This thesis presents an in-depth theoretically underpinned empirical analysis of the challenges to integrate the fragmented health information systems within the Zanzibar health care system. The research is situated in the broader topic of health sector reforms, which advocate and implement a number of healthcare organizationalchanges in which decentralization and integration of the disparate health information systems is one of them. The study sought to meet three objectives: 1) to understand the challenges in the processes of achieving integration; 2) to study the challenges and opportunities emanating from the way users received and related to the newly integrated health information system and 3) to study the strategies used to curb the integration challenges.
In meeting the stated objectives, the research employed qualitative research methods namely, semi-structured interviews, participant observation in meetings and trainings, and document and software analysis, in an indepth case study. Content analysis was drawn upon to write up and analyze the empirical materials.
Theoretically, the study drew on the concept of installed base from the socio-technical conceptualization of large, integrated systems called information infrastructures and the user enactment concept based on the human agency perspective to analyse the empirical materials. In addition, the analysis was informed by the literaturefrom health information systems’ discourse covering integration issues in developing countries.
The study identified challenges in two major integration processes as follows. The first is the standardization process, in which the installed base presented the following challenges: heterogeneity of interests among health care stakeholders, inadequate knowledge on indicators and public health issues, and use of multiple languagesin the previous data sets and tools standards. The second process is institutionalization of the standards which also faced a number of challenges from the installed base, which included lack of clear management structure, inadequate skills in computer, inadequate human resources, institutionalized work practices hampering traininginitiatives and relatively low education levels of health workers at the health unit level of the health system.
The study found different ways in which users enacted the integrated health information system standards, which in turn presented both challenges and opportunities to the integration initiatives. The challenges came to play as some users such as vertical program managers, district officials and health unit staff enacted limited andnon-use technologies in practice towards the new system. Conversely, the opportunities came as some users enacted different applications of the new standards, where some were able to reinvent different ways of using the standards as an attempt to workaround some misfits.
Cultivation strategies which advocate on a piecemeal incremental process in the change attempts, to give room for experimentation and revision of strategies were drawn upon to curb the challenges. Specifically, the cultivation strategies included use of participatory approaches and modularization. However, the study suggests the need to build and strengthen communication and collaboration linkages between the stakeholders in theattempt to curb the inertia of the vertical and parallel reporting systems.
Theoretically, the study contributes to information systems knowledge base on the use of the installed base and user enactment concepts to analyze the use of the integrated health information system. Furthermore, the research contributes through theoretical implications drawn from the use of the user enactment and userparticipation. The study shows that user participation does not always lead to compliance due to the power that users have to apply agency and enact different ways to respond to the new technology, irrespective of their participation.