Planning - for every project it is crucial to have an idea of where you’re going and what you want to happened. For health information systems this is a make-or-break deal. Innovation being developed will change the system. It has to be accepted and integrated for it to stay - to be sustainable. So how do we do that?
Based on a study by Richard Heeks, the success or failure of a HIS can be evaluated by measuring the design-reality gaps - the amount of difference between the ideal design and what happens in reality. He determined that there are seven dimensions of HIS that can be evaluated he called IPTOSMO. They are information, technology, processes, objectives and values, staffing and skills, management systems and structures, and other resources like time and money.
Kimaro and Nhampossa did a comparative case study of two HIS projects from Mozambique and Tanzania to determine the problems that need to be resolved to make HIS sustainable in developing countries. They determined that there are three key sets of relationships between the user organisation (called the Ministry of Health in the study), the systems developer (called the software development agency), and the donors. They recommend that communication and cooperation between them is required for the HIS to succeed.
So incorporating both of these studies, we can see that each of these three core groups have responsibilities in each of these seven dimensions. Forgive the redundancies, but it is important to know that they are all important for the HIS to work in the long run.
The project begins with a plan. During the initial phases, it is important for each group to communicate what their objectives and values are. Each group usually has their own vision of the project, but this may be in conflict with the others. So all groups have to come into agreement of what the the project will encompass. This way, everyone’s expectations on it will be on a similar page.
Next, the system developer needs to design the system, this includes the process involved, management systems and structure, technology and information used. To do this, they need to understand the current situation of the system. This is where the user organisation is important. They must provide the developer with a background - their experiences and knowledge of all these things so that they can get an idea of how to improve the system. During this phase, the system developer needs to explain their design (or designs so that there are options) to both the user organisation and donors so that they understand what is involved and how it can be done. The developer doesn’t have to go through all the nitty-gritty with them, more of the general idea. This way, each group can provide suggestions on how to improve the system before actual testing.
Donors at this time should also think of how to allocate their resources for the project. This requires that they understand the design of the system and a background of the resources situation from the user organisation. They have to coordinate with other donors to prevent redundancies with other HIS projects. The three groups must then agree on how resources will be used.
With the donors now ready to provide resources, the implementation phase can begin. This is where all the hardware and software are installed. The developer has to gather and organise the information in the new system and teach the users how to use and eventually maintain the system, as they will not be there to do it for them forever. This is where the users have to learn the details of the technology and processes. During this, the users can develop into hybrids. Hybrids are individuals who can be considered members of two of these groups - in this case, a user and a developer.
It is important to note that this process will take a long time. Small changes can be introduced first, and slowly the complete new system will be implemented. This prevents the users being shocked by the change and can slowly appreciate and accept it. Meanwhile, the donors will continue to back the project in increments, to make sure that the resources don’t dry up.
During this phase, all three groups will discover problems - things that they overlooked. It is important that they continue to communicate these problems with one another. That way the design can be adjusted to solve these issues.
Now we get to the long-term, which involves maintenance of the system. This step is crucial for sustainability. This is when most of the support from both the donors and developers will take the backseat, and the users will be tested. The knowledge they gained from the developers has to be passed on to new users to make the system grow. This where hybrids are important as they, now as the experts, can teach others. The users can continue training by holding seminars and exercises to see if their new skills have improved. Hybrids are also important in that their new skills can help the user organisation fix new long-term problems that were not discovered during implementation. The remaining resources have to be used wisely to keep the system up and running. Users may find other sources for them, such as new donors or income-generating projects of their own.
It is important that both the developer and donors return from time to time to monitor what has happened to the project. They can be part of the continued training and exercises. Feedback from the users is important so that they can suggest solutions for problems that hybrids could not solve on their own and consider them in future projects. All these things have to be part of the plan so that all three groups are prepared for them.
Keep in mind that this is still a general framework of how an HIS project can be sustainable. As Heeks explains, the real world will not always meet what is ideal so adjustments have to be made to get to what is close enough to the original design. There may be some steps here that are not feasible for certain situations. Heck, some are close to impossible with the current culture, politics, and economics of our country. That’s why flexibility is important. It’s why I keep saying that the plan has to be modified or adjusted each step of the way.
At the present, HIS in developing countries have a high chance of failing, with so many social, economic, and political factors going against it. Coordination between all groups involved is important for system sustainability. While it will take time for people to accept and integrate to innovations, with the proper planning and a whole lot of tweaking, it might just reach that small chance of success.
Sources:
- R. Heeks. Health Information Systems: Failure, Success, and Improvisation. (2006). Int J Med Informatics;57:125-137. Retrieved from Universitetet i Oslo website: http://www.uio.no/studier/emner/matnat/ifi/INF5761/v12/undervisningsmateriale/Heeks%20-%202006%20-%20Health%20information%20systems%20Failure,%20success%20and%20i.pdf.
- H.C. Kimaro, J.L. Nhampossa. The Challenges of Sustainability of Health Information Systems in Developing Countries: Comparative Case Studies of Mozambique and Tanzania. (2007). J Health Informatics in Developing Countries;1:1(1):1-10. Retrieved from Journal of Health Informatics in Developing Countries website: http://www.jhidc.org/index.php/jhidc/article/viewFile/6/34.
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