Globalization: implications for health information professionals

DOI: 10.1111/j.1471-1842.2007.00761.x

International perspectives and initiatives Blackwell Publishing Ltd

Globalization: implications for health information professionals Jeannette Murphy The genesis of this column stems from the Editorial Board’s decision to expand the journal’s content and authorship to attract new audiences and enable current readers to broaden their horizons. The journal’s original remit was to inform and educate those working in the health library sector. In recent years, the Health Information and Libraries Journal has expanded its coverage to appeal to those working in health informatics. The journal is also seeking to attract authors from regions that have not been so well represented in the literature, such as South and Central America, the Caribbean, Africa and the Middle East. The purpose of this issue of the column is to speculate as to how globalization is likely to impact on health information professionals and to relate this to the three case studies published in the previous issues of this journal. What is globalization? There are many definitions of globalization and different perspectives as to its likely consequences. ‘Globalization is one of the characteristics that define the beginning of the 21st century. Yet, there is no single agreed definition of what it is, and there are widely divergent views of what it means in terms of its economic and social repercussions, including its impact on health. What is clear is that it is a multidimensional process encompassing economic, social, cultural political and technological components, and that it defines much of the environment within which health is determined.’1 p.3 Woodward et al.1 see economic globalization as a key element of globalization and a critical determinant of how it impacts on health. They describe economic globalization as a process made up of three interrelated components:

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1 cross-border flows of goods, services, capital, people, information and ideas; 2 increased pressure for the development of international institutions and rules regulating national policies in relation to such flows; 3 further increases in the level of cross-border flows as a result of regulatory changes.1 p.3 In a paper directed towards the UK Faculty of Public Health Medicine in 2000, Lee highlights the diversity of perspectives on globalization: ‘For economists, globalization is an emerging global economy; for international lawyers, it is threatened changes to the legal status of states and their citizens; for information technologists, it is a global information networks; and for researchers in cultural studies, it is the potential creation of a global culture through, for example, the mass media.’2 p.254 Globalization and health There is a growing literature on the topic of ‘globalization and health’, including an Open Access journal (Globalization and Health).3 The World Health Organization website has a variety of programmes and projects relating to globalization, one of which is Globalization, Trade and Health.4 The Carnegie Endowment has an online course devoted to Health and Globalization.5 Challenges of globalization for health information professionals There is a very limited literature dealing with the consequences of globalization for health information professionals. A  search retrieved one article from 2005 by Madge and Plutchak relating to health librarians.6 A Chartered Institute of Library and Information Professionals (CILIP) workshop in 2003 touched on the topic of globalization. Margaret Watson pledged support for the international dimension of CILIP’s work and referred to the consequences of globalization on

© 2008 The author Journal compilation © 2008 Health Libraries Group. Health Information and Libraries Journal, 25, pp.62–68

International perspectives and initiatives Table 1 Features of globalization New global governance structure

Globalization influences the interdependence among nations as well as the nation state’s sovereignty leading to (a need for) new global governance structures.

Global markets

Globalization is characterized by worldwide changes in economic infrastructures and the emergence of global markets and a global trading system.

Global communication and diffusion of information

Globalization makes the sharing of information and the exchange of experiences around common problems possible.

Global mobility

Global mobility is characterized by a major increase in the extensity, intensity and velocity of movement and by a wide variety in ‘types’ of mobility.

Cross-cultural interaction

Globalizing cultural flows result in interactions between global and local cultural elements.

Global environmental changes

Global environmental threats to ecosystems include global climate change, loss of biodiversity, global ozone depletion and the global decline in natural areas.

Source: Huynen et al. The health impacts of globalisation: a conceptual framework. Globalization and Health 2005, 1,14.8 doi: 10.1186/1744-8603-1-14.

the information market place.7 However, a search of the CILIP website produced no major reports or guidance on this topic. The Medical Library Association (MLA) website mentions the issue of globalization in various annual reports. As it is difficult to directly demonstrate the consequences of globalization for health information professionals, in this article a more indirect approach is adopted. If we look at the impact of globalization on health, this should help us to tease out what globalization means for those who work in the field of health information. Huynen et al. have proposed a conceptual framework to make sense of how globalization impacts on health.8 Table 1 identifies what they see as the important elements of globalization. Using the model developed by Huynen et al., together with an analysis by Pang and Guindon,9 I have identified a number of ways in which globalization is likely to impinge on health information professionals. Global health governance Globalization will result in global health governance being increasingly influenced by bodies such as the World Health Organization, the World Bank and the International Monetary Fund. For example, these organizations now have the power to determine whether a country has the right to ban the import of products on health grounds. For national govern-

ments to successfully ban products such as hormonetreated meat, they must be able to cite sound scientific evidence.8 Health librarians will play a key role in marshalling and summarizing available evidence. One can anticipate a range of governance issues where librarians may be asked to produce guidance for clinicians, one example being issues relating to patients seeking treatment outside their own country. Multilateral trade agreements such as the TradeRelated Aspects of Intellectual Property Rights (TRIPS) are of direct concern to health information professionals. TRIPS sets the minimum standards of protection for intellectual property rights. Although it is intended to strengthen incentives to create new knowledge, there are concerns as to the desirability of treating knowledge as a global public good. Woodward et al.1 p.5 note that this could skew research towards the health needs of the rich rather than the poor. Speaking at a CILIP workshop in 2007, Ruth Rikowski drew attention to the ways in which World Trade Organization treaties are likely to affect fundamentally the way information services operate.10 In her view, library and information services are being commodified as a result of World Trade agreements. Global markets Globalization is predicated on cross-border flows of goods, services, capital, people, information and ideas. These flows are driven by and give rise


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to new markets. In the health sphere, there are potentially three different markets relating to: health information, health information and communication systems and health care services. Markets for health information One aspect of globalization with direct consequences for health information professionals is the way in which global communication and global mobility are transforming ‘knowledge capital’. There is a growing demand for online information for clinicians, health service managers, students and the general public. One manifestation of this new market is the ‘globalization of education’, which has the potential to improve health training and health education. ‘Because of new technologies, most colleges and universities are able to work together with academics from different countries, students have ample opportunities to study aboard and “virtual” campuses have been developed.’8 p.7 Health librarians, in collaboration with academic colleagues, are playing a key role in designing and delivering these online courses. There are also new opportunities to share evidence globally about the outcomes and effectiveness of health care. Eisenberg (former director of the Agency for Healthcare Research and Quality) argued that the challenge facing knowledge managers is to find ways to translate global knowledge so that it meets local needs.11 ‘For policymakers, the challenge is making that knowledge available without assuming that global health care means identical health care; in other words, to globalize the evidence but localize the decision.’11 p.167 Health information professionals can play a central role in ensuring that globalized evidence is tempered by three competing core values: choice, efficiency and equity. ‘In strengthening the local use of global evidence, all health care participants will need greater and faster access to evidence-based medicine, professional commitment to translating evidence into practice,

and a practice philosophy that embraces shared decision making.’11 pp.167–8 Markets for health information and communication systems As well as global markets for health information, there are also global markets for health information and communication systems. The development of such information systems can be carried out anywhere in the world and then tailored for local implementation. Indeed, a majority of the systems used in UK libraries and hospitals have been designed elsewhere. Likewise, systems adopted in developing countries are highly likely to have been designed, piloted and implemented in Europe or North America. Heeks has written extensively on the problems that may arise when information systems are transferred from the First World to developing countries.12,13 He contends that globalization has in the main carried ideas and systems from industrialized to developing countries. When an information system is created within and for an industrialized country, and then subsequently transferred to a developing country, the likelihood of system failure is high. ‘In such situations, the actuality of local conditions in the developing country will not have been considered at all in the original design, and a considerable design–actuality gap is therefore likely, leading to a significant risk of IS failure.’12 p.106 Heeks provides an example from the Philippines of a project to introduce a field health information system designed according to an American model which took for granted the presence of skilled programmers, skilled project managers, a sound technological infrastructure and a need for information outputs like those used in an American health care organization. None of these assumptions was correct and the system failed.12 Markets for health care services There are major barriers to the creation of international trade in health care, the most important being the need for direct physical contact between suppliers and consumers, and the fact that in many



countries health services have traditionally been subject to strong government involvement.14 Writing in Healthcare IT News, Matthews15 suggests that so far the health care industry has been resistant to outsourcing and offshore services compared with other industries. ‘This is due to many factors including environment, culture, regulatory/compliance requirements and other risk related issues. Healthcare’s payer and supplier sectors appear more aggressive with these services than the provider sector.’15 However, there are signs that health care services are also impacted by globalization. We are starting to see the use of offshore services in a variety of health care areas including medical transcription, teleradiology, claims processing, programming, report writing, interface development and call centre and help desk support services.15 In the UK, a Department of Health document reveals that a review has been underway into the possibility of allowing sensitive NHS patient data to be processed overseas.16 These forecasts about the future of health care are echoed in a report by the European Molecular Biology Organization,9 which notes that the globalization of trade is particularly relevant for health services that have become a commodity that can be traded across borders. The examples cited include a range of telemedicine tools, such as tele-diagnostics and tele-radiology, as well as medical consultation through traditional and electronic channels. According to Chanda,17 health services themselves have become an industry that attracts foreign investments. Several trans-national companies from developed and developing countries have already created commercial health services through the purchase and establishment of hospitals.17 Some countries, especially developing ones, can attract customers by offering high-quality health care at a lower cost than is available in their home country. And although this practice is relatively uncommon at the present time, Segouin et al.18 predict that, within a short time, this practice will greatly expand, partly as a result of the development of global standards of quality and the rise of processes of accreditation, both in health care and medical education.

Global mobility In the health care sector, global mobility applies to service providers, service users (patients) and the workforce itself (clinicians, medical secretaries, laboratory services, as well as health information professionals—librarians, health informaticians, clinical coders, medical records staff, audit staff and IT staff). These developments may, in future, have implications for health information professionals. The circulation of patients In recent years there has been an increase in what has been termed ‘medical tourism’. For example, treatments offered in western Europeans countries attract infertile couples from the USA because they cost half or one-third of those provided in North America. Elective surgery offered in highly sophisticated Indian hospitals tends to cost only 10–20% of identical treatment in western countries.18 p.277 ‘Patients can travel abroad to receive health care or use certain facilities—the UK government recently allowed UK patients to seek treatment in the European Economic Area (Lowson et al. 2002). Other countries, including developing ones such as Cuba and India, openly advertise to attract foreign patients to their clinics and hospitals.’9 p.3 We are also seeing a shift from personal initiatives to national incentives, with countries actively encouraging other states to send patients for treatment. Tunisia, for example, organized a conference at the beginning of December 2004 to attract health care purchasers from abroad. Purchasers, even those belonging to public systems, can potentially be interested when a reduction of costs by as much as 50–80% can be realized.18 Information professionals who work with patients will need to prepare themselves to provide appropriate information to enable patients to decide whether to travel abroad for treatment and what steps they need to take if they decide to do this. Migration of health care workers Along with the movement of patients seeking health care outside their own country, globalization


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has brought the international movement of health personnel across borders. There is evidence that this aspect of globalization is having detrimental effects on developing countries (e.g. Chanda17 and Pang et al.19) A study from 1998 estimated that 56% of all migrating physicians flow from developing to industrialized countries, while only 11% migrate in the opposite direction. This imbalance was even greater for nurses (quoted by Chanda17 p.37). Woodward et al.1 observe that there are more Bangladeshi nurses in the Middle East than in Bangladesh. ‘The economic costs of training professionals that subsequently emigrate is substantial, estimated to be tens of millions of dollars for South Africa alone.’ Health information professionals need to be aware of cultural and educational differences as the workforce becomes more and more international. Cross-cultural interaction Globalization presents new opportunities to work in partnership with colleagues around the world. Health librarians have a long history of successful cross-cultural partnerships and collaborations. Madge and Plutchak6 have reviewed this aspect of globalization. Initiatives such as Partnerships in Health Information (Phi) (http://www.intute.ac.uk/ healthandlifesciences/hosted/phi/) seek to improve health care in developing countries by encouraging the more effective flow of medical knowledge between nations. National and international groups such as the MLA (USA), the Health Libraries Group (UK) and the International Federation of Library Associations are all engaged in seeking innovative ways to work together across international boundaries. Reflecting on the case studies published in earlier issues The previous three issues of this feature column have reported on developments in Poland, Cuba and Chile.20–22 In each of the case studies, the authors have mapped out the challenges their country faces as a result of health care reforms and the impact of globalization (Table 2). Although they are struggling with common problems, their responses are different, reflecting different social, economic and political circumstances.

Actions for practitioners, professional bodies and educational providers Priorities for health information professionals The main priority for health information professionals is to keep informed about the ways in which globalization is influencing health care in their own country. The second priority is to anticipate new information requirements for their clients and user groups. It may be worthwhile to build databases of relevant documents to be shared with local networks. Actions for professional bodies and educational providers Professional bodies need to: • organize workshops, to enable members to keep up to date on changes in legislation and regulatory frameworks; • continue to encourage members to participate in collaborative ventures and to write up their experiences; • provide opportunities/resources to fund visits/ exchanges with health information professionals from developing countries; • disseminate information about globalization and highlight its implications. Conclusion This article has speculated as to how globalization may impinge on health information professionals. I am aware that there are a number of key issues neglected in this analysis, in particular the impact of globalization on clinical research. (I plan to address this in a later issue.) The ethical and legal repercussions of globalization have also been omitted. Without wishing to end on a negative note, it is important to remind ourselves of some of the risks associated with the globalization of health care. ‘It is the turn of health care delivery to be globalized. Nevertheless, health cannot be assumed to be the same as other basic goods. Linked to health care are many complex ethical, cultural, and human resource issues that we have only


International perspectives and initiatives Table 2 Summary of three case studies reviewed in this column Country and study

Challenges

Responses

Poland Duplaga (2007)20

• Rapid transformation of Polish economy with shift to market economy • Dual system—both public and private sectors • Dissatisfaction with changes to health care system (clinicians and patients) • Need to monitor services and outcomes

• Investment in IT systems for data collection and exchange (infrastructure) • Creation of e-health policies (strategy) • Development of central databases and registers (data warehouses) • Health-related education and health promotion (human capacity, public health)

• Improve access to information (for clinicians, managers and citizens) • Improve quality of information • Link information systems • Developing electronic patient records Cuba Séror (2007)21

• Improve health status of citizens • Support an evidence-based health care system • Bring health care and medicine closer to the people • Maintain a social medicine tradition • Overcome isolation arising from US sanctions

Chile Capurro (2007)22

• Major social, cultural and economic changes • Rapid uptake of communication and information technologies

• Incorporation of private participants into the health market • Legal requirement to monitor patients and the quality of care received • Enable patient-centred services • Provide health information for citizens • Enable professional development and evidence-based practice

begun to name. Further, it is the duty of health professionals to promote health as a global human right ... and, for this reason, we all must be very careful before launching headlong into the globalization of health care and health professional education, taking care to be certain that, if we do, it will be for the benefit of all around the world.’18

• Develop national infrastructures for research and publication • Establishment of Cuban National Health Care Network and Portal (INFOMED) • Establishment of the Virtual University • Provision of networked infrastructures to serve evidence-based practice • Build a Virtual Library • Disseminate Cuban research to international communities • Develop a research base in health information sciences • Development of national strategy which included health care • Systematic efforts to incorporate communication and information technology into public health, patient care and health care management • Creation of sectorial internet • Use of web portal to disseminate information

References 1 Woodward, D., Drager, N., Beaglehole, R. & Lipson, D. Globalization, global public good, and health. In: Trade in Health Services: Global, Regional and Country Perspectives. Washington DC: Pan American Health Organization, Program on Public Policy and Health, Division of Health and Human Development, 2002. Available from:


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13 Heeks, R., Mundy, D. & Salazar, A. Understanding success and failure of healthcare information systems. In: Armoni, A. (ed.). Healthcare Information Systems. Hershey, PA: Idea Group, 2000: 95–128. 14 Adlung, R. & Carzaniga, A. Health services under the general agreement on trade services. In: Trade in Health Services: Global, Regional and Country Perspectives. Washington DC: Pan American Health Organization, Program on Public Policy and Health, Division of Health and Human Development, 2002. Available from: http://www.who.International/trade/en/THpart1chap2.pdf (accessed 25 November 2007). 15 Matthews, P. What globalization in healthcare means to you. Healthcare IT News 2005, 09/01. Available from: http://www.healthcareitnews.com/story.cms?id=3639 (accessed 25 November 2007). 16 Collins, T. Is the NHS planning to send patient data overseas? Computer Weekly.com 27 November 2007. Available from: http://www.computerweekly.com/Articles/ 2007/11/27/228316/is-the-nhs-planning-to-sendpatient-data-overseas.htm (accessed 3 December 2007). 17 Chanda, R. Trade in health services. In: Trade in Health Services: Global, Regional and Country Perspectives. Washington DC: Pan American Health Organization, Program on Public Policy and Health, Division of Health and Human Development, 2002. Available from: http://www.who.int/trade/en/THpart1chap3.pdf (accessed 25 November 2007). 18 Segouin, C., Hodges, B. & Brechat, P. H. Globalization in health care: is international standardization of quality a step toward outsourcing? International Journal for Quality in Health Care 2005, 17, 277–9. 19 Pang, T., Lansang, A. A. & Haines, A. Brain drain and health professionals. British Medical Journal 2002, 324, 499–500. 20 Duplaga, M. Towards the development of e-health in Poland. Health Information and Libraries Journal 2007, 24, 137–41. 21 Séror, A. Unique lessons from the Cuban National Health Care Network and Portal—INFOMED. Health Information and Libraries Journal 2007, 24, 21–21. 22 Capurro, D. Health informatics in Chile: responding to health reforms. Health Information and Libraries Journal 2007, 25, 287–91.
