographical size and,f) contextual differences in the health systems. In order to address the challenges ofstandardizing we used strategies of modularization, evolutionary prototyping, user participation and incremental approaches.
With respect to the process of scaling, we identified the following set of four key challenges:
a) uneven infrastructure development b) varying management commitment c) the presence of legacy IS d) large geographical size, and, e) differences in organizational structure and functional requirements.
The cultivation approach for addressing the scaling process wasthrough the use of gateways, flexible and simple system, as well as an incremental approach as was the case for the standardizing process.The research contributed theoretically to IS research by emphasizing the interrelation and the associated dilemmas between scaling and standardising. We identified three sets of dilemmas:
how standardizing can support (or not) the scaling efforts; how scaling can support (or not)the standardizing effort; and the political implications of scaling standardized solutions.