Guiding theoretical approaches
The guiding theoretical approaches need to be multidisciplinary, drawing from the domains of informatics, public health, science and technology studies, and development. Some specific approaches are discussed.
From science and technology studies (Latour 1999), we learn that ‘airplanes don’t fly, but airlines do, implying that technology on its own cannot achieve much, but requires the alignment of socio-technical heterogeneous networks including institutions, culturally situated work practices, technical systems, infrastructure, and many others. A direct implication for Expanded PHI is the nature of networks that are required, and how can they be enabled and evolved in specific contexts. Theories of information infrastructure from the informatics domain (Monteiro and Hanseth 1996; Ciborra and Hanseth 1998; Hanseth and Lytinen 2010) provide multiple supporting concepts on how to approach such network building. For example, they emphasize the role of history in terms of the ‘installed base’, and how strategies of cultivation need to sensitively leverage on what already exists while shaping the new. This contrasts with the oft-repeated approach of trying to build systems by starting on a clean slate.
Informatics and organization studies have articulated various models of decision-making, critiquing rationalistic approaches, which can provide insights to the problematic of use of information which is of central concern in Expanded PHI. While information is a necessary condition to ensure action, it is by no means sufficient (Latifov 2013) requiring many other pieces to be put in place. Kelly et al. (2013) emphasize the approach of ‘conversations around data’ between different stakeholder groups to trigger action and build a supporting information culture, rather than adopting rational models of decision-making.
While informatics research has focused extensively on building innovations, there is more limited research done on how technology choices are made. However, some guiding design principles can be noteworthy to guide such choices. For example—how do new choices account for the installed base, and can leverage on the positives that exist, as contrasted with adopting clean slate approaches (Aansted 2002). Another implication concerns the need to balance the needs of the global with locally situated circumstances, so that systems are locally specific, while also allowing easy generalization to other contexts (Rolland and Monteiro 2002). New technologies should support ‘flexible standards’ (Braa and Sahay 2012), where the local user is given autonomy, but within a metalevel framework which all players need to follow to ensure compliance to standards. Research into participatory design methods, a foundational aspect of informatics research, can provide useful inputs on how technology choices should be made. Research into the scalability (Sahay and Walsham 2006) and sustainability (Braa et al. 2004) of systems provides important criteria to consider in making new technology choices. Given the extremely resource-constrained environments in which new technologies are introduced, they must necessarily be guided by cost-effectiveness and ‘frugal innovation’ criteria (Bhatti 2012).
Governance concerns the institutional structure within which decisions around Expanded PHI are made (Sahay et al. 2014). Traditional institutions are historically and socially embedded and thus difficult to change (Latifov and Sahay 2012), and respond to the multisectoral and flexible structures required for Expanded PHI. Policies made at the top without hearing the voice of lower levels are bound to fail because of the limited overlap between formal institutions and informal constraints existing at the local sites of interventions (Piotti et al. 2006). Findings from neo-institutional theory can inform about the stability of institutions, and within this the challenge of change, through highlighting the contradictions between the old and the new (Nicholson and Sahay 2009). Strategies around deinstitutionalization (Nicholson and Sahay 2009) and institutional entrepreneurship (Hardy and Maguire 2008) can help design appropriate governance models in new institutions.
While these different conceptual inputs to design and to development dimensions are paramount, insights from development theorists like Sen (1999) urge us to look at the developmental impacts, such as ‘does the HIS enable individuals to pursue the healthcare choices they value?’, and the question posed by Walsham (2012) ‘are ICTs contributing to build a better world’? (Walsham 2012).