A Case For a More Expanded Public Health Informatics Focus in Low and Middle-Income Countries
The discussions in section 1.5, Summarizing Trends in Informatics and Health Informatics, have broadly emphasized a patient-centric approach to health informatics being dominant in rich counties, and a more population-based primary health approach being evident in LMICs. These two streams have largely excluded the other, both in practice and academia. Our book is about trying to develop an ‘expanded public health informatics’ approach that transcends both these kinds of systems, with the unifying element being an interest in strengthening population-based health systems. So, this will involve design approaches which allow individual systems to be aggregated to a population- based one, and the ability to drill down from aggregate systems to individuals to help prioritize action where it is needed most. However, to this end, two disconnects are currently evident: one, between developments in the West and those in LMICs; and two, between practice and academics within LMICs.
While health informatics has grown by leaps and bounds since the 1960s, and with increasing pace in the last couple of decades, such growth has been limited in LMICs. Academia in LMICs lags significantly behind practice, with few exceptions. Brazil and China have shown growth in both practice and academics, but with a primary focus on hospital-based information systems and EHRs, as is also the case in the rich countries. Various LMICs have embarked on strengthening their HMIS, including the collection and processing of routine aggregate data, and transmitting them from the periphery through various administrative levels of the district, province, and national levels. Various books, papers, and PhD theses have been written by scholars (mostly based in Western universities) on the subject, with limited outputs coming from local in-country scholars. Academic institutions in LMICs have so far not engaged in the study of such systems in their contexts, resulting in practice far outpacing academia.
In studying national HMIS implementation efforts through their HISP (Health Information Systems Programme) research and development initiative, the efforts of the Department of Informatics, University of Oslo, Norway, are significant. HISP as a research programme was born in 1994 in South Africa, supported by Norwegian State funds. HISP was bathed in the Scandinavian action research tradition and had four inter-connected components: one, research into the design, development, and implementation of HMIS in LMICs; two, the design, development and support of open source HMIS software called DHIS (District Health Information Software—http://www.dhis2.org) at national and lower levels in countries; three, establish a Master’s programme in health informatics; and finally, PhD research involving LMIC scholars registering for academic work in Oslo, and studying problems germane to their respective countries. Through these respective inter-connected efforts, now spanning more than two decades, Oslo has established collaborative Master’s programmes with universities in Mozambique, Malawi, Tanzania, South Africa, Ethiopia, and Sri Lanka. There is a full Master’s programme in health information systems being offered by the University of Gadjah Mada, Yogyakarta in Indonesia. Other than these, there are no fully established Master’s courses in this subject specifically in and for LMICs. However, various universities in LMICs are trying to establish single courses or modules within public health Master’s programmes and sometimes within informatics.
Our direct experience in engaging with the Oslo-collaborated educational programmes has helped us to understand the tremendous demand for health informatics in LMICs, which spans at least the disciplines of public health and informatics, and the need for a ‘health information systems’ framing. The high number of efforts with computerization ongoing in most LMICs creates an urgent need to strengthen the national educational base, which can contribute to strengthening the national autonomy and ownership of systems, and simultaneously reduce crippling levels of donor dependence. From an academic perspective, health informatics provides for a unique subject of study currently ignored by universities.