Healthcare information systems implementation for public healthcare service delivery in resource-constrained environments: a critical realist perspective

Abstract

Integrated healthcare service delivery has been sought after in healthcare systems worldwide. The integration of healthcare services involves adequate organisation and management of healthcare services, enabling the population to gain access to quality healthcare. Subsequent to the need for integrated healthcare services, there has been an increase in the implementation of technological solutions to manage and organise healthcare services. Technology interventions have long been perceived as operational efficiency enablers in an organisational environment, including in healthcare. Consequently, technology has become integral to healthcare service delivery. The global demand for better public healthcare services, especially in developing countries with constrained resources, has encouraged healthcare systems to turn to technology for innovative ways of delivery. Many healthcare systems in developing countries have implemented some form of technological intervention to facilitate their healthcare processes, such as data capturing and storage in healthcare facilities. In the healthcare sector, these technological interventions are often expected to improve the quality of the healthcare services delivered and also increase the safety of patients. These outcomes are usually attributed to the ability of these technological interventions to reduce documentation in the manual paper-based process, increase the efficiency of workflow and collaboration in the healthcare delivery process, facilitate better integration across the functional silos, provide real-time access to patient medical information, reduce costs, and increase turnaround times. Based on these reasons and other factors, the drive to implement technological interventions has experience a significant impetus. Regrettably, the implementation of technological interventions across most healthcare systems in developing countries has not yielded the desired outcomes, since healthcare systems have yet to realise the benefits that technological interventions present. Scholarly articles show that the implementation of technological interventions has often resulted in poorly coordinated systems, and implementation done in a silo ad hoc manner, resulting in fragmented systems with limited interoperability and software re-use, and a plethora of small pilots that are not scalable. Instead of technological interventions being enablers, in some instances they have resulted in inefficiencies attributed to the manner in which they are implemented and used in healthcare facilities. The inefficiencies include, among others, poor data quality and bottlenecks in workflow which impact the turnaround times in the healthcare service delivery process. Literature reports a variety of causes of these inefficiencies. This raises questions about causal mechanisms that have powers that may trigger enabling or inhibiting conditions for the implementation of technology interventions in the healthcare sector. While many studies on the implementation of technological interventions have focused on providing an understanding of factors that enable or inhibit the implementation process, little attention has been paid to discovering causal mechanisms that generate those outcomes. The current study sought to address this gap within the context of a resource-constrained environment. It argues that the implementation activities of technological interventions have causal effects on frontline users’ (healthcare practitioners) ability to use these systems optimally to deliver improved healthcare services. A further argument is that of generative causation, where recognition is given to underlying factors in implementation variances of similar technological solutions in different contexts. The study employs a case-study strategy using a critical realist qualitative methodology. Semi-structured interviews and document review were used as data-collection methods. Analysis was done using a thematic analysis technique through narrative and explanatory analyses. The study employs the Activity Analysis and Development (ActAD) model as an operational tool to identify, analyse and understand contextual mediators (such as goals/motives, procedures, actions, interactions and relationships between actors, tools) that could enable or inhibit public healthcare service delivery in a resource-constrained environment. Subsequently, the study draws on normalization process theory (NPT) as an explanatory framework to gain insight into the technology intervention implementation process and the extent to which these technologies become ‘normalised’ within a specific context. NPT helped identify and analyse generative mechanisms within the implementation process of technology that would evoke the mediators/outcomes in the healthcare service delivery process. The findings in the study highlight context-based mediators such as leadership and management, availability of adequate ICT infrastructure, healthcare policies and strategies, maldistribution of resources, and skills and competency, among others, to have enabling or inhibiting effects on healthcare service delivery in public hospitals. Further, the findings also highlight generative mechanisms such as the degree of coherence, cognitive participation, collective action and reflexive monitoring that have causal effects on the implementation process of technology interventions in a particular setting such public healthcare facilities in resource-constrained environments. The study contributes to the body of knowledge by illustrating the use of critical realism methodology to identify causal mechanisms in the implementation of technology interventions within a healthcare setting.