This research proposal is about the challenges of health information systems in developing countries. Literatures were reviewed on Information systems in developing countries in general, Health information systems in developing countries and narrowed down to Africa in particular. The general research process that was discussed includes the paradigms, strategies (advantages and disadvantages) and the data collection method that will be employed.
The methods, which include the type approach, research strategy, and data collection method that will be used in doing the research was also justified. Another method for carrying out the research, if given enough time and resources was also discussed.
The ethical issues that will be considered when doing the research, the contributions the research made and the research plan were also discussed.
BACKGROUND OF STUDY
This research is about health care information systems and the purpose of study is to understand the challenges of information systems in health sectors in developing countries and contribute to how it can be controlled. Information systems in developing countries has been known to experience failures, this was confirmed based on several research on IS in developing countries. According to Heeks,R (2002) who stated that "there are high rates of IS failures in developing countries and these failures keep developing countries on the wrong side of the digital divide, turning IT into a technology IS failures is therefore a very real and practical problem for developing countries to address".
Information systems are then referred to as follows:
"Information systems are thought of as the data-based networks needed to create, establish maintain and control the organization's sets of contracts." Checkland,P & Holwell,S (1998, p71).
Walsham,G (1993) described the "concept of an information systems as a broad category of human artifacts, such as texts and books, but computers and telecommunications hardware and related software now provide a composite technology with capabilities which are quite remarkable viewed from any earlier epoch".
Information systems are the computer applications designed to help individuals or organizational to achieve their goals in a more efficient manner. The general failures of IS in developing countries might be one of the reasons why they experience challenges in health information systems.
"Health information systems are important tools in the management of health care services in both developed and less developed countries. An adequate health information systems are vital not only for assessing the health needs of population and groups but also for planning and implementation of health interventions" Azubuike and Ehiri (2009).
However, information systems are seen as a useful tool in different organizations including health organizations.
AIMS AND OBJECTIVES
The aims and objectives of this research proposal is to understand the challenges facing health information systems in developing countries such as South Africa, which will be used as a case study if doing the research. This research proposal will also discuss how the problem of failure in health information systems in developing countries can be controlled.
Literatures from high rating journals that have done a research in this area to be discussed will be used as sources of evidence and it will subsequently form the basis for the approach to be used in this research. The following questions will be addressed in this study:
- What are the major issues facing Health Information system in South Africa?
- How can the governments contribute to the success of Health Information System in South Africa?
- How can these challenges be addressed?
- What are the benefits of having a successful Health information system?
Over the years, health care sector in developing countries has been retrogressing due to lack of quality health care services relating to poor patient data record and not giving proper medications to patients, which eventually leads to premature death. In recent times, information systems have been able to contribute to the success of different organization by improving the quality of products they produce and also increasing their speed of work. There is therefore no doubt that it has been an important tool for different sectors including the health sector by improving the quality of health services. Before discussing the challenges of health information system in developing countries, we ought to look at the failures of information systems in general. This section will consist of reviews of previous researches that have been done in this area.
IS IN DEVELOPING COUNTRIES
In developing countries, information systems can be categorized as "failing either partially or totally" Heeks,R (2002) . Heeks,R (2002) discussed "measuring success and failure in information systems has been difficult to evaluate stating that it can be viewed from different perspectives" i.e, "one person's failure may be another's success" Lytinen & Hirscheim (1987) and that today's information systems success may be tomorrow's IS failure and vice -versa.
Heeks (2002), did a case study in analyzing the failures of IS in developing countries and came out with three different categories of failure.
According to Heeks (2002), "There was the total failure category which is an initiative never implemented or which new system was implemented but immediately abandoned. For example, India's Indira Gandhi Conservation Monitoring Center was intended to be a national information provider based on a set of core environmental information systems. Despite more than a year of planning, analyzing and designing the work, these information systems never became operational and the whole initiative collapsed shortly afterwards" (Puri et al, (2000).
The category of a "partial failure" was also discussed, "which is an initiative in which major goals are unattained or in which there are significant undesirable outcomes. An example of the Tax Computerization projects in Thailand Revenue Department set out seven areas of taxation that were to be computerized. At the end of the project, only two areas had been partly computerized and five others were not operational" (Kitiyadisai (2000).
Heeks (2002), stated that sustainability failure is one that particularly affects developing countries and it is of the initiative that it succeeds at first but it is then abandoned after a year or more. An example is the creation of a set of touch screen kiosks for remote rural communities in South Africa's North-West Province; these were initially well received by the communities. However, "the kiosks lack of updated or local content and lack of interactivity led to disuse and they were removed less than a year later" Benjamin, (2001). Heeks (2002) explained further that there are other failures that are difficult to identify "because identification grapples with issues of subjectivity, which led to the question whose goals are unattained? and for who are the outcomes undesirable?" He gave an example of such failure in analyzing the Accounts and Personnel Computerization Project of Ghana's Volta River Authority; most managerial staffs in finance department were pleased with the changes brought by the new systems. However, the implementation "bred a feeling of resentment, bitterness and nonuse, particularly among older workers" Tetley (2000)
Heeks (2002) discovered that these categories did not actually prove the level of information systems failure in developing countries, and did not also explain the likely causes of information systems failure. He stated "there are plenty of practical reasons such as lack of technical and human infrastructure to support the idea that failures rates in developing countries might be higher than industrialized countries" (Heeks, 2002) and then relate his lack of evidence to:
- "Lack of literature in general": explains that IS literatures are not commonly found and that the researchers and writers are not focused.
- "Lack of evaluation": explains that those who desire to evaluate lack resources and those who have resources lack the will.
- "Focus on case studies": explains that even though IS literature has grown, previous researches focus mainly on individual IS projects. Heeks,(2002).
He gave further examples of information systems failure in different developing countries such as "Health information system in South Africa: Braa & Herdberg (2002) reported widespread partial failures of high cost systems with little use of data and IS in Thai public sector: Kitiyadisai (2000) reported failure cases seem to be norm in Thailand at all governmental cases" to backup his idea and concluded that even though, there are no strong evidence, all the examples given are all pointing to the fact that there is high rate of IS failures in developing countries Heeks (2002). This research work clearly emphasized that there are general failures of information systems in developing countries and its also one of the factors affecting the success of information systems in the health care sector and it needs to be urgently addressed.
HEALTH INFORMATION SYSTEMS IN DEVELOPING COUNTRIES:
In the research work of Braa, Hanseth & et al, (2007) in a top journal article (MIS quarterly) on developing health information systems, using three different developing countries as case study ..."complexity is discussed as the main challenge that strategies for the development of information systems in general and in health sector need to address and proposes flexible standards as the key element in a sustainable infrastructure development strategy. They described an approach to development and implementation of health information systems that is both sensitive to local context and scalable to geographical areas" Braa et al. (2007)
The poor health services in developing countries is seriously affecting the growth of the countries in all aspects and effort are been made by international bodies to tackle the problem by putting the necessary things in place hence, the need for health information systems. Braa et al, (2007) "However, Health information systems development in developing countries has proved to be difficult due to organizational complexity Gladwin et al (2003), fragmented and uncoordinated organization structures all maintaining their own health information system". Chilundo et al, (2004). Braa et al, 2007 explained, ..."Complexity science emerged primarily from the study of phenomena within physics such as thermodynamics and biology. It is made up of broad range of disciplines including chaos theory and complex adaptive systems... (CAS)". "Complexity systems is also increasing been applied in the area of health care organizations and it is adopted and is adopted in information systems and organization/management studies where it is applied in a rather optimistic tone: Complex systems are best managed by enabling their self -organization" Braa et al, (2007)
The health sector of a country is a group of institutions ranging from the small to large advanced hospitals in both rural and urban areas; several international bodies such as the World Health Organization, United Nations, manage these institutions Braa et al, (2007). They described the entire health service system as a group of independent programs "which maintain their own uncoordinated reporting systems in the absence of a central standard, the lack of a standard for data collection means that the same data are often collected and reported many times through different structure, while there are gaps where important data do not get reported, this results into excessive data of poor quality and generally the poor use of it" hence, "the integration and coordination of health information system is an issue that needs to be addressed" Braa et al, (2007).
Braa et al, (2007) described the World Health Organization (WHO) important need for a centralized information system in order to achieve their ambitious goal of giving out antiretroviral treatment to HIV/AIDS patient in developing countries as an example to stress the need to implement or integrate an existing information system. The WHO HIV/AIDS unit declared an urgent need for strategic information systems in conjunction with the antiretroviral treatment programs, including monitoring and evaluation system and that governments should make efforts to integrate antiretroviral treatments into existing health information systems, they added that the antiretroviral treatment programs in developing countries can be used as a tool to enhance the need for integrating health information systems in developing countries Braa et al, (2007).
However, the need to integrate an existing health information system in a developing country has been established and the proposed strategy is ..." through flexible standardization approaches that focuses on simplicity and the essential need for information. At the first level, the challenge is to develop workable data standards, then, at the second level, the interface between the existing paper-based systems and the rapidly emerging computer-based infrastructure needs to be dealt with. In particular ART (antiretroviral) programs are pushing implementation of electronic patient records that in many developing contexts for the foreseeable future, will have to coexist with the paper based patient record system" Braa et al, (2007).
The development of the standards will be at two levels: "the technical level of software and the service delivery level for data collection and communication" Braa et al, (2007). Standardization is defined as ..."the activity of establishing and recording a limited set of solutions to actual or potential matching problems directed at benefits for the party or parties involved balancing their need and intention and expecting that these solutions will be repeatedly or continuously used during a certain period by a substantial number of parties for whom they are meant "De Vries, (2003).
The research on standardization acknowledges that the "world of standards" is rapidly changing into a more complex one Braa et al, (2007). Hanseth et al, (1996) discussed that.. "The world is changing more rapidly and standard need to be flexible to adapt to this" therefore, he proposes "two kinds of flexibility -Use and Change flexibility and argued that standards needs both". Hanseth et al, (1996) described "Change flexibility (the ability to change standards) is enabled by modularization i.e Combining simple standards with gateways translating between them Hanseth (2001), not only between computer- based infrastructures, but also gateways integrating paper- and computer -based infrastructures, which has proved very useful for improving information systems in hospitals" Hanseth and Lundberg (2001).
Also, Hanseth et al, (1996) argued that the Use flexibility gives users the opportunity to change their approach to standards without changing the standards itself.
The use of flexibility standardization approach to address complexity in the development of health information systems was adopted in South Africa and it was able to reduce complexity to the barest minimal. Braa et al, (2007). "A uniform data set and the DHIS software (district health information software) to collate and analyze data termed an attractor was created in response to the need for integration and equity and for the first time managers had access to useful and current data, these attracted more users and health care programs" (Braa et al, (2007). Another factor that determined this success apart from the development of technical part of information systems that required a huge investment was the investment on training users Braa et al, (2007). "This contributed to the development and acceptance of the standards and creation of attractors. Overtime, as the process unfolded, standards could be modified and extended as needs changed, accommodating the changes in standards has been possible because the individual standards have been simple and accordingly flexible" Braa et al, (2007).
In respect to these views, Braa et al, (2007) considered the use of flexibility standardization in addressing complexity issues in developing information systems infrastructures in less developed countries has the best practice for others to adopt.
Fraser et al, (2005), recognized the need for health information systems in developing countries, they explained this by identifying with the series of health crises that threatens the lives of millions of people, they said "recent statistics suggest that treating the rising tide of human immunodeficiency virus (HIV) in developing countries requires that large scale interventions are immediately put in place" Fraser et al, (2005). For this reason, new approach of treating a large number of patients should adopted in health sectors to achieve this an excellent information system management is required, Fraser et al, (2005). They suggests that an electronic medical record systems that will improve the quality of health care given, has a database to keep records of patients and the type of treatment given, that will also be a able to act as a decision support system, enable physicians have access to remote physicians and medical journals via internet should be implemented in order to take care of a large number of patients Fraser et al, (2005).
HEALTH INFORMATION SYSTEMS IN AFRICA:
In the research that Braa et al, (2002) did on the standardization of health information systems in South Africa and the challenge of sustainability the health information system program discovered that there were problems of low data quality and scarcity of human resources and technical skills thereby reducing the quality of health services given. This challenge was then addressed by means of a particular standardization and implementation strategy: "the creation of a hierarchy of standards to allow flexibility and a particular attention to build "local capacity". A set of essential health data are defined at all levels and additional data are added to satisfy local management needs, the set of the essential data and its hierarchy constitutes what can be called the standards. Once the standards are implemented, data quality in the entire system must be guaranteed to ensure its sustainability, the best strategy is to make sure that the data are used at all level of collection. It can therefore be argued that the sustainability of the "global" standard based health information system is highly dependent on achieving a "local" sustainability of a local system that collects and reports the data". Braa et al, (2006).
Braa,Monteiro& et al, 2004, tend to look more into the challenge of local sustainability in the particular case of rural hospitals that larger hospitals tend to receive more attention due to greater complexity of intervention and in the process marginalizing the smaller hospitals. Smaller hospitals usually have less infrastructural support and are less attractive for skilled workers; they looked at the challenges of local sustainability in the case of small hospitals and identified the general problems of sustainability of information systems in developing countries.
- Limited duration of donor's financial support
- Inadequate focus on local expertise
- Too narrow interventions (often a sustainable health information systems requires a parallel reform of the health sector)
- Technical bias of projects (Inadequate focus on human resources development)
- Pilot project orientation Braa,Monteiro& et al (2004)
These are Braa et al (2004) idea of the general problems facing information systems in less developed countries, which can also be likened to the sustainability failure of health information systems in developing countries. They emphasized the fact that the implementation of sustainable health information systems at the local level will stress a necessary condition to achieve the sustainability of the whole information system at global level.
They used a small hospital in the northern area of the Eastern Cape as a case study, the activity that takes place in the hospital were described to describe how slow and poor the process of data collection and quality of health service given is.
......"The hospital is staffed with two part time doctors as well as a hospital manager, an administration officer, one information officer and a clerk. The registers, the DHIS and a computer were installed during the DHIS rollout in Eastern Cape in 1999. The ward registers are books where the nurses should enter the data about the patients that are admitted and discharged. There is one long line to fill for each patient and often the fields (like the type of diagnosis or type of separation). The midnight census is a form compiled by a nurse during the night shift indicating the number of patients present in the hospital during the night. A ward report is then compiled on a monthly basis. The data from the monthly ward reports then aggregated at the hospital level and then usually entered in the dedicated software: the district health information software"....... Braa et al, (2004)
Overview of the diagrammatical representation of how the DHIS application works in 1999 (Braa et al 2004 p231)
The use of the DHIS in the New Cape hospital did not seem to solve their problem because; a lot of paper work is still been done which consumes a lot of time. The quality of health service did not improve either; therefore the hospital management and information systems department worked together to implement new software, which reduces paper documentation and increases their speed of work. Braa,Shaw &et al, (2006)
Overview of the redesigned district health information software (DHIS). (Braa,Shaw & et al 2006,p232).
In this chapter, the methodology that will be adopted for this research will be discussed; the objective is to explain how this research will be carried out. Here, I shall be discussing the research paradigm, strategies and mode of data collection that will be used. "In IS a wide range of research strategies with underlying philosophical paradigms, have been used to understand the use of information systems by people, Paradigms are set of assumptions that can be altered" Oates,B (2006).
This research will be having an interpretivist approach has the underlying paradigm and a case study has its strategies and the reasons for this will be discussed later in this chapter, but first, the three types of paradigms will be discussed.
According to Oates,B (2006) a positivist type of paradigm "is the oldest of the three paradigms, it underlies what is called 'the scientific method', the approach to research in the natural sciences (such as physics, chemistry, biology)"etc. "A positivist paradigm is based on the experiences of senses and can be obtained by observation and experiment" Dash,N (2005), he explained further that a positivist thinker generates knowledge by means of a scientific method. A positivist paradigm has two basic assumptions: Reality is objective, this way reality is judged based on our experiences or by a particular law or order which has been set. Our world is ordered and regular, by assuming that there is a particular way in which things are done and so predictions, calculations can be made based on our assumptions Oates,B (2006).
"A Critical research paradigm also asserts that reality is socially constructed but also go on to us say that social reality also possesses that then dominate our experiences and ways of seeing the world" Oates,B (2006). According to Dash,N (2005), "the main protagonist of this theory was Jurgen habermas, who worked at the frankfurt school in Germany to develop an approach of investigation and action in the social sciences which could describe the historical forces that restrict human freedom and expose the ideological justification of those forces". Dash,N (2005) explains that "critical theorists were critical of the earlier paradigms as they were not tuned to question or transform the existing situation. They suggest two kinds of research methodologies, ideology critique and action research, for undertaking research work".
The third type of paradigm is the Interpretivist paradigm which is the approach that is most appropriate for this research topic if I were to be carrying out the research, because the research topic is constructed based on others research in health information systems and it also creates an opportunity for my assumption to influence the research process. According to Oates,B (2006), "an interpretivist research is concerned with the social context of an information system , the social process by which it is developed and construed by people and through which it influences and is influenced by its social setting". Dash,N (2005) discussed that "interpretivists research paradigm emphasizes that social reality is viewed and interpreted by the individual , according to the ideological position they posses. Therefore, knowledge is personally experienced rather than acquired from or imposed from outside". In interpretivist research, the view of reality is based on interpreting from others experience and point of view.
There are different research strategies that can be used to carry out a research in information systems; we have the case study, grounded theory, action research strategy ethnography and so on. Here, some of the research strategies with a pros and cons shall be discussed in general and then justify the one I think is suitable for this research if given the opportunity to carry out this research. The strategy I will be discussing is Ethnography. According to Spradley (1979) ethnography is the "study of both explicit and tacit cultural knowledge and as a 'culture- studying culture'. He said explicit cultural knowledge can be communicated at a conscious level and with relative ease, tacit knowledge remains outside the consciousness and awareness". "An ethnographer spends time in the field, taking part in the life of the people there rather than being a detached observer. They try to construct a representation of the world as perceived by the people who lived there. The test for success is whether those people recognize the ethnographer's description" Oates,B (2006). Oates,B (2006) gave some advantages and disadvantages of ethnography, they are:
- "It gives a rich picture of a particular situation or work practices, putting events or practices into context rather than abstracting one or the aspects in isolation.
- It can also be used to study something over a long period of time, for example the introduction implementation and usage of a system".
- "The in depth study of one situation may not produce findings of much relevance to any other situation.
- It can sometimes end up as a story telling where a descriptive account is given at the expense of developing an analytical insight or theoretical contribution" Oates,B (2006).
The second type of strategy that will be discussed is the grounded theory method; Glaser & Strauss (1967) explained a "grounded theory as a research method that is also named a 'theory' because the underlying argument is that research should discover theory directing from the field data". The advantages of a grounded theory method are;
"It emphasizes as much or more than all other inductive methodologies the need for a researcher to be immersed in data and the need to consciously guard against imposing a theory in a related substanstive area that does not actually match patterns in the data", Urqhuart (1997).
"It draws the strength of both the positivist and interpretivist approaches", Charmaz (2000).
The research strategy that will be suitable for this research, if given the opportunity to carry out this research is the case study strategy because it gives the details of what happens in an environment and it is often associated with an interpretivist paradigm. "A case study is an empirical inquiry that investigates a contemporary phenomenon within its real life context, especially when the boundaries between phenomenon and context are not clearly evident. The case study inquiry copes with the technically distinctive situation in which there will be many more variables of interest than data points and as one result relies on multiple sources of evidence, with data needing to converge in a triangulating fashion, and as another result benefits from the prior development of theoretical proportions to guide data collection and analysis", (Yin 2003, pp13-14).
Some of the advantages and disadvantages of case study are:
- "It can deal with complex situations where it is difficult to study.
- It is appropriate for situations where the researcher has little control over events.
- It is suitable for both theory building and theory testing" (Oates 2006,pp300-301)
- It is sometimes perceived has lacking rigour and leading to generalizations with poor credibility.
- It is difficult and time consuming to implement and gain access.
There are no set of rules to follow therefore it is difficult to find your through the maze of information (Oates 2006, pp300-301).
The data collection methods that will be used for this research if carried out are written documents on failed health information systems from different health organizations and how they intend to bring up a new one, have a semi- structured interview with major health organizations workers on the existing or proposed health information system, this is because they are textual data and not numeric and they will help to understand their challenges and contribute to the solutions. The data analysis method that will be used is the thematic frameworks qualitative data analysis, because it consists of two methods that aid clarity in analysing data. The two methods are Memoing and Integrative diagrams.
EVALUATION OF METHODS
In this chapter, why the methodology chosen is most suitable for this research will be discussed. The methodology, include the paradigm, the strategy, data collection and analysis methods. The Interpretivist approach is the best approach that suits this research topic; because it gives the opportunity to be an observer (participant and non-participant) in the environment you are researching which gives the opportunity to study the people within that environment and their attitudes towards the existing information systems, it also gives the opportunity to gather facts based on other people's research's and generalize. If given an opportunity to carry out this research and there was enough time and resources, I would still have used the same approach in doing the research.
The type of strategy proposed was due to the limited amount of time and resources given but it is also a good one in that, it gives the opportunity to select an instance and then generalize to a population and it also suitable for theory testing, it has some disadvantage such like, being difficult to implement and gain access to information within an organization. However if given the opportunity I would have done the research access as an ethnographer because, I would have the opportunity to be a part of a health organization in a developing country for a period of time, where I can study people and their roles within an organization and have a rich picture of their challenges. The only disadvantage it has is that is not generalisable.
The data collection methods proposed are the most appropriate methods that will be used for the research, even if there is limited time and resources because, it gives room to observe people in that organization, access to documents and give opportunity to interview relevant people within the organization.
The ethical issues I would put into consideration, when carrying out the project are as follows:
- I intend to collect the Universities consent form and treat as appropriate.
- I am also going to follow the Universities guidelines when doing the research.
- I would seek for the consent of the organization that I intend to use as my case study by making them understand the purpose of the research, how it is going to be done and the benefit they should expect from it.
- I would ensure that I conduct a semi-structured type of interview and my questions are taking carefully when conducting the interview such that there won't be an embarrassment or harassment whatsoever.
- I would also ensure the privacy of the data collected from the organization and my participants.
- I would also ensure I treat my participant with respect irrespective of age or social status.
RELEVANCE AND CONTRIBUTION
The research will contribute to my knowledge of being an ethnographer if given enough time and resources. It will also contribute to my understanding of how health information system works in developing countries, their challenges and the attitude of health officials to the Information system.
The research will be done in three months and I intend to carry out such that I will have a month for reading and gaining access into the organization, another month for collecting data and analyzing it, then the last month for writing.