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Article Excerpt
Abstract
Our paper is motivated by one simple question: Why do so many action research efforts fail to persist over time? We approach this question, the problem of sustainability, building on a perspective on action research identifying the pivotal importance of networks. More precisely, local action research interventions need to be conceptualized and approached as but one element in a larger network of action in order to ensure sustainability. A vital aspect of our perspective is that local interventions depend heavily on the support of similar action research efforts in other locations. This is essential for the necessary processes of learning and experience sharing. We suggest that the scaling (i.e., spreading) of intervention is a prerequisite, not a luxury, for sustainable action research. Empirically, we base our analysis on an ongoing, large-scale action research project within the health care sector (called HISP) in a number of developing countries. HISP provides a fruitful occasion to investigate key criteria for our approach to action research, namely sustainability, scalability, and capacity to be politically relevant to the participants. We contribute to three discourses: (1) models of action research, (2) lessons for health information systems in developing countries, and (3) more generally, IS implementations that are dispersed, large-scale, and have scarce resources.
Keywords: Action research, networks, sustainability, politics, health information systems
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Introduction
The delivery and management of health services to deprived communities and regions in developing countries is a truly complex task. For example, South Africa, with its problem of a rampant HIV/AIDS pandemic, Mozambique, with one of the highest maternal mortalities in the world, and India, with a billion plus population, are all experiencing serious problems of providing their populations with adequate primary health care services. There is a growing recognition by international agencies (notably the World Health Organization--WHO), government authorities, and researchers from different domains including information systems, (2) development theory, (3) and public health, (4) that improved health information systems (HISs) can significantly contribute to help address health service delivery problems. For example, the total number of infants in a particular area together with the number of those fully immunized give the immunization coverage. By comparing coverage data across a district, across districts within a province, and across provinces within a country, resources and action may be directed toward areas with the poorest coverage. (5) The development of HISs that collect, manage, and analyze such data may, when combined with appropriate practices of information use, significantly contribute to increased immunization coverage and consequently to reduced child mortality. Improved information can place pressure on the government, as in South Africa where the government was reluctant to release and admit data on AIDS-related deaths (Barret and Whiteside 2002).
The WHO Alma Ata declaration worked out in 1978 describes a global vision for "health for all by 2000" through equitable access to basic health services in all countries, called the primary health care approach. Later a key role was delegated to HISs in order to achieve this end through improved allocation of resources and setting of priorities (Lippeveld et al. 2000). A district-based health system to ensure decentralized management and coordination of the health services was advocated as the appropriate level for HIS development (Lippeveld et al. 2000; WHO 1994). It has, however, proved difficult to achieve this vision.
Two broad themes can be identified underlying these rather unsuccessful attempts with HISs in developing countries. The first concerns the challenge to make an information system work, in practice, over time, in a local setting. This involves shaping and adapting the systems to a given context, cultivating local learning processes, and institutionalizing routines of use that persist over time (as well as when the researchers leave and external funding is over). We term this the problem of sustainability. (6) The second challenge, which we term that of scalability, concerns the problem of how to make one, working solution spread to other sites, and be successfully adapted there. Beyond merely the technical aspects of scalability, our concerns lie in how to reproduce and translate the necessary learning processes alongside the spreading of artifacts, funding, and people. Important questions here concern who learns what, and through what mechanisms, in order for an IS to spread to new sites and be scaled up.
The aim of this paper, then, is to analyze the conditions for developing sustainable and scalable HISs in developing countries through an action research approach, alongside the scalability and sustainability of the action research process itself. These issues are explored through a study of HISP (Health Information Systems Program) which currently is ongoing in a number of developing countries including South Africa, Mozambique, India, Tanzania, Ethiopia, Malawi, Mongolia, Cuba, Ethiopia, Nigeria, and China. (7) We trace the evolution of HISP over a period of 10 years, from its inception in 1994 by researchers from Norway (including one of the authors) and the University of Western Cape and the University of Cape Town to the present. HISP is operating in significantly different stages of implementation in these countries. Thus, in South Africa, HISP has (since 2000) been commissioned by the authorities to do a countrywide implementation, while in Ethiopia and Tanzania the seeds of the project are just being sown. Scale and sustainability have been, and continue to be, central challenges.
To get at our core themes, we draw on analytical notions and insights from distinct schools. We thus employ an eclectic theoretical framework. A key notion that we build upon is that of a network. Exactly what is a network when networks, apparently, are everywhere, including network organizations, network society, network of excellence, being networked, and network technology to mention a few? Our use of the term draws on a more selective and confined understanding. To provide the gist of this, our point of departure is the formulation by some action researchers (outside of IS) of a key lesson from earlier action research amounting to a shift of focus "from single organizations and workplaces ... to networks" (Engelstad and Gustavsen 1993, p. 209). This proclaimed shift, however, has remained somewhat problematic. There is relatively scattered experience from this type of action research although some (none involving IS) exist (see Engelstad and Gustavsen 1993). There is thus a need to flesh out in more detail exactly how learning takes place in networks, how experience travels, and how local competence and capacity are cultivated. To this end, we draw upon some elements of actor-network theory (ANT) (Callon 1991; Hanseth and Monteiro 1997; Latour 1986; Walsham 1997) and Castells (1996) in a manner elaborated in the subsequent section.
Our analysis contributes to three different discourses. First, it poses and analyzes key criteria of the sustainability of action research efforts, offering an alternative, networks of action model. Second, it feeds into the practical and policy-related debates around working out viable strategies for IS in developing countries in general and primary health care in particular. Third, it is relevant to the understanding of large-scale, infrastructural development of information systems in general, which invariably face related problems of sustainability and scale (Hanseth and Aanestad 2002; Lyytinen 2002).
The next section develops our conceptual framework by combining lessons from IS in developing countries and action research with analytical insights from ANT and Castells. The section on the research approach describes our primary goals, the structure, the process, and the researchers' involvement. A section devoted to the empirical description of HISP is then presented, followed by a section discussing and analyzing the three issues of sustainable interventions, the politics of networks, and revisiting models of action research in IS in light of our perspective. Concluding remarks are offered.
Conceptual Framework
This section develops our conceptual framework, leading up to a perspective on action research we have termed networks of action. To arrive at this, we first need to review relevant experiences from IS in developing countries, particularly within health, and lessons from action research projects. This enables us to explain where and how the analytical imports from ANT and Castells fit.
HIS in Developing Countries: The Context and Arena for HISP
The grand vision in the late 1970s by the WHO of efficient and equal delivery of primary health care (PHC) has proved difficult to realize. Problems related to scarce resources and their effective allocation and use have led to a strong focus on strengthening HIS (de Kadt 1989; Sandford et al. 1992). The WHO has since promoted a decentralized approach based on the notion of a district as a self-contained geographical entity, to better integrate the multiple health programs, including their HISs, that typically exist (WHO 1994). Currently, most developing countries have routine (paper-based) HISs in place to collect and report data, but these are often inadequate to effectively support health care as data is merely collected to be fed upward (Lippeveld et al. 2000). In contrast, an action-led HIS focuses on collecting data that inform local decision making, before reporting upward (Sandford et al. 1992). Too often, attempts to computerize these HISs have only produced pilot systems or systems that fail to exist after donor-based funding (8) has ceased (Heeks and Baark 1998). For the purposes of this paper, it is important to review in more detail literature discussing this lack of sustainability.
One example comes from the Kisarawe district in Tanzania where an action-led approach to information was attempted and demonstrated glaring inequities between different areas within the district. However, efforts to redistribute resources by transferring staff were thwarted as health workers did not want to move as no resources were allocated for commuting and there was an absence of political will to support change. Sandford et al. (1994) conclude that interventions limited to HIS development alone were not sustainable in the absence of a larger health reform establishing incentives to rectify performance failings. Donor initiated projects, typically in limited time periods (of the aid package) in selected pilot sites with inadequate focus on local expertise, similarly leave a trail of unused, thus unsustainable, pilot projects (Heeks and Baark 1998; Littlejohns et al. 2003; Sahay and Walsham 1997).
Many issues about IS in developing countries are common across all applications and areas (for a review of the many ways organizational and social issues are inadequately addressed, see Avgerou and Walsham 2000; Heeks and Baark 1998). Yet, there is one aspect of our particular area of interest, the health care sector, which gives rise to a relatively unique demand on the HISs. This is the demand, intimately linked with the political visions of promoting equity in access to health services, that the local routines of managing information be replicated to all corners of a district, to all districts in a province, and to all provinces in a country. This problem, which could be termed all or nothing, implies that the interventions embedded in the successful, local use of a HIS have to spread. For this type of HIS, local success is not sufficient to be sustainable; it also has to have scale. Several authors, including Simwanza and Church (2001) reporting on their work in Zambia, point out how, despite local successes, the efforts failed to scale as "it has not been possible to devise a mechanism to transfer skills developed in these provinces to other areas of the country" (p. 228).
In what follows, we pursue issues of sustainability and scaling of interventions drawing upon related experiences and insights from the literature on action research in IS. Elements of the action research efforts in Scandinavia have been particularly attentive to these issues, thus warranting special scrutiny.
Lessons from Scandinavian Action Research in Information Systems
For our purposes, there are two aspects of Scandinavian-based action research that are relevant to our analysis of HISP. These two aspects simultaneously serve to position us in relation to Anglo-American action research: the political agenda and the focus on sustainability.
From its start in the 1970s, the Scandinavian-based action research had an explicit, political agenda of boosting the capacity of the workers and the unions in their negotiations with management. This was motivated by a perceived threat to job security from technology. The strategy at the local level, illustrated by the Iron and Metal Workers Union (NJMF) project, was to develop knowledge about the technology in question and to actively propose alternatives to those of the management (Nygaard 1979). This enabled the unions to negotiate settlements and institutional arrangements ensuring a certain influence over the process. A similar sense of political agenda is embedded in the HISP effort.
The second issue, continuing on from this, was how to ensure the sustainability of these capabilities. This challenge was emphasized by the lack of sustainability of apparently successful projects. The UTOPIA project is central here (Bjerknes et al. 1987). This project, involving the Nordic Graphical Union and several Scandinavian research institutions, was established as a response to the threat represented by new technologies to graphical workers. Their approach was to develop alternative technologies controlled by the graphical workers' skills and perspectives. They set up a laboratory where skilled graphical workers from the newspaper industry and researchers developed paper and computer based prototypes. Despite its important lessons about mock-up prototypes and future workshops (Greenbaum and Kyng 1991), the prototype failed to be sustainable. The key reason, which brings us right back to our analysis of HISP, is the UTOPIA failed to forge alliances with a surrounding network of journalists and other professional groups (Bjerknes et al. 1987). Although the earlier NJMF project succeeded in enrolling actors locally in selected workplaces and triggering national legislation, NJMF in a similar way failed to establish a network of workplaces pursuing similar strategies.
These experiences from IS action research in Scandinavia identify the key criteria of a political agenda and sustainability shared by HISP. There was, however, a relative failure to actually achieve sustainability.
Networks of Action
In Scandinavian-based action research outside of IS, sustainability has been addressed. The key observation from this body of action research is the recognition of the need to situate the action within networks rather than on singular units (9) (Elden...
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