Comparative Health Systems
Conducting a comparative analysis of health systems can be extremely challenging, both methodologically and given the contextual nature of systems. Nonetheless, there is much to learn from examining the structure, financing and delivery of care in other countries where commonalities do exist. Given the substantial level of information technology (IT) investments made in many countries, healthcare IT is one area where there has been tremendous value in conducting comparative analyses to support policies. HIMSS (Healthcare Information and Management Systems Society) and the Global Enterprise Task Force published a detailed comparative analysis in their global review, Electronic Health Records: A Global Perspective. This in-depth report cites the value of identifying common threads among countries and harnessing the lessons learned to foster cross-border education and enhance planning. The authors conclude with 8 “overarching lessons across countries”. Of these eight lessons, 5 deal with stakeholder issues and the essential need to involve end users (i.e. healthcare professionals) in the political and implementation process. Intuitively, one would expect stakeholder relationships to be a fundamental consideration for any large scale health systems program, particularly in the IT arena. However, inadequate resources dedicated to advocacy and stakeholders is commonplace in programs across many sectors-public health, corporations, non-profits, etc.
Lessons Learned from the U.K.
On September 22, 2011, the UK Department of Health announced the “dismantling of the National Programme for IT (NPfIT)”, a decade long, $20 billion+ National Health Service initiative to implement national electronic health systems. In this striking example of a health systems failure, there are many lessons to learn–ranging from technical issues to those that deal with human nature. Although there was likely some political motivation for the shut down, most agree there were substantial implementation flaws, not the least of which was a top-down approach with little regard for end users and others affected by the program. The health department admits this flaw and states: “we need to move on from a top down approach and instead provide information systems driven by local decision-making.” The U.K.’s approach was the creation of a system that was centrally procured, mandated, and provided little incentive to encourage adoption by healthcare professionals.
Policy makers now have a stark example of the risks when stakeholder engagement is not a priority in the development of health systems initiatives. The NPfIT experience reinforces the need for stakeholder engagement as an ongoing, iterative process and as a central component of risk management in health system interventions. Establishing stakeholder relationships is time consuming and expensive. It requires a sustained effort from planning through implementation and the flexibility to make adjustments as new information dictates. Advocacy development is a sound risk management strategy and a prerequisite to maximize a program’s full potential. David Brailer, MD, PhD, the national coordinator for health IT in the Bush administration, echoes this view and highlights the value of comparative analyses in his statement to the NY Times: “The experience in Britain is a warning to us. The thing that brought them to their knees was the confrontation with doctors.”
The risks associated with poor stakeholder relationships are not just applicable to the healthcare IT sector, but also ring true for many other public health areas where successful implementation requires buy-in from those on the frontlines of care.