JMIR Publications

ABSTRACT

Background:

Background:

Governments and policymakers struggle to achieve a balance between hierarchical steering and horizontal governance in systems characterized by fragmented decision authority and multiple interests. To realize its “One Citizen – One Journal” eHealth policy vision, the Norwegian government established a special eHealth board of stakeholders to ensure eHealth policy development. The aim was to create an inclusive governance model that aligned stakeholders’ interests with government ambitions through coordination and consensus. Little empirical knowledge exists on how countries realize such governance models.

Objective:

The objective of this study was to investigate how the Norwegian inclusive eHealth governance model developed as a tool to align the government’s policy ambitions with stakeholders’ concerns from January 2012 to December 2022.

Objective:

Objective:

The objective of this study was to investigate how the Norwegian inclusive eHealth governance model developed as a tool to align the government’s policy ambitions with stakeholders’ concerns from January 2012 to December 2022.

Methods:

Methods:

In a longitudinal case study we analyzed 16 policy documents and 175 consultation documents issued between January 2012 and December 2022 related to the Norwegian “One Citizen – One Journal” policy implementation process. We used a qualitative approach and employed thematic analysis.

Results:

Results:

(1) The national policy implementation process progressed through three phases, with changes in stakeholder inclusion and perceived influence on the decision-making process characterizing transitions from phase to phase. (2) Tension developed between two contrasting views regarding stakeholders’ autonomy and top-down government authority. Regional health trusts, municipalities, healthcare professional organizations, and industry actors became increasingly concerned about the model’s ability to balance stakeholders’ autonomy concerns with top-down government authority. On the other hand, patient organizations wanted a hierarchical model to ensure equal access to care and quality of care through coherent digital solutions. (3) Governmental insensitivity to participation, lack of transparency, and decreasing trust between the government and stakeholder groups challenged the legitimacy of the inclusive horizontal governance model. As a response, the government changed its approach and adjusted the model to an inclusive bottom-up network model that combined horizontal and hierarchical decision-making.

Conclusions:

Conclusions:

We conclude that Norway’s “One citizen – one Journal” policy trajectory was characterized by a process that unfolded across three distinct phases. Furthermore, the process was characterized by two contrasting stakeholder perspectives: one concerning the extent of justifiable top-down governance to realize a national journal and the other regarding the impact of top-down governance on stakeholders’ autonomy and freedom to govern their own electronic health record implementation process. Finally, it was characterized by diminishing trust in the inclusive governance model. The National eHealth Governance Board faced challenges in establishing legitimacy as a top-down defined horizontal inclusive governance model, primarily attributed to its handling of dilemmas related to participation, transparency, and trust. These dilemmas represent significant obstacles to inclusive governance models and necessitate ongoing vigilance and responsiveness from governmental entities.