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University of Oslo Department of Informatics UNIVERSITY OF OSLO DEPARTMENT OF INFORMATICS SUSTAINABILITY AND OPTIMAL USE OF HEALTH INFORMATION SYSTEMS: AN ACTION RESEARCH STUDY ON IMPLEMENTATION OF AN INTEGRATED DISTRICT-BASED HEALTH INFORMATION SYSTEM IN ETHIOPIA. HIRUT GEBREKIDAN DAMITEW AND NETSANET HAILE GEBREYESUS MASTER THESIS JUNE 2005 Sustainability and Optimal Use of Health Information Systems: an Action Research Study on Implementation of an Integrated District-Based Health Information System in Ethiopia By Hirut Gebrekidan Damitew and Netsanet Haile Gebreyesus A Partial Requirement for Master of Science Degree in Information System University of Oslo Faculty of Mathematics and Natural Science Department of Informatics JUNE 2005 Acknowledgements We would like to address our warm gratitude to everyone who made this research work possible. Thanks for your support. First of all we are grateful to our supervisors Judith Gregory and Jørn Braa for their professional support and guidance. We are thankful to Sundeep Sahay for his uninterrupted assistance through the fieldwork and writing up of this thesis and Jens Kaasbøll for his helpful comments on this thesis. We also thank Esselina Macome for her help with the study in Mozambique. We would also like to thank the HISP team for all input and productive discussion. We want to thank members of the Tigray team: Solomon Birhanu, Nils Fredrik Gjerull and Qalkidan Gezahegn. Warm thanks go to everyone in Tigray Regional States Health Bureau who has made this study possible and fruitful; their list is too long to mention everyone by name. Especial thanks to Dr. Tedros Adhanom, Dr. Atakilti, Dr. Teklay Kidane, Dr. Gebreab Barnabas, Ato Araya, Ato Hailemariam Kassahun, and Abraha from the regional bureau and Ato Awala, Ato Zemenfeskidus and Ato Endale from district offices. We are deeply grateful to Teklu Abate Bekele, for your constructive suggestions and support through the writing of this thesis. All our friends in the International Master Program, it was nice knowing you all. Thanks for your friendship. We are also grateful to Norwegian Organization for Research and Development (NORAD) and HISP for financing this research. We also take this opportunity to express our gratitude to our families for their love and support. Hirut and Netsanet I Abstract This study investigated the factors contributing to unsustainable health information systems and low level of use. Approaches to development and implementation of an integrated district-based health information system focusing on sustainability and use as well as the challenges are studied. This action research was carried out in Tigray Region, Ethiopia, at all levels of the health structure in two pilot districts: Hintalo-Wajirat and Wukro. The intervention was undertaken using an action research approach with an interpretive case study. Interviews with observations of the information management activities at Region, district and facility levels, and document analysis were the chosen methods of data collection. The empirical findings were analyzed in relation to the existing knowledge in the relevant domain area and concepts from structuration theory. The researchers found that centralization, fragmented structure and the low capacity of the health information system were the root causes of its very limited contribution to the performance of the Region’s health system. The introduction of an integrated district-based health information system was the action proposed by the researchers to change the situation and put into action. The initial phases of the implementation of the redefined routine data flow and introduction of DHIS in order to create a unified health information system and facilitate decentralization were undertaken during the period of the research. The pilot implementation process is still ongoing in the Region under the technical assistance and follow-up from the Health Information System Project (HISP) in Ethiopia. We believe that this intervention is believed to contribute to the realization of optimal usability and sustainability of the Region’s health information system. Key words: Health Information Systems, Sustainability, Information use, Integration, Decentralization, Action research, Developing countries. II CONTENTS ACKNOWLEDGEMENTS ................................................................................................. I ABSTRACT .........................................................................................................................II CONTENTS ....................................................................................................................... III LIST OF DIAGRAMS .....................................................................................................VII LIST OF FIGURES..........................................................................................................VII LIST OF MAPS ................................................................................................................VII LIST OF PICTURES .......................................................................................................VII LIST OF TABLES.......................................................................................................... VIII 1 INTRODUCTION .............................................................................................................1 1.1. BACKGROUND .........................................................................................................2 1.2. RESEARCH PROBLEM AND RESEARCH QUESTIONS .........................................................5 1.3. RESEARCH DOMAIN ......................................................................................................7 1.4. MOTIVATION ................................................................................................................7 1.5. OBJECTIVES ..................................................................................................................8 1.6. SCOPE OF THE STUDY....................................................................................................8 1.7. ORGANIZATION OF THE THESIS .....................................................................................9 2 LITERATURE REVIEW AND THEORETICAL PERSPECTIVES .......................10 2.1. INFORMATION SYSTEMS IN ORGANIZATIONS ...............................................................10 2.2. HEALTH INFORMATION SYSTEMS: WHY DO THEY FAIL? ..............................................13 2.2.1. Health information systems in developing countries..........................................14 2.3. CHALLENGES OF SUSTAINABILITY AND OPTIMAL USE OF HEALTH INFORMATION SYSTEMS IN DEVELOPING COUNTRIES ................................................................................16 2.3.1. Lack of user participation in systems design......................................................19 2.3.2. Lack of standards .............................................................................................22 2.3.3. Weak institutionalization ....................................................................................23 2.3.4. Unsuccessful scaling up of local implementations.............................................25 III 2.4. DISTRICT-BASED HEALTH INFORMATION SYSTEMS: ADVANTAGES..............................26 2.5. ORGANIZATIONAL CHANGE ........................................................................................29 2.6. THEORY OF STRUCTURATION......................................................................................30 2.6.1. Structuration theory in information systems ......................................................32 3 RESEARCH METHODOLOGY...................................................................................35 3.1. RESEARCH APPROACHES ............................................................................................35 3.1.1. Action Research..................................................................................................37 3.1.2. Interpretive Case study.......................................................................................40 3.2. RESEARCH METHODS .................................................................................................41 3.2.1. Methods and Sources of Data.............................................................................41 3.2.2. Fieldwork Documentation ..................................................................................44 3.3. DATA ANALYSIS .........................................................................................................44 3.4. LIMITATIONS RELATED TO RESEARCH METHODS....................................................44 3.5. ETHICAL ISSUES..........................................................................................................45 4 RESEARCH SETTINGS AND CONTEXT .................................................................46 4.1. RESEARCH SETTINGS ..................................................................................................46 4.1.1. Background Information about Ethiopia............................................................47 4.1.2. Tigray Regional State Health Bureau ................................................................51 4.1.2.1. Hintalo-Wajirat District...............................................................................53 4.1.2.2. Wukro district..............................................................................................57 4.2. HEALTH INFORMATION
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