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Dinara Abenova







Presented to PhD programme on the Information School

Of the University of Sheffield


supervisor: Dr Jonathan Foster













October, 2017



E-health includes many activities such as the use of
electronic media to provide information, resources and services related to
healthcare: it represents the use of information and communication technologies
(ICT) for health needs. E-Health is a way to improve the flow of information by means of electronics,
to support the delivery of medical services and management of national health
system (WHO, ITU, 2012).  As for developing
countries, healthcare information systems (HIS) are mainly developed to consolidate
statistical reports for government or other agencies. Paper based forms could
be used for this way of data collection at the health facility level, and then centrally
be entered to the computer. But, this tends to be difficult, labor-intensive,
and provides no feedback in some cases (Fraser, Biondich, Moodley, Choi, Mamlin
and Szolovits, 2005).  

Beginning from
the 1990s the Ministry of Health of the Republic of Kazakhstan (MoH) started
developing desktop applications, designed primarily with FoxPro, where the
transfer of data was carried out manually to the upper levels by health
facilities. In 2005, six components of Unified Health Information System (UHIS)
were developed mainly with ASP.NET and Silverlight.  After 2010 according to the national
healthcare development program, which included implementation of  Diagnostically Related Groups, additional
seven components started functioning. However, all of these web-portals were
mainly designed to collect statistics and accounting information. Full
centralization has led to the fact that the final users, medical workers, were
not involved sufficiently in the formulating the requirements for development,
testing and decision-making. The focus on gathering analytical information for
managerial and financial decisions was made to the detriment of the
functionality that allows medical personnel to provide safe, quality, timely
and affordable medical services. As a result, the lack of involvement and
responsibility led to rejection and implicit resistance of clinicians at the
regional and local levels.

Along with the
positive moments, the implementation of UHIS in the pilot regions of Kazakhstan
entailed a number of problems related both to the selected technologies and
architecture (lack of interoperability), and to the governance (lack of
standards). In 2013 the Government of the Republic of Kazakhstan approved the
eHealth development strategy 2020 of the MoH, which reflected healthcare needs,
expected main e-health outcomes, key technical solutions and priority
application functionality, standardization and interoperability, management and
regulation, financing, budgeting and risk management. In this strategic
document, an alignment was made between the driving forces (directions of
development) of health care and the requirements for ICT in order to meet the
healthcare needs and, thus, to influence health care. In addition, there has been
determined the priority of standardization, especially for national level
architecture of Electronic Health Records (EHR). By this time, there is initial
set of adopted standards approved to achieve the organizational and structural
interoperability of eHealth, supporting the continuity of patient care by
defining integration requirements for a national level information
infrastructure that will interacts with private medical information systems. However,
these ambitious aims have not been achieved yet properly. Currently, there are
22 public HIS in the country, developed in different programming languages and
platforms by different providers due to legal aspects. Moreover, there are
still infrastructure challenges: only 74.6% of public health facilities have
computers and only 53% have access to the internet, including in the rural
places (MoH, 2017).

In total, current
situation in eHealth of Kazakhstan can be described as a result of previous strategy
by the following statements:

on the centralization of information systems with low involvement of stakeholders and users;

significance of performance measurement information is higher than data for
clinical needs;

of architecture standards and integrity of different designed systems;

constrains and managerial competency.

The proposed
research will study factors, which caused gaps in the original national
programs, including issues in adopting international standards and the local


Research aims,
objectives, and questions

The aim of this research is to study the
process of e-Health in Kazakhstan, particularly search for ways to achieve
successful governance on macro level. The research aim will be achieved by
accomplishing the following objectives:

1.     To conduct literature review of existing work and
methods on governance of eHealth implementation;

2.     To analyze eHealth strategy, architecture design,
infrastructure, legal aspects and management approach during the whole period
of eHealth implementation in Kazakhstan;

3.     To identify main problems and assess preparedness
of further eHealth development based on standards and the analysis of current
situation with web-portals in health organizations;

4.     To compare eHealth governance with experience of
other countries;

5.     To formulate recommendations and lessons learnt for
government on monitoring, evaluation and risk management of eHealth

Research questions:

What are the problems and issues encountered during the implementation
of eHealth?

Why did these problems occur?

How can these problems be prevented?

How can these
problems be addressed?

What can be learnt
from the experience of Kazakhstan and other countries for successful eHealth


Literature review 


Conducting deep literature review will be practically
valuable to study best practices of eHealth implementation and lessons learnt
from such developed countries as the United Kingdom, Australia, Canada. One of
the last systematic reviews indicated that e-health technology, inner and outer
settings, individual health workers, implementation process are all important
factors and should be considered carefully during implementation into health
systems (Ross,
Stevenson, Lau and Murray,


In such strategic documents as eHealth Action Plan
2012-2020 by European Commission we can see the promoting of policy dialogue
and international cooperation, where challenges and barriers are discussed as
well. According to the report “From innovation to implementation” (WHO, 2016)
nowadays, most countries in the WHO European region along with policies
outlining eHealth goals, measures and implementation objectives, still need an
adequate governance and legislation. This survey showed ten specific problems
in implementing EHR systems, which identified funding as the most important
barrier, including infrastructure, measurement of results, separate work of
institutions, unattainable legal requirements and a lack of experience with ICT
implementation in long-term care. Regarding barriers to implementation of big
data for health, the most important were a lack of data privacy and security
laws, limited integration between different health services and other systems
collecting data and a lack of support for new analytical methods.

Problems and issues

There are many reviews, publications and reports on
the e-Health implementation issues. These problems are an international
phenomenon, with similar problems being widely reported (Murray, Burns, May,
Finch, O’Donnell, Wallace and Mair, 2011). Several countries face problems
in integrating and data matching from different sources, both at the level of
health facilities, and at the level of policymakers and researchers. For
instance, in the USA despite of ICT prevalence at the health organization
level, doctors still do not always have access to patient’s medical
information, which is stored in another clinic. Digital data, designed to
provide the integrity and availability of information, does not fully provide
the continuity of medical care due to lack of implementation governance. The
uncontrolled rapid increase in the use of HIS locally with no interoperability
led to the fragmentation of medical information, and hence to inadequate
services (Stange, 2009).

As for developing countries, in the report of the
Center for Health Market Innovations (where partners were Bangladesh, Bolivia,
Brazil, Vietnam, India, Pakistan, South Africa and others) implementers have
pointed out problems with end-user acceptance of the technology and a lack of
infrastructure to provide reliable electricity and internet access (WHO, 2012).
Besides adequate infrastructure, developing countries also need professionals
(Anwar, 2012 and Kundi, 2010).

Some issues during ICT implementation probably are similar
in different fields. For instance, if we compare e-learning in the universities
with e-health in medical facilities, both of them can be constrained by such factors
as a lack of supportive management, bureaucracy, a lack of resources and others
(Foster and Dang, 2015).


The term “governance” can be used in different
meanings and depends on the level on which it is considered: global, national
or local. International organizations such as the EU, the OECD and the World
Bank described principles of good governance for governments, and one of
well-drawn definition was given by the World Bank (World Bank, 2011). In the
context of this study governance is defined as the process of decision-making
and implementation of this decisions (World Bank, 1991; Sheng, 2016). Governance
of health systems using information is the best way to support healthcare management,
improve quality, and evaluate results (Friedman, Wong, Blumenthal, 2010). “Good
governance” in e-Health is determined as interventions to promote transparency,
accountability and public participation (Holeman, Cookson
and Pagliari,

At the same time, there are no studies in scientific literature
about the experience of eHealth governance in Kazakhstan on the national level as
a case study. It is supposed that each country due to certain circumstances except
those mentioned above may have unique set of factors, including cultural,
legal, economic and other aspects. For example, large-scale rapid reforms and irrational
financial expenditures in combination with lack of professional human resources
and socio-economic contrast among the regions of country could make additional
influence on the process. Thus, decision makers need useful information and
multidimensional evaluations, covering many aspects beyond technical (Kaplan,
1988). This research can be used as basis for further eHealth development in
Kazakhstan and as lesson for other governments.


          At the
first stage, it is planned to conduct literature review using academic
databases such as PubMed, EMBASE, Web of Science, and websites of relevant organizations
with reports on eHealth systems. The titles and abstracts of identified
articles will be considered against determined criteria for relevance and
eligibility to form an inclusion set.

Case study approach

Yin (1994) suggests the importance of studying information systems in
“real life” context to better understand them. Irani and Love (2008) strongly
support the use of case studies to investigate different aspects of information
systems. Several researchers have used the case study approach to investigate adoption,
implementation and use of Business Intelligence (Sammon and Finnegan, 2000;
Vuksic, 2013; Alekh et al, 2013; McBride, 2014; Spruit et al, 2014).
Explanatory case study considers the data both superficially and deeply to explain
facts (Zaidah, 2003). Based on this data, the researcher may then form a theory
and test it (McDonough and McDonough, 1997). Furthermore, explanatory cases
also can be used for causal studies where pattern-matching is aimed to
investigate certain aspects in multivariate and complex cases.

 Choice of cases

Case study method
has advantages such: it can build on and test the theory, achieve important
results by getting a wide variety of contextual data (Bhattacherjee, 2012). The
proposed study will be focused on the following cases:

1) The process
of eHealth implementation in Kazakhstan. It is essential for this study to
obtain an in-depth understanding of how eHealth implementation governance was
organized and what were the key problems of this process;  

2) Web-portals as part of
eHealth, for instance, Hospitalization register, Inpatients Register and
Quality Control register as most important health information systems. An
implementation process of these web-portals does not meet government programme
expectations, which is partly the result of ineffective application of
standards, lack of interoperability, sustainability issues.

          Data collection and analysis seeking

collection will be made by inspecting technical and strategic documentation,
reports, interview with stakeholders and description of current situation. The
research will be pitched at the national programme level. The current situation
reflects a gap between generic programme objectives, including international
standards, and actual local implementations.

           The study will use qualitative data analysis,
via systematic coding and category development, and cross-case analysis.

issues must be addressed in any kind of research (Bryman,
2012; Matthews & Ross, 2010). An important ethical principle is
voluntariness and harmlessness of participation. This
means that participants have to know that they have the choice to participate
in a study or to withdraw from it at any stage without any consequences;
moreover, the result of their decision whether to participate or not will not
affect their safety (Bhattacherjee,
2012). The proposed study will ensure participants’ confidentiality by
reporting only aggregated results in the final research paper; not using the
collected data for any purpose other than the purpose of this study. Technical documentation on public HIS, reports, decrees, and other
available information from local e-Health Center will be used for academic purpose
only in accordance with signed permission on data usage.



 The research
project is planned to be conducted in accordance with the full-time PhD
programme of the University (Figure 1).



Figure 1 – Timetable of research study


          To sum
up, the overall aim of this study is to investigate how the development and
implementation of eHealth was organized in Kazakhstan and what problems
occurred during this process. As a result, it is expected to formulate learned
lessons and create guidelines for policy makers to further governance of
eHealth implementation adapted to local conditions.



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