The development of appropriate integrated and scalable information systems in the health sector in developing countries has been difficult to achieve, and is likely to remain elusive in the face of continued fragmented funding of health programs, particularly related to the HIV/AIDS epidemic. In this article, we propose a strategy for developing information infrastructures in general and in particular for the health care sector in developing countries. We use complexity science to explain the challenges that need to be addressed, in particular the need for standards that can adapt to a changing health care environment, and propose the concept of flexible standards as a key element in a sustainable infrastructure development strategy. Drawing on case material from a number of developing countries, a case is built around the use of flexible standards as attractors, arguing that if they are well defined and simple, they will be able to adapt to the frequent changes that are experienced in the complex health environment. A number of paradoxes are highlighted as useful strategies, integrated independence being one that encourages experimentation and heterogeneity to develop and share innovative solutions while still conforming to simple standards. The article provides theoretical concepts to support standardization processes in complex systems, and to suggest an approach to implement health standards in developing country settings that is sensitive to the local context, allows change to occur through small steps, and provides a mechanism for scaling information systems.
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.