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abstract the district health information system version 2 dhis 2 is a complex health information system for collecting analyzing and reporting health related data dhis 2 is free and open source and is implemented in many developing countries such as sierra leone zanzibar india and vietnam the gambia implemented dhis 2 autumn 2009/spring 2010 and is the case i have used for my research it was decided that dhis 2 should be the official reporting tool for health data from january 2010 i had two field trips to the country during the spring 2010 and helped the ministry of health in the implementation process the research goal of this thesis is to explore how a complex health information system can successfully be implemented maintained and used in a context with poor ict knowledge i show that conception-reality gaps when implementing a health information system play a vital role extensive training of health workers and computer technicians is also important to secure sustainability of the system i also show that data quality has been significantly increased after the implementation of dhis 2 and that quality can be further increased dhis 2 has proved more user-friendly than previous reporting tools and thus contributed to ease the data entry task.

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acknowledgements i would like to thank my teaching supervisor jørn braa for giving me the opportunity to travel abroad and write a master thesis for the global infrastructure research group your feedback during the writing process has also been valuable i want to thank mr lamin b jawara the head of the it office at the gambian ministry of health for all discussions and feedback related to my work but also for taking care of me a white norwegian boy in a strange country helping me finding places to stay including me in his social life and teaching me about the gambian culture mr musa m m sowe the head of the gambian health management information system hmis has also been very valuable for my research you have provided me with useful information answered all my questions and taught me a lot on health management i also want to thank mr dembo manneh you have been a real good friend and made my stay in the gambia even more pleasant thank you for taking care of all practical things and for being my private guide i want to thank my roommate in the gambia richard thomas anthony fleming one of the british volunteers for providing valuable information on the dhis 2 work that was done before my arrival to the country i also appreciate your feedback through the writing process finally i want to thank my wonderful wife ingunn for being so patient and letting me travel abroad to do my research i

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1 1.1 introduction context the health information systems programme hisp was initiated as part of south africa s reconstruction and development program in 1994 braa et al 2004 a unified health information system his was desired to avoid fragmented information flow and so the thought of the district health information software dhis was born ibid the first version of dhis was based on microsoft access thus even if dhis itself was free users were required to use licensed proprietary software it was later decided that dhis should be redeveloped so it could be used without the need of proprietary software the result was dhis 2 dhis 2 is web based and does not require proprietary software to run dhis 2 is implemented in many developing countries such as sierra leone zanzibar india and vietnam hisp 2010 a january 2010 it was to be implemented in the gambia 1.2 motivation through my studies i experienced a lot of focus on the oil industry and how to make norway richer and better my dreams for my future were however about how i can contribute to make the world a better place for people with lesser resources and possibilities than i have when the research groups from the department of informatics presented their research fields for the new master students january 2009 all but one research group spoke about the oil industry and how the students will make a fortune when they graduate and start working the research group that differed from the rest was the global infrastructure research group when they presented their work in the third world focusing on improving the health care situation in the countries i had to contact them to explore the possibilities for writing a master thesis for their research group the head of the gambian health management information system hmis discovered dhis 2 and wanted to implement it in his country as the official health data reporting tool the design and implementation would take place the autumn 2009 and it was decided that data should be reported through dhis 2 from january 2010 as i finished my last courses at the university december 2009 i could thus travel to the gambia the spring 2010 and help in the start-up period i was first introduced to dhis 2 through some courses at the university and learned that if utilized good enough dhis 2 can increase the quality of the reported data and it can also make data collection and reporting easier for the health workers 1

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1.3 research questions based on the background presented in section 1.2 i have chosen to explore the research questions presented below research questions the overall research question is how can a complex health information system such as dhis 2 be implemented maintained and used in a context with constrained and weak ict knowledge such as the gambia to approach this question i will explore the following sub questions o how can the needed human capacity be built o can the quality of the data be increased through the use of dhis 2 o can dhis 2 ease data collection and reporting research approach to answer these questions i had two trips to the gambia with a total length of 13 weeks in the country i worked with dhis 2 implementation together with the hmis head and the head of the moh it office my research approach is described in more detail in section 3.2 to learn from previous research on ict in developing countries and the work of hisp i have explored literature covering those topics in more detail i have explored literature on system development in developing countries as that is the primary field of interest for the research group i am writing this thesis for as dhis 2 is a health information system i have also investigated literature on health information systems in developing countries dhis 2 is a computer program so i have therefore also read some literature on ict in developing countries 2

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2 literature review in this section i will cover the areas of interest for my research first i will present literature on system development in developing countries i will move on to ict in developing countries and finally i will present literature on health information systems in developing countries 2.1 system development in developing countries 2.1.1 design process prototyping and evaluation are important both in software development as well as in the implementation process of an his berg 1999 recommends an iterative approach to the analysis design implementation and evaluation of patient care information systems the advantage of using an iterative approach to the design process is the early and continuous evaluation and feedback as the system is being prepared for deployment the feedback helps reveal errors at early stages in the implementation process lowering the cost for fixing the errors krutchen 2000 compares the iterative design process to the waterfall model in which he states development proceeds linearly from requirements analysis through design code and unit testing subsystem testing and system testing with limited feedback on the results of the previous phases if/when errors are discovered late in the implementation process it will be costly to fix them compared to if they were discovered earlier in the process figure 2 1 shows a model of a life cycle of an iterative design process first needs must be identified and requirements established before software design may start thereafter follow several work loops consisting of prototype releases evaluation updating needs and requirements redesign new releases etc finally when the last release passes evaluation it can be deployed 3

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figure 2 1 a life cycle model for iterative design image courtesy of sharp et al 2007 448 some of the advantages of choosing an iterative design process are according to krutchen 2000 that misunderstandings and inconsistencies among requirements designs and implementations are detected early also he points to the fact that the workload of the testers is more evenly spread out during the lifecycle of the design process the overall quality of the product will in the end he states be better for products resulting from an iterative design process than for products resulting from a sequential design process he explains this the system will have been tested several times improving the quality of the testing the requirements will have been refined and will therefore be more closely related to the users real needs and at the time of delivery the system will have been running longer ibid 2.1.2 participatory design participatory design pd dates back to the 1970s when scandinavian research projects on user participation in system development started bødker 1996 since then the attention from the western setting has increased gould lewis 1985 grudin 1991 a b kyng 1991 schuler namioka 1993 the action research had an explicit political agenda braa et al 2004 and developed strategies and techniques for workers to influence the design and use of computer applications at the workplace bødker 1996 citing nygaard braa et al 2004 claim that t+he strategy at the local level was to develop knowledge about the technology in question and to actively propose alternatives to those of the management the norwegian iron and metal workers union njmf project implemented this research approach as they moved from traditional research to working with people directly changing the role of the union clubs in the project bødker 1996 the unions were thus able to negotiate settlements and institutional arrangements ensuring a certain influence 4

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over the process braa et al 2004 bødker 1996 states that the key issue of the scandinavian action research projects was building on people s own experience providing for them resources to be able to act in their current situation another central action research project is the utopia project it was established as a response to the threat represented by new technologies to graphical workers braa et al 2004 the nordic graphical union and several scandinavian research institutions were involved in the project and they wanted to develop alternative technologies controlled by the graphical workers skills and perspectives they set up a laboratory and developed prototypes but due to the fact that utopia failed to forge alliances with a surrounding network of journalists and other professional groups the prototype failed to be sustainable ibid when it comes to software development pd aims to involve all stakeholders when designing the software so that it can meet the users needs and requirements participatory design n.d pd and hisp in a similar way as the utopia project failed to forge alliances with a surrounding network the njmf project failed to establish a network of workplaces pursuing similar strategies braa et al 2004 braa et al say that these experiences identify the key criteria of a political agenda and sustainability shared by hisp and state that a political agenda similar to that within the njmf project is embedded in the hisp effort the political economy of hisp they state is that hisp represents a marginal alternative and at times opposing network relative to the significantly larger and dominating network through the who various donor agencies the world bank national health authorities and large corporations selling hardware and software braa et al ibid claim that the hisp approach reiterates the articulation from former scandinavian-based action research of sustainability and scalability as key criteria in action research as the hisp research s primary goal is to design implement and sustain his following a participatory approach to support local management of health care delivery and information flows in selected health facilities districts and provinces and its further spread within and across developing countries braa et al ibid present a figure which they say illustrate well the political agenda of hisp 5

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figure 2 2 drawing depicting the past and envisioned future information flows in the apartheid era colored town of atlanits 1995 figure as presented by braa et al 2004 pd raises an issue when applied on software development in resource-constrained developing countries titlestad et al 2009 explore this issue by drawing on their experiences from their work within the hisp network both the lack of skilled people and the shortage of money in these settings make reliance on foreign actors necessary for developing good his south africa a good example of participatory design is the development of the first version of the dhis software in south africa where prototypes were released on a weekly ­ and sometimes even daily ­ basis providing updates based on the users suggestions for improvements braa et al 2004 the hisp network who stands behind the development of dhis was initiated during the process of creating a unified his in south africa after the apartheid a professional software development team was later established to develop dhis ibid the hisp team thus consisted of domain expert on both health care as well as computer programming sierra leone sl the norwegian development team was not directly involved in dhis 2 until 2008 at that time t+he customization for sl was organized as a collaborative effort between a software 6

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company in mali and the team of coordinators and developers ion norway staring titlestad 2008 software issues especially related to usability were discovered and fixed and through close cooperation with the users in sierra leone a norwegian developer put in place a generic reporting framework ibid as this framework was later presented on a workshop it also quickly got popular amongst the other dhis 2 development teams 2.1.3 top-down vs bottom-up amonoo-lartson et al 1984 14 suggest a bottom-up instead of a top-down planning to meet the needs at the community level sæbø and titlestad 2004 state that an his that captures and uses data at local level is of the utmost importance when choosing a bottomup approach for the planning of the his the local level s needs can be incorporated into the system case cuba in their field work in cuba sæbø and titlestad followed a bottom-up approach identifying problems with local staff and having local trainings sæbø titlestad 2004 as the cuban system is highly centralized however and things tend to be run in a top-down manner requiring control it proved difficult to follow the chosen bottom-up approach in fact they state that the bottom-up approach followed will not succeed without political support at the highest level first ibid sæbø and titlestad hence suggest that hisp adjust their approach to a middle ground solution between the hisp bottom-up approach and the cuban top-down approach furthermore they state that it is difficult to undertake a participatory approach in a culture where people are used to agreeing with people in positions of power and are not used to opposing official views their conclusion is that in cuba with a highly centralized system implementation must have a top-down approach while the design process should use a bottom-up approach they also stress that there often exists knowledge at local level that does not exist at the national level 2.1.4 prototyping titlestad et al 2009 claim that a key pd principle is to apply mutual learning processes to bridge and blur the user-designer distinction from both directions this requires that the designers understand the context in which the users live so that they can get a clearer opinion on the requirements of the system they are about to design during the process towards a final product prototyping and numerous face-to-face discussions are used as effective methods to reach the goal but a threshold in this process is the significant lack in computer knowledge of the potential users for the system hampering participation titlestad et al ibid suggest therefore interactive prototyping to deal with this threshold and claim that mutual learning processes often start with exploration and struggle to make things work furthermore they claim that a successful design team needs to include both software architects and domain experts by sharing technological and contextual understandings kraut and streeter 1995 knowledge gaps can be resolved in joint collaboration davis 1982 oliver langford 1987 correspondingly greenbaum and kyng 1999 143 state that 7

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u]sers as well as professional designers have knowledge and skills that are central to the design of useful computer applications therefore design needs to be organised as a cooperative activity between the users and the designers volkow 1998 concludes that it is important to take into account local conditions when developing information systems according to gumm 2006 however mutual learning processes are difficult to accomplish as cultural and organizational differences often lead to misunderstandings mozambique in mozambique they used a participatory process when implementing dhis 2 and that process suggested that dhis 2 was seen by all as a prototype rather than a ready-to-use software puri et al 2004 the authors explain that reactions to the system were gathered through observations interviews workshops and training sessions and that those reactions were quite helpful these interactions helped to identify limitations in the prototype and implement suggestions for improvement ibid boundary spanners boundary spanners titlestad et al 2009 are described as mediators ­ persons traversing borders and thus make communication between designers and users easier as the users of his are far from software developers the user-designer gap can best be bridged by technically conversant people who are also adept at communicating with the core developer team referring to finck et al 2004 who speak about using communication tools combined with a human mediator titlestad et al 2009 stress that such boundary spanners will understand the users concerns as they normally interacts closely with them and at the same time they know some of the developers by name 2.1.5 cultivation of the installed base according to braa and hedberg 2002 the design strategy followed in the south african hisp process can be denoted by the term cultivation which they explain as a slow incremental bottom-up process of aligning actors by enabling translation of their interests and gradually transforming social structures and information infrastructures where the resources already available form the base braa and hedberg ibid contrast the term cultivation to construction the latter being explained by hanseth and monteiro 1998 ch 9 quoting dahlbom and janlert as selecting putting together and arranging a number of objects to form a system this is the opposite of cultivation which they explain as interference with the natural process ibid thus while construction denotes the creation of a system more or less from scratch cultivation is more about modifying the existing system/infrastructure quoting braa and hedberg 2002 cultivation of new standards is then about transforming and changing the behaviour and routines of a social system ibid 8

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hanseth and monteiro 1998 ch 3 also stress that an infrastructure is never developed from scratch but rather develops through extending and improving the installed base ­ the already existing infrastructure furthermore they define an infrastructure as an evolving shared open and heterogeneous installed base it is shared by a community open meaning it has no limitations for the number of users and it is consisting of heterogeneous elements as an information infrastructure ii is heterogeneous it becomes increasingly difficult to make changes when it expands as the different elements of the ii are so tightly interconnected ibid ch 9 to change an ii they claim that only very few components of the ii can be changed at a time ­ t+he whole infrastructure cannot be changed instantly thus the installed base will influence the design of the new infrastructure ibid maciaschapula et al 1998 also stress that s+ystems analysts/thinkers need to be aware of the interaction of all the elements that participate in the information system if an information technology is to be successfully implemented westrup 1998 says certain relationships ranging from infrastructures to organisational characteristics have to be put in place backwards compatibility when developing computer software an issue to be aware of is backwards compatibility backwards compatibility denotes the case when a new version of a product functions also in conjunction with older versions of associated products hanseth monteiro 1998 ch 9 hanseth and lyytinen 2010 state that whatever is added needs to be compatible with the installed base and imposes constraints on what can be designed at any time ibid the concept of black-boxing should as well be mentioned when speaking of system development hanseth et al 1996 explain that t+he effect of black-boxing is that only the interface the outside of the box matters as long as the interface looks the same the inside does not matter latour 1999 also explains black-boxing when a machine runs effectively one need focus only on its inputs and outputs and not on its internal complexity applied on ict and system development this means that as long as the system offers the services it is supposed to the complexity on the inside does not matter for the users 2.2 ict in developing countries the third world has been and still is several steps behind the industrialized countries when speaking of industrial development one can argue that the reason for this originates from the colonization of the third world and the great suppression the colonized countries were put under nevertheless the developing countries are now far behind the industrialized countries in terms of knowledge their economies and political governance and are thus dependent on cooperation with the industrialized countries to make significant progress within these fields in fact increased knowledge will also lay the foundation for a better economy and politics 9

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2.2.1 research on ict and is in developing countries walsham et al 2007 state that there was at one time some debate on whether ict was relevant to the developing countries the answer they say is a clear yes and so the question is now how ict can benefit development icts have high potential value and can contribute to health delivery in rural villages as well as to software business in urban areas despite the importance of ict in developing countries walsham et al points out that literature on the topic to date is relatively sparse sahay and avgerou 2002 illustrate that as they claim that there probably exist less than five articles that deal explicitly with developing countries in journals like mis quarterly information systems research organization science the information society journal of mis and so on for the past five years there are however signs that this is changing walsham et al 2007 say and mention that there are now special journals devoted to the topic e.g it for development as well as special issues of mainstream journals e.g the information society 182 2002 also the ifip working group 9.4 see section below on information systems in developing countries established in 1988 has produced a number of volumes of conference proceedings they say sahay and avgerou 2002 explains that in may 2000 the ifip working group 9.4 held a conference on information flows work practices and local improvisations where they tried to shift the focus from why are technology initiatives often failing in developing country contexts to what can we do about it furthermore they state that this shift in focus was also reflective of a larger trend in the field that acknowledged that no longer was it productive to debate `are computers good or bad for developing countries but instead the need was to address the question of `how can the potential of icts be harnessed to address locally relevant problems furthermore walsham et al 2007 say that in 2003 the ifip working group 9.4 held a joint conference with ifip working group 8.2 on organizational is in the context of globalization these activities walsham et al state provide further indication of a coming together of is researchers whose interests span both developed and developing countries ibid brown and grant 2010 acknowledge the increased research on ict and development they have studied 184 journal articles and conference proceedings and propose a framework that suggests a partitioning of the existing literature on the topic into two distinct streams of research 1 those studies that focus on understanding technology for development 2 those studies that focus on understanding technology in developing countries they state that b+y explicitly separating the two research streams each stream can focus on advancing the understanding of relationships specific to their individual agendas ibid 10

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ifip working group 9.4 the ifip working group 9.4 is titled social implications of computers in developing countries and has the following aims and scope ifip n.d aims 1 to collect exchange and disseminate experiences of developing countries 2 to develop a consciousness amongst professionals policy makers and public on social implications of computers in developing nations 3 to develop criteria methods and guidelines for design and implementation of culturally adapted information systems 4 to create a greater interest in professionals from industrialized countries to focus on issues of special relevance to developing countries through joint activities with other technical committees scope 1 national computerization policy issues 2 culturally adapted computer technology and information systems 3 role of transnational corporations regional and international cooperation and selfsufficiency in informatics 4 social awareness of computers and computer literacy 2.2.2 ict s influence on the third world the one laptop per child1 founder negroponte predicts the significant influence information and communication technologies ict will have on developing countries as it brings knowledge to the people for example for a school in a rural area where there are no libraries and almost no books the schoolhouse is sometimes a tree to suddenly have access to the world s libraries ­ even at 4,800 bits per second ­ is a change of such magnitude that there is no way to understand it from the privileged position of the developed world negroponte 1998 osterwalder n.d claims referring to negroponte that many see ict as an important tool for developing countries that can help them skip some stages of industrial development and jump right to the information economy closing the gap on the developed world some sceptics will however have problems understanding how ict can improve health and education for instance as they cannot see how internet connectivity can fight poverty sahay et al 2009 give an example on this matter from the health sector quoting the indian commissioner s question to the hisp president how will your computers help to prevent mothers from dying in our health facilities 1 http laptop.org/en 11

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osterwalder n.d states that the debate cannot be framed in these terms it is not a matter of choosing between ict and health or ict and education but instead that of choosing the most effective way for ict to help in the delivery of health education and small business development services post 2006 supports this view as it states that development and ict are related since ict can improve access to basic services such as health and education it also points out that the introduction of ict in developing countries is urgent since any delay puts developing countries at risk of being further marginalised technology in itself cannot solve social problems osterwalder n.d concludes but is rather a pre-requisite for economic and social development in our world torero and von braun 2005 stress that ict is not a panacea ensuring development but rather offers an opportunity for development they mention three cs when speaking of ict ­ connectivity capability and content ­ and explain that a+ccess to information through icts is a question not only of connectivity but also of capability to use the new tools and relevant content provided in accessible and useful forms connectivity has been a priority and it is a prerequisite for the other two `cs considering the speed of the technology evolvement however they rather see the three cs progress simultaneously 2.2.3 the digital divide the expression digital divide refers to the gap between people with access to ict and people with very limited or no ict access besides physical access post 2006 lists six other factors that contribute to the disparities lack of appropriate products as products are often not designed to meet the needs of the poor the relatively high cost 46 of the sub-saharan population lives on less than 1 us a day husby 2009 education ­ a certain amount of technical skills are needed to benefit from ict language as ict is dominated by english and many of those who can read only know a local language human resources ­ skilled ict people migrate to the industrialized world and cause a lack of human resources to support ict lack of robust regulatory framework for ict ­ e.g i+n ethiopia 40 import tariffs on ict equipment makes it too costly for all but the elite post 2006 bridging the digital divide post ibid proposes some ways to bridge the digital divide since open source software oss is free of charge oss is cheaper to acquire than proprietary software and is thus more attractive than proprietary software for poor countries as proprietary software often requires the users to pay licensing fees in kenya lpakenya n.d asks could software costs be cut instead of government jobs in order to reduce the deficit they want that 12

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question to be investigated and further state that oss counterparts to proprietary software obviously will eliminate licensing costs post 2006 refers to the one laptop per child olpc project to exemplify how the use of oss can contribute to bridging the digital divide as the olpc computers are mainly open source based the olpc project s mission is t+o create educational opportunities for the world s poorest children olpc n.d through the project they will also be connected to the world and to a brighter future their vision corresponds to the united nations statement t]he true meaning of what icts should be used for [is to enable communities to find out more and to make choices and take decisions to improve their standard of living united nations 2005:38 post 2006 emphasizes the responsibility of the national governments by cutting taxes on ict equipment and liberalising the markets the ict uptake might increase expensive taxes will make it hard for all but the elite to buy equipment as exemplified with the ethiopian example in the list above to raise awareness and generate demand in the population familiarising the people with ict is however necessary some say donor-funded telecentres have a role to play such telecentres offer a range of telephone computing internet and information services ibid the united nations 2005 also conclude that telecentres should be grafted onto existing infrastructure and existing customer bases to reduce startup costs and to take advantage of existing infrastructure and connections the un and the mdgs the international community must also be involved in bridging the digital divide the united nations un launched the millennium development goals mdgs2 in 2000 aiming to reduce poverty and making lives better for the poor ict can be used in the work towards many of the goals and one sub-target of one of the goals explicitly says in cooperation with the private sector make available the benefits of new technologies especially information and communications united nations 2010 as less than 5 of the people in the developing regions are fixed broadband subscribers many of the most effective development applications of ict which is requiring high-speed internet connection remain unavailable to far too many potential users ibid cnet s bridge the digital divide other actors are also in the field trying to help bridging the digital divide cnet networks international media has in cooperation with uk charity computer aid international launched the web site bridge the digital divide3 to undertake the effort of bridging the digital divide between the developed world and the developing world cnet networks n.d a they encourage both individuals and companies to donate money or computer accessories as they see access to ict as useful to share information and raise awareness to combat poverty and injustice cnet networks n.d b 2 3 http www.un.org/millenniumgoals http www.bridgethedigitaldivide.com 13

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