FOSS HIS in Public Health Domain: Case Study of Design-Reality Gap and Local Improvisa-tion in Global South


  • Roshan Hewapathirana Department of Informatics, University of Oslo, Oslo, Norway
  • Shan Semuthu Rodrigo National Programme for Tuberculosis Control and Chest Diseases, Ministry of Health, Colombo, Sri Lanka



Background and Purpose: Health Information Systems (HIS) are an integral in health reform agendas even in developing countries, although technological and financial limitations found to be the major barriers. Hence, free and open source software (FOSS) plays an enabling role in global south. FOSS HIS are developed based on generalized domain requirements and, FOSS implementations faces challenges of discrepancy between global design and local requirements. This is known as design-reality gap. The disagreement between abstract requirements and local actuality was found to be crucial for the sustainability of HIS, and design and actuality improvisations were coined as remedial measures.

Methods: This comparative case study encompassing empirical experience of introducing FOSS HIS to Sri Lankan public health sector, expects to discuss health managers' awareness of possible design-reality gaps in embarking on FOSS HIS implementation decisions. It also tries to explore to what extent health managers are ready to accept a design-reality gap and to change the business actuality of health organization to accommodate functional restrictions of FOSS HIS. A series of semi-structured interviews and focus group discussions with health programme managers and public health experts were major source of data for this discussion.

Results: It was revealed that the health programme managers were aware of possible design-reality gap in considering FOSS artefact as a HIS implementation candidate. Also, in Sri Lankan context, health managers preferred design improvisation over actuality improvisation with a conservative view towards business process revision.

Conclusions: Abstract functionalities of FOSS HIS required to be extended to suit the business contexts of health programmes. The specific business routines demanded FOSS artefact to be further customized and the level of customization required ranged up to the source code level.  Ability to reach consensus over design improvisation was successful than proposing for business process revision.

Keywords: Health Information Systems, Open Source, Requirement Abstraction, Design-Reality Gap, Local Improvisation


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World Health Organization. Report on the interregional meeting on strengthening district health systems based on primary health care. 1987.

Câmara G, Fonseca F. Information policies and open source software in developing countries. Journal of the American Society for Information Science and Technology. 2007; 58(1):121-132.

Staring K, Titlested O. Network of open source health care action. In open source systems. US. Springer; 2006. p. 135-141

Staring K, Titlested, OH. Development as free software: Extending commons based peer production to the south. In proceedings of the 29th International Conference on Information Systems; 2008. Paris.

Twaakyondo HM, Lungo JH. Open source software in health information systems: Opportunities and challenges. Tanzania Journal of Engineering and Technology. 2008;2(1):36-45.

Subramanyam R, Xia M. Free/Libre Open Source Software development in developing and developed countries: A conceptual framework with an exploratory study. Decision support systems. 2008:46(1):173-186.

Braa J, Monteiro E, Sahay S, Staring K, Titlestad O H. Scaling up local learning: Experiences from South-South-North Networks of Shared Software Development. In Proceedings of the 9th International Conference on Social Implications of Computers in Developing Countries; 2007.Sao Paulo.

Feller J, Fitzgerald B. A framework analysis of the open source software development paradigm. In Proceedings of the twenty first international conference on Information systems; 2008. Association for Information Systems.

Pollock N, Williams R., D’Adderio L. Global Software and its Provenance: Generification Work in the. Social Studies of Science. 2007;37:254-280.

Pollock N, Williams R, Procter R. Fitting standard software packages to non-standard organizations: the ‘biography ‘of an enterprise-wide system. Technology Analysis & Strategic Management. 2003;15(3):317-332.

Lind P. Computerization in developing countries: Model and Reality. London: Routledge; 2002.

Heeks R. Information systems and developing countries: Failure, success, and local improvisations. The information society. 2002; 18(2):101-112.

Heeks R. Health information systems: Failure, success and improvisation. International journal of medical informatics. 2006; 75(2):125-137.

Kimaro HC. Strategies for developing human resource capacity to support sustainability of ICT based health information systems: a case study from Tanzania. The Electronic Journal of Information Systems in Developing Countries. 2006;26.

Baark E, Heeks R. Donor funded information technology transfer projects: Evaluating the life cycle approach in four Chinese science and technology projects. Information Technology for Development. 1999; 8(4): 185-197.

Braa J, Sahay S . Integrated Health Information Architecture, Power to the Users.New Delhi. Matrix Publishers; 2012. p. 139-177.

Meystre S, Müller H. Open source software in the biomedical domain: Electronic health records and other useful applications. Swiss Medical Informatics. 2005;55(3):1-25.

Braa J, Monteiro E, Sahay S. Network of action: Sustainable health information systems across developing countries. MSI Quarterly. 2004; 28(3):337-362.

Titlestad OH, Staring K, Braa J. Distributed development to enable user participation. Scandinavian Journal of Information Systems. 2009;21(1):27-50.

Berg M. mplementing information systems in health care organizations: myths and challenges. International journal of medical informatics. 2001; 64(2):143-156.

Littlejohns P, Wyatt JC, Garvican L. Evaluating computerised health information systems: hard lessons still to be learnt. Bmj. 2003; 326(7394):860-863.

Tulusan JG. Perspectives of Success and Failure in Healthcare Information Systems: An Evaluation of Existing Theories and Models. [cited 2013 September 10]. Available from :

Lungo JH. Design Reality Gaps in Open Source Information Systems Development: An Action Research Study of Education and Healthcare Systems in Tanzania. Doctoral Thesis. Oslo. University of Oslo;2008

Miscione G, Staring K, Georgiadou P YA. A federative view for information infrastructures in developing contexts. In Proceedings of the 10th International Conference on Social Implications of Computers in Developing Countries: Assessing the Contribution of ICT to Development Goals; 2008. United Arab Emirates, Dubai.

Donner J. Innovations in mobile-based public health information systems in the developing world: an example from Rwanda. In Workshop on mobile technologies and health: benefits and risks; 2004 June.

Mingers J, Brocklesby J. Multimethodology: towards a framework for mixing methodologies. Omega. 1997; 25(5):489-509.

Manoj S, Wijekoon A, Dharmawardhana M, Wijesuriya D, Rodrigo S, Hewapathirana R., Dissanayake VH. Implementation of District Health Information Software 2 (DHIS2) in Sri Lanka. Sri Lanka Journal of Bio-Medical Informatics. 2013;3(4):109-114.

Gaur AS, Mukherjee D, Gaur SS, Schmid F. Environmental and firm level influences on inter-organizational trust and SME performance. Journal of Management Studies. 2011;48(8):1753-1781.

Miles MB, Huberman M. Drawing valid meaning from qualitative data. Towards a shared craft. Educational Research. 1984;13(5):20-30.

Manoj MS. Customising DHIS2 for Maternal and Child Health Information Management in Sri Lanka. Sri Lanka Journal of Bio-Medical Informatics. 2013;3(2):47-54.



How to Cite

Hewapathirana, R., & Rodrigo, S. S. (2013). FOSS HIS in Public Health Domain: Case Study of Design-Reality Gap and Local Improvisa-tion in Global South. Journal of Health Informatics in Africa, 1(1).