Ideas about what is important gain currency in the international development community with the regularity of ocean waves reaching the shore. As yesterday’s important idea recedes back into the ocean, today’s idea laps at our feet. A few years ago, the idea of country ownership came up in nearly every conversation about health information system (HIS) strengthening. We wanted to be sure that systems were not just dropped on a country, and that the country in question would value the system enough to use it and maintain it. After a few years, the salience of country ownership gave way to the idea of sustainability. The two terms share some elements—both express an interest in long-term maintenance. But this particular notion of sustainability explicitly included the transition of funding from donors to host governments.
While our feet are still wet from the wave of sustainability, a new wave has come our way bearing the name of resilience. Prompted in part by the challenges that West African governments experienced in responding to Ebola, the development community wants to see systems that can withstand the next shock. Recent meetings focusing on resilience include the May 2016 summit in Bangkok on Harnessing the Data Revolution for Resilience, and the July 2016 Cracking the Nut conference in Washington, DC, with the theme of “The role of communities in building resilient health systems.”
Each of these terms encapsulates important concepts that are worthy of our shared attention and our concerted efforts. But none of them can be achieved in the short time that they stay in the development headlines. Country ownership, sustainability, and resilience all require long-term commitments and collaboration. In their 2015 article on resilience, Kruk et al. describe slow and fast variables. Slow variables take a long time to change but are required for a stable platform of health care delivery. The development of health information systems and training people to use and maintain them are slow variables. Fast variables, like the ability to quickly implement quarantine and isolation units, rely on the presence of a stable platform.
With an infusion of resources, some slow variables can be sped up. But there are limits to what speed can achieve. Speed begins to work against country ownership, sustainability, and resilience when it is a result of centralized processes that exclude stakeholders. Including stakeholders in decisions requires time that allows for disagreement, discussion, and compromise. Without these, stakeholder buy-in is compromised, which reduces country ownership, sustainability, and resilience.
Just as speed has limits in what it can achieve, so does efficiency have its limits. In my research on organizational networks addressing HIV prevention and treatment, I have seen communities where a central organization holds sway, usually a large hospital, and where no other single entity stands out. In a centralized network, the main organization can bring about change quickly and efficiently, by fiat. It might say, for example, “If you want to work with us, you must use this form.” But centralization also makes the network vulnerable. If the main organization suffers a blow—say from a sudden decline in funding—the dependent organizations can quickly fall into disarray. On the other hand, where no single organization drives processes, if one of them fails, the others more easily adapt and carry on—the very definition of resilience.
Resilience is important. Too important to flirt with for a while, then discard for the next big idea. We should, indeed, consider it in depth and pursue it wholeheartedly. But the slow processes required are not sexy. For that reason, resilience is often paired with another trendy topic, like technological innovation. While some innovations can, indeed, speed our progress toward strong and resilient health information systems, let’s not lose sight of the fact that technological innovations in HIS are useful only when they extend the utility of the platform—not simply because they are innovative.
In building the platform, we must, for example, ensure that health care providers know how to collect high quality data, that they find it useful to their jobs, and that managers, planners, and policy makers are adept at using data in their decision making. As the next wave reaches for our feet, let’s resolve to continue the fundamental and slow processes of building systems that make everything else possible.