The Euro-East Asia Healthcare ICT Markets Dyadic

Jun 23, 2007
(Originally published on July 20, 2006)

Severe weather is one of the many natural disasters common
to both Europe and East Asia. Typhoon, Monsoons, and
earthquakes hit many East Asian countries with noteworthy
frequency. Harsh winters, overheated summers, excessive
rains and floods, and in some parts, even earthquakes, are
frequent occurrences in Europe. These events interruptions
in water and power supplies, disruptions in communications,
and in many cases large-scale evacuations of individuals to
safer areas, including refugee camps, with families
truncated, health services disrupted, yet a variety of
health problems emerge due to unsanitary living conditions,
among others. Disaster preparedness and response are
therefore, major issues common to both Europe and East
Asia. There disasters are not all natural, though, nor are
they all due to severe weather if even so. We have seen in
recent times the emergence of new microbes, viruses,
causing epidemics, and potentially, even pandemics. We have
seen novel bacteria, and the resistance of even known ones
to treatment. There is also the threat of terrorism, local
and imported, also common to both Europe and East Asia,
with potentially devastating immediate, short-and long-term
implications for health and health service provision. Both
regions thus on the one hand, have many health and related
issues in common yet have those that are contextual. They
could therefore no doubt benefit from each other in many
ways regarding addressing their healthcare delivery issues,
including those concerning disaster preparedness and
response. Many of these issues are uncomplicated and
require measures that individual countries in each region
could handle without outside help, but there are also many
that require the involvement of international technical and
other assistance. In general, the principles of disaster
preparedness apply to all countries starting with a
consideration of the needs of the family unit1, 2, in
particular those of children3, who are even more vulnerable
at these times. In the U.S, the Joint Commission Joint
Commission on the Accreditation of Healthcare Organizations
have stricter standards for hospitals’ backup
communications4, hence many communities now have
hospital-to-hospital radio communications using amateur or
Ham radio operators via a local Metropolitan Medical
Response System (MMRS)5,6,7. It is clear even from the
above that healthcare ICT plays a major role in
communication between relief personnel prior to and during
disasters, and in several other aspects of disaster
management such as surveillance and tracking activities,
and indeed, in public health education. It is also
important to recognize the overlap in many areas between
preparedness and response, hence the need for efforts in
both directions to be in tandem. Each country also needs to
have a National Disaster Response Plan, all involved in its
implementation trained well in advance in all its aspects,
and there are valuable courses and manuals to help with
such training8, 9. In short, countries in both regions need
to invest in healthcare ICT to prepare for and respond to
these disasters efficiently and effectively, both of which
could save many lives. Countries in the more advanced
countries already have sophisticated communications
infrastructure, yet many have had to depend on Amateur
Radio Disaster Services (ARDS), when disasters essentially
wiped out existing telecommunications avenues. This
underscores the need for investments in these technologies,
even in developed countries, in electronic health records
and data management technologies that ensure data and
information safety and accessibility, which would not only
guarantee communications between emergency relief
personnel, but also enable the sharing, in real time, of
crucial patient information between healthcare
professionals. The UK's National Health Service (NHS) has
programs such as Connecting for Health in England. It also
has the Informing Healthcare in Wales, and the National
eHealth / IM&T Strategy in Scotland. Other European
countries would also need to have such programs but in fact
also a National Healthcare ICT Policy. Indeed, these
technologies could help countries in both regions and
elsewhere in the world achieve the dual healthcare delivery
objectives of providing their peoples with qualitative
health services while simultaneously reducing health
spending. The decision on July 12, 2006 by German
Chancellor Angela Merkel’s cabinet to approve controversial
reform plans aimed at shore up the country’s beleaguered
health system and reduce corporate tax rates, underscores
some of the themes of our discussion on the importance of
healthcare ICT in healthcare delivery10. Thus, it not only
underscores the finiteness of resources allocable to health
services in any country, and the need to reduce health
spending while simultaneously delivering qualitative
healthcare, but also the connection of health to the
economy. The German health service costs an annual 144
billion euros (US$183 billion,) and health spending is
increasing, population aging, and recent high unemployment,
expected to rack up a shortfall in 2007 or roughly 7
billion euros. It is little wonder that Merkel’s government
plans to increase healthcare charges by 0.5% from 2007 to
help finance the pecuniary-challenged health service, a
move unpopular among voters and that threaten the grand
coalition government. The Government also plans to reduce,
in its company tax reforms, corporate tax rates from a
nominal 38.65% to 29.16% with effect from January 2008,
both the health and tax reforms going to parliament later
in 2006. The country’s Finance Minister Peer Steinbrueck
noted detailing the tax plan, that it would make Germany
more attractive to invest in, and bolster its comparative
advantage. Although the tax changes will cost the
government more than 5 billion euros annually in the medium
term, it seems overall that the benefits accruable from the
plans, which include the introduction of a flat capital
gains tax from January 2008, capital gains currently
subject to personal income tax rates, particularly in
preventing capital flight outweigh the costs. Indeed,
Government plans to go ahead with the plans, despite
protestations by Germany’s eight industry associations,
which cautiously welcomed the plan but released a joint
statement recently indicating that tax burden would
escalate with the plans in the investment phase. Government
plans to use the extra tax revenues to help buoy service's
financing, including healthcare delivery, in particular
children’s health. Government had earlier introduced a
3-percentage-point rise in the country’s consumption tax to
19%, to which parliament concurred in June 2006, many of
course piqued by this VAT increase, which they claimed
would slow if not stagnate the country’s economic recovery.
The financial crunch facing Germany’s health services is
not peculiar to the country and neither are the prospects
of healthcare ICT diffusion and the implementation and use
of the appropriate health information technologies to
address its issues resulting in the achievement of the dual
healthcare delivery objectives mentioned earlier. The Bush
administration in the U.S., for example, on July 11, 2006
projected that the elderly will confront another
double-digit increase in their Medicare premiums in 2007,
leading to monthly payments of almost $10011. The monthly
premiums for supplementary medical insurance will increase
from $88.50 to up to $98.40, or more, an 11.2% increase,
projections, which if the presupposition underlying it
that Congress would cut Medicare payment rates for doctors
by about 4.7% in 2007, did not materialize could mean even
higher insurance costs for seniors. According to Mark
McClellan, administrator for the Centers for Medicare and
Medicaid Services, the increased volume of care provided
Medicare patients necessitate the higher premiums, as
doctors are utilizing services more in providing these
services, for examples, imaging, physiotherapy, lab tests,
and prescription medications use, on the rise. What is
more, a CMS fact-sheet released the same day noted, “Use of
these services varies substantially across practices and
geographic areas, with no clear impacts on health,” and
according to McClellan, “We can’t keep pumping more money
into a payment system that is not sustainable.” How true,
but what then is the answer? Does this not underline the
need to seek ways to achieve the dual healthcare delivery
objectives? The premiums help support physician services
and outpatient care (Medicare Part B,), which taxpayers
also finance. Government programs fund the premiums of
roughly 7 million of the poorest beneficiaries,
ex-employers help some retirees, but most of the country’s
43 million beneficiaries pay for themselves, and would also
the increase in premiums. What are the chances of these
increases compromising and perhaps eliminating the access
to health services or at least some of them, by these
senior citizens? Could we avert such situations by
exploring credible ways to achieve the dual healthcare
delivery objectives, specifically promoting healthcare ICT
diffusion and utilization of these technologies,
appropriately, in the execution of healthcare programs at
the primary, secondary, and tertiary prevention levels? Do
such measures not also apply to other countries including
in Europe and East Asia, and indeed, in the rest of the
world? As Kirsten Sloan, national coordinator for health
issues of the American Association of Retired persons
(AARP) noted, we could reduce costs for seniors by reducing
costs in the entire health care system via increased
utilization of technology. She also noted that legislation
aimed at making medical care paperless cut health spending,
and indeed, medical errors, improving the quality of
healthcare delivery and saving lives all at once. According
to Sloan, “We’re going on several years of repeated
double-digit increases, and it's also roughly three times
the rate of the Social Security (cost-of-living)
increase…It puts a real squeeze, particularly on
moderate-income seniors.” The observation by McClellan that
premiums for the new drug benefit have been lower than
projected, the average premium projected a year ago to be
roughly $37 a month, which fell to $24 a month as seniors
and the disabled sought plans offering lower monthly
premiums, attests to this squeeze.

Increasing healthcare costs no doubt put significant strain
on the budgets of many countries, and influence their
public finances. New Organization for Economic Co-operation
and Development (OECD) data in fact confirms this for its
member countries, many of which are in both regions under
consideration. OECD Health Data 2006, an all-inclusive
database of comparable health statistics in major developed
countries, showed that health spending continues to
increase in OECD countries and, if current trends persist,
governments would have to increase taxes, slash spending in
other sectors or make people pay more out of their own
pockets in order to sustain their current healthcare
systems12. The data indicated that health spending has
grown more rapidly than GDP in all OECD countries apart
from Finland between 1990 and 2004, accounting for 7% of
GDP on average, in 1990, and 8.9% in 2004, an 8.8% increase
from 2003. With many of these countries obtaining most of
their health services funding via taxes, these developments
are ominous for their peoples, particular the poor, this is
more as projections indicate probable increases in health
spending as a percentage of GDP even further because of
expensive new medical technologies and population ageing.
Again, we see the potential of healthcare ICT to cut costs
without compromising care as they could obviate the need
for many of these pricey technologies by strengthening
aspects of health services delivery that do not require the
use of costly technologies. In other words, by facilitating
the prevention of diseases in the first place, or their
treatment in ambulatory/domiciliary/community settings,
rather than in hospitals, thus eliminating the
often-substantial costs involved with the latter, yet not
compromising care, healthcare ICT could help achieve the
dual healthcare delivery objectives mentioned earlier. The
public share of health spending is increasing in many
countries in these regions, for examples in Korea, from 38%
in 1990 to over 50% in 2004, the percentage of direct,
out-of-pocket spending 37% in the same year, versus in
Greece, 45%. On the average, private insurance contributes
only 6% of total health spending in OECD countries.
Nonetheless, it is an important health-funding source for
some individuals in some European countries such as
Germany, the Netherlands, and in France, in which latter,
it covers between 10% and 15% of total health spending, and
is more prominent in payments for prescription medications
rather than for hospital or ambulatory care, in many
countries with publicly funded health systems. Money for
more than 75% of drugs spending in several European
countries in 2004, for examples, France, Germany, Austria,
Sweden, and Spain came from public funds12. Regardless of
where the funds come from, however, an ever-increasing
health spending is unsustainable in any country be it in
Europe or in East Asia, or indeed, in any country in the
world. Furthermore, the higher a country’s health budget,
the more it compromises its ability to provide other
important services to its peoples. What is more, that the
country spends an increasing proportion of its economic
resources on health does not necessarily translate into the
provision of better health services. In fact, the reverse
is sometimes the case13. Studies have also shown that
investments in new medical technologies have led to
increased and often unnecessary service utilization, which
drives up costs14. The reasons for increased service
utilization under these circumstances vary with health
system, ranging from the absence at least in theory of
adverse selection in publicly funded health systems, to
that of Tort law reform in others, where healthcare
professionals practice “Defensive Medicine” in order to
avoid litigation, among others. Yet, in either instance,
healthcare ICT could reverse the trend, in publicly funded
systems for example, obviating the need to invest
significant amounts of money on medical technologies that
would be redundant in some circumstances, or would at least
not duplicated in others, in particular, the
infrastructure-intensive, diagnostic imaging technologies,
or those for treating cardiac and cancer patients. At the
most basic levels, we could, via intensive, healthcare
ICT-based, primary prevention programs, start to see the
need to coalesce secondary prevention services, with
reduction in the prevalence of diseases requiring the use
of costly technologies such as magnetic resonance imaging
(MRI), computed tomography (CT) scanners, cardiac
catheterization, and coronary artery bypass graft (CABG),
among others. Healthcare-ICT related services such as
business process outsourcing and client resource management
would make the need to duplicate certain health services
unnecessary, thus saving costs, possibly significantly.
There thus needs to be system changes in many countries
were they to reap the immense benefits of healthcare ICT in
achieving the dual healthcare delivery goals mentioned
earlier. This would require policy changes in regard
healthcare ICT in these countries, many, both in Europe and
East Asia, which currently lack a National Healthcare ICT
Policy, the essential starting point for such systems
reforms. Many countries in Europe have actually embarked on
the path of widespread healthcare ICT adoption. In January
2003, the U.K government struck a £168m “broadband” deal
with BT, which aimed to enable the NHS improve its
infrastructure to connect hospitals and GP surgeries across
the country to a fast internet connection. The high-speed
network would underline the NHS modernization program. It
would enable for example, online appointment scheduling,
easier access by healthcare practitioners to patient
information at the point of care (POC), and the electronic
transfer of prescriptions. The deal gave credence to Prime
Minister Tony Blair's declaration in November 2002 to bring
broadband to all GP surgeries and schools in the U.K by
2006. It would take much less time for patients to see a
specialist as doctors exploit the capabilities of the
network to carry out online diagnoses using imaging or
video-conferencing, for examples, and patients receive
treatments form doctors in their local hospitals with
remote expert guidance saving transportation costs, even
lives due to prompt and effective treatment. Government
also envisaged experts in one region being able to share
knowledge with a variety of hospitals and care centers, and
the streamlining of health service provision. However,
things have hardly turned out the way Government hoped in
many ways. Many would insist that the gridlock in the
system persists, and that the fundamental problems of the
NHS remain unsolved, for example, the management issues
arising from the increasing market orientation of health
service provision in the country, one of which in fact
include the vagaries inherent in the development of
pervasive healthcare information and communication
technologies. Many have called for example, for an
independent investigation into the £6.2bn upgrade of the
NHS IT system, querying if the robustness of the plans to
meet NHS demands. Nonetheless, Government is adamant that
the 10-year IT (NPfIT) program aimed at connecting over
30,000 GPs in England to nearly 300 hospitals by 2012, and
has an online booking system, a centralized health records
system for 50m patients, e-prescriptions and fast computer
network connections between NHS organizations, undergoes
periodic evaluation, and is resilient16. There is no doubt
that the development process of such massive projects is
fraught with hitches, some of which could escalate costs.
There is also no doubt that investing in these technologies
involves much more than implementing them successfully. For
example, what if afterward, the end-use refused to have
anything to do with them, or did not utilize fully their
potential? What about issues of the safety and
confidentiality of patient information, or its security,
and what in fact would happen were these technologies,
which necessarily have different origins, could not
communicate with one another, or did defectively, causing
communication delays? Such concerns have led some to
propose that the Health Select Committee helps resolve
uncertainty about NPfIT by requesting the government to
commission an autonomous technical assessment as soon as
practicable. Government on the other hand remains sure that
the technical architecture of the national program is
apposite, would deliver benefits to patients, and ensure
value for taxpayers’ money. These issues, policy,
technical, management, end-user, and many others are not
peculiar to healthcare ICT efforts in the U.K. In fact,
they are issues every country would likely confront, as
they are inherent in technology implementation, including
healthcare ICT. They also illustrate possible market
openings and which, for every country of interest to ICT
vendors, they need to identify and elucidate. In other
words, that any health system attempting to implement new
healthcare ICT would likely confront end-user resistance is
doubtless, particularly were the implementers oblivious to
the importance of end-user buy-in, from the outset of the
ICT project. Even if they were not, there would likely be
ongoing need for training and for building on the support
garnered by prior change management efforts. There would
also be need for example, for any country serious about
disaster preparedness to examine on an ongoing basis, the
biosurveillance challenges it faces. In the U.S for
example, a federal advisory group is working on
recommendations regarding the data elements required to
help healthcare providers and public health agencies
communicate and share crucial healthcare data during an
array of scenarios including pandemic outbreaks, natural
disaster, and biological attacks17. On July 07, 2006, this
biosurveillance workgroup from the American Health
Information Community met to advance toward its goal of
making recommendations that would enable physician offices,
hospitals, ER departments, and labs to send within 24
hours, information in a standardized and de-identified
format to public health agencies. This workgroup
exemplifies the need for the sort of identifying,
understanding, and elucidating issues germane to healthcare
delivery and the role of healthcare ICT in addressing these
issues mentioned above that not only healthcare ICT vendors
keen on doing business in any country, but on which the
country itself needs to embark, on an ongoing basis.

Eighteen million people in the EU and about 58,000 EU
citizens commit suicide annually, tens more attempting it.
Do these statistics not point to the urgent need to
formulate and implement an action plan for mental health
promotion and the prevention of mental illnesses in all EU
member states? What role could healthcare ICT play in such
programs? Would an appreciation of the ramifications of
such statistics not help a healthcare ICT in devising
strategic market options? Would it not help an EU country
in policymaking, program development, and in healthcare ICT
investments decisions? Would addressing these issues
vigorously not help reduce the significant health and
economic burden of these disorders, and facilitate the
achievement of the dual healthcare delivery goals mentioned
earlier? There is no doubt that early intervention and
preventive initiatives could help save the lives of many
persons that have depression, yet on average, EU member
states allocate only 3% of their healthcare budgets to
disease prevention in general, that of mental illnesses, a
small part of this amount, annually. Would this not have to
change in light of such grim statistics as mentioned above?
A recent EU report noted that 25% of Europeans would likely
experience mental health problems in their lifetime, and
that more than 27% of European adults have mental ill
health annually18. The EU report also noted that depression
and anxiety disorders, and stress-related disorders, are
the most prevalent mental health problems, and that by
2020, neuropsychiatric disorders, with depression most
prevalent, would constitute the commonest cause of illness
in the developed world. A key objective of the Program of
Community Action in the Field of Public Health (2003-2008),
termed “The Program Decision”, which the European
Parliament and the Council adopted on September 23, 2002 a
key instrument behind the development of its health
strategy is harnessing health for economic growth and
sustainable development15. Article 152, § 1, of the EU
Treaty guarantees a high degree of human health protection,
which broadly expressed the intent of the “The Program
Decision” to support an integrated and intersectoral health
strategy embodies. One of the chief aspects of this intent,
which is in keeping with a new European health strategy,
launched on 15 July 2004, is to develop connections with
relevant Community programs and actions and with national
and regional initiatives, to promote synergy and shun
overlaps19. The EU also plans to improve the analysis and
knowledge of the effect of health policy formulation, and
of other EU policies and initiatives, for examples, that of
the internal market on health systems, and how these could
enhance its goals of health promotion and disease
prevention. It also plans to develop criteria and
approaches for evaluating policies for their effect on
health as well as other links between public health and
other policies. Again, these plans underscore the need for
understanding and elucidating health issues, both peculiar
to countries, both in Europe, East Asia, and indeed,
elsewhere in the world in order to determine the best
approaches to addressing them. This exercise, or process
cycle analysis, essentially involves identifying health
issues and those influencing health, decomposing them, to
expose more underlying issues and their processes,
eschewing historical fallacies. Process cycle analysis
would reveal the processes that need addressing and in what
manner, that is, whether to expunge, facilitate, or modify
them in some way or another, and which health information
and communication technologies would best do the job. It
is, therefore not surprising that the EU’s plan stressed
the need for cooperation between Member States regarding
information about health systems. Other priority issues
include the effects of patient and healthcare professional
mobility on health systems, healthcare quality assurance,
and health technology evaluation, cross-border
collaboration in health services, and economics and health.
The pivotal role in the EU actualizing these priorities is
self-evident, an indication of the domains of likely future
healthcare ICT investments, the EU’s interests in better
understanding if, why and how cross-sector health, has
economic benefits, also indicative of the crucial link
between healthcare delivery and the economy. It is also
indicative, though, of the importance of aiming to achieve
the dual healthcare delivery objectives mentioned earlier,
which creates the prospects of buoying both health and the
economy simultaneously. To underscore the key role that
healthcare ICT would play in the healthcare delivery scheme
in future, including in financial and economic issues, the
EU also wants to develop a Hospital Activity, and Resources
Information System to fortify the cross-analyses of health
accounts information of hospitals and their impact on
health services provision, and on patients’ access to it.
The EU would support its members’ efforts to implement the
System of Health Accounts it set up under the Community
Statistical Program, again, the foregoing an indication of
the non-health information systems whose role nonetheless
influences healthcare delivery. These accounting and other
non-health information and communications technologies
would continue to feature prominently in healthcare ICT
investments budgets throughout the EU, and elsewhere in
Europe in the coming years, creating for example, intense
competition between vendors of enterprise software-based
and the increasingly popular, web-hosted, customer
relations management technologies, for example. This is
more so with the increasing emphasis on customer-focused
healthcare, and efforts to reduce waiting times, and
enhance client satisfaction. With the mobility of patients
and healthcare professionals likely to be a major issue in
a milieu that is actively promoting labor mobility, these
technologies and those that would facilitate cross-border
access to patient information, hence improve the quality of
healthcare delivery, would gain market ascendancy in
Europe. There is no doubt, that East-Asian firms, keen to
enter the European healthcare ICT markets would benefit
from understanding the tide of health services provision on
the continent. The key goal of the first two years of the
“The Program Decision”, for example involved establishing
the basis for an all-inclusive and coherent approach, via a
focus on three key priorities: health information, health
threats, and health determinants, initiatives designed to
fashion self-sustainable means for member states to
synchronize their health-related activities, 130 projects
chosen by 2004 for funding20. Collaboration with
international organizations for examples the World Health
Organization (WHO), the Council of Europe, and the
Organization for Economic Co-operation and Development
(OECD) are ongoing. For example, the EU would offer
financial assistance for WHO-activities, unless otherwise
agreed in exceptional circumstances, in keeping with the
Financial and Administrative Framework Agreement between
the European Community and the United Nations, which became
effective on April 29, 2003, areas of cooperation including
data and information gathering, health monitoring and
disease surveillance. Considering the previously mentioned,
these areas would continue to attract significant
healthcare ICT funding in the years ahead. The EU also has
direct grant agreements with the OECD, which would address
public health programs for examples, performance assessment
of health care facilities for quality strategies, health
economics and cost-effectiveness issues in the different
levels of prevention, labor mobility issues, including of
healthcare professionals, System of Health Accounts support
outside the EU’s Statistical program. In other words, there
is also a wide scope for healthcare ICT investments in
actualizing programs relating to this agreement. The global
budget for the program in 2005 was € 61,460,411,
administrative and operational budgets, the indicative
global amount for grants, € 48,316,546, the EU co-funding
up to 60%, typically, and with projects with strong
European benefit, and in new member states or candidate
states, sometimes up to 80%. There are compelling reasons
that not just EU countries but also indeed, all countries
have a stake in health, the most fundamental being the
maintenance of the health of their peoples, but there are
also economic reasons, which attest to the intimate
connections between health and the economy mentioned above.
In other words, countries in Europe would increasingly
invest in healthcare ICT that would help them achieve the
dual healthcare delivery objectives. The contribution of
the Commission on Macroeconomics and Health (CMH), whose
final report appeared in 2001, to this link between health
and economy is undoubted, in developing countries21, as is
its value in guiding investments in health, even if its
bearing to EU countries, with different health issues seem
unclear. The CMH report not only confirms that investing in
people’s health in developing countries, a noble objective
in its own right, has noteworthy economic paybacks, for the
peoples and their countries. Despite its focus on
developing countries, which incidentally some of the
countries in East Asia, are, some of the empirical evidence
gathered referred to industrialized countries, not to
mention the intuitiveness of the applications of the
concept of the economy/health connection to all countries,
whether developed or developing. The report noted a variety
of cost-effective investments that could result in the
achievement of the dual healthcare delivery goals, which
essentially is saving lives and money simultaneously. In
short, that healthcare investment in the less financially
endowed would not only help lift the poor from the poverty
abyss, but the country’s economy overall from it. This
further highlights the need for the implementation and use
of healthcare ICT in healthcare delivery in these countries
in particular, and indeed, in all countries, including
those in Europe. With 87,000 recorded protests incidents in
2005 in China, over the effect of the country’s economic
policies on the poor, for examples, farmers displaced to
make way for industrial growth, and with the country’s
population aging, and birth rates falling, due to
deliberate government policy, could China for example,
afford to ignore this need? Would China for example, not
have to invest in technologies that could save it money
while it could deliver qualitative health services to its
aging population? Should it not continue to seek ways to
sustain its economic development in the likely event of a
dwindling labor force? What could a healthy seniors’
population offer the country in the years ahead when it
might need them to keep its industrial engine rolling? Do
these queries not suggest the likely healthcare ICT
investment scenario in the country in the near future, for
example, the increasing use of
ambulatory/community/domiciliary technologies? The
characteristic quantitative effect of life expectancy on
economic growth is that a 10% increase of life expectancy
at birth boosts economic growth at least by 0.3 to 0.4%
points of GDP per year21. The CMH report on developing
countries and its focus on investing in communicable
diseases in the main are instructive, and with the main
types prevalent in each country identified, the most
appropriate healthcare ICT for addressing them would be
more readily determinable. Does this not underscore the
point we made earlier about the need for process cycle
analysis in every instance by interested parties be they
healthcare ICT vendors, non-governmental, or governmental
organizations? While East Asian developing countries might
be focusing more on communicable diseases, hence healthcare
ICT vendors seeking to business there more on the
technologies most appropriate for addressing the issues the
decomposition/exposition exercises revealed and their
processes, the reverse would be true of vendors in East
Asian seeking to do business in Europe. That said, that
does not mean that Europe does not have communicable
diseases, or that East Asia lacks noncommunicable diseases.
In fact, the latter at least in the more affluent
countries, are starting to see increased prevalence of
chronic noncommunicable diseases, and the former,
communicable diseases such as HIV/AIDS, Syphilis, and
Tuberculosis, in some areas not to mention the avian flu,
which is in fact causing global health concerns these days.
There is no doubt that we need to determine the priority
interventions that would, and perhaps, significantly reduce
the burden of disease in the country in question. In Europe
for example, the burden of disease in the main due to
chronic noncommunicable diseases, the approaches to
addressing the issues would likely involve more complexity
in terms of the need for multidisciplinary, intersectoral
collaboration in devising sophisticated healthcare
ICT-enabled programs that would help in achieving the dual
healthcare delivery goals. The programs would involve
primary prevention, which lends itself to the use of these
technologies particularly in a region where the
telecommunications infrastructures are available. They
would also involve secondary and tertiary levels disease
management strategies, for examples for mental health, and
cardiovascular disease, and intricate infectious diseases,
for examples, nosocomial, and medication-resistant
infections. Prevention at these levels would benefit from
healthcare ICT, for example, sophisticated mobile
technologies that the likes of LG and Samsung Electronics
of Korea, could compete with European companies for,
successfully in the European healthcare ICT markets. Sales
of LG, until recently better known for household air
conditioners, and plasma TV, although now ranks high in
mobile phone manufacturing, increased an estimated 21%, to
$23.6 billion (24,659 billion won) in 2004, although it
dipped slightly to 23,774 billion won in 2005. Its sales of
handsets increased from 6.9 million in 2000 to 44 million
in 2004, 20 million in the U.S alone. The company has
supplied American carrier Verizon Wireless, to which it
sold 11 million handsets in 2004, 6 million to Cingular/
AT&T the same year. LG Electronics was the first firm to
launch a CDMA (Code division multiple access)
platform-based digital mobile phone, with avant-garde
multimedia and data transmission capabilities, features
that are invaluable in delivering a variety of primary,
even secondary and tertiary prevention health programs. The
company is a major manufacturer of CDMA/GSM handsets, UMTS
3G handsets, Mobile TV Phone (SDMB/ TDMB/ MediaFLO/ DVB-H),
its 2005 global sales of 55 Million Units amounting to US$
9.9 Billion, impressive22. Samsung is the quintessential
Korean electronic firm, the 44 million handsets LG sold in
2004 just roughly half of Samsung’s output, and LG’s 3G
technologies head start, threatened in both Korea and
China. Incidentally, Samsung has reported an 11% fall in
quarterly profits, battered by decreasing margins for
cellular phones and flat screen TVs. The company reported
that it made 1.51 trillion won ($1.59bn; £864m) in the
three months prior to June 31, 2006, versus 1.69 trillion
won in 2005, although it expects recovery across its
businesses in the remaining half of the year. The company
also revealed its $1.9bn deal to manufacture LCD display
screens for Sony of Japan, under whose terms it will
manufacture LCD panels for 50” flat screen TVs subsequent
to a “significant” demand rise. With firm having to contend
with a global market awash with LCD TVs, and stiff
competition from Nokia and Motorola in the “cut-throat”
mobile phone market, seeing its second quarter mobile phone
profit margin drop to 9.5%, from 12% during the same period
in 2005, the major world chipmaker, seems to be struggling.
Nonetheless, these issues, and LG and Samsung, exemplify
those, including the potential competition foreign firms
venturing into the healthcare ICT markets in East Asia
would likely face, and possibly in European markets too. On
the other hand, European firms need to be looking at
healthcare ICT more suited to the management of
communicable diseases in developing countries, as these
constitute although not exclusively as noted earlier, the
major burden of disease in these countries.

The dyadic interactions between Europe and East Asia in
terms of business opportunities and market openings in the
healthcare ICT sector would, therefore, reflect the
dynamics of health and non-health factors, in particular
what is happening elsewhere in the economic sectors of the
countries in these two regions. However, and as noted
above, it would not just be a matter of developed versus
developing, as health and economy are extremely complex
issues, whose intricacies require in-depth analyses to
unravel. The fundamental issues confronting health systems
in developing countries differ from that Europe face, which
makes extrapolating such findings as of the CMH mentioned
above somewhat tricky. Some might also argue that because
the health status of the EU countries is already relatively
high, achieving additional health system improvement would
be harder and more expensive, hence unlikely to accrue
significant economic payoffs. Furthermore, there are
differences in demographic variables, for example,
population aging, and health indicators that could
significantly influence the economic burden of disease in
these regions. To be sure, the dichotomy of developing and
developed countries is not absolute in terms of the
individual as there is affluence in the former and poverty
in the latter, and there are prospects of transitioning
from one group to the other. In fact not only was Portugal
and Ireland until recently deemed developing countries,
there is poverty in some parts of Europe, and according to
the most recent Eurostat figures the working poor, are
becoming poorer, the purchasing power of workers on the
minimum wage varying between 1 to 7.5 among the EU-28,
seven member states not having a minimum wage23. This
report also indicated that Luxembourg, with the highest per
capita income in the EU, and the highest minimum wage, also
has the largest number of workers stuck on that minimum
wage, versus others in the same year, 2004, the U.K (1.4%,
the same incidentally for the U.S), 15.6% in France, and
3.1% and 4.5% in Ireland, and Poland, respectively. The
migration issue further complicates the picture in Europe,
with potential significant effects on its health and
economy, even if the migrants are more prone to
impoverishment in the short term. There are about 20
million migrants in the EU, and the numbers are increasing
daily. Defined as third-¬country nationals with temporary
or permanent legal residence, migrants, include immigrants,
refugees, and asylum¬ seekers, among others, and exclude
automatically, EU citizens. Caritas Europa’s recent, third
report on poverty in Europe, noted that asylum seekers are
among the most susceptible groups of the EU population,
lacking not just pecuniary wherewithal, but also social
empowerment, the combination of education, housing,
employment, and health problems these migrants confront a
potential wellspring of future socio-economic problems in
their host countries. They face health risks for example,
due to deprived living conditions, lack health insurance,
and do not have the funds to pay for healthcare. Would
these countries not need to major policy reorientation to
avert the long term health and economic, not to mention
social consequences of these issues, and what role could
healthcare ICT play in their efforts in this direction, for
example in social inclusion, health promotion, and disease
prevention? Do these issues not support the need for the
sort of country-specific process analysis mentioned
earlier, rather than depending on broad, dichotomy-based
assumptions, were efforts to address them to succeed? There
is no doubt that there are costs linked to illnesses. Even
basic COI (Cost-of-illness) studies, which reckon resource
quantity (funds), used in disease treatment vis-à-vis the
extent of its negative economic costs (lost productivity)
to society, indicate this much, the limitations of such
studies, for example, causality direction of the
health/economy dyadic, regardless. COI studies attempt to
recognize and measure all the costs linked to a specific
disease or risk factor, direct, indirect, and intangibles
costs. The point here is that in exploring the healthcare
ICT markets, there is need for process cycle analysis,
which could be at different levels, country, regional
health authority, hospital, which, among others would
reveal funds guzzling issues and processes that need
modifying. Depending on a variety of factors that govern
their overall strategic interests, a healthcare ICT firm
might want to, as the governments or local authorities
ought to do, make this an ongoing exercise in perpetuity,
because no health system could ever be perfect, and as long
as it confronts constraints, must evolve for the better or
risk oblivion. Thus, it is necessary for example to know
the drivers of direct costs, that is, those on the health
sector concerning disease prevention, diagnosis, and
treatment, and might include costs of ambulances,
in/outpatient, medications, rehabilitation, and community
health/healthcare, among others. It is also important to
know those of indirect costs, that is, costs due to lost
productivity potential of ill patients, or those that died
precipitately. Some have included in this estimation the
loss of future earnings (discounted), the so-called human
capital approach, and others have adopted the
scenario-based, willingness to-pay technique, estimates of
indirect costs, often a matter for contention. Intangible
costs, which aim to account for the psychological aspects
of illnesses to the ill person and to his/her family, are
even more difficult to measure, hence more contentious.
Nonetheless, an exploration of these different drivers, and
their costs, for examples via the disease prevalence, or
the more data-intensive incidence costing methods, would
reveal perhaps even cryptic issues and processes that
underlie them, and which the application of the appropriate
healthcare information and communication technologies could
help modify and improve, hence reducing the costs, while
not compromising healthcare delivery. Cardiovascular
diseases for example are some of the commonest
noncommunicable diseases among Europeans. The economic
burden of coronary heart disease (CHD) in the UK (direct
and indirect costs,) was GBP 1.73 billion (EUR 2.5 billion)
in 1999, GBP 2.42 billion (EUR 3.5 billion) and GBP 2.91
billion (EUR 4.2 billion) in informal care, and lost
productivity (24.1 % due to mortality and 75.9 % to
morbidity), respectively24. The overall yearly cost of all
CHD-related burdens, GBP 7.06 billion (EUR 10.2 billion),
was about 1 % of 1999 GDP and 11 % of total national health
spending for 199921. Such estimations could also reveal the
costs and their drivers for other diseases, and even enable
comparison of costs for diseases and costs within and
between countries, facilitating policy formulation and
program development. By understanding these issues,
healthcare ICT firms would be better able to develop the
appropriate product and service mix, and develop the right
strategies for the markets either in Europe or in East Asia
that interest them. It is not always that these firms have
either the resources or willingness to embark on such
analyses, in which case, they need to hire someone to do
the job. With regard countries, should the U.K for example,
knowing that in 1999, CHD had the highest burden their
direct, indirect, and total costs respectively, GBP1730,
GBP 5325, and GBP 7055, not do something to reduce these
costs21? What role could investing in the appropriate
healthcare ICT for example play in this regard, considering
that many of the risk factors for these conditions are
preventable for example? The same questions apply to other
“high-burden” diseases such as obesity/diabetes, mental
illnesses, and substance use/dependence not just the U.K,
but in most of Europe, where they constitute significant
disease-burdens. These disorders need prioritizing and
measures taken to reduce their prevalence and their burden
in both human and material terms, and governments in
countries where they are prevalent cannot afford to do
otherwise. Considering that these diseases are preventable
in the main, this says something for the sorts of health
information, and communication technologies that these
countries would need to invest on in the years ahead in
order to tackle these problems. Let us illustrate this
point further with some figures. In 2001, the US Surgeon
General’s report estimates of the direct and indirect costs
of obesity were US$117 billion (US$61 billion direct costs;
US$ 56 billion indirect costs), albeit underestimates, the
condition’s effects on social well-being, and among those
outside the labor force excluded25. In 2001, the direct and
indirect economic costs of physical inactivity and obesity
in Canada were US$5.3 billion (EUR 3.5 billion), US$1.6
billion (EUR 1.1 billion), and US$ 2.7 billion (EUR 1.8
billion) in direct and indirect costs, respectively. In the
same year for obesity, the costs were US$4.3 billion (EUR
2.8 billion), US$ 1.6 billion (EUR 1.1 billion) and US$2.7
billion (EUR 1.8 billion), in direct and indirect costs,
respectively, both physical inactivity and obesity, in
total, 2.6 % and 2.2 %, respectively, of the country’s
total healthcare costs26. In 2001, estimates also revealed
that treating obesity in the U.K, cost the NHS roughly GBP
500 million (EUR 715 million) annually, and with costs to
the entire economy of reduced productivity and lost output
added, another GBP 2 billion (EUR 2.8 billion) annually.
The devastation that Typhoon Bilis, which hit the
Philippines and Taiwan on July 14, 2006, and China, caused
is another example of the need to appreciate the health
issues of each country fully in order to better determine
the most appropriate healthcare ICT required in the
delivery of cost-effective and qualitative health services
to the country’s peoples. The floods and storms of the
Typhoon killed at least 115 persons, in China’s southeast
Fujian, Hunan, and Guangdong provinces27, more than 100
people in Hunan province alone, thousands of homes and
hectares of farmland, swept off, train services, disrupted,
and power lines cut, torrential rain predicted to continue
across southern China for the next many days. Such rain
only in June 2006 killed at least 349 people also in China.
In fact, seasonal heavy rains and typhoons cause hundreds
of deaths in China yearly. Should the country not invest in
and deploy the appropriate healthcare technologies to
address the varieties of health issues that these natural
disasters cause? Do these examples not underline the
contextual approach that healthcare ICT vendors should
adopt regarding their strategies in their markets of
interest? The healthcare ICT sector is no doubt evolving in
many countries, including those in the regions under
consideration. However, this evolution would likely have a
pattern, based on the issues and approaches we have
discussed thus far among others. These issues would be
different for each country, and indeed, for each region,
but what would be the same for all is the need to achieve
the dual healthcare delivery objectives mentioned earlier.
Besides considerations for individual’s health, investing
in healthcare information and communication technologies
would also be a means to an end, that of sustainable
economic development. These are two potent reasons that
governments cannot afford to shun the important role that
these technologies could play in their achieving these
health and economic objectives. We have not identified the
markets for specific healthcare information and
communications to any precise level for the same reasons we
have advanced in this discussion regarding the need for
process cycle analysis to a more or less extent in the
particular setting in which we are interested. To do
otherwise would either mean having particular information
on the specific healthcare ICT projects that that setting,
a country, health region, or hospital, for example, has
lined up, or merely speculating on them. It is possible to
obtain the former information from the appropriate sources
since it would probably be on open tender, but it is
important to be able configure a strategic view on the
direction the health system of interest is headed as this
might be crucial for the distinctions value proposition
that confer competitive advantage.

Part of the process analysis involves also determining the
technical issues involved in healthcare ICT diffusion,
implementation, and utilization in these settings, which
would also likely reveal the nature and extent of their
markets. Interoperability for example, is a major technical
issue in healthcare ICT implementation in many countries,
although it has other dimensions for examples, research and
development, regulations, and standards, among others. In
this connection, some developers are addressing the
interoperability issue from a Service Oriented Architecture
(SOA) software design perspective, for example, hoping by
overcoming the challenge to launch a new age of efficient
network services, cross-organizational business
collaboration and novel services with valuable applications
in the health industry. SOA is essentially a novel,
software development methodology that rather than of
individual programs that perform, a variety of functions
enables the design of individual functions that could blend
to offer a variety of diverse services, the programs
compiled when required and extensively reused, SOA thus
lithe and cost-effective. It is also likely to be
invaluable in connecting organizational, services,
platforms, and networks, facilitating the seamless
information communication and sharing that the typically
disparate systems in the health sector needs, yet the need
to scale the interoperability hurdles, literally, is
crucial for this to happen. That this requires addressing
at levels other than the technical is not in doubt
considering the need for business to drive IT rather than
the reverse, which again underscores the need for process
analysis, which reveals underlying issues and processes and
the best health information and communication technologies
to modify/improve them. The IST-funded, ATHENA project, for
example, involves research, research, technological and
industrial partners, and aims to develop solutions to the
different interoperability issues that firms confront at
various levels, such as data, services, processing and
business levels28. Researchers are utilizing semantics,
mostly semantic data transformation to help translate
information stored in different formats and systems among
dissimilar enterprises, focusing in the service area, on
model-driven SOA to address the issue of running different
applications on diverse architectures, for examples, Web
services, Grids or P2P28, and a ‘process abstraction
concept’ at the process level for automated
cross-organizational processing. The researchers’ success
with the latter for example would mean no longer the need
for wagering between efficiency and security in connecting
corporate applications for information sharing to protect
some crucial data from general view, a scenario that
applies in particular to health systems, besides companies’
supply chains, for example. With ATHENA, the abstraction
concept translates to every business partner or authorized
user-department in a health system is able to define public
processes positioned above its internal, private processes
keeping private and confidential processes, and data
cloaked, simultaneously. In other words, the researchers
hope to develop an integrated yet secure milieu. According
to Rainer Ruggaber at SAP Research in Germany, one of the
principal developers of SOA solutions, “Though this concept
is not new, the value of our solutions revolve around the
creation of an integrated but secure environment. It means
that my internal processes are linked to my public
processes which in turn are connected to your public
processes and to your internal ones but where outside
access to the private processes of both sides is
restricted.” There is no doubt interoperability solutions
in SOA will have important applications in any sector
including the health sector where efficient, seamless
information communications and sharing are key processes in
its operations. For example, the SOA-based, SODIUM project
has developed two prototype systems addressing risk
management and healthcare utilizing a standards-based
approach to determine, compose, and execute mixed web,
peer-to-peer and grid services, trials underway in Romania
and Norway. Its scientific coordinator, Aphrodite
Tsalgatidou recently noted, “SODIUM is providing solutions
on top of existing standards to create a unified way to
discover and compose heterogeneous services…The main
challenge for us is to achieve syntactic and semantic
interoperability.” He added, “In crisis management, for
example, emergency services have to use a variety of
services some of which will be P2P, others will be Web
based and others will be Grid based. All of them have to
work together.” As noted earlier, there are varieties of
natural and manmade disasters that countries in both Europe
and East Asia regularly confront. With risk and crisis
management, being no doubt domains where interoperability
is crucial, would countries in these regions not therefore
need to explore the potential of ATHENA, and similar
technologies, for example? Have the researchers not for
example, and as we have advocated thus far, critically
examined the issues involved in interoperability,
decomposed them, and determined their underlying processes
and those that need modifying and improving for more
efficient and cost-effective, systems interoperability, in
fact able to offer novel and intuitive value propositions
in the process? In fact, another SOA-based project,
ORCHESTRA, aims to address procedural, technological and
communications challenges that compromise efficient risk
management. According to project coordinator José Esteban,
“Our architecture will allow interoperable risk management
services to be created to overcome the barriers between
different actors who use different procedures, databases,
systems, and languages…The standards-based approach aims to
ensure compatibility between systems, databases and
services including those that are already in use by
different public administrations across Europe.” These
technologies would certainly be useful in healthcare
delivery, and would play a key role in improving
interoperability standards. In fact, the ATHENA project has fashioned the Enterprise Interoperability Centre (EIC) to use ATHENA results for forging accord, and as Ruggaber noted, “The EIC is currently working on business profiles for interoperability focusing on public business processes and building on existing messaging standards. Initially starting in the construction sector it will continue with scenarios in the automotive industry, healthcare, and logistics”, the EIC aiming to facilitate the collaboration of stakeholders in securing the wider applications of research findings. ATHENA is also involved in the Enterprise Interoperability Research Roadmap that the European Commission would publish in July/August 2006, and intends to contribute to EU policies aimed at improving systems interoperability among European firms. These examples buttress many of the points we have made about the importance of process cycle analysis. The direction of the dyadic between Europe and East Asia with regard the healthcare ICT markets would in future hinge on this sort of analysis. New and sophisticated information technologies emerge routinely, many with features applicable to healthcare delivery although not necessarily set out to deliver such services. The question is whether ICT software and other vendors are aware of developments in the health industry or are at all interested in them. The examples of ATHENA and others mentioned above indicate that at least some are collaborating with research and other organizations to design and develop ICT focused on issues that bear direct relevance to healthcare delivery. However, the markets for healthcare ICT is unimaginably wide open considering the innumerable processes that currently hamper healthcare delivery efforts, hence yearning for technologies to improve them. The issue of hospital wait lists for example, plagues many European and East Asian countries, and these issues no doubt could benefit from appropriate healthcare ICT applied to addressing some of the underlying issues and processes involved. Would a healthcare ICT vendor that conducts process cycle analysis in its preferred market in order to understand fully these underlying processes, and then designs and develops the appropriate technologies to tackle the issues successfully not likely to find sufficient market opportunities to recoup its costs, for example, or be gratified additionally by the social grace of perhaps saving lives? These are clearly questions that these companies would need to ask in time seeking market opportunities in the health sector, not just in Europe and East Asia, but also worldwide.