Shifting Ground for Health Information Systems: Local Embeddedness, Global Fields, and Legitimation

Introduction

ICT infrastructure and information systems have come to play a vital role in globalization. Walsham (2008) highlights three major aspects of this phenomenon: software outsourcing, virtual teams, and information system (IS) rollout. In this article we examine shifts over several years of globally distributed development and rollout of an open source information system targeted at the public health care sector in developing countries, which touches on all three aspects. In following the development of a system as it co-evolved with the various settings in which it was embedded, we highlight shifting sources of legitimation in institutional processes involved in health information systems implementation. The attention to changing sources of acceptance and legitimation frames our view on knowledge between local cultures and related stakeholders, in the interplay with global free and open source software (FOSS) development.

Paraphrasing Bowker (2000), health information systems operate simultaneously at the concrete level of design and implementation (fields in a database, capacity building, integration of datasets and organizational practices…) and at an abstract level (dealing with the relationships between information science, organization, public health, and global software development, among others). Thus, social studies of science and organization have a significant contribution to make to the process of growing information systems in order to create tools for health monitoring and policy making. For this, we need to historicize our action and its organization: “it is vital to dissolve the current disjunction between database (as technical storage medium) and policy (as way of acting in the world). The production of the database is productive of the new world we are creating.” (ibid).

By examining the scaling of development and implementation of health information systems in developing countries, this article aims at understanding collaborative knowledge development across heterogeneous networks of local, national and global actors, and between public health workers and FOSS developers in dissimilar contexts. We will use “PHIs” as an acronym to refer jointly to PHI (Project for Health Information) and HIS (Health Information System, the principal software developed within the project). This hybrid acronym represents the socio-technical nature of the actor-network. PHIs began in South Africa in 1994 as health services underwent major restructuring post apartheid, aiming at standardization of information for local action. Subsequent international expansion underscored tensions between the local and the global (Rolland and Monteiro: 2002) related to knowledge gaps and communication practices affecting rollout and institutionalization. After nearly five years, the project to cross the South African border and be initiated in Mozambique. In the following two years, early prototype implementations were started in Malawi and India. Tanzania, Vietnam and Cuba (which was abandoned quickly) and Ethiopia followed in a couple of years. After 2002, a number of pilots flourished, mainly in South and East African countries, with different degrees of development and institutionalization. It is impossible to clearly delinate periods for all countries involved, because of the “karstic” dynamic of the project in most places: a pilot can be started, achieve some acceptance, remain dormant for indefinite time, be activated again depending on new conditions, and so on.

Figure 1 illustrates a model to interpret shifts in PHIs over time. The vertical axis indicates the intensity of relevance of specific places and local settings. The horizontal time line relates to the stages of PHIs evolution we have identified: pioneer, field constitution, and full-scale implementations, demarcated by 1) a switch of legitimation from local contexts to an organizational field, and 2) a further switch to legitimation relying on state structures.

Figure 1.

A model to interpret shifts in PHIs over time

First Switch: From Local Bounds To Organizational Field

This section aims at illustrating how changes to the PHIs are significant to understand the different set of regulatory forces which affect ICT development and implementation when shifting from accountability in a local context, to accountability in relation to the larger field constituted by organizations engaged in the same kind of activity.