Moving Forward: At the Level of Policy, Academics, and Practice

The era when the health information systems could be perceived as a tool for health sector reforms is behind us. Health information systems,, in our understanding, are better perceived as co-evolving with health systems—requiring similar policy environments for facilitation and overcoming institutional barriers for their performance. However, this rather negative portrayal of the problems that beset current public health informatics should not in any way detract from the potential of ICTs to revolutionize the performance of healthcare systems in LMICs, or the determination to work towards this; as Gramsci once said, ‘Pessimism of the intellect, optimism of the will’. It is the duty of academic thought to lay out the problems, barriers, and approaches, just as it is the task of implementers and governments to factor these in and move forward. The experience from other sectors, like banking and transport where informatics has revolutionized performance, provides the impetus to try again and do better.

An understanding of health sector reform which sees HIS as contributing to improved performance primarily through enhanced vertical accountability and results-based financing is a limited and questionable vision. Instead, enhancing organizational capacity with and through Expanded PHI needs to be made a central and guiding vision. Expanded PHI has the potential to transform the healthcare system to enable a dynamic learning and adapting system, to make decentralization effective, to improve quality of healthcare at costs that would be unimaginable for the developed world.

Clinical and biomedical informatics have already demonstrated that transformations are possible in individual patient care, in resource-rich Western environments. But with Expanded PHI, this continuity of care needs to be made possible across multiple episodes of care provision, providers, administrative levels, and sites of care. This approach has the potential to optimize solutions in contexts where there are massive structural constraints such as overcrowding, lack of skills, poor infrastructure, suboptimal healthcare-seeking behaviour, health inequities—all constraints that clinical informatics is seldom called on to grapple with. Finding appropriate solutions for Expanded PHI thus provides unique opportunities for innovations in both research and practice.

Currently existing HIS in LMICs have evolved to support roles of programme monitoring and measuring utilization of select services, including in a more limited way in logistics. Unfortunately, the last mile(s) of data quality and reliability, of use of information and the fragmentation of information, have remained stubbornly a bridge too far for the reform process. Expanded PHI holds out the promise of being able to close some of these gaps by identifying the barriers and overcoming them through a combination of technological and institutional innovation.

However, the real promise of Expanded PHI is in transforming the current models of care delivery, the measurement of health, and governance of health systems. But this requires informed political choices, including the build of a truly dynamic participatory information architecture by multiple communities of practice, where conversations over data interpret it, where legal and regulatory mechanisms safeguard the individual rights, and where systems of interoperability integrate and increase access to public information while helping to rationalize work burden of data providers. Such a choice has the potential to build the healthcare systems of the future, helping LMICs close the gap with developed nations in health outcomes at much lower cost and time requirements.

To reach out to this promise there are three levels of movement: policy; research and academia; and practice and activism. Each of these are now discussed.

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