Producing the Agora: Appropriation of Health Information Systems in Developing Countries

175 Pages·2016·3.78 MB·English

Producing the Agora: Appropriation of
Health Information Systems in Developing
Countries

Rangarirai Matavire

A thesis submitted in partial fulfilment of the requirements of the degree of
Doctor of Philosophy (PhD)

Department of Informatics
Faculty of Mathematics and Natural Sciences
University of Oslo
February 2016
© Rangarirai Matavire, 2016

Series of dissertations submitted to the
Faculty of Mathematics and Natural Sciences, University of Oslo
No. 1717

ISSN 1501-7710

All rights reserved. No part of this publication may be
reproduced or transmitted, in any form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard.
Print production: Reprosentralen, University of Oslo.
Seasons come and seasons go
The vitality of spring
The rustling of autumn
The defiance of heroes
The sacrifice of martyrs
What is done is done
Everything is soon forgotten
But half
Is yet to be told
Hope
-The Elder-
i
Acknowledgements

Thank you JAH. I would like to express immense gratitude to my supervisors Kristin Braa
and Sundeep Sahay for the comments, faith and support on this journey. Thank you to my
colleagues in the Global Infrastructures group, particularly Terje Sanner, Chipo Kanjo,
Tiwonge Manda, Bob Jolliffe, Marlen Chawani, Jasmina Masovic, Abyot Gizaw, Roshan
Hewapathirana, Pandula SIribaddana, Hanne-Cecilie Gierbo, Lars Roland, Saptarshi
Purkayastha, Anna Zaytseva and Zeferino Saugene. I say to you all, ‘vakamboonana
havashayani’, a Shona language proverb which means that those who have met before will
always find each other again. I am thankful to Jørn Braa for his contributions, support and
mentorship along the way. I thank Eric Monteiro and Margunn Aanestad for the invaluable
assistance and comments provided. I also thank Miria Grisot and Jens Kaasbøll, for their
constructive critique of the Kappa. Also gratitude to Johan Ivar Sæbø and Petter Nielsen for
supporting this process. I would also like to acknowledge my former mentors at the
University of Cape Town, that is Irwin Brown, Ojelanki Ngwenyama, and the late Dewald
Roode. How can I forget Chipo Nancy Ngongoni for the willingness to read many versions of
this document. Thank you as well for the memories and wonderful times.
Gratitude is extended to Anthony Sox, Judge Muzinda, Henry Chidawanyika, Joshua Katiyo,
Emmanuel Boadi, Jason Owen and Ponesai Nyika whom contributed to the good work done
in Zimbabwe. In the Ministry of Health in Malawi, I would like to express gratitude to Chris
Moyo who was accommodating and showed trust in the work. I also extend thanks to the
DHIS 2 team including Simen, Erling, Morten, Lars, Ola, Matthieu, Arthur, Wilfred, Lungo,
John Mukulu and Marta Vila. Appreciation is expressed to the greater HISP community,
particularly the DHIS 2 teams in Vietnam and India. Thanks in particular goes to Arunima S.
Mukherjee, a wonderful lady and friend. Thank you for thinking of me before I thought of
you, for the Gita and the spicy food. Thanks and gratitude also to Marit Moi for the
friendship. Honour and respect to my parents Sibongile and Brave Matavire. To my aunt and
uncle, Moureen and Dzimbanhete Matavire, thank you. I express profound gratitude to those
not mentioned by name but who through moments of interaction contributed in small and big
ways to this work. Sown with tears, may we now reap with songs of joy.
ii
Table of Contents
Abstract ...................................................................................................................................... v
1 Introduction ........................................................................................................................ 1
1.1 Research Aims and Questions ..................................................................................... 3
1.2 Empirical Setting ......................................................................................................... 3
1.3 Research Contributions ............................................................................................... 4
1.3.1 Contributions to Theory and Practice .................................................................. 4
1.3.2 Selected papers..................................................................................................... 5
1.4 Outline of thesis .......................................................................................................... 5
2 Health Information Systems in Developing Countries ....................................................... 7
2.1 The Health Systems Strengthening Agenda ................................................................ 7
2.2 How DHIS 2 ‘Conquered the World’ ......................................................................... 8
2.3 HIS Strengthening Challenges and Visions .............................................................. 10
2.3.1 Fragmentation of Health Information Systems .................................................. 10
2.3.2 Poor Data Quality .............................................................................................. 10
2.3.3 Legacy of paper-based systems ......................................................................... 11
2.3.4 Political Context of HIS ..................................................................................... 11
3 Theoretical Framework ..................................................................................................... 13
3.1 Background ............................................................................................................... 13
3.2 Biography of Artefacts Framework........................................................................... 14
3.3 Appropriation of Information Systems ..................................................................... 15
3.4 Emergence of Spatial Concepts in Information Systems .......................................... 17
3.5 The Agora metaphor.................................................................................................. 18
3.5.1 The Athenian Agora ........................................................................................... 18
3.5.2 The Agora of Techno-Organisational Change ................................................... 19
3.5.3 Managing the Agora .......................................................................................... 20
3.6 Lefebvre on the Production of Space ........................................................................ 21
3.6.1 The Spatial Triad................................................................................................ 23
3.6.2 The Appropriation of Space: Making it one’s own ........................................... 24
3.7 Summary of Conceptual Framework ........................................................................ 25
4 Methods ............................................................................................................................ 27
4.1 Access to cases .......................................................................................................... 28
4.2 Data Collection .......................................................................................................... 29
4.2.1 The case of the Malawi mobile tools pilot ......................................................... 29
iii
4.2.2 The case of the Zimbabwe DHIS 2 Project ....................................................... 30
4.3 Data Analysis ............................................................................................................ 34
4.3.1 Emergence of key concepts ............................................................................... 36
4.4 Reflections on method ............................................................................................... 38
4.5 Ethical Considerations............................................................................................... 39
5 Research Cases ................................................................................................................. 42
5.1 Malawi’s Context ...................................................................................................... 42
5.1.1 Country Background .......................................................................................... 42
5.1.2 Malawi’s Health System .................................................................................... 43
5.1.3 Malawi’s Health Information System ................................................................ 43
5.1.4 The ‘DHIS 2 Mobile’ Pilot ................................................................................ 45
5.2 Zimbabwe Context .................................................................................................... 48
5.2.1 Zimbabwe’s Health System ............................................................................... 49
5.2.2 National Health Information and Surveillance System ..................................... 49
5.2.3 The Nationwide DHIS 2 Implementation .......................................................... 52
6 Findings ............................................................................................................................ 57
6.1 Paper I: Shaping the Evolution of Health Information Infrastructures ..................... 57
6.2 Paper II: Articulating Mobile Health Information Infrastructures ............................ 59
6.3 Paper III: From Co-optation to Production ............................................................... 61
6.4 Paper IV: Producing a New Agora ............................................................................ 63
6.5 Synthesis of Findings – ‘Producing the Agora’ ........................................................ 64
6.6 Paper contributions to the research questions ........................................................... 66
7 Discussion and Implications ............................................................................................. 70
7.1 Theoretical Contributions .......................................................................................... 70
7.1.1 Appropriation of Information Systems .............................................................. 70
7.1.2 Information Infrastructures ................................................................................ 72
7.1.3 Information Systems and Development ............................................................. 73
7.1.4 Social Production of Social Space ..................................................................... 75
7.2 Practical Contributions .............................................................................................. 76
8 Concluding Remarks ........................................................................................................ 79
9 References ........................................................................................................................ 82

iv
Abstract
With the proliferation of generic software solutions in the healthcare sectors of many
developing nations, it is important to understand the processes through which such
technologies are appropriated in order that they may meet their system strengthening goals.
Generic software is a class of information system that can be used in diverse settings and is
developed in such a way that it is customisable to meet local needs. Given that generic
software projects in the healthcare sectors of developing nations are largely dependent on the
inflow of donor resources, there is a concern that once these dry up the systems will fail. It
becomes important to develop theoretical ideas that provide an account of this phenomenon
and strategies through which such a problem can be confronted and the technology
successfully and sustainably appropriated.
The aim of the study was to develop a relevant and fitting theoretical account on the
appropriation of the generic District Health Information Software (DHIS 2) in the context of
health ministries in Malawi and Zimbabwe. The theoretical questions that led the inquiry
were (i) ‘How can we understand and explain the processes implicated in the appropriation of
generic open source health information systems in developing nations?’ and (ii) ‘How can the
transformations sought when adopting these technologies be better realised?’. The study
adopted a mixed method research approach, largely deriving influences from Grounded
Theory methodology and the Case Study method. Data was collected through interviews,
observation, emails, official documents and by participating as intermediary or consultant in
the change initiatives. While some interviews were recorded, the predominant method of
collecting data was the taking of field notes. Data was initially open coded for concepts, but
the analysis soon evolved toward iterative engagement with emergent theoretical categories
that could fit the phenomenon being studied.
Given the degree of spatial and temporal changes that generic information systems imply,
their adoption can be considered as akin to a paradigm shift for ministries of health in
developing nations. The global distribution of actors that are essential to appropriating these
technologies creates a challenge for the adopting agencies. This is more so in the politicised
context of health ministries where there is a need to contend with multiple perspectives and
interests. This study develops a theoretical framework that may be useful in shaping the
appropriation of generic health information systems in these contexts. The framework is
v
based on contemporary information systems research which has problematised the spaces
which emerge with the adoption of generic software systems. Using these conceptions, we
find that the adoption of DHIS 2 signals the emergence of a space similar to an agora. The
agora was a central meeting place in ancient Athens and such a conception of information
systems has prior to this study been applied to understand the development and use of generic
software systems. To complement this perspective, this study borrows conceptions from
Henri Lefebvre’s theory on the ‘production of space’ which strengthen the argument for the
study of social space and its transformation.
The core contribution of the study is the socio-spatial conceptual framework, termed
‘Producing the Agora’, which is useful for explaining the process of appropriation of generic
health information systems in developing countries. Its application to the study shows how
new technologies can serve to reinforce the status quo rather than mediate espoused techno-
organisational transformations. It surfaces the dialectical interaction between the domination
and appropriation of the agora as a mechanism through which the space attains shape. It
demonstrates how Henri Lefebvre’s theory on space can reveal the content of the emergent
techno-organisational interactions and struggles. It also demonstrates how socio-spatial
conceptualisations of technology adoption can enrich the health information systems domain.
When sensitised by these ideas, it is envisaged that health ministries will be able to take a
more decisive leadership role in order to attain to the goals of adopting these new
technologies. The conception particularly revealed how the space of server hosting for the
web based application was a central arena where struggles of appropriation ensued, powerful
influences dominated and stronger leadership was in want.

vi
1 Introduction
States worldwide, especially in the developing world, have been engaged in processes to
develop integrated health information systems in order to improve access to data on
healthcare services, which may in turn be used to craft policies and strategies for
interventions in the sector. This occurs in the context of complex organisational structures,
public and private institutions, numerous technology vendors and a multiplicity of programs
which often have their own funding sources (Braa & Sahay, 2012; Pollock & Williams,
2010). Contemporary health information systems development, implementation and use also
occurs in a context where global and local networks are enmeshed, to form what has been
referred to as the ‘glocal’ (Robertson, 2012; Swyngedouw, 2004). In particular, the
information technologies that often emerge within this glocalised healthcare context are
standardised across national and organisational contexts. Such standardised technologies,
known as generic software, are typified by the popular Enterprise Resource Planning (ERP)
systems which are used in virtually all organisational sectors including healthcare (Pollock &
Williams, 2008).
Known generic technologies in the healthcare sector fall into the categories of human
resource information systems (HRIS), electronic medical record systems (EMRs), laboratory
information management systems (LIMS) and routine health management information
systems (RHMIS) among others. There are efforts by many states to develop and implement
these classes of information technologies, and for them to be integrated, to enable the storage,
use and sharing of accurate up to date healthcare information (Braa & Sahay, 2012). In
developing countries, such systems are often developed with the espoused aims of
empowering health workers to strengthen the provision of healthcare services and to improve
outcomes (Lippeveld, Sauerborn, & Bodart, 2000). Furthermore, the implementation of these
technologies falls within the developmental agenda which was until recently promoted
through the Millennium Development Goals (MDGs) framework. However, health
information systems development is a monumental task, where success occurs far between,
comes at an enormous cost and failure is common (Aanestad & Jensen, 2011; Heeks, 2002).
A challenge that is found in the domain is the difficulty of developing sustained
collaborations across individual, organisational, territorial and regional boundaries in order
that the transformatory objectives of the interventions are met and sustained (Braa, Monteiro,
1
& Sahay, 2004; Ezz & Papazafeiropoulou, 2006; Pollock & Williams, 2008). It is
consequently of prime importance to endeavour in substantive theory development within
this space in order that the understanding of such technologies can be refined for researchers
and practitioners to increase the chances for appropriation (Braa et al., 2004). To appropriate
technology is to make it ‘one’s own’ and is concerned with the process through which an
artefact is adopted, adapted and integrated into a practice (Arakelyan & Lamas, 2014).
To assimilate the theoretical ideas and formulations to understanding appropriation of generic
information systems is not an easy task. Kaniadakis (2009, p. 3) notes that the
“interdisciplinary study of technological and organisational innovation appears fragmented
and unable to analytically capture and explore in an integrative way the emergence and the
shaping of the global market for techno-organisational change”. In particular, there are intra
disciplinary separations into, for instance, practice based studies, Information Technology
and Development (ICTD or ICT4D) research, Science and Technology Studies (STS) and
Computer Supported Cooperative Work (CSCW) among others, all leaning on different
problem contexts and theoretical traditions. However, a realisation for the need of spatially
sensitive conceptualisation of contemporary information systems phenomenon is a common
and emergent thread (Castells, 2000; Monteiro & Rolland, 2012; Orlikowski, 2010; Pollock,
Williams, D’Adderio, & Grimm, 2009). This is driven by the emergence of new modes of IT
production where new relationships with spatially dispersed actors and the pervasiveness of
the Internet are implicated in local changes (Castells, 2000; Lefebvre, 1991). Furthermore,
traditional discipline centred accounts of information systems have either privileged the
micro over the macro or the agent over the institution and vice versa thereby neglecting key
aspects of the distributed and fragmented social phenomenon (Czarniawska, 2004; Monteiro
& Rolland, 2012). Much research has particularly favoured a micro understanding of this
phenomenon by focussing on the user level (Carroll, 2004; DeSanctis & Poole, 1994;
Stevens, Pipek, & Wulf, 2009). Such accounts tend to propagate the assumption that
information technologies are developed in one arena and used in another given their ‘black
boxing’ of the artefact (Jorgensen & Sorensen, 1999; Sanner, Manda, & Nielsen, 2014).
Understanding the creation and evolution of networks of organisations, persons and artefacts
in the context of fragmented health systems is a key consideration in any discussion on the
appropriation of technology (Braa et al., 2004; Sanner & Sæbø, 2014). This research
2