Complexity and Public Health Informatics in Low and Middle-Income Countries
Information and communications technologies (ICT) solutions in healthcare are becoming increasingly complex, interdependent, and large scale. Rapid changes in both the landscape of healthcare, with its increasing sophistication and number of services, and in the supporting ICTs, which are becoming internet, devices and cloud-based, are driving this development towards higher levels of complexity. The rapid scale-up of the internet and the mobile networks in low and middle-income countries (LMICs), and their combination—internet over the mobile network—have given health workers and communities access to the internet, even in the remote rural settings of LMICs. This vast and far- reaching new internet and cloud-based infrastructure is providing an electronic platform for the rapid scaling of ICTs in reach, as well as in scope and size. Health workers even in remote communities are becoming connected to the internet, using and getting familiarized with Google and social media platforms such as Facebook and WhatsApp. Given the enabling cloud-based infrastructure, the number and types of ICT solutions are rapidly growing and systems and data are increasingly being moved to the cloud, and ‘big’ data, as discussed in Chapter 5, is becoming the new paradigm. The increasing number of systems is followed by an increasing need for their integration, as the services they are reflecting have high levels of interdependencies. While the cloud and the internet provide a better platform for networking and interoperability between systems than did the ‘old’ stand-alone systems, the process of moving data and systems to the cloud as such is not leading to integration and it is, in most cases, only replicating the previous fragmentation with more data and technical sophistication.
Fragmentation and complexity of systems are two terms that are sometimes used interchangeably, but here we will emphasize an important difference. While fragmentation may be understood as a bit destructive in the context of health information systems (HIS), with systems being broken into small or separate and uncoordinated parts, complexity is a term used to denote that systems consist of many different parts that interact in multiple ways, such that the whole system seems to be evolving on its own. While the term fragmentation is referring to a lack of interaction and coordination, complexity may be seen as having a focus on the potential and actual interaction, both intended and unintended, between the different parts of an overall system. Complexity is therefore useful as a perspective to understand HIS and ICTs in the age of the internet, where systems have inherently increased interdependencies. In this chapter, we discuss different aspects of complexity and provide a model which helps provide a perspective to understand Expanded PHIs. The model conceptualizes complexity along the two dimensions of systems: being more or less networked, and, being more or less characterized by uncertainty as to the context of use.
Furthermore, we discuss strategies to manage complexity using the concept of ‘attractor for change’ (Plsek and Wilson 2001) from the field of complex adaptive systems (CAS). We conceptualize HIS as socio-technical systems where cultivation is suggested as a strategy for creating attractors for change and complex HIS.