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Page 5 of 7 Original Research

‘It’s a paradigm shift, how we used to work in the past, and now While the introduction and potential of electronic TB data at
we don’t work like that anymore. It’s tough, because many facility level can be considered an important step forward for
colleagues don’t trust the process; they’re used to a different the TB programme, many of the participants recounted
process. It is our responsibility as senior managers to turn those strong initial reactions and resistance towards the proposed
heads.’ (Participant 20, male, TB manager, 15 September 2016)
change that affected the efficiency and effectiveness of
implementation. These anxieties and resistances were
Given the breadth of the proposed change that some
participants felt the electronic facility level TB register concerned with: firstly, the vertical position of the TB
ushered in, participants at sub-district and district programme and TB programme data which ushered in
management levels spoke about the need for change changes to staff’s conventional, familiar roles and
management: responsibilities; secondly, with perceptions about the ‘new’
electronic register as deleterious and unnecessary and the
‘When introducing something, come with change management ‘old’ paper-based register as functional and reliable; and
to enable the people to grasp it and to internalise it. You get it thirdly how adoption of the new register would be facilitated,
today, and tomorrow must implement it. And that’s why people
put up these walls. Resistance, resistance.’ (Participant 14, which participants felt lacked a process whereby they could
female, TB manager, 05 August 2016) internalise the proposed change.

For staff at facility level, one of the most challenging aspects We make three recommendations for facilitating the
of implementation was related to their historic use of transition to an electronic TB register at facility level in South
paper-based registers and subsequent underexposure and Africa and for moving to integrated electronic systems in
distrust of technology. Some participants also voiced concerns general.
over the safety of electronic data during power outages, in
case of computer theft and possible system failures. As such, Firstly, implementers must invest in a process of change
computer literacy at facility level was a consistent concern of management alongside the transition to electronic facility
participants at all levels of the health system: level TB data in South Africa. Kuhn and Giuse define change
management as ‘the process of assisting individuals and
‘I think one of the shortcomings [in rolling out further] will be that organizations in passing from an old way of doing things to
colleagues aren’t excited about technology or that they are not 23
ready to embrace computers.’ (Participant 12, male, TB manager, a new way of doing things’. To be successful, a change
23 August 2016) management process should involve the management of the
practical aspects of the change (e.g. resources and training),
The question ‘Who is best-placed to capture TB data?’ divided and should address how the change might challenge the
TB stakeholders into two camps: those advocating for TB sense of security, confidence and identity that individuals
24,25
clinicians to continue to capture data and those advocating associate with the conventional or old way of doing things.
for the responsibility to be handed over to clerks as is the In the South African example, such a change management
practice in the HIV programme. In the two facilities with process must endeavour to achieve buy-in across all levels of
smaller patient numbers, the TB clinicians had quickly the healthcare system by identifying the individuals or
become adept at capturing TB data into the electronic register groups who will be affected by the change, and creating a
and drawing reports. At the time of the evaluation, clinicians space in which their anxieties can be voiced, acknowledged
in all three facilities were either responsible for or assisting and addressed. This process could be facilitated by
with capturing TB data and were regularly accessing reports showcasing experiences and outcomes from pilot sites and
on the system. providing practical examples of how challenges can be
mediated and resolved. In other TB treatment contexts, such
Discussion a change management process should involve prior formative
research, which can include desk research, to establish the
There are numerous factors that influence transition from health and political context within which the TB programme
paper to electronic records and information systems in health is required to transition. In particular, this involves
services. 13,16,17 These include organisational culture, for establishing how existing TB programmes and systems
instance, readiness of the organisation and its end users to function, the relational nuances between people and
adopt a new technology, 18,19 the ability of the innovation to programmes that might affect implementation (as is the case
integrate with existing, conventional workflows or to require between the HIV and TB programmes in South Africa) and
people’s loyalties to particular ways of operating within the
changes to it, 19,20,21 and more practical aspects such as TB programme.
computer literacy of staff which may influence how confident
they feel to successfully implement the innovation. As such, Secondly, individuals driving implementation should
15
even a seemingly simple replacement of a paper-based include individuals from within the TB programme in order
register with an electronic one may bring about important to bring expert knowledge of the existing system and to lend
shifts in power for different users by requiring adapted credibility to the proposed change. Implementers should
skillsets, resulting in complex changes to the status quo. directly address the potential challenges of transitioning,
These factors ultimately shape the response of those affected work with staff to set realistic expectations of individuals’
22
by the proposed change. roles and responsibilities and how these may change with
http://www.sajhivmed.org.za 254 Open Access