JMIR Publications

ABSTRACT

Digital health transformation has absorbed tens of billions of dollars in public investment over two decades and produced a consistent pattern of failure. The United States spent $36 billion on electronic health record incentives that achieved adoption without interoperability. England's National Programme for IT was cancelled after a decade and £13 billion. Australia's My Health Record required twelve years and legislative compulsion before providers shared data. These failures have been attributed to management shortcomings, funding gaps, and political interference, yet none of these explanations accounts for why the same pattern recurs across countries with different political systems, funding models, and vendors. This paper proposes that the cross-national consistency reflects a structural governance problem. Drawing on Elinor Ostrom's polycentric governance framework, the analysis argues that digital health ecosystems function as commons governed by multiple autonomous decision centers with overlapping jurisdictions. When Ostrom's eight design principles are absent, coordination fails predictably regardless of technology or funding. The paper tests this claim against six initiatives across three countries, mapping each against the design principles and identifying which are systematically absent. A contrast case, OpenNotes, demonstrates that partial presence of these principles improves outcomes. The analysis translates these findings into a governance-first strategic planning framework specifying requirements for boundary definition, stakeholder inclusion, outcome monitoring, graduated sanctions, conflict resolution, and nested governance. For digital health strategic planning, the contribution is foundational: hierarchical planning frameworks are structurally inadequate for polycentric environments, and Ostrom's design principles offer a rigorous alternative.