Health Informatics Developments in Low and Middle-Income Countries
This domain of health informatics has been largely absent in most LMICs with a few exceptions, such as in China and Brazil. In China, a key focus has been on hospital information systems, aimed at minimizing unnecessary waste and repetition, and subsequently promoting the efficiency and quality- control of healthcare. By 2004, China had successfully spread their hospital information systems through approximately 35-40 per cent of nationwide hospitals, with a high degree of regional variations, with the east being far ahead than the north. China has been greatly improving its health informatics since it finally joined the World Trade Organization (WTO), and is simultaneously also improving its higher education. At the end of 2002, there were 77 medical universities and medical colleges in China, and 48 of these offered Bachelor’s, Master’s, and Doctorate degrees in medicine. In 2003, Severe Acute Respiratory Syndrome (SARS) played a large role in the rapid improving of the healthcare system, with the hospital information system being swiftly expanded to cover 80 per cent of hospitals. Comparisons with the Korean healthcare system have also spurred the Chinese to strengthen their health informatics component.
Similarly, in Brazil, the first applications of computers to medicine and healthcare started in around 1968, with the installation of the first mainframes in public university hospitals for supporting the hospital census in the School of Medicine of Ribeirao Preto and patient master files in the Hospital das Clinicas da Universidade de Sao Paulo. In the 1970s, several hospitals acquired computers for various units such as intensive care, cardiology, diagnostics, and patient monitoring. In the early 1980s, with the arrival of cheaper personal computers
(PCs), a great upsurge of computer applications in health ensued, and in 1986 the Brazilian Society of Health Informatics was founded, the first Brazilian Congress of Health Informatics was held, and the first Brazilian Journal of Health Informatics was published. In Brazil, two universities (University of Sao Paulo and Federal University of Sao Paulo) offer undergraduate and postgraduate programmes in medical informatics.
There are limited other examples noted in LMICs regarding the institutional development of health informatics as a field of academic specialization in established educational institutions. This is despite the fact that in nations like India, Thailand, or South Africa, the introduction and use of health informatics products in their top private corporate hospitals was usually on par with that in the hospitals of developed nations. This is similar to the difference between importing the latest car or MRI machine, and being able to design and deploy one. However, there have been significant developments taking place in informatics for primary healthcare in LMICs.
While as an academic discipline the field of health informatics has not really evolved in LMICs, tremendous experience has been generated in the practice of building systems to support primary healthcare, largely population- based efforts through national routine systems, for specific programmes such as immunization, mother and child health, tuberculosis (TB), and Human Immunodeficiency Virus (HIV). Since the 1980s, various LMICs have made reform of these information systems as an integral component of their health system strengthening efforts, supported by strong donor investments. However, the potential of these IT projects has been largely untapped, and Heeks (2002) has noted that about 90 per cent of such efforts have been complete or partial failures. However, this has not deterred governments and donors. On the contrary, efforts have accelerated, especially in the last 5 to 10 years.
Various global initiatives have contributed to this increased interest in IT for health projects. One significant effort was by the Health Metrics Network (HMN), set up in 2006 as a Secretariat of the WHO to help countries develop and implement national strategies for the strengthening of systems. HMN developed a framework based on principles of data warehousing, which sought to create common repositories of shared data that could satisfy the information needs of a wide range of stakeholders, rather than developing individual standalone systems for particular programmes or departments. This data warehousing approach, drawn from the enterprise architecture framework and geared to addressing the problem of fragmentation of information systems, achieved significant success in the short lifespan of HMN. Many countries developed strategies and started implementation of such models. Some countries like Sierra Leone made significant advances, also becoming a role model for other countries in West Africa. However, much longer-term efforts and support were needed to enable full fruition of the HMN initiative, which did not happen.
Traditionally health informatics deals with a diverse range of systems including health management information systems (HMIS), EHRs, clinical decision support systems (CDSS), laboratory information systems (LIS), radiology information systems (RIS), picture archiving and communication systems (PACS), Telehealth, and various others. LMICs largely have subsystems of public health information systems for health administration support, district health management, hospital management, procurement, and logistics support (for drugs and other supplies), human resources management systems, geographic information systems for health, disease surveillance, emergency response support, healthcare financing systems, and various others. These different systems have varying supporting infrastructure and platforms. Such systems could be of little or no interest to clinicians per se—but public health management increasingly depends on such systems and cannot do without it.
New technologies are often positioned as silver bullets to solve problems that are necessarily health or institutionally related. The extensive deployment of mHealth (mobile health) applications and the resulting ‘pilotitis’ reflects efforts which die as small-scale pilots. While web-based deployment of systems is increasingly becoming the norm in many LMICs, there are institutional considerations of ownership, access, and data regulation which are matters of intense debate, some of which we take up in this book. From the perspective of institutional and technological conditions in LMICs, considered design choices are required which can account for the diversity of media and platforms, and where paper often remains the dominant one. Another key aspect of the informatics positioning concerns the discussions on standards. While medical standards like SNOMED CT and HL7 are becoming widespread, their relevance cannot be ignored by LMICs, as they carry various political and commercial dimensions. Public health systems are also engaging with more routine standards concerning nomenclature, formats, and periodicities. Building understanding of these different standards, and how they relate (or not) to each other will be an important focus of reform efforts in the future.
Today, the scenario with respect to health IT has changed dramatically with the proliferation of new tools such as web technologies, mobile devices, other forms of data entry devices, cloud computing, and improved models for technical integration. The growth of open source software solutions helps countries to avoid lock-ins to large-scale and failed proprietary-based systems, and experiment with relatively lesser risks. Web-based systems, based on open source software, have been instrumental in enabling countries like Ghana and Kenya to develop national scale HMIS. These developments have been made possible through access to cloud computing, an issue which we discuss in detail in Chapter 5.
Now many LMICs are experimenting with different forms of name-based or individually focused systems. India has developed a mother and child tracking system (MCTS) for tracking pregnant mothers from the time of their first antenatal registration, through different stages of their care including delivery and postnatal care. This MCTS is also designed for child immunization, to track by name of the child the vaccination cycle from the first dose to full immunization. In Ghana, there is a line listing application being used to register births, although only to record the events, not to track them. In Tajikistan, there are ongoing efforts to create a system to register all civil registration events of births and deaths. Many countries are seeking to track individual TB or HIV cases. This shift to the use and tracking of systems based on names raises various new and unexplored issues, including those related to system design, integration, governance, data privacy, security, and infrastructure requirements. Furthermore, while there is an explosion of data which becomes available, the capacity to use it is not growing in the same manner. In subsequent chapters, we will try to explore these issues from a PHI perspective in order to understand how to shape research and practice.
In summary, most LMICs have made significant progress in the last decade on strengthening their systems in support of primary care systems, which are primarily aggregate and population based. Efforts to strengthen individual- based systems at the community level through recording and tracking are typically at a nascent stage, with limited ability to be aggregated to a population base. The focus on EHRs has been largely absent in most LMICs, but is likely to grow in the future. While efforts in practice are rapidly evolving, academic studies in health informatics in LMICs is not moving at a comparable pace.