I MPLEMENTATION CHALLENGES : I SSUES OF SCALE AND SUSTAINABILITY

There have been many attempts to introduce HIS in developing countries, but most efforts have not been successful; “the task of health information system reform is both formidable and complex, particularly in the context of govern-ment bureaucracies and developing countries. Failures tend to be more com-mon than successes.” (Lippeveld et al. 2000, p. 225).The issue of scale and sus-tainability are important challenges to address while planning for the imple-mentation of HIS. Sustainability of the HIS is a natural factor to consider be-cause of the resources put into the system, and also bebe-cause of the expectations it raises for the deprived who ultimately seek to be benefited by the system.

The scale of a HISs is also important because it must be of value for health managers and decision-makers. There is a need to scale from small scale sys-tems, which do not adequately provide a “view” of the complete health status of a region. A wide picture is required to make relevant decisions. A scalable system is thus an essential condition for success.

Reynolds and Stianson (1993) describe sustainability as maintaining something that already has existed over time or is equated with sustaining’ and ‘self-sufficient’, meaning that no outside support is needed. However, in informa-tion system practice, ‘sustainability’ can mean the ability to identify and man-age the risks threatening the long-term viability of the information system pro-ject (Korpela et al. 1998). Sustainability is therefore considered from the birth of the system, and the processes once external support is pulled out (Braa et al.

2004).

Braa et al. (2004) describe scalability as the problem of making a working sys-tem solution, that can be spread out to other sites and successfully adapted there. This spread relates to both technical issues of scalability, as well as the reproduction and translation of learning processes alongside the spreading of artefacts, funding and people. Braa and Hedberg (2000) describe the difficul-ties of implementing a health information system in South Africa were one of the major obstacles relates to the scale of the project; it was not possible to im-plement the system in small independent areas when the rest of the county had other ways of collecting and using the health data. The problem is analyzed through the concept of standardization – how a national hierarchy of flexible standards can be adopted to empower mangers at local level.

Anja et al. (2000) mention constraints like the lack of modern and adequate information and communication technology and skilled personnel, low income and morale, and cultural differences as reasons for a poor functioning health information system. Because of the degree of these constraints, the risk of fail-ure of HISs in developing countries is very high, making sustainability a major challenge. In the following paragraphs I will thus review key domain challenges influencing the problems of scale and sustainability. The issues are analyzed under the topics of: 1) Political challenges, 2) Donor related challenges, 3) In-frastructure related challenges, 4) Human resource related challenges, and 5) Other cultural challenges. These challenges are briefly elaborated on below.

Political challenges

The political challenges that HIS reforms often experienced in developing countries are embedded in how governments are run. The democratic pillar of

“the people electing a government” is a firm and solid tradition – however, a dilemma is that it may result in instable governments that only pursue short term goals. Democratically elected governments often do initiate bold long term reforms, which are either cancelled or changed significantly to reflect the agendas of the new elected government. For example, Braa et al. (2004) men-tion how the HISP project is affected by political instability because of the way HISP is supported politically. Because of such instabilities, HIS reforms that typically require five to ten years before results can be made visible to the voters are often subject to frequent change, adversely influencing the sustainability of the system. Since often projects live and die as “pilot projects“, they can never be scaled up to a level where they become useful to manager for dealing with operational decisions, for example how to allocate limited available drugs amongst all the clinics in a area.

Donor related challenges

Typically, information system projects in developing countries are funded by international aid agencies. Funding is often short term and the projects are soon left in the hands of local beneficiaries. The local organization capacities

wither away after the withdrawal of donor financial and technical support (Heeks and Baark 1998). The short term funding often result in a lack of trans-fer of expertise and knowledge, and thus local beneficiaries are neither in a po-sition to scale nor keep the system sustainable when the system is not institu-tionalized.

One can also question the way donor funding is spent. Millions of dollars are often wasted in developing countries where organizations such as the WHO, IMF and World Bank sponsor short-term HIS reforms efforts. These pro-grammes are often implemented at a large scale, but fail because they tend to focus too much on the technology as the driving force of the reform. This technological determinism makes the systems unsustainable and the end result is often of no value when the funding is over. Puri (2003) summarizes how do-nors historically have continued to support techno-economic development pro-jects that fail, and how this has led to the demand for alternative development models that can influence the success of the projects, and consequently the sus-tainability of the development projects. Increasing community based participa-tion in the design and implementaparticipa-tion of these programmes is a crucial ele-ment of these alternative models

Infrastructure related challenges

The infrastructure in developing countries is of poor quality compared to de-veloped countries and this puts several preconditions on how HIS are imple-mented especially in rural areas. Communication technologies, like the tele-phone, mobile networks, broadband, wireless networks etc, are either not avail-able or the extent of these technologies is limited; roads and public transporta-tion are often very limited or of poor conditransporta-tion in rural areas; and access to electricity can also be inadequate in various rural areas, which again influence the availability and use of communication technologies (Walsham et al. 1988).

In addition, investments in ICT may be seen as an unaffordable luxury when faced with problems such as high illiteracy and shortage of basic needs (Bhant-nagar 1992). For example, Mosse and Sahay (2003) describe how the relation between the constraints of communication and physical infrastructure of roads contribute to the limited use of HIS in Mozambique. Another example is the lack of logistics relating to ICT needs; when for instance a computer peripheral becomes faulty it may take days to get a replacement. These infrastructural dis-advantages impede health information reforms in time and resources. Scaling the reform/system and making it more sustainable gets harder as distances be-come greater, and as a consequence, more communication and travel are needed.

Human resources

The United Nations Millennium Development Goals (UN 2004) emphasizes the lack of educated people in rural areas in developing countries, and

empha-sizes education as a way of reducing poverty and building a viable workforce that is able to compete within an increasingly competitive and global economy.

The shortage of skilled, experienced and adequate human capacities, for in-stance in IT, makes the problematic process of adapting, developing and using IT (Walsham et al. 1988). Nevertheless, the lack of expertise in rural areas to deal with local problems influences the sustainability of HISs because of several reasons. On the one hand, people with little or no domain understanding of analysis, design, implementation and management of IS are left in control over the systems when donor and external experts disappear. On the other hand, not having general expertise nearby, e.g. for fixing computer hardware, shapes the way projects are run, and creates overwork among those who have the exper-tise. In scaling up, the system is affected by diversity of resources available at the different geographical locations. Resources available at one place, may not be available at the other, thus different problems have to be dealt with differ-ently, consequently constraining the project in time and resources, adversely influencing both the scale and sustainability of the system.

Other cultural challenges

Lippeveld et al. (2000) mentions the need to have high-level interest and spon-sorships as a precondition for a successful implementation of HIS. This means that senior officials and decision makers with strong commitment and political influence must be heavily involved in the restructuring of the HIS. In develop-ing countries, like for instance in India, where “networks” and social “connec-tions” play significant roles for getting support (Frøystad et al. 2000), corrup-tion frequently occurs (Tully and Wright 2003). As mencorrup-tioned above, these political “networks” and “connections” are unstable and short-term, and thus influence sustainability.

Furthermore, Heeks (1995) argues that new computerized information systems cannot alone solve the difficulties of corruption because “corruption is a phe-nomenon rooted in the cultural, political and economic circumstances of those involved. Computerization does little to affect these root causes, and so cannot eliminate corruption.” (p. 11). Similarly, Monteiro and Hepsø (2000) describe how decisions within organizations may be “soft-corrupt” because of the status of the company who offer services. Working with renowned companies or agencies gives more status to organizations and the decision-makers, as com-pared to smaller and more local companies or agencies that perhaps have a bet-ter solution (and betbet-ter intentions). Not being the “right” company or agency may thus affect the sustainability and the scaling of the information systems, for example because it is not local and thus cannot provide immediate support.

Because HISs are implicated in all these root causes, the scalability and sustain-ability of the system may be affected in a negative way exactly because it deals with changes within the cultural, political and economic context.