International perspectives and initiatives

Although the main aim of this column is to survey international trends and initiatives relating to health information, an important secondary goal is to bridge the gap between two communities—health informatics and health science librarianship. (Several years ago the title of this journal was changed to reflect our aspiration to appeal to two different groups of readers.) Even although these two communities have much to learn from one another, they speak quite different languages and are often unaware of how much they have in common. The challenge is to find authors who can help to promote communication between these two different professional worlds. This issue of the column describes how information and communication technology is being used in Cuban health care. As in our last issue on Poland, the current author, Dr Ann Séror (based at the eResearch Collaboratory in Quebec City), relates these trends to the country's social, economic and political context. She notes that Latin American social medicine initiatives remain largely unknown throughout much of the English-speaking world and makes the case for more inclusive scientific collaboration. The most recent editorial board meeting endorsed the view that all contributors to the journal be asked in future to situate their articles within a global context so as to appeal to an international readership. This policy is timely in view of an initiative of the Council of Science Editors (CSE) to raise awareness and stimulate research into poverty and human development. Science journals throughout the world have undertaken to simultaneously publish papers devoted to this topic with a common publication date of Monday, October 22, 2007. HILJ will be participating in this important international collaboration with journals both from developed and developing countries. We are pleased to be part of this collaboration and believe that the unique perspective HILJ will contribute is to highlight the importance of disseminating science and improving access to medical information in developing countries. Full details about the CSE initiative can be found on their website http://www.councilscienceeditors.org/globalthemeissue.cfm For this column to succeed, I need feedback from readers about the scope and coverage so far and what you would like to see in future issues. I am mindful too that, so far, the articles have tended to be more about health informatics than health science libraries; future issue will redress the balance. Jeannette Murphy Ann C. Séror, eResearch Collaboratory, Quebec City, QC, Canada Since the revolution in 1959, the Cuban government has pursued strategies to improve the health status of its citizens, recognizing the fundamental necessity of national infrastructures for research and publication in science and technology. The Cuban system's perspective on health care integrates evidence-based practice and performance evaluation, including both medical and social science criteria.1, 2 Critical to an analysis of the Cuban case are the socialist ideological principles upon which institutional infrastructures are founded.3-5 The socialist priorities of free and equal access to health care and education for all Cuban citizens shape patterns of institutional and technological evolution in Cuban society.6, 7 The Cuban National Health Care Network and Portal (INFOMED) provides a rich context for studying the emerging roles of information and telecommunications technologies in an integrated socialist health care environment.8 The underlying premise of this analysis of developments in Cuba is that a national health care system is a dynamic set of interconnected institutions and individuals, motivated by ideologies which give rise to consumer-driven as well as social medicine models of service delivery.9 The study of such a complex health care system performance requires a holistic consideration of national institutional infrastructures and their economic environments.10, 11 As measured by population health criteria, the Cuban National Health Care System has achieved a significant level of health care quality and equity for its 11.3 million citizens: the highest life expectancy in the Caribbean region as well as a concentration of 5.91 physicians per 1000 population—the highest in the world.12 Infant mortality and infectious disease rates are comparable with those observed in the developed world. When these achievements are evaluated against national expenditures for health care, the contrast with the developed world is striking. For example, in 2000 the World Health Report published rankings of national health care systems in translating expenditure into health. These showed the US system—with the highest health care expenditure in the world—ranked 37th and the Cuban system ranked 39th of 191 member countries.13 In 2003, total health care expenditure per capita was estimated to be $5711 in the USA and $251 in Cuba.14 Comparative analysis of national health care system performance suggests the unique efficiency and effectiveness of the Cuban model in organization and resource allocation.15 Since the revolution in 1959, an infrastructure of integrated polyclinics has been extended throughout the country to serve the Cuban population. This aim was to bring health care and medicine closer to the people according to the vision of Che Guevara and the Latin American social medicine tradition.7, 16 In 1984, the family doctor-and-nurse model was introduced to integrate family doctors, usually assisted by nurses, in neighbourhoods of approximately 150 families.17 Community and family participation, as well as continuous individual medical assessment (dispensarización), link the collective and individual levels of health care.18 Governance and control of this system is assured by the Ministry of Public Health through a hierarchical structure, which includes a board of directors overseeing institutions at the national, provincial and municipal community levels. At the municipal level, the people's assembly, basic work groups (grupos basicos de trabaho) and the family doctor contribute to local health care management.19 Integrated government and health care organizations facilitate the collection of public health data and local participation in system governance. While the Ministry of Public Health is generally responsible for hierarchical governance, INFOMED's mission is to improve communication, coordination, and information management throughout the Cuban National Health Care System.20, 21 INFOMED was founded in 1992 with support from the United Nations Development Program, the World Health Organization, the Pan-American Health Organization, and UNICEF.22 As the network was extended throughout the 14 Cuban provinces, it became critical for health care workers’ access to information—connecting provincial information centres, research institutes, hospitals and universities.8 Largely developed with open source software,23 these infrastructures have resulted in reduced health care costs under the difficult economic conditions brought about by the collapse of the Soviet Union and ongoing US sanctions.24-26 The key web-based services of the virtual infrastructure maintained through the INFOMED portal include the Virtual Library, the Virtual University, a continuous health care information observatory, and national networks in a growing number of medical specialties.27 The Virtual Library offers open access to Cuban electronic publications in medicine and public health (more than 40 online Spanish-language journals), as well as links to important Latin American and international publication initiatives.28 medline, the US National Library of Medicine, and ebsco offer English language bibliographic databases, while scielo, the Latin American Scientific Electronic Library Online initiated in Brazil, offers medical journals by country of publication (Brazil, Chile, Cuba, Costa Rica, Spain and Venezuela) in English, Spanish, and Portuguese. INFOMED also provides access to the Health Internetwork (hinari—UN and WHO initiative), the Cochrane Collaboration, the Directory of Open Access Journals (doaj—Lund University Libraries), and Amadeo: The Medical Literature Guide.29, 30 Thus, the Virtual Library integrates a large number of open access resources from the developed and developing world, including the most advanced scientific research, accounts of medical experience in developing countries, and documentation of natural and traditional approaches to medicine. The Virtual University (UVS)31 was created by the Ministry of Public Health in 1999 to improve continuing postgraduate medical training for more than 100 000 Cuban health care professionals and to offer an international centre for postgraduate education in medicine and related disciplines.32 This institution links the Cuban health care information and publication infrastructure with Cuban higher education and international initiatives, such as the Global Health Network University offering the supercourse, Epidemiology, the Internet, and Global Health.33, 34 This supercourse includes more than 3100 lectures freely shared in 26 languages. Within the Cuban Virtual University, a Virtual Clinic supports consultation among physicians and health care professionals.35 The interactive design of the Virtual University promotes an international community of learning and practice.29, 36 INFOMED also offers networked infrastructures serving evidence based practice of medical specialties. The first such infrastructure was the Cuban Paediatric Surgery National Network (Red Nacional de Cirug’a Pediátrica—RENACIP)—founded in 2001 when the Cuban Ministry of Public Health designated the lead network institution, the Paediatric Teaching Hospital ‘Octavio de la Concepción de la Pedraja’of Holguín.37, 38 The objectives of these networks include development of critical medical specialties through identification of regional and local collaborating experts, definition of best-practice protocols, diffusion of high quality research results for evidence based medical practice, and linkage of the resources of all participating health care institutions across the country.39 Key features of specialized networks include software development and websites,40 specialized virtual libraries, and strategic alliances with provincial universities and enterprises. This model has been extended to a growing number of medical specialties with centralized access through the INFOMED portal. One of the most distinctive features of the Cuban health-care information system is the role of human resources in a matrix of networks focused on open access to specialized content, processes of research, learning and service, and community participation through provincial and local institutions, and open access to published research results. This matrix has contributed to an extension of the family doctor-and-nurse model of primary care, increased interdisciplinary integration of the activities of diverse health care actors, and further emphasis on continuous data collection, analysis, and dissemination throughout the system.41 The services of INFOMED are now being extended to health care providers outside Cuba—in Venezuela and other countries—through mirror sites as adequate broadband connections become available.20 Additional developments of INFOMED since 2002 include a strategic plan initiated by the Center for Health Information Sciences through a participative process42, engaging both the National School of Public Health and the Ministry of Higher Education. Some of the objectives formulated through this process of consultation are:20, 21 to develop the Virtual Library as an interactive work space linking institutional resources of national, provincial and municipal libraries to better respond to Cuban health care priorities, as well as requirements for international collaboration; to build technical, organizational and human resource infrastructures for sustainable institutional growth in information services; to promote publication of Cuban research in the health sciences and related disciplines for national and international scientific communities; to improve the technological and methodological infrastructures of the Virtual University serving a health education network; to develop a research base in the field of health information sciences and medical informatics. The strategic plan also calls for the design of a system-wide health information Intranet linking the Center for Health Information Sciences and networks of local institutions.43 These objectives guide parallel processes of local system empowerment, centralized coordination and control through INFOMED, and growing international collaboration for research and education in medicine and the health sciences. An analysis of INFOMED in the context of the Cuban National Health Care System shows the critical role of virtual infrastructures in developing a universal service for Cuban citizens. Of particular importance is the coherence between the design of the system and the socialist ideological values of its institutions: the ethic of universal and free access to health care services emphasizing attention to the collective social and environmental dimensions of health.44 While the values of individual privacy and intellectual property limit the transferability of this system design to developed countries, its institutional integration and managed information market structures offer distinct strategic advantages for effective service delivery. Firstly, the tightly integrated virtual infrastructures of INFOMED—linking institutions and human resources for education, research and clinical practice—distinguish the Cuban model from fragmented structures observed in other countries. In some developing countries, fragmentation is partly the result of external funding and control exercised by international aid organizations and powerful non-governmental organisation networks.45, 46 External control of funding and other resources threatens national health care system priorities and effective coordination of diverse services. In other systems, fragmentation is because of competition and redundancy among public and private services. In India and the USA, further problems are the result of population diversity and the significant health illiteracy of many consumers. Such illiteracy compromises the efficiency and effectiveness of health care systems motivated by consumer demand.47 The second strategic feature of INFOMED is an effective dual market system designed to promote original research and innovation in medicine, medical informatics, and health sciences within its national boundaries, while creating links to external global markets beyond those boundaries. The foundation of this system is open electronic access to Cuban and international scientific research results through linkages of the Virtual Library. Strong research and innovation within the Cuban system foster productive adaptation and integration of research results and evidence from external sources. Within the boundaries of this public knowledge, the integrity of electronic networks of collaboration and practice is preserved.48 In other developing countries, weak educational and research institutions are more vulnerable to unregulated market forces, especially through uninformed efforts to import expensive and inappropriate products and services from the developed world. Despite lessons to be learned from the achievements of the Cuban health care model, and efforts to develop social medicine models in other countries of the region, Latin American social medicine initiatives remain largely unknown throughout much of the English-speaking world.49 Furthermore, reports on research efforts in Latin America and the Caribbean often exclude explicit consideration of Cuban contributions to health sciences, while US sanctions impose ongoing restrictions on collaboration with Cuban scientists.50, 51 Learning from the unique experiences of Cuba and other developing countries requires open access to information and inclusive scientific collaboration. Such collaboration is essential for better understanding of ideologically diverse health care models and global integration of sustainable and equitable national systems. Dr Ann Séror is currently developing an independent research programme focused on the impact of the Internet and telecommunications technologies on the institutional infrastructures of national health-care systems. Her interests include qualitative and quantitative research methodologies, as well as organizational behaviour and theory. She completed her BA at Mount Holyoke College, her MBA at IMD, and her doctoral studies in administrative sciences at the Krannert Graduate School of Management, Purdue University. She has taught at the Faculty of Administrative Sciences, Laval University, Quebec City, Canada, and the Owen Graduate School of Management, Vanderbilt University. Recently, she spent an academic year at Wuhan University in Central China where she taught research methods and organizational theory at the WTO Studies School and the School of Economics and Management. She is a member of the Academy of Management, the Association for Computing Machinery, and the Society for the Internet in Medicine.

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