National Health Care Systems: A Research Program on Globalization and Virtual Infrastructures
National Health Care Systems
Globalization and Virtual Infrastructures
American Medical Informatics Association Spring Congress
May 22-24, 2007
Ann C. Séror, MBA, PhD
To present a framework for study of virtual
infrastructures in national health care
To suggest issues for future research and
The Commonwealth Fund Report:
Mirror, Mirror on the Wall: An International
Update on the Comparative Performance of
American Health Care (May, 2007)
Ranking of UK, Germany, New Zealand,
Australia, Canada and the US on quality,
access, efficiency, equity and healthy lives
Health Care Systems
A health care system is a dynamic set of
interconnected individuals, institutions,
organizations, and projects offering products
and services in health care markets:
Patient care - preventative and curative
Overlapping distribution networks, systems brokerage
functions, and the adoption of a software perspective
emphasizing the devices and channels through which
information is processed and distributed.
Accessibility through Internet websites and gateways
designed to facilitate integrated use of the resources.
“VIRTUAL” describes any web-based service,
organization or institution arising from the technical
infrastructure defined above.
Economic analysis of national health care systems
shows that the important positive correlation
between gross national product and indicators of
health care quality such as life expectancy is
mediated by variables related to equitable
distribution of wealth as well as rates of public
expenditure in the healthcare sector.
Source: Sen A. Economics and Health. The Lancet 1999;354:20
According to evolutionary economic theory, the
transformation of organizational systems must
be examined within their social and institutional
contexts. This transformation emerges through
the “co-evolution of physical and social technologies”
where social technologies include institutions
and their network configurations.
Sources: E. J. Castilla, quot;Organizing Health Care: A Comparative
Analysis of National Institutions and Inequality Over Time,quot;
International Sociology, vol. 19, pp. 403-435, 2004; and R. R. Nelson
and B. Sampat, quot;Making Sense of Institutions as a Factor Shaping
Economic Performance,quot; Journal of Economic Behavior &
Organization, vol. 44, pp. 31-54, 2001.
Global health care services markets and networks
exert powerful influences on the institutional
ecologies of national health care systems.
These pressures pose the convergence hypothesis.
Compatibility between organizations and the characteristics
of their environments.
Response to external requirements for legitimacy rather
than functional efficiency or effectiveness in local service
Source: P. DiMaggio and W. Powell, 1983, quot;The Iron Cage revisited:
Institutional Isomorphism and Collective Rationality in Organizational
Fields,quot; American Sociological Review, vol. 48, 147-160.
Ideology: integrated theories and values that
constitute a coherent socio-political system
expressed in patterns of stakeholders’
participation in financing, administration, and
regulation of health care.
National Health Care Systems
Infomed – Cuban national health care network and portal,
Ministry of Health See Séror AC
A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications
Network and Portal
Journal of Medical Internet Research, 2006;8(1):e1
Ministry of Health and Family Welfare - India
Ministry of Health Online – Uganda
Kaiser Permanente – USA
British National Health Service – NHS – UK See Séror AC
Internet Infrastructures and Health Care Systems: a Qualitative Comparative
Analysis on Networks and Markets in the British National Health Service and
J Med Internet Res 2002;4(3):e21
COMPARATIVE COUNTRY CONTEXT
Country Cuba Uganda UK India USA
Population (millions) 11.3 28.8 59.7 1,103.4 298.2
Total Health 229 135 2,560 91 6,096
Expenditure per capita
External Resources (% 0.2 28.5 0.0 1.6 0.0
of total health exp.)
Private exp. (% of total 13.2 (2003) 69.6 (2003) 14.3 (2003) 75.2 (2003) 55.4 (2003)
Out-of-pocket exp.- 75.2 (2003) 52.8 (2003) 76.7 (2003) 97.0 (2003) 24.3 (2003)
percentage of private
Life expectancy (m/f – 75/80 48/51 76/81 61/63 75/80
Child Mortality (m/f per 8/7 144/132 6/5 81/89 8/7
Physicians per 1000 5.91 0.08 2.30 0.60 2.56
population (WHO 2004)
Literacy 97.2/96.9 79.5/60.4 99/99 59.5/48.3 99/99
(CIA World Factbook
Qualitative Case Analysis
Qualitative case analysis is a research methodology particularly
appropriate to the study of the health care sector.
Ragin CC. The distinctiveness of case-oriented research. Health Services Research, 1999, 34(5
Technological innovation and economic globalization drive rapid
changes rendering nomological model identification elusive.
Idiographic case research methods offer tools for descriptive
analysis and assessment of complex health care management
systems within their social, economic, and cultural contexts.
Sources: Séror AC. Internet infrastructures and health care systems: a qualitative comparative
analysis on networks and markets in the British National Health Service and Kaiser Permanente.
Journal of Medical Internet Research, 2002, 4(3); Yin RK. Enhancing the quality of case studies
in health services research. Health Services Research, 1999 ,34(5 Pt 2):1209-1224.
Multiple sources of data include:
Internet sites of the health care institutions.
Health Care Markets: Four Models
Control Clans Hierarchies
Free Markets Business
Norms and Standards : Behavioral Control- CLANS Institutional Infrastructures : HIERARCHIES
S PROFESSIONAL COVENANTS NATIONAL CONSTITUTIONS
U * PROPRIETARY NETWORK STRUCTURE (WAN/LAN). *PROPRIETARY NETWORK STRUCTURE (WAN/LAN).
P *Distributive multi-agent system architecture. *Federation architectures.
P *Subject gateways. *Institutional gateways.
L *Associative clinical process integration. (medical specialties) *Federative structural integration.
P *Access controlled by healthcare professionals. *Access controlled by institutional and telecommunications
U network structures.
S *Decentralized professional authority. *Centralized national and regional hierarchies.
*Professional criteria for presentation of Web content and other *Institutional standards for presentation of Web content and other
electronic healthcare information. electronic healthcare information.
*Professional certification of healthcare workers, services and *Institutional certification by network affiliation.
PROFESSIONAL VALUES CITIZENSHIP VALUES
Example: American Medical Association -http://www.ama- Example : British National Health Service -http://www.nhs.uk/
PRINCIPLE : System performance effectiveness: Universal
PRINCIPLE: Professional norms, Hippocratic oath. service and citizen equality. Social contract.
D FREE MARKETS BUSINESS CONTRACTS
E *OPEN INTERNET NETWORK STRUCTURE. *PROPRIETARY NETWORK STRUCTURES.
M *Search engines. *Corporate gateways.
A *Dynamic associative integration. *Federative business process integration. (business transactions)
N *Access controlled by individual consumer choices and *Access controlled by collective choices and network structures.
D availability of products and services in the market.
- *Decentralized and deprofessionalized authority with individual *Managerial authority with enterprise hierarchies governing
P consumer participation. institutions.
U *Certification of products and services by independent evaluators. *Certification of products and services by institutional
L evaluators, consumer organizations, and accreditation agencies.
L *Criteria for individual consumer evaluation of web content and *Criteria for collective consumer evaluation of web content and
other electronic information developed with consumer other electronic information by accreditation agencies.
CONSUMER VALUES MANAGERIAL VALUES
PRINCIPLE: Responsible self-regulation. Emergent norms. PRINCIPLE: Consumer contract efficiency.(cost/benefit)
Health Care System Transformation
Pressures for collaboration, data-sharing and access to
distributed resources increase the focus on interconnection of
services both within and across institutions.
Technological trends and commercial pressures foster service
decomposition and distribution through networks rather than
Three generations of medical informatics system evolution:
System creation at the enterprise or institutional level beginning in
Integration of enterprise architectures in the 1980’s
Horizontal linkage and coordination across contemporary system
Effective contemporary systems encompass components of all
Evolution of the CNHCS
Development of a science base and infrastructure (1959-1973):
early transformation of the health care system and creation of
integrated polyclinics (1963) to serve the Cuban population.
Elaboration of a centralized management model (1974-1989):
integration of information from various sources through
institutional information architectures. Introduction of community
medicine (1974) and subsequently (1984) the family doctor-and-
Horizontal coordination and globalization through virtual
infrastructures (1990-present): emphasis on national
infrastructure for institutional linkage through Infomed and
integration in international telecommunications infrastructures.
The Virtual Medical Library
Electronic access to diverse publications through the Cuban Virtual
Medical Library (1992):
- The U.S. National Library of Medicine.
- The Cuban National Library of Medicine.
- The collection of specialized Cuban medical journals.
Foreign authors contribute articles translated into Spanish, thus creating
a controlled electronic information market in medicine and health
The Cuban VML integrates resources from the developed and
developing world with a view to present the most advanced scientific
research, accounts of medical experience in developing countries, and
documentation of natural and traditional approaches to medicine.
The Virtual University
Inaugurated by the Ministry of Public Health in 1999, the Virtual
- An international center for postgraduate education in
medicine and related disciplines.
- Linkage between the health care publication infrastructure
and Cuban university resources.
- Linkage to international content such as the supercourse,
Epidemiology, the Internet, and Global Health.
- A Virtual Clinic for expert consultation among associated
physicians and healthcare professionals.
- A forum for discussion of cases presenting particular
The interactive design of the Virtual University promotes a
market for reciprocal sharing of expertise and learning.
The Pediatric Surgery National Network
Red Nacional de Cirugía Pediátrica (RENACIP)
Selection of the lead network institution: the Pediatric Teaching
Hospital quot;Octavio de la Concepción de la Pedrajaquot; of Holguín by
the Cuban Ministry of Public Health in 2001:
To develop the specialty of pediatric surgery throughout the
To make available high quality research results for the
practice of this specialty.
To link the resources of all the concerned health care
institutions across the country.
Source: Trinchet Soler RM, Pedrianes Vigo M., Origen, estado actual y perspectivas de la Red
Nacional de Cirugía Pediátrica. Acimed 2004; 12(3). Available at:
Identification of regional experts.
Creation of a discussion list for cases treated by designated
experts or through collective consultation and analysis.
Best practice protocols.
- Evidence-based development.
- Face-to-face discussion for approval.
Provincial university and enterprise alliances with the Cuban
Empresa de Servicios Informáticos
A virtual library specialized in pediatric surgery.
Linkage to international discussion lists focused on this and
Characteristics of the CNHCS
A systems perspective integrating health care service delivery,
research, information resources and education.
Horizontal coordination and integration through INFOMED and
telecommunications infrastructures with vertical control through
MINSAP and government hierarchy.
Government and health care administration serving social control,
universal citizen access and humanitarian service.
Dual health care service market structure with emphasis on open
information markets in education, research and practice
supporting trade on international services markets.
Privatization of information and science.
Protection of intellectual property.
Individual privacy and the common good.
Transferability and System Development:
Intellectual property and innovation
Individual privacy and confidentiality
Government and health care administration
Public and private sectors
Modern and traditional medicine
Cultural, ethnic and linguistic diversity
Educational attainment – literacy
Research community and innovation
Role of human resources
Evidence-based design of sustainable social systems.
Development of quantitative and qualitative
methodologies for system description and evaluation.
Cross-national research programs.
1. Séror A. A Case Analysis of Infomed: The Cuban National Health Care Telecommunications Network
and Portal. Journal of Medical Internet Research 2006;8(1):e1. Available at:
2. Séror A. Internet Infrastructures and Health Care Systems: A Qualitative Comparative Analysis on
Networks and Markets in the British National Health Service and Kaiser Permanente. Journal of Medical
Internet Research 2002;4(2). Available at: http://www.jmir.org/2002/3/e21/index.htm
3. Dallago B. The Organizational Effect of the Economic System. Journal of Economic Issues
4. Séror A. The Internet, Global Healthcare Management Systems and Sustainable Development: Future
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