Governance in Public Health Informatics
We can now go back over each of the challenges of public health informatics we discussed in Chapters 1-8 and map the governance role and challenges in each. Governance is a cross-cutting issue affecting all the domains discussed earlier. But there are some governance challenges, as in the development of standards or data policies, which are addressed more comprehensively in this chapter.
In Chapter 3, we discussed the constraints to the use of information. We noted that the potential for use of information for management action is highest at decentralized levels, and therefore the greater the commitment to decentralization, the greater the use of data. Centralized information systems designed with an almost exclusive focus on monitoring, as a form of vertical accountability, tend to encourage data of poor quality and discourage data use. Similarly, the less hierarchical the system and the greater its commitment to local empowerment, the higher is the likelihood of establishing conversations over data which can positively enable better data quality and use. A corollary is that information use at local levels is far more likely when stakeholders see themselves as a community of practice than as part of a command and control chain. These are all governance-related choices.
The less transparent and democratic the government, and the less given it is to the rule of law, the more it is penetrated by vested interests. This translates to greater pressures on the health information system (HIS) to become a tool for control or surveillance over populations. In response, the workforce will seek to generate only those versions of the truth as are convenient to it and to subvert the systems of control being exercised, and what they believe the ‘top’ wants to see.
In Chapter 4, the problematic discussed was of ‘integration. Multiple systems with different ownerships emerge rapidly, often duplicating each other, but even when under pressure to do so, they are unable to communicate with one another. Although to the lay observer the government is a homogenous monolith, in practice it is quite heterogeneous internally with multiple centres of power: different programme management divisions within each department (i.e. each disease control department, or the maternal and child health division); different departments within the government (such as for IT, health, audits, procurement, and so on); and different levels of government in a federal polity (federal, provincial, district, and local administrations). Furthermore, the government also has to negotiate a wide variety of external pressures, ranging from external donors and corporate forces, to civil society groups—each with different information requirements and priorities. Courts and the legal process can intervene in unpredictable ways. There is also a legacy that present governments inherit from the past.
Therefore, should not such multiple centres of power be fewer in less democratic or plural societies, and least in, say, military dictatorships? On the contrary, the impression we have from having worked in a large number of low and middle-income countries (LMICs) is that these problems are invariable— and perhaps more so where political power is centralized. Where processes of negotiation are explicit, transparent, and well-documented, they are likely to hold better across stakeholders, and for a longer period of time, than when decisions are pushed through by a sleight of hand, or by someone with the transient authority to ride roughshod over others’ views. But negotiations in a terrain that is so technically demanding will always be characterized by high degrees of information asymmetry and uncertainties about future developments. Addressing them requires its own particular governance and institutional mechanisms.
We have discussed the problematic of integration to involve building consensus at least on three levels: creating data standards including data and metadata; creating technical standards specifying common codes of communication and storage; and, most challenging at the level of institutions, creating the readiness for them to be transparent and collaborative in their endeavours.
Other than institutional mechanisms, this multilevel integration requires a visionary leadership—ideally a democrat with necessary authority, and who exercises it judiciously. To no one’s surprise, that is currently a rather tall order across most nations.
In Chapters 5 and 7, a host of new technologies related to the cloud and big data and their ensuing complexity are discussed. Here a number of new governance challenges emerge. One is reconciling potential benefits to population health, with risks to individual privacy; as technical developments continue to outpace legal advances, or even administrative and civil society’s scrutiny. Many LMICs and emerging economies do not have adequate laws in place to define or safeguard privacy. Another challenge is to define ownership over data given the multiplicity of actors involved, the geographical dispersion of where the cloud is, how data is used and reused, and the ambiguity of jurisdiction. Data is often collected by an agency for one stated purpose, and then further exploited for a number of other purposes including commercial ones. The definition of ownership, and of owners’ rights to data, as well as a definition of what information should mandatorily be put up on the public domain, are eminently governance functions. With respect to design of the cloud architecture and related new technologies too, government has a stewardship role- to promote technologies less susceptible to vendor lock-ins and more supportive of innovation, allow for ease of upgradation and greater degrees of participation, and above all to push for capacity development within nations so as to defend sovereignty and local ownership.
In Chapter 6, the discussion is about institutions, those of healthcare provisioning, management, policymaking, and financing. If we understand institutions as rules of the game, the pre-eminent role of governance is rulesetting and the pre-eminent rule-setter is the government. However, management of all organizations—the players of the game—need the autonomy to define their own processes and rules within a larger rule framework defined by governance. Such rules define their relationships with other organizations and boundaries within which they operate and exercise decision-making, and demarcate areas that are out of bounds. Where governments are direct service providers of health or IT services, their internal rules have a major influence on the domain, since they are by nature a large-scale monopoly on the terrain.
In Chapter 8, we have discussed the challenges of futuristic public health informatics solutions using the examples of universal health coverage (UHC) and Sustainable Development Goals (SDGs). Governance is concerned with futuristic agenda setting; defining new needs for information and technical solutions to meet those needs. Predicting the future is complex, full of risks, and definite expertise is limited. Governance then is about making technical and institutional choices where taking particular paths does not preclude other choices which may become relevant in the future.
One area of governance not discussed earlier, but which is central to the regulatory and stewardship roles of governance is the setting and implementation of IT standards, and establishing a general policy on data. Both fall more in the realm of IT governance than health governance, but with important overlaps. We discuss some of these issues in the next section.