community participation in health informatics in africa: an experiment in tripartite partnership in...

Computer Supported Cooperative Work7: 339–358, 1998.© 1998Kluwer Academic Publishers. Printed in the Netherlands.

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Community Participation in Health Informatics inAfrica: An Experiment in Tripartite Partnershipin Ile-Ife, Nigeria

MIKKO KORPELA1, H.A. SORIYAN2, K.C. OLUFOKUNBI2, A.A.ONAYADE3, ANITA DAVIES-ADETUGBO4 & DURO ADESANMI5

1University of Kuopio, Computing Centre (Email:<[email protected]>); 2Obafemi AwolowoUniversity, Dept. of Computer Science and Engineering (Email:<[email protected]> and<[email protected]>); 3O.A.U. Teaching Hospitals Complex, Eleyele Comprehensive HealthCentre;4Obafemi Awolowo University, Dept. of Community Health;5Iremo District HealthCommittee

(Received January 1, 1998)

Abstract. Participatory Design has mainly been practiced in Europe and North America. Our seven-year experience in Nigeria suggests that user participation is also a must in developing countries.However, the scope of participation needs to be expanded. For instance, in health informatics thecommunities served by the health facility in question need to be involved along with computerprofessionals and health providers. This paper presents the results of an experiment in tripartitepartnership in systems design for Primary Health Care by designers, users/providers, and communityrepresentatives in Ile-Ife, Nigeria. The experience was extremely encouraging.

Key words: Africa, communities, health information systems, participation

1. Introduction to the problem: Participation and developing countries

Participatory Design of information systems is often seen as rooted in the Scan-dinavian tradition of Cooperative Design. In the Participatory Design Conferences(PDC) since 1990, Denmark and Norway have been well represented. The strongrole of trade unions and social democratic parties in Scandinavia has been regardedas conducive to participation. Indeed, in the first PDC conference Joan Greenbaum(1993) raised the issue of whether cooperative design as practiced in Scandinaviawas even possible in the harsher socio-political context of the USA. She concludedthat for a ‘home-grown’ American participatory design movement, indigenousopportunity factors must be identified and built upon. Similarly, Steven Miller(1992) emphasised that the survival and success of participatory design in theworkplace depends on the ability to act within larger societal coalitions.

If participation is so strongly conditioned by national political climate, is coop-erative design of information systems possible at all in developing countries wherefew “indigenous opportunity factors” seem to be available to ordinary workers?

340 MIKKO KORPELA ET AL.

For instance, since her independence in 1960 Nigeria has been ruled by militarygovernments for more than two decades. A middle-income developing country ofthe 1970s has become one of the poorest in Africa in terms ofper capitaGDP(Gross Domestic Product). In a country where the price of food has increased ten-fold in five years while salaries have only doubled, there are many things to worryabout besides than participation.

In addition to political and economic obstacles, it has been suggested thatthe traditional cultures of developing countries also are hostile to participation.Chrisanthi Avgerou and Frank Land write:

Methods for socio-technical design [. . . ] were devised to fit the organisationalbehaviour norms prevailing in specific industrialised countries. There is littleevidence, for example, that the idea of deciding on feasible information systemschanges through an effort to reach consensus can be effective in many develop-ing countries. Even ‘user participation,’ one of the most fundamental featuresof socio-technical design is doubtful whether it is applicable and effective inrigid bureaucracies traditionally run by the authority of superiors rather thanthe initiative of employees. (Avgerou and Land, 1992)

We must ask ourselves if Participatory Design of information systems is just aluxury for the well-to-do in ‘democratic countries’ and not for Nigerians or othersin developing countries? In the remainder of this paper we present our experiencesin applying participatory methods in Nigeria in the domain of information systemsfor Primary Health Care (PHC). Our experiences working on an informationsystem project at a university teaching hospital in Ile-Ife, Nigeria is then presented.We conclude that for PHC information systems design, tripartite participation isrequired – a partnership between designers (computer personnel), users/providers(healthcare personnel) and community representatives.

This paper reports on an experimental tripartite workshop organised in Ile-Ifefor a participatory requirements analysis of a PHC information system. Drawing onthe workshop experience, we discuss the potential for and obstacles to participationin systems design in developing countries. We argue that community orientation,or tripartite partnership, is a challenge that the participatory design movement mustface both in industrialised and in developing countries.

2. Participatory methods in primary health care

Information systems design is not the only productive activity where the needfor participatory methods has been identified. The dismal experiences of manytop-down international development projects pushed non-governmental and inter-governmental organisations to develop various Participatory Rural Appraisal andDevelopment approaches since the late 1970s (e.g., Chambers, 1992; see also thePRA Notesseries by the International Institute for Environment and Development,London).

COMMUNITY PARTICIPATION IN HEALTH INFORMATICS IN AFRICA 341

If Avgerou and Land are correct in suggesting that the traditional structuresof developing countries make user participation unfeasible, then participatorymethods are unlikely to work in any socioeconomic development projects in thesecountries. On the other hand, if participatory methodsdo work in such projects,then this experience should be valuable for information systems development aswell in developing countries.

Since our field of application is health informatics (the application of moderninformation and telecommunications technology in health care), we discuss belowthe experience of participatory methods in health care delivery in Nigeria.

2.1. THE NATIONAL HEALTH POLICY OF NIGERIA

Nigeria is a Federal Republic which consists of thirty states. Each state is dividedinto local government areas (LGAs). Each LGA is further divided into politicaland health districts or wards. Each political ward is the constituency of one localgovernment councilor. With some 100 million inhabitants, Nigeria represents about20 percent of the Sub-Saharan African population.

The recently revisedNational Health Policy and Strategyand the newNationalHealth Planof the Federal Government of Nigeria (1996a, 1996b) are based onthe principles and philosophy of primary health care (PHC) as stated in the AlmaAta declaration of the World Health Organisation (1979). The policy makes theprovision of primary health care the responsibility of the Local Governments. PHCis defined as:

Essential health care based on practical, scientifically sound and sociallyacceptable methods and technology made universally accessible to individ-uals and families in the community through their full participation and at acost the country and community can afford to maintain at every stage of theirdevelopment in the spirit of self-reliance and self-determination. (World HealthOrganisation, 1979)

2.2. COMMUNITY PARTICIPATION IN PHC IN NIGERIA

The importance of community participation has been emphasised in the implemen-tation of primary health care services over the years. There has also been a shifttowards multidisciplinary programs in PHC. This has been achieved in Nigeria bythe promotion of health systems research and university/community partnershipprograms. When the academicians, local government authorities and communitieswork as partners in a project, this encouragescapacity building(i.e. empowermentof local or indigenous communities with information and skills needed to carry outspecific activities), a sense of ownership and sustainability of the project when thedonors leave.

This has been noted for instance in the Applied Diarrhoea Disease Researchprojects in Nigeria, funded by the Harvard Institute for International Development.


These projects involved the communities in the implementation of programs as aresult of baseline information collected from these communities. The communitieswere given a feedback of all data collected in their community.

University/community partnership projects have also been funded by the Pri-mary Health Care Development Agency, Nigeria, with all the medical schools inthe country. This has involved primary health care workers at the Federal, State andLocal Government levels, LGA officials, university staff, students and communitymembers all over Nigeria.

2.3. LESSONS FROM PHC PROJECTS

The full participation of all parties in PHC projects is dependent on how three basicsteps or activities are managed: (i) entry into community, (ii) capacity building, (iii)project implementation.

The correct entry points into the communities need to be found. The entrypoints in this case are the Local Government authorities – the Chairman (who isthe elected government head), the Supervisory Councilor for Health (one of theelected councilors), and the PHC coordinator (the most senior local civil servant inhealth care). Opinion leaders from among religious and professional organisationsas well as elders also are involved.

There is a need for capacity building for all the arms of the partnership – LGAofficials, health workers, university staff, and community members. Different levelsof participation will exist and this should be spelled out from the beginning of theproject. Where different groups with different backgrounds are involved, it is essen-tial that each participating party has a relatively good understanding of the othergroups. Difficulties can develop, for example, since the pace of the researchersis not always identical to the pace of the community. If possible these potentialdifficulties should be anticipated at the beginning of the project so as not to causeproblems later on.

The positions of the team members should be understood to allow for effectiveand sustainable implementation. For example, in Nigeria LGA officials changefrequently, making it important that the community members involved understandwhat will happen to the project when an official leaves. It is essential to havea mechanism for feedback which will facilitate community empowerment andsustainability and help keep the project on course and in focus.

2.4. THE PHC INFORMATION SYSTEM

The National Health Policy has identified that for effective management of healthservices there is a need to establish a national health information system. Infor-mation on vital health statistics such as births and deaths are needed to plan andmonitor health services at the local level. Decisions must be made regarding whatinformation is needed and who should provide it.


This information must be obtained largely from the community, as most of thedeaths and births still take place at home in most parts of developing countries.This is why there is a need to actively involve the communities at all levels inany program to develop a Health Information System (cf. Braa, 1996; Braa andHeywood, 1995). The community must be educated about the reasons such infor-mation should be volunteered to the appropriate authorities. To assure continuedparticipation the processed information should then be fed back to the community.

3. The case setting: The Ife Project on Health Informatics

Computers have been in use in Nigeria since the early 1960s. Since the adventof the microcomputer in the late 1980s, information technology has been in usein most sectors of the economy. However, in the health care sector the use ofcomputers is limited to non-clinical, non-managerial applications like text editing.

The Obafemi Awolowo University (OAU) in Ile-Ife, South-Western Nigeria isone of the biggest federal universities in the country. It has an established MedicalSchool and a Department of Computer Science and Engineering. The OAU Teach-ing Hospitals Complex (OAUTHC) comprises two teaching hospitals and threeteaching health centres. One of the hospitals, the Ife State Hospital, is situated in IfeCentral Local Government, which is one of the 23 local government areas of OsunState. There is a working relationship between the OAUTHC and the PHC staffof the local government. For instance, the Urban Comprehensive Health Centreat Eleyele in the town of Ife is part of the OAUTHC teaching facility in generalpractice and community health and at the same time is in charge of PHC deliveryfor Iremo District of the Ife Central LGA.

In the late 1980s the OAUTHC decided to introduce computer technologies tofacilitate the management of medical records in its two hospital units. No appro-priate off the shelf applications packages were available at that time and it isdoubtful that any exist today. Coincidentally, however, the OAU Department ofComputer Science and Engineering was simultaneously embarking on researchcooperation with the Computing Centre of the University of Kuopio, Finland,which had notable practical experience in health informatics. A Joint Project wasestablished by the three institutions.

In the beginning it was not self-evident that a computer-based informationsystem would prove feasible and sustainable, so a stepwise strategy was adopted. In1989 a rudimentary in-patient system was jointly designed in a bottom-up mannerby OAUTHC Medical Records officers and the computer scientists. Public domainsoftware available from the U.S. Department of Veterans Affairs was used as astarting point (Makanjuola et al., 1991; Soriyan et al., 1996). The in-patient system,running on a microcomputer with three dumb terminals, has been in routine usesince January 1991 (Daini et al., 1992). The Joint Project partners also initiated theHELINA conferences onHealth Informatics in Africa(Mandil et al., 1993).


Figure 1. The main stakeholder groups in healthcare systems development.

After a few years’ operation, the Joint Project partners critically assessed theexperience thus far and concluded that not enough clinical benefit was gained fromthe system. It was decided that in the next phase of the project, the scope of thecomputer-based system must be expanded. First, it must be expandedwithin thehospital, to include laboratory test results, drug prescriptions, pharmacy stores andout-patient clinics. This would make the system much more directly relevant toa majority of the hospital personnel. Second, the benefits of the computer systemwould be extendedbeyondthe hospital – to use the hospital as a resource centrefor primary health care delivery in, for example, Health Centres and Health Posts(Makanjuola et al., 1995; Adejuyigbe et al., 1996).

For the PHC, the plan was to develop technologies and practices as an actionresearch case to improve the cooperation between the local communities ofthe Iremo District, the Eleyele Health Centre, and the Ife State Hospital. Ourhypothesis was that information collected from the local communities and theHealth Centre’s activities could be processed by the hospital (e.g. by using theGeographic Information System technology) and then fed back to the local com-munities. Such information would empower the communities to be more aware oftheir health risks and to better manage the health care services at their disposal.

4. Tripartite partnership in Information System design in Ife: Anexperimental workshop

During the critical assessment of the previous phase, we had already theoreticallycome to the conclusion that the scope of participation should be expanded fromdesigners and users (health care workers) to the communities (Korpela, 1994).In essence, the tradition of designer–user collaboration in systems design and thetradition of health provider–community collaboration in PHC should be combinedinto three-tier participation (Figure 1).


To explore the feasibility of three-tier participation in healthcare systemsdevelopment, a workshop was held. The workshop was attended by:-

• computer professionals from the OAU and the OAUTHC;• health care providers and administrators from the Ife State Hospital and the

Eleyele Health Centre, as well as health administrators of the Ife Central LocalGovernment;

• representatives of the local communities from the Iremo District.

In the following sections we present some basic information about the communityand narrate the course of events before and during the workshop.

4.1. THE COMMUNITY: IREMO DISTRICT IN IFE TOWN

The Iremo District is one of the twelve health districts of the Ife Central LGA. Ifeitself, or Ile-Ife, is one of the most ancient Sub-Saharan African towns, foundedabout a thousand years ago (Phillipson, 1993). It is traditionally considered thespiritual capital of the approximately 20 million Yoruba people who inhabit south-western Nigeria and parts of neighbouring countries. Nevertheless, without majorindustries and with only 200,000 inhabitants, Ife is not considered a major city.The university is the biggest single employer.

Previous studies (Awotidebe and Adesina, 1993; Adesigbin et al., 1993) foundthat the Iremo District is home to approximately 42,000 people who are predomi-nantly urban and illiterate. The District is composed of some of the town’s mosttraditional quarters (in the vicinity of the King’s Palace) as well as some of themost “modern” residential areas. According to the LGA clinic reports, the prevail-ing health problems in the district are malaria and diarrhea, which are linked toproblems in water and sanitation. An average household is composed of 12 peoplebelonging to 4 family units.

Iremo District has its own traditional political system, with traditional rulersand leaders for each ward within the district. The district is divided into tenhealth wards, each with a health/development committee and two voluntary healthworkers who are nominated by the community members. In addition to the EleyeleUrban Comprehensive Health Centre, there are nine private health facilities in thedistrict.

4.2. THE PREPARATION OF THE WORKSHOP

The purposes of the workshop were (1) to build an initialshared understandingof current problemsin the health care services as perceived by the communities,the service providers and the system development team, and (2) to build an initialshared “vision of the future”concerning what should be targeted by the project.

The workshop was a three-day event. The first two days (Thursday and Friday,4–5th July 1996) were devoted to introductory lectures and group discussions


and the third day (Monday, 8th July) was spent touring around Iremo District.The reason for this arrangement was to first allow participants time to understandthe purposes of the workshop and the project that would follow, and then to seefirsthand the local operations of the three partner groups.

The participants came from three groups. Theinformatics groupincluded thetechnical personnel from the Department of Computer Science and Engineeringwho had been previously involved in the project, the Medical Records staff fromthe OAUTHC, and some new volunteers from the university.

Thehealth care groupincluded doctors (residents and consultants), nurses fromEleyele Health Centre, a community health expert from the university, and the IfeCentral LG’s health authorities represented by the PHC Coordinator and some stafffrom the Monitoring and Evaluation Unit.

The community groupwas composed of people who were nominated by theLocal Government’s PHC Coordinator from the Iremo District Health Committeeand from voluntary health workers. The 10 group members represented differentage and professional groups. Three were male and seven were female. Initially allwere required to be literate in English, but this condition could not be met and stillretain a good representation of the community. Therefore the core contents of theworkshop was translated into Yoruba.

Resource persons were drawn from among the workshop participants forspecific assignments, including session chairpersons, facilitators, rapporteurs, andtour guides. The facilitators were advised to be flexible, create a non-threateningenvironment (i.e. no right or wrong answers), encourage participants to expressopinions and ask questions using their own terms and expressions, and interact.

A general outline of a few key topics was prepared ahead of time for eachgroup’s deliberation. Of course, these outlines changed during the workshop,reflecting the observations and discussions of previous events. At the end of eachday, the workshop officials met to review the day’s events and to modify the outlinefor the following day.

Rapporteurs also were assigned to each group and general session. The officialworkshop languages were English and Yoruba. To accommodate community mem-bers who were fluent in only one of the workshop languages, a translated summarywas prepared for each session. Audio tape recordings were made of the workshopsessions, notes were taken, and anonymous comments were collected at the end ofeach day from all participants.

4.3. THE COURSE OF EVENTS

The workshop was attended by 42 participants. According to local tradition andto emphasise the importance of the event, the workshop was started by a formalOpening Session. In the beginning, all participants introduced themselves and saidwhat they expected from the workshop. Of course the expectations were still rathervague. Then the Chairman of the Ife Central Local Government and the acting


Figure 2. Group discussion during the workshop.

Chief Medical Director of the OAUTHC delivered their welcoming addresses, andone of the researchers briefly explained the rationale for the workshop.

After a break the workshop continued in a less formal atmosphere. Twoinvited papers were presented that provided participants with some degree of ashared background. These papers, presented both in English and Yoruba, wereAnoverview of PHCandAn overview of Health Informatics. As part of these presen-tations, participants were asked to explain concepts like ‘health’, ‘information’ and‘system’ from their own perspectives. A community member defined (in Yoruba) a‘system’ asa plan, set-up, steps taken, a nurse (also in Yoruba) asunits put togetherto make up something comprehensive, and a computer professional (in English) aspeople, resources and tools working together. The speakers then summarised andgave their own perspectives. Participants were invited to ask questions. Answerswere offered not only by the speakers but also by others who had ideas to share.

The third session of the first day was for group discussion on the problems,objectives and solutions as perceived by the group (Figure 2). The three groups –informatics, health care, community – first met separately and discussed an out-line of issues that had been prepared earlier. Each group chose a chairperson andsecretary for the meeting. After this brainstorming session, the group chairpersonor secretary gave a summary of their discussions in a plenary session. Missingpoints were added by the group members and questions were entertained.

The problems and solutions presented reflected the perspective of the groupin question. The community group emphasised economic hardship, nutritionalproblems, lack of public toilets, inadequate sources of water, insufficient infor-mation about immunisation services, and so on. To keep the discussion within thescope of the project, the researcher linked these problems to a lack of availabledata by decision makers. Regarding solutions, the health providers and voluntaryhealth workers were challenged to visit the communities and educate people on


the various issues that would lead to good health for all. The members stressedthat the communities were ready to contribute money and time to voluntary workthat would lead to the agreed upon objectives. Key was the mobilisation by theWard Health Committees of opinion leaders, including landlords, for achievingenvironmental sanitation.

The health care group summarised the problems asmanpower, money andmaterials.Their main objectives were to increase awareness of health issues amongthe communities, to expand community participation and involvement, and toprovide adequate services. The informatics group mentioned the lack of trainedhealth informatics personnel, maintenance and funding/sustenance as the mainproblems. They suggested various awareness programs, formal training and sharingof existing resources as solutions.

The health care group lamented that patients do not give correct informa-tion when attending the Health Centre. During the general discussion communityrepresentatives explained that patients don’t know why information is needed andare afraid that it can be used against them (e.g. for tax collection). The com-munity members urged doctors and nurses to visit the District and Ward HealthCommittees to educate them about the issue.

On the second day, another group discussion session was held, this time inmixed groups. Discussion centered on what information should be collected bywhom and to whom the information should be made available. Since many of theparticipants were not well aware of the information collection procedures currentlyin place within the health care delivery system, this session focused on clarifyingcurrent practices. The group results were again reported to a plenary session fordiscussion.

In the afternoon, a third brainstorming session on implementation and nextsteps took place, again in three mixed groups. One of the groups in their reportto the general session, reminded others that a manual PHC information systemis already in place – based on a house numbering scheme, home-based personalPHC cards and clinic-based records. Work should be concentrated on improvingthe existing system. Another group suggested that a broad-based Task Force withrepresentation from all three partner groups should be formed to draft a work plan.

All now stressed the District and Ward Health Committees as a means ofmass mobilisation and raising awareness. The health and informatics groups wereadvised to use churches and mosques, markets, schools, and meetings of profes-sional and trade unions to further the project’s objectives. Also seen as importantwas educating policy-makers and involving various levels of government, particu-larly since fund-raising was likely to be one of the big problems.

The last day of the workshop was a tour by bus to the “home grounds” of thethree partner groups. First, the participants were led through various parts of theOAUTHC’s Urban Comprehensive Health Centre in Eleyele and the Ife CentralLG’s main Health Centre in Enuwa (Figure 3). Special attention was paid to theinformation recorded at each point and the use to which it was put. The participants


Figure 3. Visiting the LG’s main Health Centre.

were given copies of the most important home and clinic based forms and cardsused.

The Local Government’s PHC Coordinator explained in detail the EssentialDrugs Revolving Fund, which is operated by the District Health Committees. TheFederal Ministry of Health gave the Health Committees of the LG 500,000 naira(about US$ 6,250) as seed money for purchasing essential drugs at a preferentialrate through the LG. The drugs could be distributed to the voluntary health workers,who could sell them to patients at a slightly higher cost. The Health Committeescould then use the difference as they chose, such as increasing the amount of drugsavailable, digging a well, or indeed an awareness campaign.

Led by the community representatives the tour continued to three sections ofthe Iremo District. The district boundaries and the number of health facilities inthe district were identified, and the distances to the nearest health facilities wereobserved. During the tour, the PHC house numbering system and the effective-ness of the home-based PHC cards were discussed. Voluntary health workers told(Figure 4) their involvement in the healthcare of the community. For example, avoluntary birth attendant reported that she may help her neighbours in six births aweek, besides taking care of her main job as a trader. These voluntary workers mayreceive small gifts as encouragement from the Health Committees, but no salary isgiven.


Figure 4. A voluntary birth attendant and the Local Government’s PHC Coordinator explain-ing a home-based PHC card.

The next stop of the tour was at the Computer Building of the OAU, wherethe focus was on the computer and its relation to social issues. For many partici-pants this was the first time they had seen a computer. The informatics groupdemonstrated computer-based communication over the Department’s new LocalArea Network and explained the recent achievement of an international emailconnection. The community representatives were particularly impressed by thecommunications potential.

The tour ended at the OAUTHC’s Ife State Hospital, where Medical Recordsofficers demonstrated the existing computer-based information system (Figure 5).The Health Centre’s nurses were very enthusiastic about the ease with whichindividual patients’ information could be retrieved.

At the end of the workshop, the participants convened over lunch to review thetour and the workshop, and to prepare a communique. All participants of variousbackgrounds were in high spirits, inspired by the number of new things they hadlearned. The leader of the community group summarised a general feeling byurging that the workshop must not be a single event, but the start of continuedcollaboration to implement the proposals for future action that had been discussed.

The workshop ended with the community members leading the group in thesinging of a Yoruba song given below:


Figure 5. The Ife State Hospital’s main computer.

Yio see se asiko ni o ma gba oYio see se asiko ni o ma gba oAseti o si oo yeAseti o si fun wa ni’le e ‘feYio se e se asiko ni o ma gba o.

It will be possible though it will take timeIt will be possible though it will take timeThere is no impossibilityThere is no impossibility for us in Ife,It will be possible though it may take time.

5. Discussion: Participation and developing countries revisited

Early on in the Ife Project it was recognised that the initial success of the systemimplementation could be attributed to the active participation of users and man-agement alike (Daini et al., 1992). It became evident to us that the slow progressin producing clinical benefits could also be linked to participation; this time to thelack of it. If doctors and nurses had been as involved in the project as the Medical


Records staff, then the requirement for a greater amount of feedback would havebeen discovered earlier on.

However, we were initially uncertain whether cooperation could be extended tolocal communities when designing a PHC information system, given the wide dis-parity of backgrounds and the complexity of the task. The results greatly surpassedwhat we dared to hope.

In the following, we will reflect on our experience from wider political, culturaland societal perspectives, before drawing some practical lessons.

5.1. PARTICIPATION AND THE POLITICAL CONTEXT

When the issue of community participation in Nigeria is raised, people fromEurope and North America often assume that the military government is the mainpotential obstacle. However, what matters is whether ordinary people are able tohave an affect on their everyday life at the local level. Except in extremely totali-tarian regimes, theformof the top level of government only has anindirectaffect onlocal community practices. The top-level government, be it military, single-party ormulti-party can, by promoting popular participation, motivate the population, givethem faith in the future, and provide equal opportunities. On the other hand thetop-level government, can by creating an authoritarian political climate, produceapathy, a sense of insecurity about life, and increased poverty.

The local level of government has a more direct influence on local practices. InPrimary Health Care, for example, the fortunes of bottom-up participatory initia-tives are largely dependent on the degree of popular influence on local government,and the latter’s capacity to support such initiatives. In Nigeria, an important changewas the creation of the elected Local Governments in 1976 to replace the coloniallegacy of top-down local administration. During the last ten years, the LGs havegained more autonomy and influence (Adejumobi, 1995).

However, the economic base of the LGs is fragile and the State Governmentscan severely curtail their autonomy. For instance, the PHC Coordinators of theLGs, who are appointed by the State Governments, are rotated frequently whichcreates a lack of continuity. Without a significant local base of funding, the LGsare financially dependent on the state. This has left them vulnerable to changes inadministration at the top.

It is true that organisational barriers, economic hardship and the generalinsecurity of life create obstacles to cooperation in developing countries. Yet itis not totally impossible to overcome these obstacles. Braa and Monteiro (1996)have noted that in order to flourish and become viable, people-based local initia-tives need to incorporate themselves into broader institutionalised networks, ina government-created ‘enabling environment’ – recognising that the situation isnever static. A participatory experiment like the workshop can grow, if it canidentify an institutionalised network of social forces to support itself – reli-gious and professional associations in the community, traditional elders, voluntary


health workers, Health Committees, PHC-oriented doctors and nurses, sociallyresponsible computer professionals and academics, committed PHC administra-tors, ‘listening’ Local Government councilors (Korpela, 1995).

The workshop experience suggests that participation and cooperation are notonly possible in a deprived African country, but a must. Simply, a computer-basedsystem will not survive the harsh socio-economic conditions without the dedicationof its users, and dedication begins by having users genuinely involved.

Whereas in Scandinavia and the USA participatory design is usually seen toinvolve the day-to-day workers only, we stress the importance of involving othergroups as well, most significantly management (Bodker, 1996). The commitmentof management may be important in industrialised countries, but in developingcountries it is doubly important because of the existence of a hierarchical admin-istrative culture. Again we believe commitment grows from management beinggenuinely involved in the project.

5.2. PARTICIPATION AND TRADITIONAL CULTURE

The hypothesis of traditional culture as an obstacle to participation in developingcountries has been discussed in detail elsewhere (Korpela, 1996). In brief, existingscientific literature on the Yoruba people inhabiting South-Western Nigeria doesshow a trend towards hierarchy in the traditional society, but also a strong balanc-ing endeavour towards consensuality. Existing “rigid bureaucracies” in Yorubalandcannot be attributed to traditional Yoruba culture, but to anti-democratic colonialrule. Participation cannot be excused as something alien to indigenous cultures;rather it should be seen as an antidote to the administrative culture imported by thecolonial lords.

We would regard traditional culture as a potential “indigenous opportunityfactor” in Greenbaum’s (1993) sense, rather than as an obstacle as Avgerou andLand (1992) have suggested. For instance, the traditionally strong position ofwomen in West Africa is visible in the computing profession (Soriyan and Aina,1991). It would be interesting in the next phase of the Ife project to intentionallyexperiment on how to harvest consensual aspects of the local traditional culture foran “Ife Approach to Participatory Design.”

5.3. SOCIETAL JUSTIFICATION OF INFORMATION SYSTEMS: THE NEED FOR

THREE PARTNERS

The PDC’96 Call for Papers states that “participatory design projects have com-bined the skills and knowledge of workers with the technological and organi-sational expertise of design practitioners in efforts to develop technologies andpractices that improve people’s work lives”. In our experience, this definition hasto be expanded in one important direction. Who decides what is ‘improved work’?


Let us take an extreme example to illustrate the point. What if the Mafia askeda Participatory Design practitioner to enter into a participatory project to developtechnologies and practices that “improve the Mafiosos’ work lives” – i.e. black-mailing, drug pushing, murdering? Apparently it is not sufficient to require that thedesigner should improve their work lives in a participatory way, as they wish.

In order to avoid “Participatory Design with the Mafia”, it is important to con-sider theoutcomeof the people’s work in each case. In essence, work activitiesproduce services for other people; a hospital produces health care services, a farmerproduces food. It is not enough only to consider how to improve the work lives of agroup of people from their own viewpoint. The viewpoint of those to be served bythat work should also be taken into account. In order to avoid Participatory Designwith the Mafia, the victims of the Mafia should be involved in the design process.They certainly would change the design objectives considerably.

In the case of PHC information systems, we think that an important criterion for“improved work” is that the introduction of new information processes and capa-bilities into PHC must lead toimproved health care servicesthrough (a) strongerfocus on priority needs as determined by the communities, (b) more equal coverageof and access to the services, (c) increased continuity of care, (d) more informedand educated communities, and (e) cost-effectiveness.

In a deprived economy it is more clearly visible that the purpose of a hospitalsystem design project cannot just be to make life easier for the doctors and nurses.If a computer system in a Nigerian hospital does not, at least indirectly,lead tohealth improvementsfor the population, then it is not justified. We think that thesame applies even in Finland and the USA, although such issues are seldom consid-ered when new computers are installed in hospitals and health centres. This issuewas raised at the 1996 Participatory Design Conference by the panel titledWhereis the patient in patient-centered health care?

In brief, “Informatics for Development”, or the societally justified applicationof information technologies, requires the involvement of a third partner group intothe participatory design setting, in addition to workers and design practitioners.The communities to be served by the workers and the technology should also beinvolved. This will help guarantee that the benefits of the system design effortextend beyond the immediate users.

5.4. ISSUES OF IMPLEMENTATION

Tripartite partnership is not a simple thing to implement, and our experiment wasby all means just a start. The workshop succeeded in building “an initial sharedunderstanding” and a sense of partnership, but we were not equally successful inoutlining the “vision of the future” and the way forward. That will take more time.

We have decided on four next steps. First, a tripartite Task Force was establishedfor project planning, monitoring and implementing. Second, the healthcare andinformatics groups will attend the District and Ward Health Committees’ meetings


to learn more about the communities’ problems and capacities. Third, the infor-matics group will study and document the existing PHC information system incollaboration with the two other groups. The findings will be presented at anothertripartite workshop. Finally, national and international agencies will be approachedto raise research funding for the project.

It is not self-evident who should represent the communities since all the 42,000inhabitants of the Iremo District cannot directly participate, not to mention the IfeCentral LGA or OAUTHC’s entire region of admission. However, since PHC isbased on a preventive philosophy rather than a curative one, it is clear that thewhole community must be involved and not only the patients being treated at anygiven time. The difficulty of deciding who should participate was made easier inour case because of an existing structure of genuine community representation inthe form of the Health Committees. In other cases, grassroots health activists mustbe identified through other civil society organisations.

It is also important to ensure that different stakeholder groups (e.g. men,women, various social and cultural groups) are represented in an authentic way andthat they can speak freely for themselves. In many countries the professional groupswithin healthcare delivery, doctors and nurses in particular, have difficult relationson a national or institutional scale. This may have an effect, even in participatorysettings, on their grassroots involvement. It is important that conflicting views canbe aired without fear of being oppressed. This is especially important in ensuringthat less powerful partner groups do not suffer from the outcome of the project. Itis equally important that inevitable differences among groups do not disintegrateinto hostilities and blaming each other.

In a multicultural society like Nigeria where some 250 languages are spoken,choice of language is also an issue. It was clearly an empowering factor that Yorubacould be freely used in the workshop. On the other hand, not all of the healthproviders and computer professionals are Yoruba, and even in Iremo District itselfother ethnic groups are present. The mixed usage of the local language and alinguafranca, with interpreted summaries, worked well in our case.

Finally, we wish to stress that all three partners of this tripartite collaboration areindispensable. As the early part of the Ife Project shows, in developing countriesit may often be the informatics group who are the hardest to be included, becauseof a sheer lack of trained professionals. If the health providers and communities donot find capable computer professionals who are able to spend time and willing tolearn from the other groups, then the potential of the computer technology cannotbe realized for Primary Health Care in Africa. This is an issue because of an acutedearth of trained computer professionals, especially in the public sector, but alsobecause of a lack of training in participatory approaches.

In the next phase of the Ife Project, in collaboration with our Finnish,South African and Norwegian colleagues, we intend to develop participatorymethods applied to the specific requirements of an African country, especially inhealth informatics (seehttp://www.uku.fi/laitokset/atk-keskus/ tj/indehela/). These


methods need to be appropriate for routine adoption by Nigerian professionals andcommunities.

6. Conclusion: Can Europe and North America learn from Africa?

The Ife Project has shown that Participatory Design is possible in developing coun-tries. More generally, our discussion of the political and economical contexts ofparticipation in developing countries suggests that, despite severe constraints, inmost cases, ordinary people are able to affect their everyday lives on the local levelin such a way that participatory initiatives are possible. Participation might even beviewed as a must, since a computer-based system will not survive the harsh socio-economic conditions of developing countries without the dedication of its usersand beneficiaries. This dedication grows from genuine involvement.

We also suggested that traditional cultures should not be seen as obstacles toparticipation, but as potential “indigenous opportunity factors”. Furthermore, theinvolvement of communities and management in Participatory Design projects canhelp sustain the benefits of the partnership after the project has ended. The experi-mental workshop, described in detail, highlighted methodological aspects (e.g. theuse of two languages or the tours to the home grounds of the partner groups) thatcould be tried in other projects.

Our main conclusion is that the scope of Participatory Design must be expandedfrom designers and workers only, to the communities which are served by theworkers and the system. We are convinced that community involvement is espe-cially crucial in developing countries where scarce resources cannot be wasted.However, we also believe that tripartite partnership in systems design – bydesigners, workers, and communities – is valuable in industrialised countries aswell. This will help avoid the risk of “Participatory Design with the Mafia” andensure societal justification for the would-be system.

Acknowledgements

This paper is based on the work of the workshop facilitators, rapporteurs andgroup leaders: Dr. A. Adegboye, Mrs. A. Adegoke, Prince A. Adegoke, Prof. O.Adejuyigbe, Prof. A.D. Akinde, Mrs. I.O. Awoyele, Dr. Balogun, Mr. M.O. Bello,Miss J. Ehinmuan, Miss F. Farewo, Dr. K.T. Ijadunola, Mrs. E.K. Makinde, Mrs.F.O. Oladipo, Mrs. R.A. Osewa, and all the other participants. The reviewers’comments were very helpful in editing this article from the original conferencepaper.


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