Expected Challenges in E-health Implementation--A case of rural Hospitals
in Pakistan
Author: Jahanzeb Iqbla Khan Date of Birth: 19790414 Examiner:
Shang Gao
Course Name: Informatics, Thesis, Second Level, 15 Credits (IK4003)
Örebro University School of Business,
Örebro, Se-70 182, Sweden
Abstract:
Introduction: The main objective of this study was to investigate e-health implementation challenges in the hospitals of rural communities of Pakistan.
Methodology: The data was collected by carrying out a final literature review of 17-articles from the developing countries followed by interviews as a qualitative approach. The interviews were selected based on their knowledge of using e-health systems in the public hospitals.
Data Analysis: The analysis of the data collected through the literature review was done in the form of author’s own conceptual table and the data collected through interviewees was analyzed by identifying 32-important themes from the interviewees’ statements.
Conclusion: After analyzing the data, it was observed that the public hospitals of Pakistan were also experiencing the similar nature of e-health implementation challenges which were already highlighted by many different developing countries. The challenges are Financial, ICT-Infrastructure & Technology, Social and Cultural, Governance and Resistance to Change. The reason of having similarities was that the structure of the traditional health system of Pakistan is similar to the developing countries selected in the literature review. To overcome these issues, the government’s federal-level ministries such as ministry of IT, ministry of roads and transportation, ministry of energy should work together and create corporation and co-ordination.
Keywords: e-health; Challenges; Implementation, Developing countries, Themes; Literature Review.
Acknowledgements
I would like to thank the participants who gave me their precious time for the interviews. Special appreciation goes to the superintended of medical department at Mayo Hospital who helped me in arranging these interviews at the convenient timing.
Regards, Jahanzaib Khan
TABLE OF CONTENTS 1. Introduction... 1.1 Background... 1.2 Problematic Area... 1.3 Research Question... 1.4 Study Objectives... 2. Research Methodology... 2.1 Articles’ selection—Inclusion and Exclusion Criteria:... 2.2 Data Collection... 2.2.1 Interviews... 2.2.2 The Selection of Interviews Questions... 2.3 Data Analysis... 3. Results and Discussions... 3.1 Financial Barriers... 3.2 ICTs-infrastructure and IT-professionals... 3.3 Social and Cultural Barriers... 3.4 Government Policies... 3.5 Resistance to Change... 4. Conclusion... 5. Limitations and Future Implications... References... Appendix A... Appendix B... Appendix C... Appendix D...
1. Introduction:
1.1 Background:
Health is considered to be an economic determinant of a county’s GDP which has a significant impact on per capita income of a country and it is considered to be an investment rather than expenditure [1]. The growth of the population in the developing countries is rapidly increasing which has put pressures on governments to plan for the accessibility and delivery of healthcare services to such a huge number of health- seeking people which seem to be a challenging task because of limited economic resources, costly medical examination, few hospitals and healthcare staff [2]. Taking into consideration on how to deliver health-related services to masses in a cost-effective way, e-health technology is evidenced as an enabler for availability and accessibility of healthcare services with the help of Information and Communication Technologies (ICTs) [3]. Many healthcare providers and policy-makers from developing countries expect that the use of ICTs in health industry has the capability to improve healthcare quality and has also the ability to address health-related issues being faced by resource-constrained countries [4]. The use of e-health technology within the traditional healthcare systems of developing nations has brought tremendous changes such as: enhancing accessibility to improved healthcare for low income holders; remote consultation; educating patients via tele-education and storing patients’ medication information in archives [5].
E-health consists of different ICTs-based health-related information systems such as: Patients' Information Systems (PIS), Hospital Information Systems (HIS), Decision Support Systems (DSS), Electronic Health Record Systems (e-HRS) [6]. Such systems have produced significant results after deployment in the hospitals of many developing countries [7]. E-health technology covers many functions such as: managing patients' E-health records in a digital format, compiling lab results and helps co-ordination and collaboration among healthcare providers [8]. The implementation of E-health in different health settings has widely been accepted among the physicians and recommended its deployment in hospitals [9]. Many developing countries (e.g. Kenya, Tanzania, Bangladesh etc.) have used e-health technology for the purpose of managing medical data, enabling healthcare staff to get an access to patients’ history of medical examination. [11].
1.2 Problematic area:
Pakistan, being a developing country has a total population of more than 190 million; of which 72% inhabitants are living in rural areas where healthcare facilities are inadequate due to many factors such as: shortage of healthcare workers and poor road and transportation infrastructure [37]. Socio-economic progress is below the belt, a high illiteracy rate combined with poverty and provision of health services are underprivileged as people from rural areas suffer many life-threating health diseases [15]. The common diseases are: malaria, hepatitis,
diarrhea, tuberculosis and even polio cases have also been reported. People complain that they are deprived of sufficient healthcare facilities such as: lack of qualified doctors and poor transportation for carrying patients for long distances [40].
The use of ICTs in the healthcare sector of Pakistan is in its initial stage and incorporating e-health technology into the ordinary e-healthcare system of Pakistan has been confronted with many challenges such as: lack of IT training programs, lack of proper ICTs tools and shortage of IT professionals [40]. Government has set up Rural Healthcare Centers (RHCs) who lack of trained workforce to be required to use ICTs and advanced e-health technology [39].
Despite the advantages of e-health technology, healthcare implementers in developing countries need to be aware of the challenges which are of different nature such as: expensive IT-infrastructure, financial, political and scarcity of skilled IT personnel [12]. World Health Organization (WHO) has also pointed out some of the challenges being faced by developing countries which include: insufficient financial resources, scarcity of power supplies, resistance to accept new technology, poor IT infrastructure, illiteracy regarding ICTs usage among physicians [13] [14]. Many e-health projects have failed in developing countries due to shortage of skilled IT-professionals, complaints about the usage of interfaces and unavailability of training programs for physicians and IT-professionals [37]. Investigating these challenges in the context of Pakistan is paramount as few studies have been conducted before and identifying these challenges will help healthcare officials improve the performance of health sectors [38]. One of the reasons of exploring these challenges in the context of Pakistan is that the healthcare system of Pakistan follows the similar structure of a developing country’s ordinary health system and another reason is that the socio-economic system of Pakistan is also almost similar to any developing country [28]. However, considering the above mentioned challenges, we have created our research question as follows:
1.3 Research Question:
What are the expected e-health implementation challenges in the rural hospitals of Pakistan?The research term ‘Challenges’ implies in this study as ‘barriers’ to implementing e-health technologies in hospitals which can be as: financial funding, IT training, change management etc. and ‘Implementation’ refers to ‘integration’ of e-health systems in traditional health settings [63]. Our aim is also to investigate barriers in the rural hospitals of Pakistan in order to integrate e-health systems successfully in the traditional healthcare system of Pakistan. The term “Expected e-health Implementation Challenges” refers to those five similar challenges which have already been identified from the final literature review related to different developing countries (see Appendix A). To answer this question, this study predicts that these underlying challenges can also be investigated in the context of Pakistan due to some factors such as: e-health technology is in its initial phase; the same international donors from other developing countries are operating and running e-health pilot-projects in Pakistan and the socio-economic structure of Pakistan is also similar to any developing country [28].
1.4 Study Objectives:
The aim of this study is to draw the most common e-health implementation challenges from the literature review of the 17th developing countries (see Appendix A) and further apply them in the rural hospitals of Pakistan in order to make a comparison if they are similar in nature or not and later we will briefly suggest how these challenges can be tackled.
2. Research Methodology:
For data collection purpose, this study is based on a literature review combined with qualitative interviews. A literature review is a systematic way of reviewing, gathering, organizing and scanning with an intention to retrieve main concepts and issues and then highlight them in a critical way [17]. The following search strategy has been adopted:
2.1 Articles’ selection—Inclusion and Exclusion Criteria:
Literature related to e-health published in the range of (2005-2018) was considered and the reason of setting this range seemed to be reasonable as most of developing countries had started to implement e-health projects in this era. This selected range helped the author to concentrate more on the relevant articles.
Search process—Articles’ Selection Criterion:
In fig 1, we have diagram the process of the selection of the articles. The process follows the guidelines suggested by Webster & Watson as this search approach was considered to be an appropriate source of searching literature for this study [18]. While searching for the relevant literature, the focus was to avoid relying on specific journals and geographical areas [18]. For this purpose, we have extended this study to other developing countries because of a limited research found on the current study particularly in the geographical area of Pakistan [38]. The research methodology is divided into two phases: in the first phase, an extensive literature review was conducted by using some search engines (e.g. Google & Google Scholar), some databases such as Primo (i.e Örebro), IEEE Explore and some books. The thirst of capturing more articles was saturated by accessing more articles from the popular journals (see Appendix B).
In order to refine the web search to get the relevant data specific to our research topic, we followed some recommended techniques by Webster & Watson [18] on how to get specific literature. First we looked into the specific keywords mentioned in our research question and
later we tried these keywords in combination with some synonyms namely: ‘e-health’, ‘challenges’, ‘implementation’, ‘rural areas Pakistan’. To make our queries more precise and logical, we also used ‘Boolean Operators’ (AND, OR, NOT, *) (see Appendix C).
Initially, we retrieved roughly (n=30) articles from the search engines, from the databases and journals (n=40) articles (see Fig1) above. While searching for the intended articles from these digital sources, we found 14 matched articles or duplicated which were 6 from Google, 5 from Databases and 3 from the journals. The study had also not included 39 more articles due to their irrelevancy and mismatch to the scope of this study. The remaining 17articels were considered to be eligible for the final round of literature review as they were given more weightage because they were related to the field of e-health domain and had rich material of explaining challenges related to e-health implementation in the context of developing countries particularly in the context of Pakistan. The selected articles were thoroughly read through their abstracts, the bodies and the conclusions so that we could have saturated to a point of relevancy to the scope of this study. While searching for the articles from developing countries, the concentration was to have an access to the individual country which helped the author know the situation of every country. The countries selected were Bangladesh, Egypt, Saudi Arabia Iran, Iraq, Sri Lanka etc.
2.2 Data Collection:
2.2.1 Interviews:
Semi-structured interviews are the second phase of data collection process for this study. We chose interviews because they were considered to be a widely used method for collecting data and were helpful to capture attitudes and views of interviewees on an underlying research topic [20]. This study also aims to investigate the views of physicians, IT-professionals and government officials on the e-health implementation challenges. However, interviews are appropriate method for this study too.
*MBBS (Bachelor of Medicine/Bachelor of Surgery).
A total of 8 participants (4 males & 4 females) were selected for the interviews which was a convenient size of sampling for a qualitative research [20]. They were requested to let the author know about their demographics (see Table 1 below). The interviews session prolonged no more than 20 minutes between 5th & 10th of February, 2019. This time slot was suitable in order to reach out to the participants more conveniently because of their presences in the hospital. Interviewees were promised to privilege their personal data and were also explained the real purpose of this study [56].
We took some notes while recording the interviews and the permission of recoding was requested and granted [22]. For reliability and validity of the interviewees’ statements, the interviews were stored by using a tape recorder and were also transcribed in a simple Microsoft Word Program. Later, the participants were emailed the transcripts to make sure that the facts and their interpretations are not tempered and also aligned with what we were agreed upon on the purpose of this study [56].
The interviewees were selected from Mayo Hospital located in Punjab, Pakistan, which is the biggest and oldest hospital of the country offering nearly all types of medical treatments [57]. It treats more than 6000 out-patients and approximately 17000 in-patients on every day at emergency cases [58]. Participants from different backgrounds who were working on the e-health systems in the government and private hospitals were the major participants in this study. They were categorized as: physicians, IT-managers, Government employees and patients. Participants were met personally during the visit of the hospital. However, this diverse sampling helped the author probe more about their perceptions and views on the e-health challenges being faced by the hospitals.
The reason of selecting the participants was that they were already working in the hospitals where e-health systems were in place. Another reason of targeting such diverse group was that they were having different backgrounds of education, experience and had also been appointed in different hospitals in the rural areas of Punjab. They were regularly performing their duties
in the rural hospitals located in the south Punjab (Bahawalpur, Rajanpur and Rahim Yar Khan Districts). These regions lie in the southern Punjab and having more than 25 million inhabitants who lag behind the basic health infrastructure [59].
2.2.2 The selection of interview questions:
The categorization of the five e-health implementation challenges is based on the number of times a challenge has been cited in the findings of the 17 articles selected particularly in the domain of developing countries as a final literature review. In order to see which challenge has more dominance than the others, we have drawn a conceptual table (see Appendix A) by following the suggestions from Webster & Watson [62]. This conceptual table represents how many times a particular challenge had been reported in a particular article and how many authors had cited them in their findings. For example, ICT Infrastructure has been dominant challenge (25 times has been cited) compared to others followed by other challenges such as: Social and Cultural, Financial, Resistance to Change and Governance. Some challenges have been cited by the same author in one article and this can easily observed in the table. While extracting the five challenges from the articles, we also found some other challenges (interoperability, cyber Security, Privacy etc.) which we considered them as least significant challenges and had not been included in the table because most of the authors had not cited them in their findings.
The first six questions were asked to every participant interviewed. The remaining 18 questions were categorized into five major groups. This grouping is done by taking the five e-health challenges into consideration. Each question was designed in a way that it could relate to its relevant category of the particular challenge. For example 5 questions were made for physicians, 5 for IT-mangers, 5 for Govt. employees and 3 for patients to explore their views on each challenge mentioned (see Appendix C). However, the author had designed the interview guide by using the brain storming technique and author-concept table as guided by Webster and Watson [62]. The questions were open-ended and written in a plain English language [56]. During the interviews, the participants were asked the questions by changing their order of sequence which enabled us to probe much of their views on the topic of e-health implementation challenges [56].
2.3 Data Analysis:
The data analysis for this study was done in two ways. Firstly, the final 17-articels were analyzed by designing a three-column table. In the first column we grouped the challenges into five different groups (see Appendix A). In the second phase, the textual data collected from the participants was organized with the help of data matrix [61].
In the data matrix table, five categories of e-health challenges were distinguished separately in order to avoid overlapping. After that, we observed the participants’ statement and noticed that these statements could be related to the relevant challenge. For this purpose, we further analyzed the statements and broken down into chunks of units (themes). Each theme was carefully observed and later correlated it to its corresponding category of a challenge. For
example, themes related to finance were placed against the financial challenge. The rest of the themes were linked in the same way. In total, 32 themes were identified from the interviewees’ data (see table 2). A symbol (x) was placed against each theme extracted from the interviewees’ statements. An inductive reasoning is also employed as this technique is useful when it comes to analyze a qualitative data which is also intended in this study to make an analysis on the interviewees’ views and attitudes [21].
The current study considers the literature review process and the author-concept table as a conceptual framework guided by the suggestions from Webster and Watson [18]. This flexible approach enabled the author to consider most of the literature covering e-health challenges in many developing countries. For example, if we select a single e-health framework called (i.e Khalifehsoltani), it has only limited number of challenges which can restrict the author to cross the boundary. However, we use literature review as a framework.
Table 2. Data Matrix---The analysis of Participants’ statements in the form of 32-themes which are categorized against the five-common e-health implementation challenges
Categories
Concepts / Themes
Participants1 2 3 4 5 6 7 8
F
in
a
n
c
ia
l
C
h
a
ll
e
n
g
e
s
1. Public hospitals I visit have budget issues to buy costly computers and software
X
2. Private hospitals are better equipped with e-health technology than public because they have adequate source of finance
X
3. Physicians and IT-mangers need finance to get training to use the latest e-health technology.
X
4. We can’t replace the old computers with the new ones because the public hospitals’ financial departments do not approve funds
X
5. Most of the e-health projects in the public hospitals are not running successfully because of inadequate budget every year from the
government
X
6. Insufficient finance is the main issue to deliver better health services in the government-run hospitals
X
1. Patients need to travel long distance to reach the hospitals in rural areas because of poor infrastructure
IC
Ts
.
In
fr
a
s
tr
u
c
tu
re
&
T
e
c
h
n
o
lo
g
y
2. Public hospitals very low speed of internet which affects my performance of work when I need to get health-related info from the Internet
X
3. We have shortage of IT-skilled people in public hospitals because they do not like to work in the rural hospitals because of fewer salaries
X
4. We have not replaced the ten-year old computers with the latest ones and only three computers are there which sometimes work and stop
X
5. Power supplies is the big issue which interrupt in delivering e-health services; hospital staff need training on how to use e-e-health tools etc.
X
6. There is only one IT technician who has to visit other public hospitals as well; many times we have technical issues with the systems and we do not have IT-training to solve the technological issues when arise
X
R
e
s
is
ta
n
c
e
t
o
c
h
a
n
g
e
1. I would prefer to work manually as I can check more patients and prescribe them medicine more easily; I am not used to this technology
X
2. I am more productive when I use e-health technology as it saves my time and helps me to save patients’ medical history and diagnose them based on their medical data
X
3. Use of e-health in the public hospitals will be cost-effective and patients can be accessed everywhere and they do not need to travel long distances
X
4. Public hospital administrations are not serious to use e-health technology as they like to work with the old health systems.
X
5. I would not use this technology if it replaces my job X
6. I do not have skills to use e-health systems, I enroll patients on my manual books for appointment and I am happy with it
X
1. Patients from rural areas mostly get treatments from non-professional doctors
X
2. Patients from rural areas are more reluctant to get treatment with the e-health technology as they think that it is against their religious
S
o
c
ia
l
&
C
u
lt
u
ra
l
F
a
c
to
rs
beliefs3. People living in rural areas have attacked on healthcare workers X
4. Patients living in the villages are used to visit quacks whom they worship as spiritual healers
X
5. Most of the patients who visit our hospitals have life-threating diseases because of their treatments from fake doctors
X
6. Due to illiteracy and unawareness, patients from rural areas prefer to eat their own hand-made medicine
X
7. Whenever I fee ill I always call my Hakeem who is available at any time and the examination fee is so cheap
X
8. I am happy to go to my local Hakeem who knows my medical history more than 10 years; so cheap; will never go to any doctor
X
G
o
v
e
rn
a
n
c
e
1. Public hospitals are being neglected and need government attention more seriously
X
2. Lack of rules and standards in using e-health technology in hospitals. For example: rules of saving patients medical data etc.
X
3. There is a lack of co-ordination between different government departments
X
4. lack of governance issue has resulted in poor IT-infrastructure and shortage of skilled IT labour
X
5. Ministry of health is not working closely with the ministry of IT X
6. Ministry of IT is not working closely with the ministry of transportation
3. Results and Discussions:
3.1 Financial Barriers:
Total six themes against the financial challenges have been discovered from the interviewees’ statements (see table 2). These themes are pointing to the financial issues being faced by the public hospitals. The physicians, IT-managers and government employees described that they need to procure hardware and software applications.
Healthcare expenditures in the rural areas of Pakistan are extremely at low level in comparison to other developing countries as .75% of the total GDP of Pakistan is being spent on the provision of health care services which is around 4.2US$, a quiet low as per the recommendation (Recommended: US$ 34 per-capita) of the World Health Organization (WHO) [24]. Pakistan has the similar socio-economic background to most of the developing countries [24]. The current allocation of healthcare budget in the fiscal year (2018-2019) of the rural hospitals of Punjab is approximately 14 million US$ [26]. Such a dismal number of budgets even are not enough to cater the financial needs of the hospitals situated in the southern Punjab where more than 100 million people are living and healthcare issues are challenging and expensive [25]. Finance is the driving force to run e-health projects successfully but most of the e-health projects have failed in many developing countries due to lack of securing proper funds and this is also the main reason that failures of most of the IT projects in Pakistan are because of insufficient funds [14]. Without allocating adequate financial resources, e-health implementation in the public hospitals of Punjab cannot be implemented successfully because expenditures of buying hardware, software, e-health tools and technologies are expensive and to train physicians and hospitals’ employees are expensive too [27].
3.2 ICTs-Infrastructure and IT-professionals:
Regarding the situation of IT-infrastructure and IT-skills, six themes have been extracted. Physicians and IT-managers’ concerns regarding the ICT-infrastructure was the unavailability of computer hardware, utilities software and the need of special training for installation and running e-health systems in the public hospitals. As on IT-manager expressed:
“We have only three old computers which stop running and they are not capable of recording patients’ medical data because of less storage capacity to work with e-health technology; we need to buy latest hardware
and software and need special IT-training.”
One of the IT-managers said that the hospitals had only one printer and three computers being used for billings and patients’ appointments. Outdated software/utilities programs were installed and running resulted into very slow processing speed. IT-managers and physicians complained that we had always issue with the slow speed of Internet as one physicians told that I did not managed to have access to e- health information on the Internet in the public hospitals because of slow speed of Internet. The reason of low speed dial-up connections in the rural areas of Pakistan is hampered by the old copper wires which have affected the growth of broadband [60]. Power supply was another issue which was reported by one of the interviewees. Pakistan is facing huge energy crises such as break down and fluctuation of electricity across the country and situation in the rural areas is even worse as duration of load shedding is normally more than eight hours long [23].
Another claim from most of the participants was the unavailability of the IT-workforce needed to implement e-health systems. The role of ICT-infrastructure and trained professionals is crucial for the successful e-health implementation in a developing country like Pakistan but they lack of required ICT- infrastructure and skillful people [40]. Pervious research has highlighted the importance of IT-professionals and emphasized that IT-experts, proper hardware and software are the backbone for the successful execution of e-health projects but unfortunately these facilities are inadequate to meet the required standards to run e-health projects in Pakistan [40]. Apart from ICT-infrastructure, road and transportation structure found to be a barrier as patients from rural areas needed to travel long distance to get access to basic healthcare facilities.
3.3 Social and cultural barriers:
When inquired the patients about their experience of getting treatments through e-health services, it appeared that they were reluctant to use e-health technology as they had been relying on local uncertified ‘Hakeems* (quacks), old fashioned-illiterate medical practitioners whom they worshipped as spiritual healers. Due to illiteracy, poverty and unawareness, people from rural areas are inclined to trust on non-professional medical skills and knowledge which ultimately result in the survival of quackery in Pakistan [33]. Another reason of getting treatments from the quarks was low consultation fee, easy accessibility and customized medical methods of treatments according to patients’ demands [34].
Pakistan ranked 144 in the literacy field in the world and the rate of literacy of the rural areas of the southern parts of Pakistan is devastating which accounted for 12 percent literacy rate and only one school is serving for 7500 villages in the south Punjab [31]. Physicians had also expressed their serious concerns that they received thousands of patients being treated through non-scientific medication methods which resulted in loss of innocent lives and many health
diseases such as Hepatis, kidney failures, hearth attacks and. Such a medical negligence can be attributed to many factors such as: poverty, illiteracy, religious extremism and even expensive medical examination in the private hospitals [29].
Apart from above mentioned challenges, religious extremism and beliefs are one of the burning issues especially in the remote and rural regions when it comes to accessing healthcare services [32] as religious groups think that health workers are foreign secret agents working against their religion. These are very serious issues especially in the rural and remote areas of Pakistan where deadly attacks on healthcare workers have been reported by the press media and violence on streets are still on the rise [30].
Though e-health technology has improved its delivery of healthcare services to rural and remote areas but some issues such as ethnicity, poverty, illiteracy have negatively affected on accessibility of e-health services and its utilization in the rural communities of Pakistan [28].
3.4 Government Policies:
The need of a uniform e-health policy and governance on e-health utilization has been voiced by the government officials and IT-managers. It was emerged from the interviews of government employees that hospital administration from public hospitals did not prefer to keep the medical history of patients in an electronic format as patients were handed-in paper-based medical records and advised them to bring with them in the next appointments. The reason of not saving patients’ medical credentials was found to be lack of hardware resources, electricity and shortage of skilled IT-professionals and software applications. Such a practice of not saving medical data can be a time-consuming for physicians and can also be a life-threating issue for patients in case of absence of patients’ medical records. Public hospitals in Pakistan are still relying on manual records being used to record patients’ medical history and to avoid such orthodox system, e-health demands well-defined policies which govern rules and standards to make sure that institutions are practicing these rules [35]. Though the federal government in collaboration with WHO has devised e-health policies [36] but there are lack of such policies at the national level who can govern the private and public hospitals’ administration regarding the unethical use of e-health systems such as deleting medical history from the computers etc.
There is lack of collaboration and co-ordinations among these ministries which is a serious hindrance in the way to e-health implementation in the public hospitals. There is no e-health governance system at the national level established yet in Pakistan [30] which should regulate Ministry of National Health Services Regulations and Coordination (NHSR&C), Ministry of IT and Telecommunication (MoITT), Ministary of Energy and Power Division (MoWP) and Minister of Communications. The ministry of NHSR&C needs to look into the demands of the hospitals for e-health tools and technologies, the ministry of MoWP should take care of the power supplies needed to run e-health systems and the Ministry of Communication (MoC) needs to co-operate with ministry of IT so that they can erect switches, routers and towers on the appropriate locations.
3.5 Resistance to change:
An issue of resistance to integrate e-health systems in the hospitals was reported both from the senior physician and government employee too. As one of the senior physicians (55 years old) having a little knowledge of Internet usage expressed his idea of using e-health such as:
“I have been examining patients more than 27 years and I am used to with my old experience; can’t be able to organize patients’ files in computer as I write handwritten prescriptions more easily”
One of the government workers responded that I would not use e-health system because it would replace my job. Motivation and lack of will from the hospitals’ administration and from the employees were the main barriers towards the e-health implementation in the public hospital. But one young female physician aged (35years) old was more optimistic to use e-health technology.
Based on the results and the discussions mentioned above, we can compare the findings of this study with the findings of some other developing countries from the literature review in order to evaluate if the challenges are similar or different in the context of Pakistan.
Table3: A Comparison of E-health Implementation Challenges with some other Developing
The above table shows that the five e-health implementation challenges reported in the findings of the different countries have also been found in the findings of this study too. But the difference lies in their order of dominance. For example, the financial and ICTs infrastructure challenges are dominant in the context of Pakistan as compared to Saudi Arabia, Turkey and India [36][45][49] as they have stronger economy. Likewise, Cultural and Social barriers have also more dominance compared to Indian, Bangladesh and Iran [49][48][54] because the literacy rate of Pakistan is lower as compared to these countries.
4. Conclusion:
The research question of this study was aimed to explore e-health implementation challenges in the public hospitals serving the rural population of Pakistan. To answer the research question, a qualitative method combined with literature reviews was adopted. Literature related to e-health implementation challenges in the developing countries was selected from the 17 articles (see Appendix A). Qualitative data collected from the interviewees were further organized into themes and matched them against the challenges presented in the author-concept table (see Appendix A). The findings of this study have shown that e-health challenges in Pakistan are almost the same in nature as have previously been highlighted by the researchers in the developing nations but the difference lies in their order of dominance. For instance, the Financial and ICTs infrastructure challenges are more dominant in the context of Pakistan when compare to Saudi Arabia, Turkey and India as these countries have strong economies. Similarly, Cultural and Social barriers have also more dominance compared to the challenges reported in Indian, Bangladesh and Iran because the literacy rate of Pakistan is lower as compared to these countries. The challenges found to be as: ‘Financial’, ‘ICT-infrastructure and Technology,’ ‘Social and Cultural’, ‘Resistance to Change’ and ‘Governance’. The main reason of having the similar kinds of e-health challenges is that the traditional health system and the socio-economic system of Pakistan are similar to the structure of any developing country.
In (Appendix A) it seems that ICT-Infrastructure has more weightage than the other ones which should not be interpreted like that as all the challenges are interlinked and have equal importance in a sense that if there is an ICT-Infrastructures, the need of IT-professionals is always there. The same correlation exists in the other challenges as well. It can also be concluded that the success rate of e-health implantation in the private hospitals is better than the public hospitals but they are expensive and only elite class can have access to health services.
To overcome these challenges, all ministries such as Ministry of National Health Services Regulations and Coordination (NHSR&C), Ministry of IT and Telecommunication (MoITT), Ministry of Energy and Power Division (MoWP) and Ministry of Communication (MoC) should work together; enhance co-ordination and corporation in order to implement e-health systems successfully in the public hospitals.
5. Limitations and Practical Implications:
The current study encompasses with some limitations. The sample size of 8 participants is limited due to time constraint which does not reflect the views and attitudes of the whole of the population (e.g. Physician, IT Managers, Patients and Govt. Employees) from various hospitals situated in different provinces of Pakistan such as Sindh, Balouchistan, Kheber Pakhtunkhwa. We believe that by reaching out to more participants from various hospitals will produce findings which would be more beneficial in order to overcome the imbalanced responses we have experienced in this study from the 8 interviewees. Another limitation is the limited number of articles selected for literature review which restricted the study to come up with only five e-health implementation challenges. Including more articles and extending the existing time frame (i.e. 2005-2018) will help the study to cover up more than five challenges which will help produce more interesting findings.
The findings of this study has some practical implications in relation to e-health implementation challenges based on the experience emerged in the context of Pakistan. In practice, the findings of this study can be used as guideline for the government and practitioners. For practitioners, it will help them to explore more on the issues concerning e-health implementation challenges in the different rural areas of Pakistan and help them come up with solution on how to integrate e-health systems successfully.
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Appendixes
Appendix A:
Search Process Framework (Keywords/Synonyms, Boolean Operators & Strings) The e-health Implementation Challenges from the 17- Developing Countries
E health implementation Challenges
no. of Articles
Authors & Years
Financial
9 F. Harry41 (2014); HF. B. Mandirola et al.43
(2015); N. C. I. Uluc et al.45 (2016); P. Soumya et
al.49 (2015); G. A. K. Mohd et al.51 (2016); H.
Rada et al.52 (2012); R. A. A. Ali53 (2005); J.
Sharmin et al.54 (2014); A. L. Jayantha55 (2009).
ICT-Infrastructure & Skills
25 F. Harry41 (2014); O. Stella et al.42 (2008); M. M.
David et al.44 (2014); B. E. Peter14 (2017); N. A.
Amir et al.48 (2012); H. Rada et al.52 (2012); R. A.
A. Ali53 (2005); A. L. Jayantha55 (2009).
F. Harry41 (2014); O. Stella et al.42 (2008); B. E.
Peter14 (2017); N. A. Amir et al. 48 (2012); P.
Soumya et al. 49 (2015); H. Rada et al.52 (2012); R.
A. A. Ali53 (2005); A. Khaled et al.57(2015); J.
Sharmin et al.54 (2014); M. Maryam et al. 47
(2018); N. A. Amir et al. 48 (2012); P. Soumya et
al. 49 (2015); A. Khaled el al.50 (2015); G. A. K.
Mohd et al.51 (2016); H. Rada et al.52 (2012); J.
Sharmin et al.54 (2014); A. L. Jayantha55 (2009).
Resistance to change
6 N. Azliza et al.46 (2018); M. Maryam et al.47
(2018); A. Khaled el al.50 (2015); G. A. K. Mohd
et al.51 (2016); A. Khaled et al.57 (2015); A. L.
Jayantha55 (2009).
Social & Cultural Factors
10 F. Harry41 (2014); HF. B. Mandirola et al. 43
(2015); N. C. I. Uluc et al.45 (2016); N. Azliza et
al.46 (2018); A. Khaled el al.50 (2015); G. A. K.
Mohd et al.51 (2016); H. Rada et al.52 (2012); A.
A. L. Jayantha55 (2009).
Governance
6 F. Harry41 (2014); N. C. I. Uluc et al.45 (2016); M.
Maryam et al. 47 (2018); N. A. Amir et al. 48
(2012); G. A. K. Mohd et al.51 (2016); J. Sharmin
et al.54 (2014).
Appendix B:
List of acronyms for the journals used in this study:
(IJISPM) – International Journal of Information Systems and Project Management
(SAJIM) – South African Journal of Information Management (AJE) – American Journal of Evaluation
(JMML)– Journal of Management, Marketing and Logistics (JBM)- Journal African Journal of Business Management (NJCM) – National Journal of Community Medicine (AJBM) – African Journal of Business Management
(JAMIA) – Journal of the American Medical Informatics Association (ETIJSS) – World Academy of Science, Engineering and Technology International Journal of Humanities and Social Sciences
(WIJAC) – World International Journal of Arts and Commerce
(IJARPED) – International Journal of Academic Research in Progressive Education and Development
Appendix C:
Concepts
Databases
(Primo, IEEE Explorer, Web of Science)
Search Engines
(Google & Google Scholar)
e-health & e-health Record
e-health OR electronic health OR web health OR e-HR OR m-health OR mobile health OR tele-health OR “electronic health” OR “e-health” OR “mobile health” OR “tele-health” OR “m-health” OR “e-health Record” OR e-HR* OR electronic health* records* OR e-health* OR e-health AND m-health OR tele-m-health AND e-m-health or e-HR AND e-health
e-health OR e-HR OR electronic health records OR m-health OR e-health AND e-health records OR m-health AND mobile health Challenges e-health implementation Barriers OR execution OR implement* OR deployment OR operating OR hurdles OR
barriers AND hurdles OR e-health hurdles * OR
implementation e-health* OR “e-health challenges” OR
“hurdles e-health” OR “barriers e-health” OR “ e-health
implementation challenges”
Challenges OR e-health OR hurdles OR e-health AND challenges OR e-health AND tele-health OR tele-health AND challenges OR e-health implementation challenges AND hurdles OR
implementation e-health challenges
Bangladesh OR e-health challenges OR Dubai health challenges OR India e-health challenges OR Iran e-e-health challenges OR Turkey e-health hurdles OR Saudi Arabia e-health obstacles OR Ghana tele-health challenges OR Philippines e-health challenges OR Kenya tele-health challenges OR
“e-developing countries OR low GDP countries OR under-developed countries OR low per-capita countries OR developing countries AND low-income countries
e-health Developing countries
healthAfrica” OR “Iran e-health” OR “Bangladesh” OR “Ghana e-health” OR “tele-health Egypt” OR “electronic health Palestine” OR “Iraq e-health”
Appendix D:
Interviews Guide:
1. Name of the interviewee (if he/she wants to disclose) 2. Age & Gender
---3. What is your education/diploma?
4. Are you working in public or private hospital?
5. What is your designation (Physician, IT-manager, Government Employee, Patient etc.)? 6. Computer Experience/ Internet Experience: How much knowledge of computer or Internet Experience he/she has? What kind of experience do you have in using computer? Have you used computer before?
Doctors
Questions
Financial
Can you please tell me about any financial challenges in implementing e-health in the hospitals you are working in?
Cultural
Could you please share your experiences regarding the patients’ behavior about e-health technology?
IT- infrastructure & IT-skills
Do you think that there are barriers of infrastructure (i.e. Internet, IT-professionals power supplies etc.) in implementing e-health systems in the hospitals you are working in?
Resistance to change
Do you think that e-health technology have affected your performance of examining patients? Do you feel e-health system you are using will replace you in the future?
Govt.
policies/Governanc e
Could you please tell me if there are any government level policies supporting e-health technology?
IT-Manager
Questions
Financial
Could you please explain about financial challenges regarding the implementation of e-health technology in the hospitals you are working now?
Cultural
What do you think about the psychological behavior of patients vising the hospitals regarding their treatment through e-health technology?
infrastructure & IT-skills
Can you please address if there are barriers (i.e. Internet, IT-skilled persons, technology and power supplies issues etc.) in the e-health implementation in the hospitals?
Resistance to change
Do you feel that e-health technology have affected your profession, as you told me before you have worked in the hospitals when e-health was not implemented?
Govt.
policies/Governance
Do you think that government policies are the challenges in implementing e-health system in the hospitals?
Govt. Employee
Questions
Financial
Could you please describe if there are financial issues regarding the implementation of e-health in the hospitals you are still working?
Cultural
Could you please describe me what the social are and behaviors of the patients being treated by e-health technology?
IT- infrastructure & IT-skills
professionals, inadequate telecommunication systems, Internet, issue with power supply.
Resistance to change
Do you think e-health technology will not replace your career and what is your experience about e-health technology being used in the hospitals?
Govt.
policies/Governanc e
What types of policies of government facilitate e-health technology in the hospitals? Are there any policies at government level?
Patients
Questions
Social &Cultural
How and where do you get your medical treatment?
What type of issues have you faced in the public hospitals when visit for medical check-ups?
Do you think that government hospitals in your areas have shortage of doctors? If they are few then why it is like that?
