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Abstract

The purpose of this paper is to explore digital global public goods (DGPG) as a foundation for theorizing platforms for development. Global public goods (GPG) are widely accepted as fundamental for socio-economic development due to non-rivalry, non-exclusivity and global relevance. However, the challenges of extending the ideals of GPG to the digital platform domain are poorly understood and further theoretical developments are needed to advance our current knowledge of this relationship. To theorize the challenges, we draw on the GPG, digital platforms literature and concepts related to paradoxes. We illustrate the value of these ideas in making sense of the case study of the DHIS2 digital platform for health information primarily used in developing countries. Furthermore, the case analysis provides some practical implications on DGPG platforms.
Working Papers in Information Systems, University of Oslo 5/2021
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Working papers in
Information Systems
DIGITAL PUBLIC GOODS PLATFORMS FOR
DEVELOPMENT: THE CHALLENGE OF SCALING
Brian Nicholson, Petter Nielsen, Sundeep Sahay and Johan Ivar Sæbø
WP 5/2021
Copyright © with the author(s). The content of this material is to be considered preliminary.
Working Papers Series Edited by Petter Nielsen
Information Systems Group
Department of Informatics
University of Oslo
Gaustadalléen 23b
P.O.Box 1080 Blindern
N-0316 Oslo
Norway
http://www.mn.uio.no/ifi/english/research/groups/is/
Working Papers in Information Systems, University of Oslo 5/2021
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Digital Public Goods Platforms for Development: The challenge of scaling
Brian Nicholson
Alliance Manchester Business School
University of Manchester
Manchester, UK
brian.nicholson@manchester.ac.uk
Petter Nielsen, Sundeep Sahay and Johan Sæbø
Department of Informatics
University of Oslo
Norway
pnielsen@ifi.uio.no, sundeeps@ifi.uio,
johansa@ifi.uio.no
Abstract:
The purpose of this paper is to explore digital global public goods (DGPG) as a foundation for
theorizing platforms for development. Global public goods (GPG) are widely accepted as
fundamental for socio-economic development due to non-rivalry, non-exclusivity and global
relevance. However, the challenges of extending the ideals of GPG to the digital platform
domain are poorly understood and further theoretical developments are needed to advance our
current knowledge of this relationship. To theorize the challenges, we draw on the GPG,
digital platforms literature and concepts related to paradoxes. We illustrate the value of these
ideas in making sense of the case study of the DHIS2 digital platform for health information
primarily used in developing countries. Furthermore, the case analysis provides some
practical implications on DGPG platforms.
Suggested bibliographic references: Nicholson, B., Nielsen, P., Sahay, S., and Sæbø, J. I. (2021). Digital
Public Goods Platforms for Development: The challenge of scaling. Information Systems Working Paper Series
at University of Oslo. Edited by Petter Nielsen. 5/2021. Retrieved from the website:
http://www.mn.uio.no/ifi/english/research/groups/is/publications/working-papers-in-information-systems
Working Papers in Information Systems, University of Oslo 5/2021
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1. Introduction
Various discourses around digitalization emphasize the increasing centrality of information
and communication technologies (ICTs) to the research and practice of ICT for development
(ICT4D). The discourse of “development 2.0” refers to ICT for digital production and
innovation offering the potential for grassroots development (Heeks, 2008). The discourse
around “digital platforms for development”, shifts the focus from standalone ICT applications
to “platforms and how these may enable a greater “level playing field” for developing
countries to drive locally desired socio-economic development (Bonina, Koskinen, Eaton and
Gawer, 2021; Nielsen, 2017). Complementary to this discourse is that of digital public goods,
and how platforms can take on characteristics of a public good to become more scalable,
enabling wider and easier access to the global development community. However, there is
limited conceptual and empirical knowledge of the challenges to scaling of digital platforms
in a global context, and approaches to engage with them.
Most prior research on digital platforms involves studies of commercial, for profit platforms
situated in the regulative institutions of the Global North (see for example Cusomano et al
2019, Gawer & Cusumano, 2014; Ghazawneh & Henfridsson, 2013; Parker et al, 2016). The
potential for translating and contextualizing digital platforms for the purpose of socio-
economic development remains understudied (Nicholson et al. 2019). A key goal of this paper
is to theorize the link between digital platforms and development, with a focus on health.
Towards this goal, we draw on and extend a conceptual lens centered on global public goods
(GPG) (Ostrom and Ostrom 1977) to further our understanding of digital global public goods
(DGPG) platforms.
The relevance of GPG in development is well established in the domain of health (see for
example Moon, Røttingen, & Frenk, 2017; Smith, Beaglehole, Woodward, & Drager, 2003;
Smith, 2003; Smith & MacKellar, 2007; Yamey et al 2018). However, there is a paucity of
literature that extends the ideals of GPG and the challenges presented by DGPG. Our point of
departure for understanding DGPGs are digital technologies and content that “are freely and
openly available, with minimal restrictions on how they can be distributed, adapted, and
reused” (UN, 2019, p 17). In line with the call of this special issue, we focus on twin
interrelated challenges: i) what is the nature of a DGPG in the context of global health; and, ii)
what are the specific scaling related challenges and how can they be best addressed.
We believe such an analysis is crucial for both the research and practice of ICT4D.
Conceptually understanding the nature of DGPGs and their scaling related challenges will
provide rich contributions to ICT4D discourses, particularly on how the potential of
technology can be better materialized for development. Theoretically, we draw on the notions
of “paradoxes” for this analysis, as arguably they help to capture the dynamics of the DGPG
phenomenon as they evolve over time and space. Empirically, we take the case of the DHIS2
(District Health Information Software), one of the largest and long-standing digital platforms
being used for global health. As the HISP (Health Information Systems Programme)
community strives to make DHIS2 take on more public good characteristics (Braa, et. al.,
2004), there are significant scaling related challenges experienced, which we analyse through
the lens of paradoxes.
The paper is organized as follows: in the next section, we present related literature on global
public goods and digital platforms and present our conceptual framework based on the lens of
paradoxes. The following section presents the methodology and case description which is
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around an overview of the DHIS2. The analysis is built around the conceptual vehicle of 3
vignettes, which we analyse through the lens of paradoxes and then relate to the scaling
challenge. The paper concludes with some implications for theory and practice.
2. A public goods perspective on digital platforms
In this section, we introduce the core concepts of GPG and digital platforms, from which we
derive an understanding of the nature of Digital Global Public Goods (DGPG). We then
introduce the notion of paradoxes to theoretically unpack the challenges of DGPG, with a
focus on their scaling.
The theory of public goods originates from the economics discipline based on two
foundational principles of non-rivalry and non-exclusion (Ostrom & Ostrom, 1977;
Samuelson, 1954). Public goods are non-rivalrous, implying that one individual’s
consumption of the good does not influence what is available for others. They are also non-
excludable, in the sense that no one can be excluded from consumption of a public good. An
oft-cited example is a lighthouse, where one navigator’s use of the light does not prohibit
other navigators from doing the same. Many goods exhibit only one of these properties,
illustrated by the tragedy of the commons (Hardin, 1968) where access to pastures are
unrestricted for nomads (non-excludable) while overgrazing will lead to degradation and
collapse in the ecosystem (rivalrous). In her critique of Hardin's pessimistic model, Ostrom
(1990) questions the expectation of degradation and depletion of benefits when they are based
on voluntary contributions. Based on several empirical examples, Ostrom shows that under
certain conditions, individuals govern themselves collectively, and without market or
regulation, to obtain benefits, even if the temptation to freeride is present.
In this paper, our focus is on understanding digital public goods with a global scope. DGPG in
addition to being non-rivalrous and non-excludable would also be available across groups of
people, social groups, geographies, and generations (Kaul, Grunberg, & Stern, 1999).
Prior research demonstrates that digital technologies do satisfy these conditions as they are
reprogrammable, can easily circulate, and can perform many different functions by combining
multiple forms of data. With the malleability and flexibility of digital technologies, innovation
potentially becomes inclusive and accelerates further scaling (Yoo, Henfridsson, & Lyytinen,
2010).
The combination with digital technology provides characteristics to public goods that are
distinctive and go beyond the popular examples of lighthouses, watchtowers, and public parks.
Bonina et al. (2021) classify digital innovation platforms as facilitating the production of
content, products or services developed by one or more parties, and to serve as the foundation
upon which other external actors can effectively build further derivative and complementary
innovations (see also Gawer & Cusumano, 2014; Ghazawneh & Henfridsson, 2013; Reuver,
Sørensen, & Basole, 2017). There are thus strong potential network effects associated with
digital technologies, which forms the core of digital platforms’ rationale. For example, the
Google mobile operating system ‘Android’ used as the operating system on smartphones such
as Samsung and many others, facilitates third-party developers to build supporting
applications that are distributed on App stores such as Google Play. The digital enables agility
in future product development, facilitates ease of change, encourages variations, and opens
the potential for new actors to participate in innovation (Boudreau 2018, Nielsen & Aanestad,
2006).
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Digital innovation platform can thus be defined as structures enabling the development of
multiple, different software products based on a common central framework. Such a platform
architecture helps deal with complexity (Tiwana, Konsynski, & Bush, 2010) where reusable
and generic functions are bundled as a platform core and specific services are developed as
compliments, known as apps (Roland, Sanner, Sæbø, & Monteiro, 2017). Such an
architecture has the potential to satisfy the technical conditions of a DGPG enabling non-
rivalrous and non-excludable access. However, the market logic of deriving customer value
and monetizing it, potentially distorts these DGPG characteristics with adverse implications
on their scaling (Gawer & Cusumano, 2014; Ghazawneh & Henfridsson, 2013; Reuver et al.,
2017). For example, Google Play operates on a market logic that emphasizes platform
governance practices based on monetization, profit and shareholder value. Platform
ecosystems (e.g. Jacobides et al 2018) presents “semi‐regulated marketplaces” that foster
entrepreneurial action under the co-ordination and direction of the platform sponsor
(Wareham, Fox, & Cano Giner, 2014, p. 1211), or as “multisided markets” enabling
transactions among distinct groups of users (Cennamo & Santaló, 2013). Although the
platform ecosystem model offers an alternative conceptualization to arm’s length market-
based relationships, the emphasis on monetization of value is a barrier to the realization of the
normative goals of a DGPG. This market logics focus is unsurprising given the overwhelming
dominance of major commercial global platforms such as Apple, Amazon, Facebook, Google
and Microsoft (Taplin, 2017). The challenge which we address in this paper is how some of
the conceptual thinking around DGPGs be made relevant to the context of the public health
sector of developing countries.
In table 1, we define and sum up our understanding of DGPG. First, in addition to the
principles of non-rivalry and non-exclusion and being available across social groups and
geographies, we posit that relevance should be of importance. Such relevance can be afforded
by the adaptability offered by the digital. Furthermore, the digital characteristics of
malleability, generativity and flexibility can be summed as providing positive network effects,
which is especially clear for digital platforms.
Digital Global Public Goods are digital goods designed as non-rivalrous, non-excludable, locally relevant
on a global scale, and displaying positive network effects.
Adaptable, reusable, re-programmable and re-combinable
Relevant locally and on a global scale
Non-rivalrous and non-excludable
Table 1: A Definition of Digital Global Public Goods (DGPG)
2.1 The scaling challenge of DGPGs: the analytical lens of paradoxes
DGPGs in the public sector of developing countries require alternative conceptualizations to
that of commercial platforms in the global North because of differences in incentives,
institutional context and resource constraints (Bonina et al 2021; Nielsen, 2017). The
ecosystem supporting DGPG platforms across various settings is highly complex requiring
technological and institutional change (Sahay, Nielsen, & Aanestad, 2019) combined with
social innovations (Msiska & Nielsen, 2018). Yamey et al (2018) posit that Ebola and other
recent outbreaks like Nipah in India or Zika in Latin America have renewed attention to
financing and delivering “global public goods for health”. Initiatives driven by global health
institutions like the World Bank and World Health Organisation (WHO 2020) are also trying
to promote digital means towards public goods. Furthermore, Digital Square, a marketplace
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initiative in digital health, has developed a Global Goods Guidebook (Digital Square 2019)
and a Global Goods Maturity Model (Digital Square 2020), reflecting the growing interests
in DGPG for health which has been further catalysed by the global COVID-19 pandemic.
Several open source systems have been launched to support outbreak management, such as
the Surveillance Outbreak Response Management and Analysis System (SORMAS) being
used in Nigeria, Ghana, Fiji and Germany. SORMAS was developed during the West African
Ebola outbreak in 2014/15 as an early warning and disease management system that was
migrated into an open source software application in 2016. SORMAS displays many features
of a DGPG: it is free of charge, open source, independent from IT companies and
interoperable with other platforms such as DHIS2.
The challenge of freeriding and the “tragedy of the commons” (Ostrom and Ostrom 1977),
provides a lens to understand the different paradoxes that challenge scaling processes of these
various DGPG initiatives. Paradoxes are “comprised of contradictions that persist over time,
impose and reflect back on each other, and develop into seemingly irrational or absurd
situations because their continuity creates situations in which options appear mutually
exclusive, making choices among them difficult” (Putnam et al. 2016, p72). A contradiction
represents “bipolar opposites that are mutually exclusive and interdependent such that the
opposites define and potentially negate each other” (ibid). A paradox perspective highlights
organizations as conflicted sites of activity containing dynamic relationships between
“contradictory yet interrelated elements that exist simultaneously and persist over time”
(Smith and Lewis 2011, p.386). In this paper, we aim to explore the value of the paradox lens
to understand the challenges of scaling of DGPGs.
Poole and van de Ven (1989), in a seminal paper identify various conditions that contribute to
paradoxes and how best they can be resolved. They identify a paradox as concerned with
tensions and oppositions between well- founded, well-reasoned, and well-supported
alternative explanations of the same phenomenon” (p565). They propose a theory building
approach to make sense of paradoxes around four generic ways in which two opposing theses
might be related : (1) the opposites are kept separate and their contrasts appreciated; (2)
paradoxes are resolved by clarifying levels of reference and the connections among them,
which could be at micro or macro levels, for example a global multinational trying to relate
operating standards to different local levels; (3) A third approach is around the temporal
dimension, where different time periods result in paradoxes; and, (4) synthesis of a new
concept or perspective. Poole and van de Ven argue that these four approaches can be used in
combination to make sense of and for understanding resolution of paradoxes. For instance, an
acceptance of paradox (principle 1) opens consideration of the influence of micro & macro
levels and of the effects of time (principles 2 and 3) in making sense of the causes of the
paradox.
In summary, Poole and van de Ven identify the following different conditions that contribute
to the construction of a paradox: i) different levels micro and macro levels; ii) different
temporal dimensions; and, iii) different reference standards. Our analysis will focus on
understanding what are these conditions that generate different paradoxes, how do these
conditions challenge the scaling process, and how best these paradoxes can be resolved with
positive implications for scaling.
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3. Research approach
In this section, we present the research methods, followed by the overall case context. This
provides the backdrop to discuss three case vignettes which highlight the use of the theoretical
frame of paradoxes to understand the scaling challenge.
3.1 Background and case description
This research was carried out under the aegis of the global Health Information System
Program (HISP), a network of North-South-South collaboration where the Department of
Informatics at the University of Oslo, Norway (UiO) has a key role as platform owner. This
collaboration is a movement of actors in the health informatics domain with the ambition to
strengthen health information systems in developing countries (Braa & Hedberg, 2002). We
base our choice of this case partly on the authors’ extensive and long-term engagement with
this project, which has provided for unique insights, experience and access. A key output of
HISP is the DHIS2 digital platform, which is released as a free and open source artefact.
Since its inception as DHIS Version 1 in the mid-nineties in South Africa, the DHIS2 has
grown in stature and maturity and now represents one of the most important digital platforms
globally in the health and other sectors, such as education and food security. The DHIS2
today is supported by several development partners (such as GAVI, Global Fund, UNICEF,
Gates, etc.) within the framework of a public good, implying central funding to UiO for the
development of the platform should lead to the benefits of the same being made available to
all (currently 70+ countries use DHIS2). UiO seeks to build and release DHIS2 as a DGPG
but face many practical challenges in meeting the ideals of non-rivalry and non-exclusivity,
which has implications on its scaling. The aim of this case study is to unravel some of these
challenges through the lens of paradoxes, and specifically focus on understanding them in the
context of scaling.
3.1.1 Case context: Building and evolution of DHIS2 as a DGPG
DHIS started as a small-scale pilot in South Africa in the mid-1990s. As a fusion of
participatory approaches to software development and a health management philosophy of
decentralization, it was strongly inscribed with the needs of district health managers to design
and manage their information system themselves (Braa and Hedberg, 2002). The adoption of
DHIS grew over the years up to national coverage in South Africa and various initiatives
began to adopt it in other countries by the early 2000s. To take advantage of the growing
internet penetration DHIS version 2 (DHIS2) was introduced in 2006 taking the form of a
web-based interface, incorporating novel functionalities based on the specific implementation
needs in new countries. The Indian state of Kerala and Sierra Leone were the first
implementations, and by 2010 Kenya was the first country to implement a fully online and
web-based system as mobile internet was considered adequate at the district level (Manya et
al, 2012).
It was, and continues to be, a digital software platform primarily to support decentralized
routine health management. The functionalities support all stages of the information cycle,
from data collection, through processing, to analysis and presentation. We can explain the
basis of DHIS2 by an innovation platform logic (Bonina et al 2021; Cusomano et al 2019);
the architecture is designed with a generic core that enables local innovation. Anyone with
internet access can at any time download the most recent version of DHIS2, the source code,
as well as required libraries and required third party products (such as Chrome or Firefox
browsers). DHIS2 also comes with a set of bundled apps, developed by UiO or through their
partners in the South (such as HISP Tanzania, an independent entity with close collaboration
with UiO) available in an “app store” maintained by the platform owner. The app store is
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similar in concept to Apple App Store or Google Play and some DHIS2 apps are also
available on these platforms too. Thus, we posit that the digital software platform DHIS2 fits
well with the two key criteria of a public good as downloading the software does not hinder or
reduce the possibility for others to do so (non-rivalrous); it is not possible to prevent anyone
from downloading it (non-excludable). In accordance with the criteria for a DGPG it is
globally available and relevant across a wide range of user groups. The platform architecture
allows local innovation as apps, increasing its potential relevance globally.
A cause and effect of the growth and global scale of DHIS2 platform is its generic nature. The
process by which DHIS2 has become increasingly generic is not linear, intentional, nor has it
followed a strict pattern. However, over time, functionalities, which may initially be
developed to address a specific problem in a particular context, are “polished by diversity”
into a generic and global version available for download (Sahay, Sæbø & Braa 2013). DHIS2
is composed of a core of generic and flexible meta-functionalities, allowing customization to
varied contexts. A second dominant process is platformization (Roland et al 2017).
Platformization involves the creation of a marketplace as a service and maintaining the
process value through transaction facilitation, user experience, and integration.
Platformization has not been an intentional strategy but grew out of efforts to respond to
increases in scale and to decrease dependencies in an increasingly complex software
application. At the time of writing, DHIS2 consists of a stable core, APIs, bundled apps
covering most use cases and apps developed by partners and third-party developers available
in the DHIS2 'app store'. The organizations in the ecosystem around DHIS2 have also grown
over the same period.
Thus, DHIS2 reflects GPG principles as it is open source software available for anyone to
download, implement and use. It is also a flexible platform demonstrated in the adaptation for
use in other sectors than health, including education, water and sanitation, agriculture, road
safety etc. Due to its openness and flexibility, it is impossible to know the exact number of
DHIS2 implementations. It is known that Ministries of Health and other organizations in more
than 100 developing countries use DHIS2, together covering an estimated population of 2.28
billion people (dhis2.org/in-action). In November 2020, the Ministry of Health in 73 countries
(primarily developing countries) used DHIS2, out of which 60 were nationwide
implementations, and 13 were in the pilot stage. In addition, 22 Indian states used DHIS2.
There is also a range of other organizations using DHIS2 independently for reporting in the
countries they are operating, including PEPFAR, Médecins Sans Frontières (MSF),
International Medical Corps, Population Services International (PSI), and Save the Children.
The activities around DHIS2 is also reflected in the DHIS2 Academies. The Academies are a
core part of the DHIS2 community and crucial to develop the national and regional capacity
to successfully set up, design and maintain DHIS2. The Academies have three levels,
including the Fundamentals, available online and for free; Level 1 covering the basic features
of DHIS2; and Level 2 covering specialized topics, including disease surveillance, server
administration, implementation strategies etc. The Academies in 2020 were primarily online,
and Level 1 attracted approximately 170 participants, and Level 2 attracted 400. The digital
DHIS2 annual conference attracted 940 participants globally, to share their experiences from
DHIS2 implementation and together build knowledge from the various usages and settings.
As of November 2020, HISP UiO had 82 employees working with the DHIS2 software and
supporting its implementation. This included 47 software developers, out of which 15 were
located at UiO (the other in, e.g. Spain, Vietnam and the US). In addition, UiO had an
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implementation support team of 23 (10 located at UiO) and 12 working with information and
support (10 are located at UiO). UiO supports the implementation of DHIS2 in countries
through a network of 10 HISP groups. HISP groups are long term and trusted UiO partners
located in developing countries (currently in Vietnam, Bangladesh, India, Sri Lanka, Uganda,
Tanzania, Nigeria, Togo, Rwanda, and Mozambique). HISP groups engage in DHIS2
software development, and they arrange national, regional and global capacity building
activities including hosting and arranging DHIS2 Academies. They play a key role as a local
capacity that can provide implementation support to Ministries of Health, health programmes
and others in their country and region. Regarding funding of the team at UiO and
implementation projects in countries, UiO has a range of financial partners (donors),
including the University of Oslo, The Norwegian Agency for Development Cooperation
(Norad), The Global Fund to Fight AIDS, Tuberculosis and Malaria, The President's
Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Center for
Disease Control and Prevention (CDC), the vaccine alliance Gavi, UNICEF and the World
Health Organization (WHO).
3.2 Data collection and analysis
We follow a similar approach to Roland et al. (2017) in data collection and analysis. The data
collection has emerged from the authors’ individual activities, analyses, collective discussions
and reflections concerning DGPG and paradoxes related to DHIS2. The involvement of the
authors with HISP, DHIS2, and health information systems spans contexts, processes and
several decades, but only more recently has a focus emerged on DHIS2 as a DGPG.
Our case study is interpretive (Walsham, 1995, 2006) and data was collected during
participant observation in processes involving activities such as software development,
strategy development, international seminars, discussions at conferences, implementations in
multiple countries, discussions with funders and participation or running training workshops.
This broad and longitudinal participant observation across different software development
processes, implementation sites and user-groups act as a background for this paper.
We base our analysis on three vignettes with associated paradoxes related to DHIS2
positioned theoretically as a DGPG, and we use these vignettes to analyze how the paradoxes
relate to scaling. A vignette is as a tool to zoom in on, illustrate and examine key processes
and episodes in a case study (Kotlarsky et al. 2014). They have a story-like structure with a
chronological flow and are limited in time, space and the number of actors involved (Miles,
Huberman and Saldana 2013). As a result of a series of intensive discussions between the
authors we chose the 3 vignettes as representing revelatory cases of paradoxes in DGPG
scaling emerging from a larger body of data.
The source of data for vignette 1 is mainly derived from regional meetings of monitoring and
evaluation (M&E) officers in 2-3 districts in India in 2018, where two of the authors were
present and engaged as participant observers. However, this vignette is positioned as an
episode in a participant observation engagement that was longitudinal in nature, involving
contact with the field site over a period of about 2 years and involved extensive interviewing
of key participants, coupled with access to documentary evidence such as memoranda and
reports. Data collection for vignette 2 is positioned in the backdrop of the authors active
engagement with prioritization debates and actions in UiO. The authors are co-located with
the DHIS2 development team in Oslo, participate actively in development projects and have
regular daily contact as participant observers including attendance at formal (eg. DHIS2
development roadmap presentations) and informal meetings (over lunch, coffee and social
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events), related presentations and events such as the DHIS2 conference when the global
community of DHIS2 users are invited to Oslo. The authors also collected data on ongoing
development priorities by accessing the DHIS2 discussion forum
1
and the internal DHIS2
development Slack community discussion where functionality changes are often discussed
and reported. Furthermore, some of the detailed specifics that are reported in the vignette
concerning the introduction of the new tool for roadmap prioritization were derived from an
interview that was recorded and transcribed with one of the DHIS2 product leads. Lastly,
vignette 3 is derived from the longitudinal PhD research into DHIS2 implementation
conducted by Abyot Gizaw (2014) who is one of the DHIS2 core developers now based in
Oslo. Abyot’s PhD was supervised by one of the authors who acted as advisor, participant
observer and also carried out some of the interviews with Abyot in India and Ethiopia. As
well as participant observation, all three studies from which we select the vignettes used semi
structured interviewing following the interpretive case studies tradition (Walsham 1995).
Interviewees were asked to respond to broad questions and encouraged to offer their own
world view and respond more broadly than in a structured interview. The interviews were
supplemented by other data sources such as company documents, the minutes of meetings,
and informal contact. A second feature of the studies from which the vignettes are derived is
longitudinal research. Respective sites were visited regularly or several times over a period of
years. This style of study captures the process of change over time including shifts in the
action and perception of the actors.
Our vignettes are based on a storyline, a narrative development of a sequence of events,
responses and interpretations through the voices of central participants. With the aim to
theorize paradox in DGPG, we have used the vignettes to focus our analysis and to explore
relevant dimensions of the concepts. The vignettes are thus illustrative examples used to
articulate and express the paradoxes playing out in practice. The aim of the data analysis is
interpretive generalization (Walsham, 1995) where we are attempting to develop concepts,
apply theory and derive specific implications which may be valuable in contexts other than
the particular case study.
4. Case Analysis
We present our analysis through the vehicle of 3 vignettes. These are now presented and
analysed, particularly using the theory of paradoxes to understand the scaling challenge of
DHIS2.
4.1 Vignette 1: The paradox of using sophisticated tools for relatively simple analysis
4.1.1 Context
Uttar Pradesh is the most populous state in India, and with 200 million inhabitants represents
the most populous sub-national division in the world. Administratively, the state is divided
into 75 districts and 800+ sub-district units (called Blocks) which become the focal units for
the delivery of health care services to the population of the state. Given the size of the state
and its historically poor health indicators, the Bill and Melinda Gates Foundation (BMGF)
established a strategic alliance with the state to support health system strengthening processes,
including those relating to health information systems. These efforts are being implemented
through the India Health Action Trust (IHAT) established in 2003 by the University of
Manitoba, Canada under a bilateral agreement of the governments of India and Canada. IHAT
in turn contracted HISP India, an NGO, in 2015 to carry out various HIS strengthening
activities. A central focus was on creating a statewide central portal on the DHIS2 which
1
https://community.dhis2.org/
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would host all state health related data in one database, to enable stronger analysis and use of
information.
4.1.2 The vignette: the case of output related tools
The vignette concerns a visit of two Oslo researchers in 2018 to 2-3 districts to observe
regional meetings of M&E officers covering 5-6 districts. The focus of these meetings was for
the M&E officers to discuss their monthly health data (generated from the DHIS2) and see
how it can support decision making and follow up in respective priority areas of districts. The
vignette particularly focuses on the use of the Pivot Table feature of the DHIS2 for enabling
user defined statistical analysis
2
.
At the end of the meeting, the two Oslo researchers initiated an open discussion with the
M&E officers on the various output related tools in the DHIS2, including the dashboard,
analytical tools such as the pivot table, and other features for generating output reports, the
ease of effective visualization, data quality tools and various others. Through the discussion,
the aim was to understand how these various output related tools were relevant to the officers
for their everyday use and analysis, and how could it be improved to suit their needs.
In general, the officers said the system was easy to use, but they had the following complaints:
Generating reports was a time-consuming process due to poor internet connectivity.
To get around this challenge, at the sub-district level, the staff entered data into excel
sheets which was then imported into the UPMIS portal. However, this was a laborious
time-consuming process, particularly because multiple facility data was being
uploaded. While this uploading process helped with addressing the internet challenge,
it meant the data validation functionalities available at the point of data entry in the
DHIS2, could not be used.
IHAT team took responsibility for validating data on a monthly basis by correcting
data entered in the UPHMIS portal and the paper data through local validation
committees. There was limited ownership of the data by the district doctors since they
were not entering the data. The doctors also believed their problems were elsewhere
(lack of medical staff, medicines and equipment) and not directly related to the HIS.
As users were not able to provide feedback through the system or view inter-district or
inter-block comparative data, their motivation levels were low.
There were also basic problems with the data configuration in the application. For
example, there were too many data elements to report on (monthly dataset was 8 pages
long), even though some services relating to those elements were not provided at the
facilities. Similarly, in hospitals the staff had to report data on services provided in the
night, which never happened. This resulted in many blanks or zeros in the reports,
which showed the facilities in a bad light. The state would have liked to include a
summary of how many zeros and blanks had been filled for a month.
There were reasonably well-established institutional processes around routine data
management. Sub-district level block validation committees made monthly data
quality analysis. The M&E officers had monthly review meetings with the district
magistrate (civil servant who is head of district administration). For these routine
processes, the M&E officers expressed the need for easy to use tools for visualization
through charts and bars, and to be able to do easy export to ppt files. They also needed
tools to drill down on the data to perform root cause analysis, which was currently not
2
For more detail on pivot table in DHIS2 see https://docs.dhis2.org/2.34/en/dhis2_user_manual_en/analyze-
data-in-pivot-tables.html
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possible. They would also like to see more detailed error messages. For example, they
would get a message that “36 data elements are ignored”, but it was not clear which
were those elements. They would like to see the results of a validation analysis in a
summary table which gave in one place, the errors, its type, source and time period,
and what was checked and what was violated. Sometimes it would seem that data is
being uploaded, but the users would not get to know if the process has been completed
or there has been an error.
Given the challenges of weak internet, users stated they would also like the option to
download only parts of the raw data, which was not possible. There were also issues
highlighted about the layout, for example, to see other users’ favorites in the
dashboards, or the Apps should be more clearly visible on the screen and not be
hidden in a corner.
On the pivot tables, they believed that there were given too many options (such as on
periods daily, weekly, fortnightly etc.), while they needed just one or max two
options. They also wanted easier to use information on how to populate min/max
values for conducting data validation.
They were issues in creating outputs, for example the HMIS report was only available
to download in pdf, while they needed it in Excel. In creating the monthly report, they
would like to just give the name of the month and not the start and end dates. They
complained about the inconsistent nomenclature (such as “institutional deliveries” and
“institutional deliveries new”) which made it difficult to select reports. They also got
confused from the point that the data list came in alphabetic order while in the report
there was no data entry order followed. In the reports, with the ID for facility, they
would also like to know the corresponding district and block names, which was not
possible. They also would like more analytical outputs such as score cards, league
tables, with more descriptive labels (not just short names). There were also challenges
in printing of reports, particularly in terms of formats and completeness of printouts.
4.1.3 Analysis of vignette
The key paradox inferred from this vignette is that while the development team continued to
add in their releases new features for strengthening outputs and analysis, the typical user in a
district of a developing country required more basic functionalities, and the new features
added on with a release, often detracted and not added to the value the users got from the
software. An example was the different options of periods which the user got, which confused
them as it required additional knowledge of how to navigate different options, while they
wanted to work only with two periods.
The explanation of the paradox, in terms of Poole and van de Ven (1989) was the competing
effects of trying to deal with the macro and micro simultaneously. At the macro level, the
development team in seeking to cater to the “universe” of users, including district users,
researchers, and data analytic experts in multiple country contexts. This required them to
continuously add new features, often for increasingly sophisticated use. This process went
counter to the needs of the micro-level of the district level users, who wanted specific and
easy to use functionalities to help support their everyday use, such as of generating required
reports and downloading them to ppt files. This paradoxical relationship resulted in opposing
scaling effects. While making the product more comprehensive helped the scaling at the
macro level (such as movement across countries and user groups), it proves detrimental for
various local contexts to adopt the system, thus constraining scaling processes. Resolving this
scaling paradox would require effective scaling to simultaneously take place at both the levels
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of the macro and micro, with mutually synergistic effects, described by Gizaw (2014) as
generative innovation.
4.2 Vignette 2: The paradox of prioritizing voices that tend to be unheard
4.2.1 Context
At its inception, DHIS2 was designed based on the needs in South Africa and progressively
expanded to the context of other Low- and Middle-Income countries (LMICs). Initial software
development in developing the first versions of DHIS2 (in 2006 and further to about 2012),
was carried out primarily by Master and PhD students who were intimately involved in local
implementations and worked with those who used the information systems. With the massive
growth of DHIS2 implementations over the last one and a half decades, this in-context
development style has become unfeasible. Concurrently the development process has been
professionalized, with up to 50 full time developers organized in various product teams
coordinated from the University of Oslo. This corresponds with growing number and
heterogeneity of users and organizations and the demand for new development is far
outstripping the availability of resources. It has also become much more difficult for
developers, detached from sites of actual use both culturally and geographically, to assess
what should be prioritized. Central to the continuous evolution of DHIS2 is the platform
development roadmap, based on prioritized user requests for changes originating from
different regions, specific countries and user groups. Inevitably, the core team in Oslo cannot
accommodate all user requests neither can commensurate resources (i.e. developer time) be
dedicated to each request. This leads to a process of prioritization, which is inherently a
complex task where all cannot always be equally satisfied.
4.2.2 The vignette: roadmap prioritization initiative
The product lead of the DHIS2 Analytics team responded to the challenge of prioritizing
requests in what was thought to be an objective manner by developing a roadmap
prioritization matrix. Most use-cases need analytics functionality and a great variety of
requests are directed towards this team. The product lead estimated that they can only
accommodate about half the requests at any stage of the product development cycle. The
question facing this individual is which requests should be prioritized, coming from who,
and in which release cycle?”. While the primary implementations of DHIS2 are users from
governments in global South low and/or middle income countries, according to the product
lead they tend not to actively voice their requests for changes in functionality. These groups
are constrained by geographical distance implying the physical separation often across great
distance, limited ability to meet in person and develop social relationships. By contrast, users
from donor organizations and other users in the West, tend to have closer proximity and
resources to visit Oslo and make their voices heard implying greater influence over the
DHIS2 functionality. This mismatch led the product manager to develop this “objective”
prioritization methodology.
Overall, the prioritization of requests for changes to functionality is applied based on four
main criteria: perceived benefits of the request for different user groups, global relevance,
ease of implementation and the availability of developer resources. To measure the relevance
and benefits, a score calculation was introduced. The basis of the score calculation is the
request’s impact classified from “very low” to “critical”. Secondly, origin of the request is
classified in order of priority:
Internal request (highest score)
Ongoing projects (thus tied to deliverables)
Partners
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Known users
New users
Unknown (such as being picked up from the public discussion forum)
The internal requests and ongoing projects request can emanate from several sources, as the
core team seeks to be directly or indirectly involved in implementation projects, including
those by Ministries of Health. The two axes of impact and origin provides a combined score,
with a certain threshold for requests to be accepted on the DHIS2 platform roadmap. For
example, a single new user will have to request something assessed as having critical impact
to make it to the DHIS functionality roadmap, whereas a Ministry of Health involved in an
ongoing project can request requirements assessed as having low impact but accepted on the
roadmap. At least, this is the principal in theory, in practice, the process of determining
potential impact of new functionality is problematic. UiO software developers are responsible
for this determination of impact, using several inputs to aid them:
First, some requests originate from the online discussion forum for DHIS2 users and it
is possible to quantify impact by counting replies to a request, voting, and number of
‘likes’. A forum administrator typically processes several requests and formulates
these into “tickets” in the DHIS2 issue tracking system.
Second, developers will attempt to document the reasoning behind the request. This
process is facilitated by the group of experienced users that commonly make requests
and have good habits of documentation. However, most users tend not to provide
detailed explanation of the reasoning behind the request thus influencing the outcome.
Third, the origin of the user making the request will influence the evaluation of impact.
A user who is well acquainted with DHIS2 will probably have good reasons for suggesting
improvements, even if the full reasoning behind it is not immediately obvious to developers.
This leads to a major quality difference between the requests. A company with long-term ties
to the core team and much experience in using and deploying DHIS2 will provide well-
articulated and well-motivated tickets, making it easier for the core team to work with the
request. At the same time, description of tickets coming from the Global South users tend to
be relatively skimpy on details required, and thus more difficult for the developers to work
with. The Ministries of Health from LMICs are typically not directly paying for their requests
to be materialized as these are met through a complex mechanism of pooled funds from
donors to the Oslo core team. Consequently, their voices tend to be heard less than those
directly paying for their requests.
This systematic method for ranking requests leads to a score between 0 and 1000. However,
the DHIS2 product lead estimated that the scores of around half of the requests change at least
once. These changes can emanate from a further round of prioritization considering the
estimate of effort to implement the new functionality. For example, implementation of
demanding requests depends on a very high score. Further, unimportant requests can end up
in larger groups and receive a “bundled” score. This is typical for some user interface requests,
which may be minor such as changes to font sizes. These would never be prioritized to the
roadmap for a single user but if bundled together may be accepted onto the roadmap. Once on
the roadmap, with a score from the ranking exercise, requests go through one more stage of
prioritization that deals with requests with the same score. To resolve these cases the various
DHIS2 product leads will meet to agree the respective priority.
Change requests are conditional on available resource which in the case of DHIS2 was
initially provided by grants from the Norwegian government aid agency Norad. While this
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core funding has continued, other global donors and NGOs have also joined to provide
financial support. However, these users often tie their funding to deliverables of functionality
serving their needs. While the functionality will be available to all, these users are in a very
different position compared to Ministries of Health and health programs in developing
countries without any financial resources to invest. The product lead estimates that 60-70% of
requests come from HISP groups and other partners in the South, while the rest comes from
International NGOs. The HISP groups typically want stable features, while the NGOs want
more cutting-edge features.
4.2.3 Analysis of vignette
The paradox identified in this vignette, is that while Ministries of Health in low and/or
middle-income countries are the core target group for DHIS2, given that HISP is funded by
development partners (like Norad and UNICEF) primarily as a development project, they
have limited influence in shaping the prioritization of the development road map. This
mismatch then has implications as described in vignette 1, where increasingly sophisticated
features are consistently added to the DHIS2, which may be of marginal relevance to Ministry
of Health users. Various reasons contribute to this paradox. Fragmented Ministry users have
weaker abilities than the macro level international NGOs to coherently voice their priorities in
a way that their influence is heard and acted upon. Donor voices are supported by contractual
stipulations and representatives travel to Oslo for lobbying activity leading to high levels of
priority and influence in shaping the trajectory of growth of the DHIS2 platform. There are
also inherent difficulties the Ministry users have in collecting and communicating their voices,
arising from language, resources, which contribute to keep their voices relatively muted.
While the product lead has sought to bring in a degree of objectivity to the prioritization
process, the views of Ministry users may not reach this stage due to failure to document
effectively for example. The rational principles underlying the prioritization matrix is
inherently ill-equipped to deal with the many subjectivities involved.
This paradox is related to the macro micro category of Poole and van de Ven (1989) which
is manifested in the evolution of the DHIS2 roadmap and attempts are made to meet multiple
unequal competing interests. DHIS2 scaling is taking place across geographies and domains
of usage however the production process has distortions arising out of the processes of
prioritization that favor the macro influence of the donors and where voices of the relatively
fragmented micro level are not adequately heard. It has proven impossible to neutralize
subjectivities in the implementation of the supposedly objective prioritization methodology.
Similarly, on the consumption side, there are challenges of unequal infrastructure, resources
and knowledge. Overall, the implications of this paradox is to constrain processes of scaling
in accordance with the GDPG principles of non-rivalry and non-exclusivity.
4.3 Vignette 3: The paradox of building software simultaneously relevant for global and local
contexts
4.3.1 Context
The context of this vignette is from the perspective of the global core DHIS2 software
development team. This is based on the experiences of a core development team member,
Abyot Asalefew Gizaw, who carried out DHIS2 application development both at the level of
countries (in Ethiopia, India, and Tajikistan) and with the core development team at Oslo over
the last 14 years. In his PhD thesis, Gizaw (2014) analyzed through the notion of “open
generification”, the paradox of making the DHIS2 simultaneously relevant both for local and
global settings. This vignette is made up from two examples from his research to illustrate the
paradox, one of a success and the other a failure.
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4.3.2 The vignette
The development team of the DHIS2 is engaged with designing generic technology that fits
into multiple contexts, trying to find a pragmatic balance between global and local settings.
The premise of this development effort is that while software travels as a global actor, its use
is situated in multiple local settings, characterized by their respective social, cultural, political
and technical realities. The inherent challenge is how to bring these sets of processes into a
virtuous cycle and generate a continuous interplay that enables global software to travel and
for local use to be a success.
The first example is from India, where the HISP India team in 2007 was working for a
particular State, engaged with building a dashboard based on the DHIS2. At the time, the
DHIS2 was at a very nascent stage, and the concept of the dashboard did not exist. The
Commissioner of Health from this state, who was a visionary and very interested in data
analytics, invited the HISP India team to design dashboards. The lead developer from HISP
India, literally sat in the Commissioner’s office for several months, and he would be given
specific instructions on what kind of visualizations were needed, going into micro details of
color, location on the screen and other details. To say the dashboard was hardwired to the
requirements of the State would be an understatement.
In addition, there were issues around the skill levels of the Indian developers and the quality
of the software code being written. The local team had their own software code writing style,
and in general, they did not practice modular and architectural design principles, as was being
promoted by the global team. The limited communication between the global and Indian
teams, resulted in the local team working within their own framework and practices. At a later
point, the global team attempted to refactor the local dashboard solution and build a generic
solution out of it but could not succeed because of the code limitations and inadequate
documentation. Going through the thousands of lines of code to refactor and restructure
turned out to be a frustrating encounter, which convinced the global team to abandon the local
solution and develop a new dashboard solution from scratch. In conclusion, the dashboard
solution while becoming very well embedded into the Indian state system, could not be
disembedded from that context, rearticulated and reembedded as a global generic solution.
The other story is from Ethiopia, also around the same time as the Indian case, concerning the
development of multidimensional attributes to data elements in the DHIS2. With this
functionality, different categories could be assigned to data elements (such as children 0 to 5
years and 5-10 years), and respective values noted against each category. Prior to this
functionality being provided, each category was treated as a separate data element. The limit
of such an approach was experienced by Gizaw when he was designing the national health
information system for Tajikistan. In Tajikistan, each data element had an extremely high
number of categories and sub-categories, leading to the national system having more than
30,000 data elements. Catalyzed by this experience, Gizaw was driven to find an appropriate
technical solution, which could then also be used for his project involving the Ethiopian
Morbidity and Mortality system. This system also needed to be able to report morbidity and
mortality figures by multiple categories of age and gender. Several factors contributed to the
success of this functionality. One, the developer (Gizaw) had a direct field experience (in
Tajikistan and Ethiopia) of the problem and the urgent need to find an appropriate technical
solution. Two, subsequently Gizaw joined the global team in Oslo, and was able to interact
with the global team to understand global design approaches and gradually refactor his local
solutions and make it more generic and relevant for the global core. Three, Gizaw also took
generification as a central problem of his PhD thesis, and thought deeply of how to address
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this challenge, both conceptually and practically, which helped to design a well thought out
and elegant solution. Four, the quality of the code developed in the Ethiopian case was higher
than in the Indian example and was thus more easily amenable to refactoring and
generification.
4.3.3 Analysis of the vignette
The fundamental paradoxes highlighted through this vignette are again related to macro
micro, that the DGPG must be relevant simultaneously for multiple local and global settings
where the fundamental premises for their sustainability are opposing. For the macro (global),
the software needs to be transferrable while for the micro (local), it needs to show ability to be
deeply embedded and institutionalized. To be relevant locally, the code must be deeply
embedded in the local context, and to be globally relevant, it should be possible to disembedd
the code from the local context and to circulate across multiple settings. This requirement is
inherently paradoxical. As our two case examples highlight, the ability to resolve the paradox
is reliant on a number of factors the quality of the code, the possibility of the developers to
engage with both local and global conditions to understand competing requirements, and other
institutional and technical conditions. At the local level, are local innovations, specific
artifacts and development practices. It is normal to have multiple instances of local
innovations and specific artifacts at the local level depending on the existing sociotechnical
realities and situated design practices. Between the global and local, there is the need to
enable continuous and cyclical interactions. Scaling involves processes of embedding, when
going from the generic to multiple specifics; and disembedding, when coming back to the
generic from multiple specifics. The interaction takes place in a broader contextual space
characterized by work practices, organizational structures, infrastructures, standards, policies,
and funding, as well as political, cultural and societal values.
5. Discussion and conclusion
The case vignettes highlight some of the challenges regarding the nature of a DGPG in the
context of global health, specifically related to scaling. In various ways the vignettes explain
how actors have encountered the paradoxes associated with scaling a DGPG while sustaining
the key conditions of a DGPG regarding rivalry and exclusion. The paradoxes are chiefly
associated with Poole and van de Ven’s (1989) description of the macro and micro: in the first
vignette, we encounter the paradox of the micro level user knowledge and needed
functionality positioned against the necessity to scale the DGPG to serve the macro level
global “universe” of users. The second vignette tells the story of the paradox related to the
much greater influence of donors on the DHIS2 functionality and how the voices from users
at the micro level such as individual health ministries are unheard. In the third vignette the
story concerns two episodes of micro level customization for local functionality that shows
differing outcomes for scaling to the macro level of the global platform. These paradoxes in
various ways display the empirical challenges related to realizing the non-rivalry and non-
exclusion ideals of a DGPG. In this section, we proceed to discuss two main themes: i) the
relevance of DHIS2 as an exemplar DGPG ii) how paradoxes may be addressed in relation to
subsidiarity and collective action. Finally, we summarize our contributions and draw
implications from our research.
5.1 Is DHIS2 an exemplar DGPG?
We posit that DHIS2 is a relevant exemplar of a DGPG, implying a typical or ideal model
drawing on the definition of public goods as non-rivalrous and non-excludable, in which free
market forces will not efficiently produce such goods alone. Our findings concur with Ostrom
and Ostrom (1977) that public goods are usually supplied by the State, or some other
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collaborative network, which seeks to coordinate collective action on behalf of the public. In
the case of the DHIS2 platform, the platform owners, UiO have taken this responsibility
together with partners, including donors and Ministries of Health. DHIS2 illustrates the
concept of DGPG building on the limited literature (Yamey et al 2018) presenting a digital
format with close to zero cost of replication and an ability to re-program, combine, build upon,
and share. This corresponds to the emphasis on adaptability and reusability described in a
recent report commissioned by the UN Secretary-General (UN, 2019). The DHIS2 app store
mirrors the success of commercial platform ecosystems such as those around iOS and
Android, reaping the benefits of positive network effects (Cusomano et al 2019, Tiwana et al.,
2010). However, our analysis of all 3 vignettes reveals the implications of an absence of
governing market mechanism for DGPGs in a dynamic state that must be continuously
monitored as non-exclusive and non-rivalrous. Our conceptualization of DGPG is thus
positioned as an ideal or an accomplishment influenced by the unique characteristics of a
digital innovation platform that permits changes in the platform characteristics (the core of
DHIS2 and apps) over time. The key implication of this understanding is that there are mutual
dependencies between the constituent parts of DGPGs. For example, the trait of being locally
relevant expressed in vignette 3 is achieved by the opportunities offered by the digital nature
of the public good. Positive network effects increase with adoption in a self-reinforcing cycle
and the scaling towards global adoption adds contextual diversity necessary to develop for
global relevance. Concomitantly there is a paradoxical effect that the platform scaling towards
serving the macro level priorities will become overly generic and in the worst case scenario
into a state of ‘design from nowhere’ (Suchman, 2002) that is prohibitively difficult to re-
program, adjust, or localize thus challenging the ideals of non-exclusion and non-rivalry.
5.2 Collective action and subsidiarity
The next important area of relevance to our focus concerns collective action and subsidiarity
(Olson 1989, Sandler 1998; Føllesdal 1998) and the potential of South South community-
based networks to address at least some of the paradoxes identified in the 3 vignettes.
Subsidiarity concerns the allocation of authority, power and tasks in a political order and
about determining at what level of government or governance these should reside
(Føllesdal, 1998). The problems of collective action were theorized by Olson (1989) in a
treatise around the mechanisms for groups of individuals to act in their common interest for
the realization of public goods. Across the 3 vignettes there are various instances of paradoxes
related to collective action. There is an effect that with greater scaling the collective action of
various groups is diminished (such as the ministries in vignette 2). Across all 3 vignettes, the
more macro interests of the donors appear incompatible with the smaller players who become
increasingly marginalized. This collective action paradox plays out as dominance of the
macro effect of donors vs. micro level requirements and becomes accentuated over time
which eventually challenges DHIS2 status as a GDPG. The problem is not insurmountable
however and subsidiarity may offer helpful mechanisms of governance. Føllesdal (1998)
interprets two main subsidiarity conditions related to effectiveness and necessity: that action
should be taken at the level where it is most effective and that action at the higher level should
be taken when lower levels cannot achieve the set goals in isolation. This is in line with
attempts at subsidiarity to promote collective action currently ongoing by UiO to build South
South community-based networks in the form of decentralization into the Health
Information System Programme (HISP) network”. This has the aim of providing more
opportunities for countries (e.g., Ministries of Health) to have greater influence in the global
HISP-UiO centre where the development and fund allocation is carried out. In this new
regional HISP strategy, the aim is to create South South consortia of nodes and coalesce
them into regional nodes directly funded by development partners (such as Global Fund)
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rather than for the funds to be routed through Oslo. It is hoped that this innovation will allow
the coordination between the micro level of analysis and alleviate the fragmentation described
in the 3 vignettes. It is proposed that by allowing the coordination between various Ministries
functionality needs and aggregation of requests from community-based groupings would lead
to greater levels of local influence and lessen the problems associated with global scaling. The
Regional Hub is the new organizational level of the HISP network, agreed by the DHIS2
investment partners, including Global Fund to increase capacity and coordination of country-
level technical assistance and other DHIS2 Implementation support across the HISP Groups
within a region. HISP Hubs will be governed by an MOU (with UiO) with a defined Steering
Committee and this level of subsidiarity it is hoped will lead to sustained collective action.
5.3 Conclusion
In conclusion, the paper provides two main contributions: firstly, it combines concepts related
to global public goods (e.g., Ostrom and Ostrom 1977) and digital platforms (e.g., Bonina et
al 2021) specific to the applications in health. The second main contribution relates to our
theoretical and empirical analysis of paradoxes in GDPG. There is significant optimism
regarding the potential of GDPG; for example the World Health Organisation Global Digital
Health Strategy (WHO 2020) Framework for Action states : The collaboration will include
building on synergies, facilitating technical collaboration, and developing quality assured and
evidence based global digital health public goods that can be shared and used globally.” This
statement is echoed by The UN Secretary-General’s Roadmap on Digital Cooperation (UN
2019) that calls for action in the realm of promoting digital public goods to unlock a more
equitable world”. The contribution of paradoxes theory to public goods illustrated with the
vignettes draws attention to our conceptualisation of the ongoing accomplishment of the
ideals of a DGPG.
The contribution to practice is to emphasize the potential but also the paradoxes of DGPG.
The analysis draws attention towards the paradoxes that occur here in the macro micro
related elements of the theory: influence of power dynamics, knowledge, and particularities of
local context vs. global relevance. Thus, our message for policymakers, consultants and other
practitioners is that DGPG should be understood as an ideal, a socio-technical
accomplishment that is ongoing rather than as embedded into a static portable technological
artefact.
Future work would benefit from two main foci: firstly, attention to other DGPG in sectors
beyond health would broaden our knowledge of the specific implications and design
considerations. Secondly, research looking specifically at the supporting ecosystem building
on the insights of Jacobides et al (2018) would enable in-depth analysis of the symbiosis and
challenges presented by the various supporting actors and networks in a DGPG platform.
Thirdly, future work could consider how social responsibility may be realized in a DGPG
governance considering for example Zuboff’s (2015) criticisms of the major digital platforms
relating to surveillance, privacy, and security.
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