The struggle for district-based health information systems in South Africa

This article describes the initial period (1994-2001) of an ongoing action research project to develop health information systems to support district management in South Africa. The reconstruction of the health sector in postapartheid South Africa striving for equity in health service delivery and building of a decentralized structure based on health districts. In terms of information systems (IS) development, this reform process translates into standardization of health data in ways that inscribe the goals of the new South Africa by enhancing local control and integration of information handling. We describe our approach to action research and use concepts from actor-network and structuration theories in analyzing the case material. In the detailed description and analysis of the process of IS development provided, we focus on the need to balance standardization and local flexibility (localization); standardization is thus seen as bottom-up alignment of an array of heterogeneous actors. Building on a social system model of information systems, we conceptualize the IS design strategy developed and used as the cultivation of processes whereby these actors are translating and aligning their interests. We develop a modular hierarchy of global and local datasets as a framework within which the tensions between standardization and localization may be understood and addressed. Finally, we discuss the possible relevance of the results 0 the research in other countries.