Analyzing the Challenges of IS implementation in public health institutions of a developing country: the need for flexible strategies.

Abstract

This paper explores the challenges of introducing computer-based health information systems in the context of the Ethiopian public health care system. Drawing empirical examples from the process of introducing computer-based health information system(HIS) in two regional states (Amhara and Benishangul-Gumuz) of Ethiopia, this paper analyses the socio-technical challenges influencing the transition towards a new computerised system and suggested the importance of developing context-sensitive strategies to tackle different challenges in different contexts. Building on the notions of installed base and cultivation the paper examines the socio-technical issues and factors that influenced the process of developing, customizing, and implementing computerised HIS in different settings. The findings of this paper revealed that contextual differences in terms of access to infrastructural reources, availability of adaquate and qualified manpower, and managerial commitment and support would significantly influence the implementation process. I argue that, such context-senitive challenges need to be dealt through flexible startegies that took in to account the specific context. In this paper, four diffferent flexible strategies: the strategy of gateways, top-down vs bottom-up approaches, flexible essential data sets and clustering have beed identified as being useful in implementing computer-based systems in different settings of the Ethiopian public health care system.

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www.jhidc.org
This paper explores the challenges of introducing computer-based health information systems in the context
of the Ethiopian public health care system. Drawing empirical examples from the process of introducing
computer-based health information system(HIS) in two regional states (Amhara and Benishangul-Gumuz)
of Ethiopia, this paper analyses the socio-technical challenges influencing the transition towards a new
computerised system and suggested the importance of developing context-sensitive strategies to tackle
different challenges in different contexts. Building on the notions of installed base and cultivation the paper
examines the socio-technical issues and factors that influenced the process of developing, customizing,
and implementing computerised HIS in different settings. The findings of this paper revealed that contextual
differences in terms of access to infrastructural reources, availability of adaquate and qualified manpower,
and managerial commitment and support would significantly influence the implementation process. I argue
that, such context-senitive challenges need to be dealt through flexible startegies that took in to account
the specific context. In this paper, four diffferent flexible strategies: the strategy of gateways, top-down vs
bottom-up approaches, flexible essential data sets and clustering have beed identified as being useful in
implementing computer-based systems in different settings of the Ethiopian public health care system.
Keywords
Health Information systems, implementation, flexible strategies, Ethiopian health care system.
Analysing the Challenges of IS implementation in public
health institutions of a developing country: the need for
flexible strategies.
Shegaw Anagaw Mengiste
Abstract
1. Introduction
Referencing this article
Mengiste, S. A. (2010).
Analysing the Challenges
of IS implementation in
public health institutions of
a developing country: the
need for flexible strategies
[Electronic Version]. Journal
of Health Informatics in
Developing Countries, 4(1),
1-17, from http://www.jhidc.
org/index.php/jhidc/issue/
view/9
This paper explores the challenges of introducing
computer-based health information systems in
the context of the Ethiopian public health care
system. Drawing empirical examples from the
process of introducing computer-based health
information systems (HIS) in two regional states
(Amhara and Benishangul-Gumuz) of Ethiopia,
the paper analyses the challenges influencing the
transition towards the new system and suggests
the importance of developing context-sensitive
strategies to tackle different challenges in different
contexts. The study has been carried out as part
of the global Health Information System program
(HISP), which is a global research and development
initiative working on the design, development and
implementation of computerized HIS in various
developing countries including Ethiopia (see Braa &
Hedberg 2002; Braa et .2004; Braa et al. 2007a).
The importance of strengthening the routine
health information systems (HISs) has been well
recognized by international organizations (Such
as WHO, UNDP), aid agencies (such as World
Bank) and national governments as one approach
to support the public health reform initiatives of
developing countries. More specifically, the Alma-
Ata declartion of 1978 set out a new approach
leading to the development of health information
systems most commonly seen in many developing
countries today. The Alma-Ata (1978) confrence
emphasised on the importance of well-designed
and well-functioning routine health management
information system as an essential mechanism
to achieve the vision of improved health services
delivery in developing countries (WHO 1994) by
allowing policy makers, managers and health
workers to “identify problems and needs, track
progress, evaluate the impact of interventions and
make evidence-based decisions on health policy,
programme design and resource allocation” (WHO-
HMN 2007, pp. 6).
Recognizing the importance of a strengthening
existing fragmented and unstractured health
information systems for better health care delivery
and management; there has been tremendous
initiatives in developing countries to reform existing
fragmented and paper-based routine health
information systems, an “initiative spurred in large
part by technological adavances, and the interest
these adavances have generated in the health
sector” (Vital Wave Consulting 2009, pp. 14). For
example, there is growing recognition that ICT can
replace traditional routine paper-based HISs with
flexible electronic means and could bring significant
cost reduction and effectiveness in terms of timely
delivery of health care services in developing
countries (see Mackenzie 1999, Braa and Hedberg
University of Oslo
Department of Informatics
P.O.Box 1080
Blindern N-0316
Oslo, Norway
mengisa@ifi.uio.no

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Vol.4 • No.1 • 2010Page 2
2002; Braa et al. 2004; Braa et al. 2007a). The
introduction of information and communication
technologies has also been promoted both to
automate and make existing paper-based routine
data collection and reporting system efficient,
such as to make different patterns (e.g. mortality,
immunization, fertility etc) visible that are often
invisible with manual systems.Technology can
also improve data collection quality, accuracy and
timeliness. Electronic systems also make reporting
potentially much more flexible and efficient by
allowing data to be analysed at the level where
the data is collected as well as the levels above
it. On the contrary, in paper-based systems data
is collected and compiled manually at each site
where the data is collected, a process that hinders
managers and decision makers at higher levels of
the hierarchy from viewing the disaggregated data
coming from lower levels of the system (Braa et al.
2001).
To tap the potentials of ICT based technologies
and tools, various developing countries including
Ethiopia embarked in ICT based initiative to
transform theor existing paper-based data
health management information systems. For
example, Alvarez (2004) reported the initiatives of
the government of Ecuador in collaboration with
donor agencies (such as IDA), to decentralise and
modernize the health management, including the
HIS, in health districts of the country to support
primary health care services. There are also similar
reform initiatives to decentralize public health care
delivery system and strengthen the existing paper-
based HIS though ICT in various African countries
including South Africa (Braa & Hedberg 2002),
Mozambique (Nhampossa 2006; Mosse 2005),
Tanzania (Kimaro 2006; Lungo 2008; Igira 2008),
Ethiopia (Mengiste 2005; Bishaw 2008) Nigeria
(Shaw, Mengiste et al. 2007) under the frame work
of HISP in collaboration with other international
organizations such as WHO and regional and
national governments (Braa et al. 2004; Braa et al.
2007a).
However, introducing such ICT based initiatives
to transform existing paper-based data collection
tools and systems in public health institutions
of developing countries is a difficalt proces
of chage often fraught with several context-
sensitive challenges and problems including: lack
of adequate resources (such as poor financial
resources and uneven infrastructural development)
(AbouZahr 2005; Mosse and Sahay 2003);
inadequate skills and knowledge at a local level to
handle new systems and technologies (Kimaro &
Nhampossa 2005); fragmented and uncoordinated
organizational structure and heterogeneity of
stakeholders (Chilundo & Aanestad 2004); and
political and bureaucratic constraints (Heeks
2002; Avgerou & Walsham 2002; Mosse and
Sahay 2003). For instance, the public health
care system in Ethiopia is characterised by
differences across regions and between districs
and zones within a region in terms of existing HISs
(paper-based, DHIS, and statistical tools such as
EpiInfo), uneven infrastructure development (such
as access to computers, internet connectivity,
availability of telephone & electricity), differences
in geographic size (large and small), differences in
human capacity and competency (both from the
In recent years, proponents of the Information
Infrastructure perspective (for example, Hanseth &
Monteiro 2004; Hanseth & Aanestad 2003; Hanseth
& Lyytinen 2004) use the cultivation approach as
analytical tool to explore socio-technical processes
in different contexts of introducing large scale and
complex information systems. In this paper, on
concepts of cultivation and installed base from
information infrastructure (II) theory (Hanseth et
al. 1996; Hanseth and Lyytinen 2004; Hanseth and
Monteiro 1998) as analytical lens to explore the
challenges of introducing computer-based health
information systems (HISs) in the context of the
Ethiopian public health care system.
Traditional IS design strategy assumes that systems
can be developed from scratch, as isolated and
stand-alone applications with defined goals, start
and ending times rather than as events changing
overtime through ongoing process (Orlikowski
1996). However, contemporary approaches treat
design and change not as traditional IS but as
Information Infrastructure (II) (Hanseth et al. 1996).
The II perspective which seeks to analyse systems
2. Conceptual framework: the
notions of cultivation and
installed base
IS and health domains), and varied organizational
and managerial commitment and support. In
such contexts, it is appropriate to get a deeper
understanding of the contextual challeges at a local
level and formulate context-sensitive startegies.
This paper, therefore, aims to explore the different
contextual challeges and choices of action adopted
in introducing change to the existing paper-
based health mangement information systems
(HMIS) in two regional states of Ethiopia (Amhara
and Benishangul-Gumuz), and draw lessons and
strategies for IS implementation in the context of
developing countries.
More specifically, this paper would like to address
the following research questions:
• What are the challenges that influence the
process of making a transition from paper to
digital HIS in different settings of the Ethiopian
public health care system?
• What strategies could be formulated to deal with
the challenges in different settings and contexts?
This paper is organized as follows. The next
section provides the conceptual framework
by conceptualizing HIS development and
implementation as cultivation of the installed
base. In section three, the research setting,
research approach and data collection methods
employed are presented. Section four describes
the case study which is related with the process
of introducing computer-based health information
software (DHIS) in two regional states of Ethiopia.
Section five presents analysis and discussion
of findings by emphasising the need for flexible
strategies. The last section provides concluding
remarks.

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as heterogeneous inter-connected socio-technical
networks (Hanseth and Monteiro 1997, 1998) is
used as an appropriate analytical tool to understand
the challenges of introducing change when there
are multiple socio-technical factors influencing
the change process. The current trend of viewing
ISs as Information Infrastructures (see Hanseth
2002; Hanseth and Monteiro 1998) is the result of
acknowledging the increasing complexity in terms
of technical as well as social entities (see Jacucci
et al. 2002) in the process of developing and
implementing ISs. For example, socio-technical
factors (such as geography, history, legacy systems,
technical support and competency, political
commitment and support, poor infrastructure and
other organizational issues) that are embedded
in the broader context significantly influences the
process of change and implementation of technical
artefacts/software, best practices, standards,
experiences and knowledge. Hanseth (2002) in
addressing how an Information Infrastructure is
changed argued that:
“the whole infrastructure can’t be changed
instantly- the new has to be connected to the
old. The new version of the infrastructure or
artifact must be designed in a way making
the old and the new linked together and
interoperable in one way or another. In this
way, the old- the installed base- heavily
influences how the new can be designed” (no
page).
Strategies for creating and managing such
processes are conceptualized as cultivation of
the installed base (Hanseth 2002). The process
of introducing change to large and complex ISs,
therefore, requires taking in to account the existing
installed base of work practices, human resource
competency, systems and standards, technological
artifacts, available resources, organizational
commitment and support.
The concept of installed base refers to what
already exists (technical and non-technical) in
terms of the existing standards, diverse software
versions, infrastructure (both physical and digital),
human resource, work routines, and organizational
structures. As such, any process of designing,
developing and implementing an information
infrastructure cannot be started from the scratch;
it should rather take into account existing systems,
procedures, processes and standards while trying
to introduce new changes. As such the installed
base influences and shapes the evolution and
implementation of the new system (Nilson, Grisot
and Aanestad 2005). However, the installed base
cannot be changed instantly because of its sheer
size and degree of embeddedness and its change
heavily influences how the new II can be designed
(Hanseth and Monteiro 1998). Thus, an II is built
through extensions and improvements of what
exists - never from scratch. Changes have to
be linked to the existing installed base, either as
extensions, revisions or replacements. Because of
its nature, II evolve beyond a single management or
actor’s control (Ciborra et al. 2000; Hanseth et al.
2001; Aanestad 2002).
The notion of cultivation (Dahlbom & Janlert 1997;
Hanseth and Monteiro 1997, 1998) considers the
design and development of II to be a long-term
incremental strategy, extending and growing upon
an existing installed base rather than to trying
and radically changing the installed base (Braa
et al. 2007a; Hanseth and Monteiro 1997). The
cultivation approach, instead of believing that it
is possible to create without being restrained,
believes that the appropriate thing to do is to be
as sensible as possible of the existing situation
and conditions of the part of reality. By doing so,
unlike the designer, the cultivator learns how and
when to intervene to change existing systems,
structures, standards, process and work practices
(Söderström. and Nordström 2005). As such, the
Cultivation approach requires a prior analysis of the
organisational, technological, social and political
context of the already existing elements of the
installed base (Hanseth and Monteiro 1998). With
cultivation approach, it means that an II is never
developed from scratch. When designing a new II, it
will always be integrated into or replacing a part of
earlier one (Braa et al. 2007a).
In this paper, therefore, the notions of installed
base and cultivation are used as analytical tools to
provide insight on how to deal with the challenges
of introducing computerized HIS in public health
care institutions of a developing country. More
specifically, changing existing routine paper-based
HIS which is currently in use at different levels of the
public health care system in Ethiopia is a complex
process that requires the actions, interactions and
negotiations of several stakeholders (including
health workers, mangers, donor agencies,
system analysts and developers). As such, the
transition process requires careful assessment of
existing installed bases and formulation of specific
strategies on how to deal with diverse challenges
in cultivating existing systems, tools, standards and
work practices for different settings and contexts.
To this end, this article investigated the challenges
of making a transition in such complex setting
based on empirical findings from the experiences of
cultivating existing routine paper-based HIS in two
regional states of Ethiopia.
3. Research Setting, Approach
and Methods
3.1 Research Setting
This section describes the research setting and
research strategy adopted. The empirical setting
for this research is Ethiopia which is located in the
north eastern part of Africa with a total area of 1.1
million km2 and a total population of 73.2 million
growing at a rate of 2.6% per year (CSA 2008).
More than 85% of its population is living in rural
areas, making Ethiopia one of the least urbanized
countries in the world (HSDP III 2005/06-2009/10).
Politically, Ethiopia introduced a federal structure
since 1994 comprising of 9 National Regional
States (NRS) and two city administrative states .
The regional states as well as the city governments
are further divided into 65 zones, 624 ‘woredas’
(districts) and around 10,000 ‘kebeles (the lowest
administrative bounty) (HSDP III, 2005/06-09/10).
The public health care system in Ethiopia comprises
of the Federal Ministry of Health, Regional Health

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Bureaus, Zonal Health Departments, and Woreda
Health Offices, with their respective health facilities
– central referral (specialized) hospitals at the
federal level, hospitals at regional, Zonal and district
levels, and Health Centres, Health Stations, and
Health Posts at district (woreda) levels. The health
care system is largely underdeveloped and under
resourced and as a result can only provide basic
health services for about 60% of the population
(HSDP III, 2005/06-09/10). Much of the rural
population has no access to modern health care,
leading to inability of the health care delivery
systems to respond to the health needs of the
people.
In Ethiopia, as per a report made by HSDP
III (2005/06-09/10), lack of timeliness and
completeness of HIS reporting remains a weakness,
and such delays contribute to the failure (at all
levels) to use data as the basis for informed
decision-making in health care planning and
management. Recognizing the weaknesses of
existing routine paper-based system, there have
been repeated efforts to reform HMIS in Ethiopia
(WHO-HMN 2007). The government recognizes
that an efficient HIS, would play a crucial role in
successful implementation of national health sector
development program’s strategic plan (WHO-HMN
2007).
As a result, both the federal government and
regional states in collaboration with international
organizations, donor agencies, and bilateral
collaborations introduced several reform initiatives
to improve the existing poor status of health
management information systems at all levels. ,
Some of such reforms include: “standardization
of procedures in data collection, analysis
and reporting; selection of sector-wide and
programmatic indicators with the involvement of
stakeholders, design of simplified items (question)
of the formats; and integrated and unified flow of
information” (ibid, pp. 4-5). This research is an
integral part of this reform process conducted with
in the framework of the global HISP initiative which
has been working on the design and development
of computerized HIS in five regional states of
Ethiopia and many developing countries in Africa
and Asia (see Braa et al. 2004; Braa et al 2007a;
Braa et al. 2007b, www.hisp.info; Sæbo and
Titlestad 2003 for details about HISP activities in
different countries).
HISP-Ethiopia has been initiated in 2003 as a
collaborative project between departments of
Information Science, Addis Ababa University and
the University of Oslo, Informatics department.
Furthermore, an agreement has also been reached
between HISP and 5 regional health bureaus (i.e.,
Oromia, Amhara, Tigray, Benishangul-Gumuz,
and Addis Ababa) to change existing routine
paper-based HIS by adapting and implementing
DHIS software; collaborate on the development of
standardized essential data sets, reporting formats
and indicators; and in building capacity through
training of health workers and managers at different
levels of each regional state. Up until HISP initiatives
disbanded by the Federal Ministry of Health in 2007
in favour of an American-based consulting agency
(John Snow Inc. (JSI)) to undertake all HMIS reform
activities both at regional and national levels; HISP
has been engaged in building local capacity of
health workers and mangers as well as in adapting
and implementing district-based health information
software (DHIS) across the five pilot regions.
For example, in Addis Ababa, the project had
supported the full scale implementation of DHIS ver.
1.3 in 11 sub-cities, 5 hospitals and 23 larger health
facilities of the regional health bureau that enabled
electronic transmission of data from the lower
to the upper levels to replace the paper-based
reporting system. In Oromia, DHIS 1.3 has been
implemented in 5 out of 25 zones and transition
from DHIS 1.3 to DHIS 1.4 was undertaken at the
time when HISP stopped its operation. In Amhara
regional state DHIS 1.4 has been deployed in 11
zones and an effort was underway to scale the
system to some selected pilot districts (woredas). In
Benishangul, DHIS 1.3 has been piloted at regional
health bureau and one zonal health office. In this
paper, the challenges and strategies of changing
existing routine paper-based HIS drawing on the
experiences from HISP initiatives in Amhara and
Benishangul-Gumuz regional states is provided.
3.2 Research Approach and Methods
This study employed a qualitative research
approach, based in the interpretative tradition
(Walsham, 1993), which seeks to understand
complex social, technological and organizational
issues related to the development, customization,
and implementation of information systems in
different contexts. As Walsham (1993) pointed
out, interpretive research is “aimed at producing
an understanding of the context of the information
system, and the process whereby the information
system influences and is influenced by the
context” (Walsham 1993, p. 4-5). The empirical
data presented here was collected by the author
who is an Ethiopian national and a member of the
HISP-Ethiopia development and implementation
team. As a member of the HISP-Ethiopia team,
the author participated in conducting situational
analysis, software customization, implementation,
and capacity building activities in Amhara and
Benishangul-Gumuz regional states since 2004.
Apart from the knowledge that comes from different
sources during long term exposure in the project,
the empirical material for this specific study was
collected through semi-structured interviews,
observation during meetings and workshops, and
document analysis.
Interview:
Interviews were conducted with managers at
regional, zonal and district levels, health workers,
HMIS officers, and HISP-Ethiopia development
and implementation team members. Questions
asked during the interview sessions were open-
ended and semi-structured. Questions were more
specifically structured to reflect on the challenges
of transforming existing paper-based HIS and
the approaches and strategies adopted to deal
with those challenges. Besides, an informal group
discussion (during lunch and coffee sessions) with
HISP-Ethiopia team members as well as managers,
and health workers at regional and district levels
was held frequently to get their opinion on different
issues related to the problem of existing paper-
based system, implication of the new system
in changing work practices and the specific
challenges encountered in making the transition.

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During each interview, notes were taken which was
then summarised and rewritten by the researcher.
Participant Observation:
As a member of the HISP-Ethiopia team, I
participated in meetings, discussions held
with HISP-Ethiopia team members. The issues
addressed in those meetings and discussions
covered different topics including progress of
the project, problems encountered by each
team member in the customization process
(understanding the technologies, capacity and
skill gaps infrastructural problems including weak
internet connectivity etc), duties and responsibilities
of members, how to link the new system to
earlier versions that are in use in different health
care institutions of different regions. The issues
raised and discussed during those meetings
and discussions assisted me to gain an overall
understanding on how the project was progressing,
what were the impediments and challenges
encountered in the development and customization
process, and on the technical competency of the
local team members
Besides, I also participated in workshops held
both in Amhara and Benishangul-Gumuz regional
states where health workers and managers from
different public health institutions come together
and discuss on issues of standards, indicators,
reporting formats and the problems and challenges
they encounter. This gave me an opportunity to get
first hand information about the challenges and,
approaches of improving the existing paper-based
system. Besides, I was able to have personal and
informal discussions with some participants to
get their opinions on the potentials of introducing
computerised system to improve their work
practices.
Document Analysis:
Analysis of existing documents (both printed and
electronic) was another source of information. The
relevant documents included strategic plans (such
as HSDP III, 2005/06-2009/10), reports, and formal
“Memorandum of Understanding” documents with
the involved partners. These documents were
reviewed to gather contextual information regarding
public health care practices, policies introduced
and strategies adopted to deal with specific
challenges and problems.
4. Case Description
The empirical basis of this article is a case study
of the initiative of implementing computer-based
health information system in the Ethiopian public
health care system in the framework of the global
Health Information System Programme (HISP).
Since its initial development and implementation
in the public health care system of South Africa
in 1998, several versions of DHIS software
have been adapted and are at different stages
of implementation in various countries in the
South including Mozambique, Tanzania, Malawi,
Botswana, Nigeria, Vietnam, India, and Ethiopia.
This case study, therefore, focuses on the trajectory
of adapting and implementing DHIS ver. 1.3 in
Benishangul-Gumuz and 1.4 Amhara regional
states. The case study gives emphasis on the
contextual factors influencing the adaptation and
implementation of the software, the strategies
adopted and the lessons learned from the process.
4.1 Benishangul-Gumuz Regional State
Benishangul-Gumuz region is one of the nine
regional states in Ethiopia, which is located in
Western part of the country. The region is relatively
small, covering 51,000 km2, with the capital city
Assosa located 687km from Addis Ababa. It is
divided into 3 administrative zones, 19 woredas and
33 kebeles. According to the 2007 Population and
Housing Census of Ethiopia, the total population of
Benishangul-Gumuz region is 670, 847 which gives
a population density of 9/Km2 (Flatie et al. 2009).
Parts of the region are seasonally inaccessible
by road or air. The livelihood of nearly 95% of the
population in the region is subsistence farming
(Flatie et al. 2009). Although Benishangul-Gumuz
regional state is endowed with potential natural
resources and has a great development potential
(Melkamu 2004); currently it is one of the remotest,
and least developed regions in the country and
remains food insecure (ibid). The socio-economic
conditions and health and nutrition status of the
communities are very poor; the prevalence of
malaria in particular is very high. HIV/AIDS is on the
increase and the status of education across the
region is also poor and consequently the majority of
people are illiterate (Melkamu 2004).
The public health care system in the region is
characterized by poor structure and inefficient
delivery of health services to the population. The
region has high prevalence of communicable
diseases like tuberculosis, malaria, and intestinal
parasitosis. The infant and under five mortality
rate for the region is 84/1000 and 157/1000 live
births respectively (FMoH 2006). The region has 2
hospitals, 15 health centers, and 88 health posts
of which 1 hospital, 3 health centers and 44 health
posts are located in Assosa zone (where Assosa
is the regional capital) (ibid). According to a report
by the Federal Ministry of Health (FMoH, 2006),
the health services coverage in the region is about
55% of the population and the health services
utilization rate is very low. This is mainly due to
the fact that actual health service delivery service
utilization is influenced by other factors such as
transport availability, level of qualification of health
workers and distribution of the health facilities
and availability of adequate equipments and
technologies in health facilities (Melkamu 2004).

4.1.1 Findings of situational Analysis in the
region
Situational analysis conducted by HISP-Ethiopia
team members (including the author of this paper)
to assess the status of existing HIS, infrastructural
(including digital and physical), and human resource
related issues revealed that existing HIS is highly
fragmented at all levels and characterized by poor
infrastructure and inadequate manpower to handle
the system. The following sub-sections, therefore,
provide findings of the situational analysis on how
existing HIS operates; infrastructural and human
resource challenges and the strategies adopted
by the regional health bureau in collaboration with
HISP to curb the challenges (see Mengiste 2005 for
details of the findings of the situational analysis).