Questions for Carl Leitner

This interview is one in a series introducing the people of iHRIS to the global iHRIS community. To nominate someone to be featured, please leave a reply below.

Carl Leitner is a core member of the iHRIS team located in Chapel Hill, North Carolina. He has been instrumental in developing the iHRIS core software as well as in training programmers worldwide to develop and customize iHRIS. He has a PhD in Mathematics.

Interview by Adam Gori

OLYMPUS DIGITAL CAMERAWhat is your role within the larger iHRIS community?  

When I started working with iHRIS back in 2004, I was just one of the developers for the iHRIS software. A lot of the work I do now is less about programming and more about mentorship and interoperability.

Recently a lot my effort is dedicated to working on the Care Services Discovery (CSD) standard profile. CSD is a system that links data on health workers, health facilities, and health services and makes that information accessible across a health information system. We are encouraging broad adoption of CSD in the global open-source health-information-systems community in order to reduce the deployment  overhead, the interoperability burden, and ultimately to promote the use of health worker information.

Standards that capture health worker information already exist. Why is there a need for CSD?

There are two issues here.  First, CSD was designed to address use cases in a way that surpasses the other existing standards. It really digs into a core issue — rather than simply listing healthcare providers, it determines the availability of healthcare.

Second, when we want to work in low-resource settings, we need to be aware that those standards are not free of charge. You have to pay for them. Personally I’ve always been really hesitant to get into these standards because I didn’t want to create an artificial dependency. CSD is different because it’s published by IHE, which has an open-access policy.  This means that all the standards, references, and examples are publically available.

And not only that, it’s free to participate in the development and refinement of the IHE standards. Any organization can join IHE and participate without any kind of fees. That allows, for example, ministries of health to get involved very directly with IHE without having to pay what can often be very high fees.

In a recent story on your involvement in CSD, you say that you are particularly excited about how CSD “opens the door to citizen-centric access” to the health system. What does that mean to you?

Traditionally it’s been very difficult to pool information about different countries’ health systems, whether it’s who works where or how many nurses there are. Part of it has just been a problem of managing the data, and that’s where iHRIS has played a large role over the years, helping countries manage that data. Now that that data is starting to get tamed and usable, we want to make it as useful and broadly accessible as possible.

Uganda comes to mind. They designed an app where anybody can type in the name of a doctor to see if that doctor is actually qualified, helping eliminate “quack” doctors. That kind of citizen access to information really can help locate problem areas and create pressure to improve the health system. If a government is willing to make health-worker information public, there is a whole community of people who want that information.

If we were to have a broad adoption of CSD, then we can readily imagine an app designed around CSD that could be quickly adopted in other countries.  It also drives the creation of a marketplace of apps — a competition within the country to see who can design the best app to look up a doctor, the best app to find the closest delivery room. That type of access to information is really critical, and that’s what CSD does a good job of opening up.

You feel strongly about open-source communities and systems. 

I’m a huge fan of open source, and I have been for a long, long time. I think it does some really great things. One of the hazards I think we need to be careful of is that there are so many different tools and so many different ways to do things. It’s so open, and there’s so much flexibility, that it can be pretty daunting for somebody who’s new.

We deploy in countries where the developers have not seen computers until they were in high school, and then never touched one until they were in college. They didn’t have the luxury that I did growing up in the U.S. and having computers since 2nd grade. I think one of our important roles is figuring out how to reduce the learning curve when we deploy these systems so that it’s not such a huge amount of new information to absorb all at once. We want to make these systems implementable without putting undo burden on the health IT staff for a ministry of health.

In your mind, what makes this seem doable? It seems like such a monumental task. Are you an optimist? 

I don’t think optimism is the right word. It’s more “duty.” I have a fundamental faith in the people who are implementing the system, the people in-country, who have a need for these systems.

They don’t want to have to write their own software from scratch, they don’t want to waste their time doing that, they have a lot more important things to do. They want to get to the information they need. So anything we can do to help as many people in as many countries as possible without duplicating effort I think is what we have to do.

I have a skill, and I intend to apply that skill to stamp out some of the inequities that exist in our world. It’s not an optimism. It’s a pessimism. In certain senses, we live in a very sad and horrible world, and I want to make it better. I see that as being part of my responsibility, of everyone’s responsibility, to try and “repair the world.”

What do you hope to achieve through your work?  

I want to make it so that other people can take and do the work that I currently do. I don’t want to create any kind of dependence on me. I want to help make it so that different countries and organizations have the skills to respond to their needs on their own, without needing people like me to come in and do the work for them.

I feel that the gap that we have, especially in computer skills, is really more of a temporal gap. We were exposed to computers so much earlier in our lives. We simply have a lot more familiarity. I want to see the countries that aren’t as resourced as we are gain an equal footing. I think that is one of things that is exciting for me about the CSD work — this temporal gap is minimizing, and more countries are ready to take CSD and make it theirs.

One of your colleagues described you as a leader in the international effort to establish standards and guidance for these types of national systems. Do you see yourself in that way? 

I’m more interested in  getting things done. I’m not shooting for a leadership role. If the most effective way to get these things done is to push some of this forward, then I can see how someone could construe it as my assuming a leadership role, but it’s not what I’m trying to do for myself.

It seems like you would come to the fore simply because of your passion for these issues. Why do you feel so strongly about these issues? 

It’s getting back to the idea that this is a gross injustice in the world, and I just have a particular skill set that can help address those issues. I just feel morally bound to try to address those issues.

What would you say is the most frustrating part of your work? 

What’s most frustrating is that there is so much demand. I can’t meet all that demand. And the help that I can offer is often tied too much to specific countries and to specific projects based on donor interest. I end up using my own time, putting in extra hours, to help where it’s needed.

What have been the highlights in your time doing this work?  

I think a lot of great things have happened. As an example, in Guatemala they have been able fairly rapidly to customize iHRIS to use their systems. They’re now identifying ghost workers. They’re going to use iHRIS to streamline the deployment of new contracts for new health workers, hopefully reducing the time that people wait to get paid from six months to a few weeks.  A streamlined system can really improve the recruitment and retention of health workers, thereby increasing access to the health system.

Another good example is Zanzibar. I started working there in 2008. They had a completely paper-based system. You couldn’t really answer any questions; you had to sort through all those paper folders. Now you can go to the Ministry of Health website for Zanzibar, and you can get a full 20–30 page document on the HRH profile for the country, based on data that’s coming from iHRIS.

They’ve used that data to justify hiring new health workers, where previously those hires had been on hold because of poor data. Because of iHRIS, and because of the ability for people to use that data and to advocate for changes to the system, we are improving services for people on the ground. This is a reality. This is happening. I feel that I played a role in helping that happen. That has certainly been a highlight.