Access to reliable information for healthcare workers in developing countries: an international perspective

‘Providing access to reliable information for healthcare workers in developing countries is potentially the most cost-effective strategy for improving the quality of healthcare delivery.’1 Yet there are many gaps in our understanding of information needs, and the international community has hardly begun to build a coherent cross-sectoral approach to meeting those needs. The current article will look briefly at the challenge, from an international perspective, of improving access to the practical information needed to deliver the safest, most effective healthcare possible with available resources. It will argue that the international community needs to clarify its approaches to different target audiences. Looking particularly at national ministries of health (MoH) and ministries of education (MoEd) as being the primary holders of responsibility at national level, the article will conclude that a coherent international co-operative approach is needed to complement and strengthen national programmes. In many developing countries, healthcare workers often have little or no access to basic practical information. Indeed, many have come to rely on observation, advice from colleagues and building experience empirically through their own treatment successes and failures. Information is important not only for effective healthcare, but also to support the generation of new knowledge and solutions from the South, and to allow critical interpretation of the relevance and quality of the highly variable new information that is increasingly accessible, particularly through increased access to information and communications technologies (ICT). What information support do healthcare workers need to deliver the best quality of care with the available resources? Needs assessments are limited by difficulty in differentiating ‘wants’ from ‘needs’. All who have undertaken such assessments are familiar with respondents recommending texts published ‘when I was a student’, perhaps 30 years beforehand. Many have little knowledge of appropriate, affordable products that might be currently available—even those produced within their own country. However, there are a few consistent messages from trainers and students alike. All practical information should be clear, simple and appropriate to the target audience. The ability to write plainly and simply is a rare skill that requires a combination of abilities in communication and language, as well as an understanding of the language level of the target audience. Equally importantly, it must be locally relevant —much of the information currently available to healthcare workers in the South is irrelevant to local needs. It must be in a language that is accessible, preferably the first language of the reader. And it must be reliable. Too many health workers in developing countries have to rely on biased information from pharmaceutical companies, out-of-date or irrelevant information from unselective donors in the North, or materials produced without adequate source materials or editorial resources. Information needs to be easy to use and accessible at the point of care. As stated by the Shaughnessy equation ‘The usefulness of any source of information is equal to its relevance multiplied by its validity, divided by the work required to extract the information.’2 A further consistent message is that the introduction of information alone is seldom effective unless it is integrated with training and learning activities. Access to information is not enough in itself for that information to be used and applied effectively, particularly in situations where health workers have previously ‘got by’ without it. There is an important role for trainers to encourage use of materials in libraries or ‘resource centres’, and such resources and collections are currently the only cost-effective way to provide help in finding information and access to relatively large numbers of books, whether through reference or lending systems—the latter often being restricted to the older, less useful texts. (The following is based largely on experience in Africa, but may be applicable to other areas of the developing world.) At national level, and particularly in sub-Saharan Africa, the responsibility for meeting the information needs of healthcare workers generally lies with the MoH and MoEd. Typically it is the training unit of the human resource division within the MoH that is responsible for meeting the needs of in-service healthcare workers plus all pre-service healthcare workers in nursing, midwifery, environmental health and laboratory technology. The current model for the ministry of health to carry out its function is through a dual system of (1) libraries or ‘resource centres’ in training colleges, hospitals, etc. and (2) local production of health learning materials (HLMs), often in partnership with local commercial publishers. Local production needs an increased skills base, particularly in writing and editing, and better access to quality source information. Also, given the need for highly selective prioritization of new publications, commissioners of health learning materials programmes need clear information about what is already available, appropriate and affordable—locally, regionally or internationally. Such information is currently unavailable or highly dispersed. A recent study by Healthlink Worldwide of the National Health Learning Materials Programme (NHLMP) in Ghana illustrates the above. The NHLMP is part of the Human Resources Division of the Ministry of Health and has the responsibility, with very limited resources, of meeting the information needs of some 30 000 preservice and in-service healthcare workers throughout the country. It is meeting this challenge through a dual strategy: support and advice for resource centre staff in hospitals and training colleges across the country, and its own modest publications programme. The main target audience (namely, responsibility) of the NHLMP’s own resource centre in Kumasi is health information workers throughout Ghana—not the local health workers who happen to live near the centre (although the latter would of course be welcome and would probably find the collection at least as useful as an ad hoc collection for health workers). To meet the needs of health information workers—and the commissioning staff of its own publications programme—the NHLMP in Ghana would like to be able to develop (or at least have access to) a unique collection of single reference copies of internationally recognized, appropriate and affordable HLMs for district healthcare workers, published both internationally and within Ghana. In international terms, such an approach would have minimal cost (involving a single selective collection for each country) but would require access to something that does not yet exist: a single authoritative source of information on recommended international publications that is reliable, affordable and appropriate for use by district healthcare workers. The MoEd in most countries is responsible for medical students, dental students and pharmacy students. It is the MoEd that is responsible, for example, for university and medical school libraries. Such libraries are usually the national reference point for medical texts in general, and specialist texts and journals in particular. Their priorities are clearly highly diverse depending on their level of resources, and correspond closely with those of university libraries in general. A detailed analysis of several university libraries in sub-Saharan Africa, including the Muhimbili University College of Health Sciences Library and the University of Zimbabwe Medical Library, can be found in Rosenberg’s University Libraries in Africa. 3 A healthy local publishing industry is essential for sustainable access to relevant health information, not least because there will always be gaps between what is correctly available and affordable internationally, and what is needed locally. Key areas to address include production, dissemination and access to locally or regionally produced materials, and co-publishing of low-cost standard texts. Better access to information on currently available titles might be useful to help plan publications programmes in response to emerging gaps and needs in the market rather than ad hoc contacts and approaches by authors. Local publishers are perhaps particularly important in meeting the needs (in co-operation with ministries of health) of healthcare workers at district and community level, as well as the production of practical manuals and textbooks for training colleges and in-service training. In both cases, personal ownership of appropriate core materials is probably at least as important as access to a resource centre. In the context of the present article, the term ‘international health information community’ refers to all persons with a professional interest in improving access to reliable information for healthcare workers. The field is diverse, and includes representatives of non-governmental organizations and international agencies, publishers, librarians, healthcare worker representatives, educationalists, health information professionals, and communications technologists, among others. The community is a complex web of individuals and organizations, North and South. In 1994 the British Medical Association and INASP (International Network for the Availability of Scientific Publications) hosted a meeting to look at a question that had not previously been addressed in a multisectoral context: How can the international health information community work together more effectively to meet the information needs of healthcare workers in developing countries? 4 The meeting showed that individual organizations were doing excellent work, and professional associations existed to provide sectoral support at global and regional level. However, there was little if any cross-sectoral co-ordination, despite the common objectives of the various players. Partnerships, where present, had formed in an ad hoc fashion, with gaps in coverage and duplication of effort. It could be argued that some approaches had created parallel systems of access bypassing rather than building on national capacity. In general no-one knew who was doing what. The conference called for a complementary cross-sectoral approach to create a shared understanding of needs and priorities, and ways of meeting those needs. To help develop such an approach a neutral focal point was needed, to foster mutual support, to share ideas and to build a foundation of information about health information activities, for the benefit of present and future players. INASP accepted the challenge and developed plans for the INASP-Health programme in consultation with some of the leading players in the UK. With seed money from the UK Department for International Development, INASP-Health was launched in 1996, and continues to be supported by Danida, the British Medical Association and the International Council for Science. The approach is to provide a neutral focal point to build co-operation, analysis and advocacy among organizations involved in health information access. INASP-Health has developed an advisory and referral service with an international network of over 600 organizations and individuals, and is mapping the activities of health information organizations world-wide, as described in the biennial INASP-Health Directory. 5 In 1998, in response to demands from INASP-Health network participants, INASP-Health launched the Health Information Forum (HIF), which shares the objectives of INASP and provides a ‘blank canvas’ to build a picture of information needs and priorities through debate and exchange of ideas, through meetings and e-mail. In line with the principles of INASP-Health, HIF seeks to be transparent, inclusive and neutral, and its remit specifically excludes activities that might compete with existing organizations. It is not in itself a provider of health information, but serves to facilitate interaction among organizations to develop more effective ways of working, both individually and collectively. In future HIF seeks to internationalize its participation and to act more effectively as a platform for healthcare worker representatives and health information workers in the South. It also seeks to strengthen debate and exchange of ideas with related sectors and networks, including educationalists, health communications experts and information professionals. Further information about INASP-Health’s activities, including reports of all Health information Forum workshops, are available on the INASP Website < http://www.inasp.org.uk>. Mapping of activities is one thing. An even greater challenge is to promote the co-operative development of a coherent cross-sectoral approach. The World Health Organization has recently taken up the challenge to work with the ‘health information community’—using INASP-Health services and the Health Information Forum as a tool—to build such a framework for co-operation between WHO and health information organizations. The aim is to develop a strategic framework to clarify priorities and the respective roles of WHO vis-à-vis other organizations, laying the foundation for a more coherent, co-operative approach in the future. The framework will draw on as wide a range of perspectives as possible and will be built co-operatively in open consultation with healthcare worker representatives, health information workers and other sectors concerned with improving access to health information. In conclusion, there is massive potential for international development co-operation in supporting national and local programmes to improve access to reliable information for healthcare workers in developing countries. The international organizations should be clear and informed in their responsibilities and roles relative to one another. And their activities should be demand-led and based on a shared understanding of needs and priorities from national and local perspectives. The author would like to thank Irene Bertrand (Library and Information Networks for Knowledge, World Health Organization), Ana María Cetto (National Autonomous University of Mexico), Francis Devadason (Asian Institute of Technology), Carol Priestley (Director, INASP) and Diana Rosenberg (consultant, INASP) for their valuable comments on the draft of this article.