Using Complexity Theory in Health Systems

The research identified here suggests that the continued dominance of paper-based systems and the apprehension of paperless systems in South Africa’s public health sector can be summarised to themes of convenience and low user acceptance. This argues for a public sector inhibited by entrained thinking or patterned behaviour. Through a social-cultural lens, we can conceptualise digital HIS as being a form of disruptive innovation in the work environment because it creates significant changes to work procedures and processes.

Simon et al. (2007) propose that the ability of a new system to integrate into the daily workflow hinges on the extent to which the workplace culture embraces quality and innovation, the attributes of the health workers involved, and technology-related factors in the workplace (such as whether the existing workplace utilises email, computer-based scheduling systems or e-prescribing) (Cline & Luiz, 2013). Goldzweig’s et al. (2009) study of the cultural barriers to electronic health record (EHR) system implementations found that 77% of health facilities without EHR were resistant to EHR systems, 72% and 64% of physicians believed that a shift towards HER systems would lead to frequent downtime and increased work time respectively, and 60% perceived insufficient computer competencies (Cline & Luiz, 2013). Cline and Luiz’s (2013) study explored attitudes towards system automation among doctors, nurses, and hospital administrators employed at two public hospitals (Albert Luthuli Hospital in KwaZulu-Natal Province and Sebokeng Hospital in Gauteng Province). The findings highlighted that hospital staff who were conditioned to non-automated environments were not significantly bothered by the inefficiencies of paper-based processes (Cline & Luiz, 2013).

In their study of nurses’ preparedness to adopt a paperless environment in a private hospital in the eThekwini municipality in KwaZulu-Natal, Ramharuk & Marimuthu (2015) found resistance to change to be a significant inhibitor, with over 60% of respondents indicating resistance to working in a paperless environment and 20% indicating a neutral perspective on a paperless environment. Their study also found that nurses’ perceived usefulness and perceived ease of use of Health Information Technology (HIT) served to enable HIT usage, with this being strengthened by any related knowledge and perceived compatibilities that they possessed.

Matlebjane & Ndayizigamiye’s (2022) study which interviewed four IT and four healthcare professionals revealed that fear of the unknown, change or new processes may be barriers to the adoption of novel HIS (specifically Blockchain). A medical doctor from the study stated: “… [F]ear of the unknown and people thinking that I don’t know this, I’m comfortable with what I’ve always used. But on another level, it’s just, I don’t like computers, I’m still happy with what I’ve been using. There is no genuine reason why it cannot be adopted, but, it’s like whenever there is a change management approach that needs to happen, it is always the same case.” (Matlebjane & Ndayizigamiye, 2022, p. 6).

The CSIR’s unpublished report interviewed selected government department officials to explore the hindrances to the adoption of digital transformation since the National e-Government Strategy and Roadmap was gazetted in 2017. The responses described an inherent risk and complexity, as well as a lack of “e-readiness” needed to implement e-Government initiatives (Maremi, Thulare, & Herselman, 2022). Dodoo, Al-Samarraie, &  Alzahranif (2021) suggest that the lack of e-readiness among countries in the SADC region is reflected in the low buy-in of telemedicine systems from healthcare professionals and bodies such as the South African Health Professional Council (Dodoo, Al-Samarraie, & Alzahrani, 2021).

This apprehension to digital transformation might not just limited to healthcare providers and professionals. Willie and Nkomo (2019) research shows that despite several medical aid schemes utilising electronic application forms through their mobile apps, 75% of respondents in a survey did not use the app, with some of the general sentiments being a lack of perceived benefits and the app’s complexity (Willie & Nkomo, 2019).

The extent of challenges faced by South Africa’s public healthcare sector has seen it prioritise the opportunity cost of improving basic infrastructure, stringent human resources appointments, and the purchasing of medicine and consumables to improve access to care in a dire economic environment. This is despite growing evidence demonstrating IT’s ability to improve capacity and resource utilisation by freeing up other ‘valuable inputs’ and the plummeting costs of and increased accessibility of information technology (Cline & Luiz, 2013; Mehl & Labrique, 2014). For example, (Appari, Eric-Johnson, & Anthony’s (2013) study of 3,921 acute-care Community U.S. hospitals that transitioned to electronic health systems showed significant process improvements (Appari, Eric Johnson, & Anthony, 2013). It also demonstrates decades-old supply-and-demand thinking observed in many low-to-middle-income countries (LMIC) (Mehl & Labrique, 2014).

 

Using Complexity Theory to Unpack the Problem

A social-cultural perspective of this challenge allows us to unpack its complexity through the concepts of entrained thinking and path dependency. Entrained Thinking refers to a conditioned response that has been acquired through past experience, training and success and is being implemented to solve a challenge under new conditions. This prevents new ways of thinking that would be more appropriate in this new reality. These ‘de facto’ decisions emanate from expertise and experience, rather than framing the health system as a unified and complex system and trying to understand the patient's journey throughout the health system (Fulop & Mark, 2010). In the healthcare context, these socially accepted thinking patterns can accumulate without being noticed and result in erroneous system-wide and decade-long struggles (e.g. The Growth, Employment, and Redistribution Policy) (Fulop & Mark, 2010).

Path dependence theory assumes that the initial events can increasingly limit present and future choices. These are random events that initiate “loops of positive feedback” and become “locked in” or sustained through recursive actions or decisions that perpetuate themselves. The reinforcing events become considerable influences that limit the future potential courses of the pathway “to a very narrow set of possibilities”, which can allow inferior processes or technology to retain a dominant presence (Burman & Aphane, 2017). The critical juncture in the path dependency process is when a positive feedback loop that incorporates the past into emerging future action potentials, is initiated.