Ethnography, with its emphasis on understanding activities where they occur, and its use of quali... more Ethnography, with its emphasis on understanding activities where they occur, and its use of qualitative data gathering techniques rich in description, has a long tradition in Participatory Design (PD). Yet there are limited methodological insights in its application in developing countries. This paper proposes an ethnographically informed PD approach, which can be applied when designing Primary Healthcare Information Technology (PHIT). We use findings from a larger multidisciplinary project, Health Information Systems Project (HISP) to elaborate how ethnography can be used to facilitate participation of health practitioners in developing countries settings as well as indicating the importance of ethnographic approach to participatory Health Information Technology (HIT) designers. Furthermore, the paper discusses the pros and cons of using an ethnographic approach in designing HIT.
Defaulter tracing systems are patient centred information systems which are used to enhance
moni... more Defaulter tracing systems are patient centred information systems which are used to enhance
monitoring of patients who have dropped out of health programs. The aim of this study is to
explore the operation of defaulter tracing systems in practice. The study has been undertaken
in Tanzanian health facilities by using qualitative data collection methods. Activity theory is
employed as a conceptual framework to analyze the findings. Findings show that the
implementation of defaulter tracing system is challenged by issues of the existing information
systems, such as absence of clear guidelines and tools, and information recording
incompleteness, as well as contextual issues. The paper contributes to Healthcare Information
System literature (HIS) which has elaborated how patient centred information systems are
utilized in practice at the level of primary health care. This study concludes by providing
implications for policy, practice, design and implementation
This paper aims at an extended understanding of the design facilitators' role, here implementatio... more This paper aims at an extended understanding of the design facilitators' role, here implementation mediators, in participatory design practices. In reflecting connectedness between use and design in a distributed open source software design practice, a particular focus is devoted to the implementation mediator’s interaction between local users, global software developers, and local designers who are geographically distributed, possess different technological skills, and different work experiences. The implementation mediators’ insights are useful in the design of large information systems that involve distributed actors. A maternal and child health setting in Tanzania was the case in this study. An ethnographic study involving interactions with global developers and participative activities in local health practices were conducted. In addition, mediators connected local and global designers to configure a computer system for a particular context; configured participation, involving health workers in designing practices. We present the role of the implementation mediators and its related participatory activities by using the notion of design-after-design. We also highlight the challenges which could face implementation mediators in distributed participatory design activities.
In this paper, we present our empirical insights from Tanzania and Malawi by showing the challeng... more In this paper, we present our empirical insights from Tanzania and Malawi by showing the challenges of participation and we provide implications which can be used to enhance human development in the health sector. Our empirical material is drawn from the Health Information Systems Project which is a global south-north network aiming at improving the use and management of health data in developing countries. Our focus is on the interaction between software implementers, end users and global open source software developers. Our study indicates participatory challenges which are related to the difficulties in identifying users, limited health domain knowledge among some of the expected end-users and software implementers; and limited participation arising due to local-global differences. We argue that for human development to occur through the use of open source software, participation skills in the design, development and use of open source software need to be enhanced through capacity development of end-users and software implementers.
Background and Purpose: This paper describes some of the complexities that face health service
pr... more Background and Purpose: This paper describes some of the complexities that face health service provision in developing countries, with the motivation to inform design of appropriate information systems. In particular, we are interested in a better understanding of the challenges to coordination and collaboration between health staff that are located in different facilities and employed to work in different health programs. Methods: The study reported and analyzed in this paper was conducted in two districts in Tanzania. Using ethnographic data collection methods, we studied health workers’ practices of coordination and collaboration in Prevention of Mother to Child Transmission (PMTCT) services in Tanzania. Results: In our study we describe the collaboration required when managing patient trajectories of PMTCT patients across facilities and programs, and how contingencies may change the course of a patient trajectory. We provide a rich empirical description of coordination work in a resource constrained setting and we propose improvements to the design of both computer and paper-based information systems. Conclusions: The rich empirical description of coordination work in a resource constrained setting and our analysis of coordination challenges contribute to a better understanding that can strengthen collaboration and thus also improve health care provision.
Every health worker collects data while delivering health services. This information will later i... more Every health worker collects data while delivering health services. This information will later inform the society about the population’s health status, for instance as diseases statistics. A shift towards decentralization in many low-income countries implies that more skills are demanded of primary health care workers, including data and information handling. There is a need to build capacity to deal with health information and one way of doing that is by introducing courses related to health information system. This paper reports the experience obtained and lesson learnt while implementing the nine month programme: Health Management Information System Course at the University of Dar es Salaam during the first two years. The course aims to understand the development of Health information system in order to strengthen health management in developing countries. The emphasis is placed on the teaching module that combined the theory, cross-country cooperation and research at the work place of participants. Through the students’ own research projects it was learnt that there is a problem of data quality at district levels and this could be attributed to poor HMIS training to health workers dealing with data management at various levels of health sector. What we have learned from this course is that there is a need to develop different course modules for different participants. We conclude by recommending the establishment of similar courses in different places.
Keywords: Health in
This research falls under the area of design and implementation of information systems in
develo... more This research falls under the area of design and implementation of information systems in
developing countries. I have studied the health information systems in Tanzania using case
studies in Ilala Municipal, situated in Dar es Salaam city, and Tabora Municipal in the Tabora
region. The purpose of the research was to study the challenges encountered by the health
workers at the local level with regard to information collection, use and reporting. The focus
of this thesis is on problems of fragmentation and challenges of integration. These have been
studied both with regard to the routine health information system (MTUHA) in general, and
specifically for the programme for prevention of mother-to-child transmission of HIV/AIDS
(called PMTCT), which is relatively new and was supposed to become fully integrated with
the ordinary health service structures. The research had been carried out as part of the Health
Information Systems Programme (HISP) initiative, an international research and development
project based in the Informatics department of the University of Oslo.
The empirical fieldwork was conducted between 1st of July 2004 and 18th of January 2005.
The study employed qualitative research methods, including; ethnographic interviews,
participation in workshops, document analysis in the health facilities, and hands-on
experience with existing computer systems in the district. The empirical data were analysed
using the principles of qualitative research, and the analysis was informed by my theoretical
framework.
My theoretical framework is based on a literature review that covers research from various
fields, including literature on health information systems (HIS) in developing countries,
research on information infrastructures and on integration of information systems. I argue that
rather than seen as information systems, HIS should be conceptualised as larger systems
consisting of human and non-human components, where the design of new information
system is done by gradually extending the existing HIS, rather than from scratch. Developing
an information system involves not only a technical solution but also social considerations,
and a socio-technical approach is, therefore, appropriate. I draw upon the metaphor of
installed base cultivation, and the emphasis on incremental and bottom-up approaches that
this perspective entails.
The findings indicated that the HIS performance is hindered by the fragmentation within and
across the HIS. Fragmentation creates duplication of work and data, lack of information
sharing, and poor quality of information, poor use of information and hindering of health care
service provision. As an organising framework to describe the findings, I categorise them into
four dimensions: fragmentation problems related to software, to data, to work practices and to
institutional factors. At the system’s level, the problems are inflexible code, poor performance
of the computerised system, and different software between programmes. At the level of
specific data items, I identify a serious problem related to identification of clients to the
PMTCT programme, with consequences for follow-up. The information integration with the
rest of the MCH health care services was weak. In terms of work practices, the study revealed
problems related to information sharing between PMTCT staff and other staff. At the
institutional level, the problems of patients (or clients) attending several and different clinics
is a challenge. The causes for the fragmentation problems include low priority for HIS work,
information flow reflecting higher needs, and lack of participation in system development.
However, the study also revealed some instances of emergence of local improvised tools
designed by health workers at the facility level, which was also being spread horizontally and
ABSTRACT
ii
used by other facilities. These tools can resolve (at least partly) the dilemmas of integration,
and they address the immediate information needs of the workers. Based on these findings
and on insight gained from theory, I end by proposing some cultivation strategies for dealing
with the challenges identified in the research. Bottom-up standardisation and “loose”
integration are central aspects here.
The thesis is positioned within work practice studies with the aim of contributing to the underst... more The thesis is positioned within work practice studies with the aim of contributing to the understanding of work practices in facilitating care trajectories in resource-restricted settings. My research has a practical motivation stemming from primary healthcare services. The primary healthcare service is an important health care component in the management of common diseases facing society since it is a client’s first entry point to the healthcare system in any country. While the HIV-AIDS disease is a major public health problem globally, Sub-Saharan Africa is the world’s most affected region. Thus, primary healthcare services play crucial role in the management of HIV care and physical wellbeing of citizens. The problem of clients’ attrition in HIV-related programs has been observed in many countries like Tanzania, South Africa, Ethiopia, Cambodia, and Kenya. The literature recommends that, in order to support client retention, a well-designed health information system, and preferably a computerized one, needs to be in place. Unfortunately, failure in computerized patient-care information systems is common due to the mismatch between the existing practices and the design of the computerized information system. To minimize failure of information systems, researchers recommend that the understanding of practitioners’ work practices – for example, how they utilize information artifacts and handle the challenges – can be valuable to information systems development teams. However, there is a dearth of HIS research which provides insights into the utilization of designed and/or implemented computerized patient-oriented information systems to support healthcare provision in the developing countries’ settings. I argue that the HIS research field has put more emphasis on managerial aspect of HIS and less on the understanding operational primary healthcare information systems, which is what this study aims at contributing to. This study has been conducted in Dodoma, Tanzania under the Health Information System Program which is based at the Department of Informatics of the University of Oslo. The study employed a qualitative research strategy and has adopted an interpretive approach for data analysis. Research data was collected in two districts (one rural, one urban) for the duration of 14 months. Some empirical fieldwork was also conducted at the Department of Informatics of the University of Oslo. The actual empirical findings were mainly obtained through multi-site ethnographic studies conducted in multiple health programs, 11 primary healthcare facilities and catchment population. Also, participatory design approaches were used to inform the design and implementation of the software for monitoring clients’ care trajectories. Activity theory has been the major conceptual lens through which the empirical data have been analyzed. This research extends the understanding of primary healthcare information systems by providing a rich analysis of health workers’ practices related to the use of IS tools to support coordination of clients’ trajectories. This research also contributes to the understanding of the characteristics of the distributed collaboration in healthcare services in resource-restricted settings by showing that there are more actors in different health programs, community, and health administration levels. I have argued that it is important that we pay attention to the role played by implementation mediators and the challenges they face in the design-after-design practices in order to develop appropriate systems to support healthcare. Moreover, this dissertation adds to the existing knowledge regarding the impact of context in the distributed practices by highlighting the role played by other forms of contextual conditions (e.g. disease specific, clients’ decisions, and rural/urban settings) in distributed collaboration. The thesis concludes by calling more attention to context-sensitive design, implementation, and use of primary healthcare information systems in resource-constrained settings.
Ethnography, with its emphasis on understanding activities where they occur, and its use of quali... more Ethnography, with its emphasis on understanding activities where they occur, and its use of qualitative data gathering techniques rich in description, has a long tradition in Participatory Design (PD). Yet there are limited methodological insights in its application in developing countries. This paper proposes an ethnographically informed PD approach, which can be applied when designing Primary Healthcare Information Technology (PHIT). We use findings from a larger multidisciplinary project, Health Information Systems Project (HISP) to elaborate how ethnography can be used to facilitate participation of health practitioners in developing countries settings as well as indicating the importance of ethnographic approach to participatory Health Information Technology (HIT) designers. Furthermore, the paper discusses the pros and cons of using an ethnographic approach in designing HIT.
Defaulter tracing systems are patient centred information systems which are used to enhance
moni... more Defaulter tracing systems are patient centred information systems which are used to enhance
monitoring of patients who have dropped out of health programs. The aim of this study is to
explore the operation of defaulter tracing systems in practice. The study has been undertaken
in Tanzanian health facilities by using qualitative data collection methods. Activity theory is
employed as a conceptual framework to analyze the findings. Findings show that the
implementation of defaulter tracing system is challenged by issues of the existing information
systems, such as absence of clear guidelines and tools, and information recording
incompleteness, as well as contextual issues. The paper contributes to Healthcare Information
System literature (HIS) which has elaborated how patient centred information systems are
utilized in practice at the level of primary health care. This study concludes by providing
implications for policy, practice, design and implementation
This paper aims at an extended understanding of the design facilitators' role, here implementatio... more This paper aims at an extended understanding of the design facilitators' role, here implementation mediators, in participatory design practices. In reflecting connectedness between use and design in a distributed open source software design practice, a particular focus is devoted to the implementation mediator’s interaction between local users, global software developers, and local designers who are geographically distributed, possess different technological skills, and different work experiences. The implementation mediators’ insights are useful in the design of large information systems that involve distributed actors. A maternal and child health setting in Tanzania was the case in this study. An ethnographic study involving interactions with global developers and participative activities in local health practices were conducted. In addition, mediators connected local and global designers to configure a computer system for a particular context; configured participation, involving health workers in designing practices. We present the role of the implementation mediators and its related participatory activities by using the notion of design-after-design. We also highlight the challenges which could face implementation mediators in distributed participatory design activities.
In this paper, we present our empirical insights from Tanzania and Malawi by showing the challeng... more In this paper, we present our empirical insights from Tanzania and Malawi by showing the challenges of participation and we provide implications which can be used to enhance human development in the health sector. Our empirical material is drawn from the Health Information Systems Project which is a global south-north network aiming at improving the use and management of health data in developing countries. Our focus is on the interaction between software implementers, end users and global open source software developers. Our study indicates participatory challenges which are related to the difficulties in identifying users, limited health domain knowledge among some of the expected end-users and software implementers; and limited participation arising due to local-global differences. We argue that for human development to occur through the use of open source software, participation skills in the design, development and use of open source software need to be enhanced through capacity development of end-users and software implementers.
Background and Purpose: This paper describes some of the complexities that face health service
pr... more Background and Purpose: This paper describes some of the complexities that face health service provision in developing countries, with the motivation to inform design of appropriate information systems. In particular, we are interested in a better understanding of the challenges to coordination and collaboration between health staff that are located in different facilities and employed to work in different health programs. Methods: The study reported and analyzed in this paper was conducted in two districts in Tanzania. Using ethnographic data collection methods, we studied health workers’ practices of coordination and collaboration in Prevention of Mother to Child Transmission (PMTCT) services in Tanzania. Results: In our study we describe the collaboration required when managing patient trajectories of PMTCT patients across facilities and programs, and how contingencies may change the course of a patient trajectory. We provide a rich empirical description of coordination work in a resource constrained setting and we propose improvements to the design of both computer and paper-based information systems. Conclusions: The rich empirical description of coordination work in a resource constrained setting and our analysis of coordination challenges contribute to a better understanding that can strengthen collaboration and thus also improve health care provision.
Every health worker collects data while delivering health services. This information will later i... more Every health worker collects data while delivering health services. This information will later inform the society about the population’s health status, for instance as diseases statistics. A shift towards decentralization in many low-income countries implies that more skills are demanded of primary health care workers, including data and information handling. There is a need to build capacity to deal with health information and one way of doing that is by introducing courses related to health information system. This paper reports the experience obtained and lesson learnt while implementing the nine month programme: Health Management Information System Course at the University of Dar es Salaam during the first two years. The course aims to understand the development of Health information system in order to strengthen health management in developing countries. The emphasis is placed on the teaching module that combined the theory, cross-country cooperation and research at the work place of participants. Through the students’ own research projects it was learnt that there is a problem of data quality at district levels and this could be attributed to poor HMIS training to health workers dealing with data management at various levels of health sector. What we have learned from this course is that there is a need to develop different course modules for different participants. We conclude by recommending the establishment of similar courses in different places.
Keywords: Health in
This research falls under the area of design and implementation of information systems in
develo... more This research falls under the area of design and implementation of information systems in
developing countries. I have studied the health information systems in Tanzania using case
studies in Ilala Municipal, situated in Dar es Salaam city, and Tabora Municipal in the Tabora
region. The purpose of the research was to study the challenges encountered by the health
workers at the local level with regard to information collection, use and reporting. The focus
of this thesis is on problems of fragmentation and challenges of integration. These have been
studied both with regard to the routine health information system (MTUHA) in general, and
specifically for the programme for prevention of mother-to-child transmission of HIV/AIDS
(called PMTCT), which is relatively new and was supposed to become fully integrated with
the ordinary health service structures. The research had been carried out as part of the Health
Information Systems Programme (HISP) initiative, an international research and development
project based in the Informatics department of the University of Oslo.
The empirical fieldwork was conducted between 1st of July 2004 and 18th of January 2005.
The study employed qualitative research methods, including; ethnographic interviews,
participation in workshops, document analysis in the health facilities, and hands-on
experience with existing computer systems in the district. The empirical data were analysed
using the principles of qualitative research, and the analysis was informed by my theoretical
framework.
My theoretical framework is based on a literature review that covers research from various
fields, including literature on health information systems (HIS) in developing countries,
research on information infrastructures and on integration of information systems. I argue that
rather than seen as information systems, HIS should be conceptualised as larger systems
consisting of human and non-human components, where the design of new information
system is done by gradually extending the existing HIS, rather than from scratch. Developing
an information system involves not only a technical solution but also social considerations,
and a socio-technical approach is, therefore, appropriate. I draw upon the metaphor of
installed base cultivation, and the emphasis on incremental and bottom-up approaches that
this perspective entails.
The findings indicated that the HIS performance is hindered by the fragmentation within and
across the HIS. Fragmentation creates duplication of work and data, lack of information
sharing, and poor quality of information, poor use of information and hindering of health care
service provision. As an organising framework to describe the findings, I categorise them into
four dimensions: fragmentation problems related to software, to data, to work practices and to
institutional factors. At the system’s level, the problems are inflexible code, poor performance
of the computerised system, and different software between programmes. At the level of
specific data items, I identify a serious problem related to identification of clients to the
PMTCT programme, with consequences for follow-up. The information integration with the
rest of the MCH health care services was weak. In terms of work practices, the study revealed
problems related to information sharing between PMTCT staff and other staff. At the
institutional level, the problems of patients (or clients) attending several and different clinics
is a challenge. The causes for the fragmentation problems include low priority for HIS work,
information flow reflecting higher needs, and lack of participation in system development.
However, the study also revealed some instances of emergence of local improvised tools
designed by health workers at the facility level, which was also being spread horizontally and
ABSTRACT
ii
used by other facilities. These tools can resolve (at least partly) the dilemmas of integration,
and they address the immediate information needs of the workers. Based on these findings
and on insight gained from theory, I end by proposing some cultivation strategies for dealing
with the challenges identified in the research. Bottom-up standardisation and “loose”
integration are central aspects here.
The thesis is positioned within work practice studies with the aim of contributing to the underst... more The thesis is positioned within work practice studies with the aim of contributing to the understanding of work practices in facilitating care trajectories in resource-restricted settings. My research has a practical motivation stemming from primary healthcare services. The primary healthcare service is an important health care component in the management of common diseases facing society since it is a client’s first entry point to the healthcare system in any country. While the HIV-AIDS disease is a major public health problem globally, Sub-Saharan Africa is the world’s most affected region. Thus, primary healthcare services play crucial role in the management of HIV care and physical wellbeing of citizens. The problem of clients’ attrition in HIV-related programs has been observed in many countries like Tanzania, South Africa, Ethiopia, Cambodia, and Kenya. The literature recommends that, in order to support client retention, a well-designed health information system, and preferably a computerized one, needs to be in place. Unfortunately, failure in computerized patient-care information systems is common due to the mismatch between the existing practices and the design of the computerized information system. To minimize failure of information systems, researchers recommend that the understanding of practitioners’ work practices – for example, how they utilize information artifacts and handle the challenges – can be valuable to information systems development teams. However, there is a dearth of HIS research which provides insights into the utilization of designed and/or implemented computerized patient-oriented information systems to support healthcare provision in the developing countries’ settings. I argue that the HIS research field has put more emphasis on managerial aspect of HIS and less on the understanding operational primary healthcare information systems, which is what this study aims at contributing to. This study has been conducted in Dodoma, Tanzania under the Health Information System Program which is based at the Department of Informatics of the University of Oslo. The study employed a qualitative research strategy and has adopted an interpretive approach for data analysis. Research data was collected in two districts (one rural, one urban) for the duration of 14 months. Some empirical fieldwork was also conducted at the Department of Informatics of the University of Oslo. The actual empirical findings were mainly obtained through multi-site ethnographic studies conducted in multiple health programs, 11 primary healthcare facilities and catchment population. Also, participatory design approaches were used to inform the design and implementation of the software for monitoring clients’ care trajectories. Activity theory has been the major conceptual lens through which the empirical data have been analyzed. This research extends the understanding of primary healthcare information systems by providing a rich analysis of health workers’ practices related to the use of IS tools to support coordination of clients’ trajectories. This research also contributes to the understanding of the characteristics of the distributed collaboration in healthcare services in resource-restricted settings by showing that there are more actors in different health programs, community, and health administration levels. I have argued that it is important that we pay attention to the role played by implementation mediators and the challenges they face in the design-after-design practices in order to develop appropriate systems to support healthcare. Moreover, this dissertation adds to the existing knowledge regarding the impact of context in the distributed practices by highlighting the role played by other forms of contextual conditions (e.g. disease specific, clients’ decisions, and rural/urban settings) in distributed collaboration. The thesis concludes by calling more attention to context-sensitive design, implementation, and use of primary healthcare information systems in resource-constrained settings.
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Papers by Nima Shidende
monitoring of patients who have dropped out of health programs. The aim of this study is to
explore the operation of defaulter tracing systems in practice. The study has been undertaken
in Tanzanian health facilities by using qualitative data collection methods. Activity theory is
employed as a conceptual framework to analyze the findings. Findings show that the
implementation of defaulter tracing system is challenged by issues of the existing information
systems, such as absence of clear guidelines and tools, and information recording
incompleteness, as well as contextual issues. The paper contributes to Healthcare Information
System literature (HIS) which has elaborated how patient centred information systems are
utilized in practice at the level of primary health care. This study concludes by providing
implications for policy, practice, design and implementation
provision in developing countries, with the motivation to inform design of appropriate information
systems. In particular, we are interested in a better understanding of the challenges to coordination
and collaboration between health staff that are located in different facilities and employed to work in
different health programs.
Methods: The study reported and analyzed in this paper was conducted in two districts in Tanzania.
Using ethnographic data collection methods, we studied health workers’ practices of coordination and
collaboration in Prevention of Mother to Child Transmission (PMTCT) services in Tanzania.
Results: In our study we describe the collaboration required when managing patient trajectories of
PMTCT patients across facilities and programs, and how contingencies may change the course of a
patient trajectory. We provide a rich empirical description of coordination work in a resource constrained
setting and we propose improvements to the design of both computer and paper-based information
systems.
Conclusions: The rich empirical description of coordination work in a resource constrained setting
and our analysis of coordination challenges contribute to a better understanding that can strengthen
collaboration and thus also improve health care provision.
Keywords: Health in
Thesis by Nima Shidende
developing countries. I have studied the health information systems in Tanzania using case
studies in Ilala Municipal, situated in Dar es Salaam city, and Tabora Municipal in the Tabora
region. The purpose of the research was to study the challenges encountered by the health
workers at the local level with regard to information collection, use and reporting. The focus
of this thesis is on problems of fragmentation and challenges of integration. These have been
studied both with regard to the routine health information system (MTUHA) in general, and
specifically for the programme for prevention of mother-to-child transmission of HIV/AIDS
(called PMTCT), which is relatively new and was supposed to become fully integrated with
the ordinary health service structures. The research had been carried out as part of the Health
Information Systems Programme (HISP) initiative, an international research and development
project based in the Informatics department of the University of Oslo.
The empirical fieldwork was conducted between 1st of July 2004 and 18th of January 2005.
The study employed qualitative research methods, including; ethnographic interviews,
participation in workshops, document analysis in the health facilities, and hands-on
experience with existing computer systems in the district. The empirical data were analysed
using the principles of qualitative research, and the analysis was informed by my theoretical
framework.
My theoretical framework is based on a literature review that covers research from various
fields, including literature on health information systems (HIS) in developing countries,
research on information infrastructures and on integration of information systems. I argue that
rather than seen as information systems, HIS should be conceptualised as larger systems
consisting of human and non-human components, where the design of new information
system is done by gradually extending the existing HIS, rather than from scratch. Developing
an information system involves not only a technical solution but also social considerations,
and a socio-technical approach is, therefore, appropriate. I draw upon the metaphor of
installed base cultivation, and the emphasis on incremental and bottom-up approaches that
this perspective entails.
The findings indicated that the HIS performance is hindered by the fragmentation within and
across the HIS. Fragmentation creates duplication of work and data, lack of information
sharing, and poor quality of information, poor use of information and hindering of health care
service provision. As an organising framework to describe the findings, I categorise them into
four dimensions: fragmentation problems related to software, to data, to work practices and to
institutional factors. At the system’s level, the problems are inflexible code, poor performance
of the computerised system, and different software between programmes. At the level of
specific data items, I identify a serious problem related to identification of clients to the
PMTCT programme, with consequences for follow-up. The information integration with the
rest of the MCH health care services was weak. In terms of work practices, the study revealed
problems related to information sharing between PMTCT staff and other staff. At the
institutional level, the problems of patients (or clients) attending several and different clinics
is a challenge. The causes for the fragmentation problems include low priority for HIS work,
information flow reflecting higher needs, and lack of participation in system development.
However, the study also revealed some instances of emergence of local improvised tools
designed by health workers at the facility level, which was also being spread horizontally and
ABSTRACT
ii
used by other facilities. These tools can resolve (at least partly) the dilemmas of integration,
and they address the immediate information needs of the workers. Based on these findings
and on insight gained from theory, I end by proposing some cultivation strategies for dealing
with the challenges identified in the research. Bottom-up standardisation and “loose”
integration are central aspects here.
This study has been conducted in Dodoma, Tanzania under the Health Information System Program which is based at the Department of Informatics of the University of Oslo. The study employed a qualitative research strategy and has adopted an interpretive approach for data analysis. Research data was collected in two districts (one rural, one urban) for the duration of 14 months. Some empirical fieldwork was also conducted at the Department of Informatics of the University of Oslo. The actual empirical findings were mainly obtained through multi-site ethnographic studies conducted in multiple health programs, 11 primary healthcare facilities and catchment population. Also, participatory design approaches were used to inform the design and implementation of the software for monitoring clients’ care trajectories. Activity theory has been the major conceptual lens through which the empirical data have been analyzed.
This research extends the understanding of primary healthcare information systems by providing a rich analysis of health workers’ practices related to the use of IS tools to support coordination of clients’ trajectories. This research also contributes to the understanding of the characteristics of the distributed collaboration in healthcare services in resource-restricted settings by showing that there are more actors in different health programs, community, and health administration levels. I have argued that it is important that we pay attention to the role played by implementation mediators and the challenges they face in the design-after-design practices in order to develop appropriate systems to support healthcare. Moreover, this dissertation adds to the existing knowledge regarding the impact of context in the distributed practices by highlighting the role played by other forms of contextual conditions (e.g. disease specific, clients’ decisions, and rural/urban settings) in distributed collaboration. The thesis concludes by calling more attention to context-sensitive design, implementation, and use of primary healthcare information systems in resource-constrained settings.
monitoring of patients who have dropped out of health programs. The aim of this study is to
explore the operation of defaulter tracing systems in practice. The study has been undertaken
in Tanzanian health facilities by using qualitative data collection methods. Activity theory is
employed as a conceptual framework to analyze the findings. Findings show that the
implementation of defaulter tracing system is challenged by issues of the existing information
systems, such as absence of clear guidelines and tools, and information recording
incompleteness, as well as contextual issues. The paper contributes to Healthcare Information
System literature (HIS) which has elaborated how patient centred information systems are
utilized in practice at the level of primary health care. This study concludes by providing
implications for policy, practice, design and implementation
provision in developing countries, with the motivation to inform design of appropriate information
systems. In particular, we are interested in a better understanding of the challenges to coordination
and collaboration between health staff that are located in different facilities and employed to work in
different health programs.
Methods: The study reported and analyzed in this paper was conducted in two districts in Tanzania.
Using ethnographic data collection methods, we studied health workers’ practices of coordination and
collaboration in Prevention of Mother to Child Transmission (PMTCT) services in Tanzania.
Results: In our study we describe the collaboration required when managing patient trajectories of
PMTCT patients across facilities and programs, and how contingencies may change the course of a
patient trajectory. We provide a rich empirical description of coordination work in a resource constrained
setting and we propose improvements to the design of both computer and paper-based information
systems.
Conclusions: The rich empirical description of coordination work in a resource constrained setting
and our analysis of coordination challenges contribute to a better understanding that can strengthen
collaboration and thus also improve health care provision.
Keywords: Health in
developing countries. I have studied the health information systems in Tanzania using case
studies in Ilala Municipal, situated in Dar es Salaam city, and Tabora Municipal in the Tabora
region. The purpose of the research was to study the challenges encountered by the health
workers at the local level with regard to information collection, use and reporting. The focus
of this thesis is on problems of fragmentation and challenges of integration. These have been
studied both with regard to the routine health information system (MTUHA) in general, and
specifically for the programme for prevention of mother-to-child transmission of HIV/AIDS
(called PMTCT), which is relatively new and was supposed to become fully integrated with
the ordinary health service structures. The research had been carried out as part of the Health
Information Systems Programme (HISP) initiative, an international research and development
project based in the Informatics department of the University of Oslo.
The empirical fieldwork was conducted between 1st of July 2004 and 18th of January 2005.
The study employed qualitative research methods, including; ethnographic interviews,
participation in workshops, document analysis in the health facilities, and hands-on
experience with existing computer systems in the district. The empirical data were analysed
using the principles of qualitative research, and the analysis was informed by my theoretical
framework.
My theoretical framework is based on a literature review that covers research from various
fields, including literature on health information systems (HIS) in developing countries,
research on information infrastructures and on integration of information systems. I argue that
rather than seen as information systems, HIS should be conceptualised as larger systems
consisting of human and non-human components, where the design of new information
system is done by gradually extending the existing HIS, rather than from scratch. Developing
an information system involves not only a technical solution but also social considerations,
and a socio-technical approach is, therefore, appropriate. I draw upon the metaphor of
installed base cultivation, and the emphasis on incremental and bottom-up approaches that
this perspective entails.
The findings indicated that the HIS performance is hindered by the fragmentation within and
across the HIS. Fragmentation creates duplication of work and data, lack of information
sharing, and poor quality of information, poor use of information and hindering of health care
service provision. As an organising framework to describe the findings, I categorise them into
four dimensions: fragmentation problems related to software, to data, to work practices and to
institutional factors. At the system’s level, the problems are inflexible code, poor performance
of the computerised system, and different software between programmes. At the level of
specific data items, I identify a serious problem related to identification of clients to the
PMTCT programme, with consequences for follow-up. The information integration with the
rest of the MCH health care services was weak. In terms of work practices, the study revealed
problems related to information sharing between PMTCT staff and other staff. At the
institutional level, the problems of patients (or clients) attending several and different clinics
is a challenge. The causes for the fragmentation problems include low priority for HIS work,
information flow reflecting higher needs, and lack of participation in system development.
However, the study also revealed some instances of emergence of local improvised tools
designed by health workers at the facility level, which was also being spread horizontally and
ABSTRACT
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used by other facilities. These tools can resolve (at least partly) the dilemmas of integration,
and they address the immediate information needs of the workers. Based on these findings
and on insight gained from theory, I end by proposing some cultivation strategies for dealing
with the challenges identified in the research. Bottom-up standardisation and “loose”
integration are central aspects here.
This study has been conducted in Dodoma, Tanzania under the Health Information System Program which is based at the Department of Informatics of the University of Oslo. The study employed a qualitative research strategy and has adopted an interpretive approach for data analysis. Research data was collected in two districts (one rural, one urban) for the duration of 14 months. Some empirical fieldwork was also conducted at the Department of Informatics of the University of Oslo. The actual empirical findings were mainly obtained through multi-site ethnographic studies conducted in multiple health programs, 11 primary healthcare facilities and catchment population. Also, participatory design approaches were used to inform the design and implementation of the software for monitoring clients’ care trajectories. Activity theory has been the major conceptual lens through which the empirical data have been analyzed.
This research extends the understanding of primary healthcare information systems by providing a rich analysis of health workers’ practices related to the use of IS tools to support coordination of clients’ trajectories. This research also contributes to the understanding of the characteristics of the distributed collaboration in healthcare services in resource-restricted settings by showing that there are more actors in different health programs, community, and health administration levels. I have argued that it is important that we pay attention to the role played by implementation mediators and the challenges they face in the design-after-design practices in order to develop appropriate systems to support healthcare. Moreover, this dissertation adds to the existing knowledge regarding the impact of context in the distributed practices by highlighting the role played by other forms of contextual conditions (e.g. disease specific, clients’ decisions, and rural/urban settings) in distributed collaboration. The thesis concludes by calling more attention to context-sensitive design, implementation, and use of primary healthcare information systems in resource-constrained settings.