Qualitative Case Analysis for Study of National Health Care Systems

Research in science policy, institutional economics, telecommunications, and organization theory has contributed to the growing literature on health care system performance, management and control. The current focus on health care system reform in the U.S. has made apparent the lack of relevant research evidence from country level studies. While many policy makers point to a fragmented health care delivery infrastructure, few reform efforts are framed at the national system level. Systems thinking seems anathema in an ideologically restricted political process.

The premise of my program of research is that study of configurations of virtual institutional health care infrastructures is critical to understanding global and regional health care ideologies and market dynamics. Little research has considered the effects of telecommunications and internet infrastructures on these dynamics, largely because theory, methods and tools have not been adapted adequately to analysis of these structures and processes profoundly transformed by new technologies at every system level.

Such analysis requires qualitative research strategies because of increasing system complexity and high rates of social, cultural and technological change. First, case analysis facilitates validation of patterns identified in data collected from diverse sources and construction of comparative frameworks from grounded theory principles. Historical analysis exposes the logic and possible path dependence of system evolution as in the phases of system creation through local unit design, control through centralization, and integration through horizontal coordination.

Another promising qualitative approach is system mapping for sociometric analysis of virtual infrastructures and their contributions to health care services markets and hierarchies. System configurations reflect institutional patterns of information management and control, including free market and centralized social medicine dynamics. For example, density or connectedness may describe the number or proportion of possible linkages appearing in a network, while hierarchy or dominance may describe the distribution of linkages throughout the network. Configurations may be interpreted as complex systems or as cases embedded in a broad context.

Taken together, case analysis, historical analysis and system mapping offer strategies to approach study of the important coherence between underlying ideologies and virtual health care infrastructures.

Some published research programs address country level case analysis of national health care systems - with a view to creation of an evidence base for comparison. Most extensive among these is the program of the European Observatory on Health Systems and Policies of the World Health Organization. The data collected for the 25 member states of the European Union include: (1)Health Systems in Transition (HiT) profiles, (2) other health-related information such as reports from institutions and health reform policy papers, and (3)
links to health-related web sites - ministries of health, national public health institutes, and research centers for health policy, public health and health economics.

The most recent template (2007) for development of Health Systems in Transition (HiT) country profiles includes some data on HIT in sections on planning and health information management (4.2) as well as physical resources (5.1). Information technology must be defined for each country profile in the context of a national IT strategy for the health care system as well as general statistics on Internet access and usage.(page 74)

Another research program on ehealth in national health care systems was initiated by the Rockefeller Foundation in the series of conferences at the Bellagio Center on Making the eHealth Connection organized by the World Health Organization-July-August 2008. The themes covered in the collection of country case studies include:

1. The path to inter-operability


2. Public health informatics and national health information systems


3. Access to health information and knowledge-sharing


4. eHealth capacity building


5. Electronic health records


6. Mobile phones and telemedicine


7. Unlocking eHealth markets


8. National eHealth policies

One background paper addresses The Case for a National Health Information System Architecture: A Missing Link to Guiding National Development and Implementation (by Stansfield, S.; Orobaton, N.; Lubinski, D.; Uggowitzer, S.; Mwanyika, H.) According to the authors, "a national health information system (HIS) plays an important role in ensuring that reliable and timely health information is available for operational and strategic decision making that saves lives and enhances health."(page 1) While this definition is generally acceptable, the strong ideological bias evident in the report is not. The enterprise architecture framework has been applied in the context of the U.S. federal government, but requires a careful adaptation to each country culture under consideration for health care sector applications. For example, in the Latin American social medicine tradition, the definition of health care work flow as a business process would be unacceptable.

The country case studies available in the collection are South Africa, Turkey, Vietnam, Rwanda, and Peru. These studies are generally organized according to the conference themes listed above as adapted by the authors. The greatest weakness of this research program is the lack of a theoretical framework or logic to guide methodological choices as well as data interpretation. Comparative analysis of the cases is especially hampered by lack of theory and the convenience sampling of country cases. According to Yin, selection of a single case for analysis may reflect a typical, critical, or unique set of observations for theory development. I have learned in my study of BIREME (Brazil) and INFOMED (Cuba) that regional leadership dynamics must be taken into account in case selection, and that regional network structures may be critical in the understanding of national health information systems.

Other collections of country studies of interest to researchers on national health information systems include Health Systems Country Briefs produced by USAID (August, 2007) to identify areas for investment in effective health systems strengthening. Published briefs include Mozambique, Rwanda, South Africa, Tanzania, and Zambia.

Earlier case studies (2005-6) examined the systemwide effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria on the national health care systems of Benin, Ethiopia, and Malawi. The interim report on findings from these three cases focused on Global Fund effects on the policy environment, human resources, the public/private sector mix, and the pharmaceuticals and commodities markets.

The larger Global HIV/AIDS Initiatives Network including researchers in 21 countries conducts research on how these programs affect national health care systems. The GHIN promotes cross-country case comparability through common research methods, builds research capacity, informs health care policy through multi-country comparisons, and coordinates dissemination of research conclusions and recommendations. The GHIN has contributed to the WHO Positive Synergies Initiative to strenthen its institutional role in national and global health policy. The WHO also publishes a very useful set of country profiles including data for cross-country comparisons.

The International Telecommunication Union offers country case studies by region and topic-providing context for analysis of national health information systems. (Many of these cases require an update.) Another series of ITU cases (2000-2004) addresses Internet diffusion in various stages of country development. (See also publications of the Mosaic Group on the Global Diffusion of the Internet Project.)