Information Technology for Development, Mar 1, 1995
The notion of technological ‘transfer’ rests on a conception of technology as artifacts. This, as... more The notion of technological ‘transfer’ rests on a conception of technology as artifacts. This, as many have argued, neglects the crucial aspects of the social and cultural context of use. Technology has to be learnt rather than transferred. Based on this, we attempt to analyze the conditions and possibilities for technological learning about IT‐infrastructure in developing countries. In so doing, we distinguish between local, contextual learning and institutional or technological infrastructure for learning. These processes of learning need to take place in areas sheltered from international competition. Examples from Mongolia and South African health care are used to illustrate our points.
This chapter seeks to contribute to the ongoing debates in the domain of Participatory Design by ... more This chapter seeks to contribute to the ongoing debates in the domain of Participatory Design by discussing the various trends and questions within the context of the Health Information Systems Programme (HISP) initiative ongoing over nearly two decades. The focus in this chapter is to discuss issues of Participatory Design during the course of the design, development, implementation and scaling of the DHIS software within an action research framework in the context of the public health sector in various developing countries. Further, we discuss Participatory Design with respect to changes over time in technological and political contexts and the challenges following from that; from stand-alone MS Office to cloud computing and fully open source technologyenabling local Participatory Design! In this chapter, we try to describe this rather complex HISP movement over time following three broad phases; 'traditional' Participatory Design; pilots and networking Participatory Design, and Participatory Design and web technologies. After this historical reconstruction, we describe and discuss current trends and challenges, focusing on the new area of cloud computing and the need for integration with other systems. We elaborate on practical challenges and potentials of doing Participatory Design in the context of developing countries and in a longitudinal perspective. The reader will learn about Participatory Design in a global development perspective and about the importance of networking Participatory Design projects and to share software, lessons and resources across countries 'South-North-South' as a way to achieve sustainability and scalability. Rapid spread of communication technologies such as mobile Internet is currently changing the context for Participatory Design in developing countries. The chapter provides the reader with analysis and discussion on the potential for Participatory Design and empowerment of users in developing countries in the new area of cloud computing and in an environment where multiple systems need to be integrated. The emerging cloud-based infrastructure represents both an opportunity and a threat. While users even in rural Kenya may now feel empowered by having instant access to own and other data, global actors are aggressively promoting their own software-based services. To counteract the latter, the challenge is to enable development of local capacity to master the new technologies, for which Participatory Design may provide both the means and the end.
An Expanded PHI perspective needs to consider institutions seriously. The institutional context h... more An Expanded PHI perspective needs to consider institutions seriously. The institutional context helps us to understand why so often public health information systems fail to deliver, and also how could they have done better. There are four sets of institutions that shape the development and use of health information systems: those that deliver healthcare; those that manage healthcare; those that make decisions on policy; and, those who finance health information systems, including external donors. The formal rules, informal conventions, and cultures in which each of these institutions function tend to constrain the introduction and use of health information systems. The introduction of health information systems thus becomes a process of negotiation where the owners of the various institutions need to find consent over what each will gain or lose. Morever, the design of information systems needs to factor in and address the design of institutions in which such systems are embedded.
Journal of Health Informatics in Developing Countries, Apr 5, 2017
The potential of work transformation as a result of Information Technology (IT) introduction has ... more The potential of work transformation as a result of Information Technology (IT) introduction has been long recognized by scholars and practitioners in the information system field. However, the relationship between technology and work practices especially in large-scale, i.e. national, is still poorly understood and somewhat understudied. To fill that gap, we extend a conceptual framework in this paper relating to work transformation in modern institutions to develop more insights into the interplay between IT introduction and daily work practice in the healthcare sector on a massive scale. This extension is empirically based on a case study involving the development and implementation of a cloud-based medical licensing system in a developing country. Apart from analyzing the case using five dimensions of work practice transformation including time and space separation, the requirement of new trust system, institutional reflexivity, concerns for deskilling and opportunities for reskilling and empowerment, the paper discusses three additional dimensions which are transformation negotiation, transformation diffusion, and transformation flexibility.
IFIP advances in information and communication technology, 2019
This paper discusses the process of implementing a district dashboard as the means for integratin... more This paper discusses the process of implementing a district dashboard as the means for integrating health information systems (HIS) in Indonesia. The project involved two processes: a bottom-up one with iterative design and implementation process and a top-down one involving data policies. Using moments of translation, we discuss the complex processes of aligning actors' interests necessary for the implementation of HIS in developing countries. The paper contributes to the existing discussions of HIS integration and information sharing in developing countries by providing a better understanding of translation processes and thereby of ways to handle fragmented HISs.
Purpose: This paper analyses an initiative led by WHO within the health information domain to sta... more Purpose: This paper analyses an initiative led by WHO within the health information domain to standardise analysis of health information through the use of analytical dashboards, using the concept of flexible standards. We focus on the implementation of these standards within existing, working information systems, analysing the implementation strategies used, and how these are enabled by the flexibility of the standards. Design/methodology/approach: The study follows an action research approach, where the authors have been involved in the development and implementation of the initiative being discussed. Findings: By analyzing the approaches taken by several countries to implement these standards we show how these different approaches are enabled by the flexibility of the standards. Practical implications: This paper demonstrates the potential importance of flexibility in standardisation initiatives around health information, with particular relevance to voluntary standardisation efforts involving independent actors, in this case Ministries of Health. Originality/value: The flexible standards concept is employed to study a multi-country initiative involving WHO and several national governments. We contribute to the literature on flexible standards by showing that beyond flexibility in the standards, flexibility in the software platform in which the standards are implemented, and the variation allowed in the standardisation process at an organisational level, are important factors that facilitate standards implementations.
This paper problematizes the way ICT4D projects are rarely equipped to anticipate for the longitu... more This paper problematizes the way ICT4D projects are rarely equipped to anticipate for the longitudinal and organic nature of ICT4D processes. As such, it aims to explore how these ever-evolving processes may be met with adaptive solutions that are responsive to their changing environments. Our analysis concentrated on uncovering the change processes of a particularly successful ICT4D implementation over time. Based on these findings, we developed a process perspective of bricolage-driven change in ICT4D in which bricolage practices move through 3 different stages we identify to be 'opportunity based', 'locally owned' and 'locally driven' in nature. These insights are aimed at aiding researchers as well as practitioners in the ICT4D domain in the implementation of long term ICT4D solutions.
IFIP advances in information and communication technology, 2017
The article is addressing the problem posed by fragmented and poorly coordinated Health Informati... more The article is addressing the problem posed by fragmented and poorly coordinated Health Information Systems (HIS) in developing countries within the framework of complexity. HISs that can provide quality data for monitoring, management and health services provision are important for countries, which requires a sensitive understanding of complexity and how they can be managed. Using a case from Indonesia, we discuss the challenges of integrating HIS using the concept of attractor for change from the field of Complex Adaptive Systems (CAS). The dashboard is positioned as such an attractor as a means to get different stakeholders to discuss and reach a consensus on how to integrate and share data without disturbing the underlying systems too much. A more generic model to manage complexity is proposed.
Information Technology for Development, Jul 1, 2006
The implementation and development of routine health information systems continue to provide a nu... more The implementation and development of routine health information systems continue to provide a number of challenges for managers-the more so in developing countries where resources are scarce and human resource and technical skills limited. This article conceptualizes the interdependence between the local adaptation and appropriation of global standards, and the value that this adds to the global standard through improved quality of data. These processes reinforce one another in the creation of sustainable information systems. The article draws upon a case study of a rural hospital in South Africa. A successful change process is documented, wherein the organization, through innovative management and leadership, actively and successfully appropriated the national standard. The case study is used to highlight three main messages, namely, that standards should be able to be locally appropriated, that the creation of networks helps to support the local adaptation of standards, and that the layering of information systems is important to encourage the use of information and helps to improve data quality.
Governance, as distinct from management, is a crucial but neglected issue in the context of publi... more Governance, as distinct from management, is a crucial but neglected issue in the context of public health informatics. Governance has two overlapping but distinct domains—health sector and IT governance. Governance is a cross-cutting issue affecting all domains discussed in the book, including the use of information, integration, cloud and big data-related issues, institutional design, and the management of complexity. A key governance challenge is the design, development, and use of standards and data policies, given the political nature of technical choices in these areas. Standards, focusing only on the technical aspects implemented in a top-down manner while ignoring the institutional and work practice-related issues, are more likely to fail than those emerging through use, bottom-up, and which add value to work processes. Governance becomes a key issue, as this function is responsible for making strategic choices and putting in place an implementation framework to make them work.
International Journal of Medical Informatics, May 1, 2021
OBJECTIVE The aim of the study is to analyse an initiative from the World Health Organisation (WH... more OBJECTIVE The aim of the study is to analyse an initiative from the World Health Organisation (WHO) to facilitate the dissemination of global standards and guidelines through digital health packages, which can strengthen the capacity of countries to monitor the SDGs. Digital health packages include data standards, guidance on data analysis, specifications for analytical dashboards for a specific health area, including a configuration of these standards for a widely used software platform. METHODS This is a multi-year case study, in which the authors have actively participated in the various aspects of development, implementation and evaluation of the digital health packages initiative. RESULTS We discuss the key innovations of the digital health package approach: First, the development process, which is based on flexible standards and an integrated approach across health programmes. Second, how the digital health packages combine several related types of standards into one package, including configurations for a widely used software platform supported by strong global and regional technical teams. OUTCOME This study shows a novel approach to dissemination of standards, through a digital platform. Currently, 40 countries have adopted one or more of the digital health packages in their national health information system.
It is well understood that use of information is essential not only for justifying the investment... more It is well understood that use of information is essential not only for justifying the investments made in building information systems, but they are also essential for improving the quality and equity of healthcare delivery. The paradox is that there is a data overload that impedes relevant information use, and to solve this more IT systems are deployed, thus creating more data, which further confounds the information use problem. One reason for this is that health information systems in LMICs are typically not conceived as built for users at different levels with varying needs, but primarily to satisfy the monitoring and control needs of central apex authorities and funding agencies. While in recent years, tremendous improvements have been made in LMICs, there still tends to exist a weak understanding and use of indicators, poor data quality that is all too readily and mistakenly attributed to non-truthful reporting when there are many other remediable factors at work. The Expanded PHI approach seeks to address these issues. It posits that meanings can be best made only through ‘conversations over data’, and user friendly systems requires ‘communities of practice’ to build and sustain.
This chapter places public health informatics within a public health context. An understanding of... more This chapter places public health informatics within a public health context. An understanding of PHI must be built on the perspective of public health as the health of populations. In LMICs it is closely related to an understanding of the primary healthcare approach, and the role and functions of public health systems, including the measurement of health status and equity, the effective coverage of different health programmes, and the utilization of different health services. This requires an understanding of the social and environmental determinants of healthcare, which need relevant data from other sectors as well. The architecture and development of public health informatics varies across nations and is path-dependent and context-specific. Many have evolved as monitoring support to externally financed vertical programmes, some as support for comprehensive primary health programmes and some from support systems for health insurance. The current information needs of health systems, transcends their respective origins, and requires both individual-based clinical information and aggregate population-based data.
This article describes the initial period (1994-2001) of an ongoing action research project to de... more This article describes the initial period (1994-2001) of an ongoing action research project to develop health information systems to support district management in South Africa. The reconstruction of the health sector in postapartheid South Africa striving for equity in health service delivery and building of a decentralized structure based on health districts. In terms of information systems (IS) development, this reform process translates into standardization of health data in ways that inscribe the goals of the new South Africa by enhancing local control and integration of information handling. We describe our approach to action research and use concepts from actor-network and structuration theories in analyzing the case material. In the detailed description and analysis of the process of IS development provided, we focus on the need to balance standardization and local exibility (localization); standardization is thus seen as bottom-up alignment of an array of heterogeneous actors. Building on a social system model of information systems, we conceptualize the IS design strategy developed and used as the cultivation of processes whereby these actors are translating and aligning their interests. We develop a modular hierarchy of global and local datasets as a framework within which the tensions between standardization and localization may be understood and addressed. Finally, we discuss the possible relevance of the results of the research in other countries.
Information Technology for Development, Mar 1, 1995
The notion of technological ‘transfer’ rests on a conception of technology as artifacts. This, as... more The notion of technological ‘transfer’ rests on a conception of technology as artifacts. This, as many have argued, neglects the crucial aspects of the social and cultural context of use. Technology has to be learnt rather than transferred. Based on this, we attempt to analyze the conditions and possibilities for technological learning about IT‐infrastructure in developing countries. In so doing, we distinguish between local, contextual learning and institutional or technological infrastructure for learning. These processes of learning need to take place in areas sheltered from international competition. Examples from Mongolia and South African health care are used to illustrate our points.
This chapter seeks to contribute to the ongoing debates in the domain of Participatory Design by ... more This chapter seeks to contribute to the ongoing debates in the domain of Participatory Design by discussing the various trends and questions within the context of the Health Information Systems Programme (HISP) initiative ongoing over nearly two decades. The focus in this chapter is to discuss issues of Participatory Design during the course of the design, development, implementation and scaling of the DHIS software within an action research framework in the context of the public health sector in various developing countries. Further, we discuss Participatory Design with respect to changes over time in technological and political contexts and the challenges following from that; from stand-alone MS Office to cloud computing and fully open source technologyenabling local Participatory Design! In this chapter, we try to describe this rather complex HISP movement over time following three broad phases; 'traditional' Participatory Design; pilots and networking Participatory Design, and Participatory Design and web technologies. After this historical reconstruction, we describe and discuss current trends and challenges, focusing on the new area of cloud computing and the need for integration with other systems. We elaborate on practical challenges and potentials of doing Participatory Design in the context of developing countries and in a longitudinal perspective. The reader will learn about Participatory Design in a global development perspective and about the importance of networking Participatory Design projects and to share software, lessons and resources across countries 'South-North-South' as a way to achieve sustainability and scalability. Rapid spread of communication technologies such as mobile Internet is currently changing the context for Participatory Design in developing countries. The chapter provides the reader with analysis and discussion on the potential for Participatory Design and empowerment of users in developing countries in the new area of cloud computing and in an environment where multiple systems need to be integrated. The emerging cloud-based infrastructure represents both an opportunity and a threat. While users even in rural Kenya may now feel empowered by having instant access to own and other data, global actors are aggressively promoting their own software-based services. To counteract the latter, the challenge is to enable development of local capacity to master the new technologies, for which Participatory Design may provide both the means and the end.
An Expanded PHI perspective needs to consider institutions seriously. The institutional context h... more An Expanded PHI perspective needs to consider institutions seriously. The institutional context helps us to understand why so often public health information systems fail to deliver, and also how could they have done better. There are four sets of institutions that shape the development and use of health information systems: those that deliver healthcare; those that manage healthcare; those that make decisions on policy; and, those who finance health information systems, including external donors. The formal rules, informal conventions, and cultures in which each of these institutions function tend to constrain the introduction and use of health information systems. The introduction of health information systems thus becomes a process of negotiation where the owners of the various institutions need to find consent over what each will gain or lose. Morever, the design of information systems needs to factor in and address the design of institutions in which such systems are embedded.
Journal of Health Informatics in Developing Countries, Apr 5, 2017
The potential of work transformation as a result of Information Technology (IT) introduction has ... more The potential of work transformation as a result of Information Technology (IT) introduction has been long recognized by scholars and practitioners in the information system field. However, the relationship between technology and work practices especially in large-scale, i.e. national, is still poorly understood and somewhat understudied. To fill that gap, we extend a conceptual framework in this paper relating to work transformation in modern institutions to develop more insights into the interplay between IT introduction and daily work practice in the healthcare sector on a massive scale. This extension is empirically based on a case study involving the development and implementation of a cloud-based medical licensing system in a developing country. Apart from analyzing the case using five dimensions of work practice transformation including time and space separation, the requirement of new trust system, institutional reflexivity, concerns for deskilling and opportunities for reskilling and empowerment, the paper discusses three additional dimensions which are transformation negotiation, transformation diffusion, and transformation flexibility.
IFIP advances in information and communication technology, 2019
This paper discusses the process of implementing a district dashboard as the means for integratin... more This paper discusses the process of implementing a district dashboard as the means for integrating health information systems (HIS) in Indonesia. The project involved two processes: a bottom-up one with iterative design and implementation process and a top-down one involving data policies. Using moments of translation, we discuss the complex processes of aligning actors' interests necessary for the implementation of HIS in developing countries. The paper contributes to the existing discussions of HIS integration and information sharing in developing countries by providing a better understanding of translation processes and thereby of ways to handle fragmented HISs.
Purpose: This paper analyses an initiative led by WHO within the health information domain to sta... more Purpose: This paper analyses an initiative led by WHO within the health information domain to standardise analysis of health information through the use of analytical dashboards, using the concept of flexible standards. We focus on the implementation of these standards within existing, working information systems, analysing the implementation strategies used, and how these are enabled by the flexibility of the standards. Design/methodology/approach: The study follows an action research approach, where the authors have been involved in the development and implementation of the initiative being discussed. Findings: By analyzing the approaches taken by several countries to implement these standards we show how these different approaches are enabled by the flexibility of the standards. Practical implications: This paper demonstrates the potential importance of flexibility in standardisation initiatives around health information, with particular relevance to voluntary standardisation efforts involving independent actors, in this case Ministries of Health. Originality/value: The flexible standards concept is employed to study a multi-country initiative involving WHO and several national governments. We contribute to the literature on flexible standards by showing that beyond flexibility in the standards, flexibility in the software platform in which the standards are implemented, and the variation allowed in the standardisation process at an organisational level, are important factors that facilitate standards implementations.
This paper problematizes the way ICT4D projects are rarely equipped to anticipate for the longitu... more This paper problematizes the way ICT4D projects are rarely equipped to anticipate for the longitudinal and organic nature of ICT4D processes. As such, it aims to explore how these ever-evolving processes may be met with adaptive solutions that are responsive to their changing environments. Our analysis concentrated on uncovering the change processes of a particularly successful ICT4D implementation over time. Based on these findings, we developed a process perspective of bricolage-driven change in ICT4D in which bricolage practices move through 3 different stages we identify to be 'opportunity based', 'locally owned' and 'locally driven' in nature. These insights are aimed at aiding researchers as well as practitioners in the ICT4D domain in the implementation of long term ICT4D solutions.
IFIP advances in information and communication technology, 2017
The article is addressing the problem posed by fragmented and poorly coordinated Health Informati... more The article is addressing the problem posed by fragmented and poorly coordinated Health Information Systems (HIS) in developing countries within the framework of complexity. HISs that can provide quality data for monitoring, management and health services provision are important for countries, which requires a sensitive understanding of complexity and how they can be managed. Using a case from Indonesia, we discuss the challenges of integrating HIS using the concept of attractor for change from the field of Complex Adaptive Systems (CAS). The dashboard is positioned as such an attractor as a means to get different stakeholders to discuss and reach a consensus on how to integrate and share data without disturbing the underlying systems too much. A more generic model to manage complexity is proposed.
Information Technology for Development, Jul 1, 2006
The implementation and development of routine health information systems continue to provide a nu... more The implementation and development of routine health information systems continue to provide a number of challenges for managers-the more so in developing countries where resources are scarce and human resource and technical skills limited. This article conceptualizes the interdependence between the local adaptation and appropriation of global standards, and the value that this adds to the global standard through improved quality of data. These processes reinforce one another in the creation of sustainable information systems. The article draws upon a case study of a rural hospital in South Africa. A successful change process is documented, wherein the organization, through innovative management and leadership, actively and successfully appropriated the national standard. The case study is used to highlight three main messages, namely, that standards should be able to be locally appropriated, that the creation of networks helps to support the local adaptation of standards, and that the layering of information systems is important to encourage the use of information and helps to improve data quality.
Governance, as distinct from management, is a crucial but neglected issue in the context of publi... more Governance, as distinct from management, is a crucial but neglected issue in the context of public health informatics. Governance has two overlapping but distinct domains—health sector and IT governance. Governance is a cross-cutting issue affecting all domains discussed in the book, including the use of information, integration, cloud and big data-related issues, institutional design, and the management of complexity. A key governance challenge is the design, development, and use of standards and data policies, given the political nature of technical choices in these areas. Standards, focusing only on the technical aspects implemented in a top-down manner while ignoring the institutional and work practice-related issues, are more likely to fail than those emerging through use, bottom-up, and which add value to work processes. Governance becomes a key issue, as this function is responsible for making strategic choices and putting in place an implementation framework to make them work.
International Journal of Medical Informatics, May 1, 2021
OBJECTIVE The aim of the study is to analyse an initiative from the World Health Organisation (WH... more OBJECTIVE The aim of the study is to analyse an initiative from the World Health Organisation (WHO) to facilitate the dissemination of global standards and guidelines through digital health packages, which can strengthen the capacity of countries to monitor the SDGs. Digital health packages include data standards, guidance on data analysis, specifications for analytical dashboards for a specific health area, including a configuration of these standards for a widely used software platform. METHODS This is a multi-year case study, in which the authors have actively participated in the various aspects of development, implementation and evaluation of the digital health packages initiative. RESULTS We discuss the key innovations of the digital health package approach: First, the development process, which is based on flexible standards and an integrated approach across health programmes. Second, how the digital health packages combine several related types of standards into one package, including configurations for a widely used software platform supported by strong global and regional technical teams. OUTCOME This study shows a novel approach to dissemination of standards, through a digital platform. Currently, 40 countries have adopted one or more of the digital health packages in their national health information system.
It is well understood that use of information is essential not only for justifying the investment... more It is well understood that use of information is essential not only for justifying the investments made in building information systems, but they are also essential for improving the quality and equity of healthcare delivery. The paradox is that there is a data overload that impedes relevant information use, and to solve this more IT systems are deployed, thus creating more data, which further confounds the information use problem. One reason for this is that health information systems in LMICs are typically not conceived as built for users at different levels with varying needs, but primarily to satisfy the monitoring and control needs of central apex authorities and funding agencies. While in recent years, tremendous improvements have been made in LMICs, there still tends to exist a weak understanding and use of indicators, poor data quality that is all too readily and mistakenly attributed to non-truthful reporting when there are many other remediable factors at work. The Expanded PHI approach seeks to address these issues. It posits that meanings can be best made only through ‘conversations over data’, and user friendly systems requires ‘communities of practice’ to build and sustain.
This chapter places public health informatics within a public health context. An understanding of... more This chapter places public health informatics within a public health context. An understanding of PHI must be built on the perspective of public health as the health of populations. In LMICs it is closely related to an understanding of the primary healthcare approach, and the role and functions of public health systems, including the measurement of health status and equity, the effective coverage of different health programmes, and the utilization of different health services. This requires an understanding of the social and environmental determinants of healthcare, which need relevant data from other sectors as well. The architecture and development of public health informatics varies across nations and is path-dependent and context-specific. Many have evolved as monitoring support to externally financed vertical programmes, some as support for comprehensive primary health programmes and some from support systems for health insurance. The current information needs of health systems, transcends their respective origins, and requires both individual-based clinical information and aggregate population-based data.
This article describes the initial period (1994-2001) of an ongoing action research project to de... more This article describes the initial period (1994-2001) of an ongoing action research project to develop health information systems to support district management in South Africa. The reconstruction of the health sector in postapartheid South Africa striving for equity in health service delivery and building of a decentralized structure based on health districts. In terms of information systems (IS) development, this reform process translates into standardization of health data in ways that inscribe the goals of the new South Africa by enhancing local control and integration of information handling. We describe our approach to action research and use concepts from actor-network and structuration theories in analyzing the case material. In the detailed description and analysis of the process of IS development provided, we focus on the need to balance standardization and local exibility (localization); standardization is thus seen as bottom-up alignment of an array of heterogeneous actors. Building on a social system model of information systems, we conceptualize the IS design strategy developed and used as the cultivation of processes whereby these actors are translating and aligning their interests. We develop a modular hierarchy of global and local datasets as a framework within which the tensions between standardization and localization may be understood and addressed. Finally, we discuss the possible relevance of the results of the research in other countries.
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Papers by Jørn Braa