Managing information systems for health services in a developing country: a case study using a contextualist framework

Abstract

Investments in information technology (IT) have been escalating in the health sector in both developed and developing countries. However, the failure rate of applications is of concern especially for countries with scarce resources. There is insufficient understanding of factors that lead to such failures in developing countries. A case study of implementing a computerised information system (IS) for health services in the Philippines is analysed using a contextualist framework. Factors that led to the failure included ambiguity in the organisation and in responsibility for the project, lack of capacity to undertake large information systems development projects and inability to retain appropriate staff. However, when the historical and contextual issues were revealed and the interplay between the content, process and context of the change was analysed it was revealed that the content of the IS was not responsive to the changes in the wider health system. The case study confirms the need to analyse and understand organisational, environmental and cultural issues in adopting models and procedures used elsewhere when managing information systems in developing countries.

Introduction

Investments in information technology (IT) have been escalating in developed countries over the last two decades and managers in the business sector have been increasingly sceptical of the efficiency of these investments (Magnani, 1990). Spending in the health sector seems to portray similar trends in implementing information systems (IS) for the health services (De Luca, 1991). On the other hand, the failure rate of applications is high enough to be of concern, (Lorenzi & Riley, 1994) There are examples of successful implementation of computerised information systems in the health sector of developing countries (Wilson, Echols, Bryant & Abrantes, 1988). However, due to the scarcity of resources, even failures of systems with modest investments translate to a major loss with high opportunity costs to the health systems in poorer countries. It has been shown that the causes for such failures and the poor performance of IT diffusion in developing countries is due to the variance in cultural values with the process of IT adoption (Walsham, Symons & Waema, 1990; Madon, 1992). Vendors of IT, mostly from developed countries tend to focus on technical issues for solving “information” problems of developing countries, though the urgent need is to deal with the management of the technology (Mohan, Belardo & Bjorn-Andersen, 1990). At a meeting held in the Western Pacific Regional Office of the World Health Organisation (WHO), countries of the region identified major problems of introducing IT to be (a) lack of skilled computer programmers leading to reliance on expatriate staff, (b) dearth of maintenance and back-up support and (c) the lack of standards for hardware and software. They did not identify skills in management of the technology or IS project management to be an issue (World Health Organization Regional Office for the Western Pacific, 1990). Many of the developing countries represented at the meeting at that juncture (1990) had only very modest investments in IT in health services. This situation has changed over time, with significant investments in IT often funded with donor-aided projects and bank loans.

Studies in developed countries have shown that introduction of computerised IS has been used to serve the interests of those in power (Danzinger, Dutton, Kling & Kraemer, 1982) and as a tool that changes the power balance (Barley, 1986). In a case study of implementing a Computerised Rural Information System Project (CRISP) in India, the IS served to reinforce the cultural context maintaining the power of the higher levels over the lower levels of administration (Madon, 1992). This study showed that IS by itself cannot force the abandoning of long established ways of administration. To successfully implement a computerised system for health services in Chad, the implementors identified that a key factor was the need to reinforce the organisational (administrative) structure whereby issues of `power’ and `territory’ had to be taken into account (Foltz, 1993).

The question of `appropriateness’ of the technology to the environment was also investigated in Chad (Foltz, 1993). The creation of an environment favourable to the introduction of technology was considered critical in this case. Other factors recognised as essential were the need to have consensus development (where both users and collectors of data were involved in the design) and leadership from top management. In India, special training of senior staff at decentralised levels was necessary to ensure that they obtained the `technology’ before their staff. This was identified as a critical factor for success (Madon, 1992).

Foltz (1993, p. 359) states that `the process used for adoption is the most important factor for determining whether the technology is implemented and whether it survives'. In a developing country context computerised IS adoption and its survival also centre around the issues of technical capacity for maintenance of the technology. In Papua New Guinea (PNG) the importance of hardware and software support was recognised as one of the key factors of success of the Provincial Information System. The recurring need to change or enhance the software placed extensive pressure and created dependency on expatriate IT personnel (Campos-Outcalt, 1991). In PNG, the importance of standards of software development was also an issue, as incompatibilities arose when different expatriate programmers were involved.

The implementation of computerised IS in developing countries tends to suffer from the assumption that models utilised for developed countries are appropriate without recognising the idiosyncrasies of the organisation and the culture. The potential for developing countries to `leap-frog’ the stages of IS development using technology has been often stated. However, there is insufficient identification of factors that need to be considered in managing computerised IS in developing countries especially to avoid the pitfalls which have been encountered in developed countries.

A case study of a computerised information system in the health sector in a developing country will be used to tease out the issues and factors that impinged on its evolution. The need for an appropriate framework to understand the historical, procedural and contextual character of the change will be presented. Issues and their context will be illustrated with examples from multiple sites that provide similarities and contrasts in the process and context. Finally, the paper will discuss issues that need to be considered in improving IS management in health services of developing countries.