In examining the unique organizational nature of health care delivery systems and their ecclectic economic model in the United States, three key challenges emerge with respect to disaster planning. Barbara and Macintyre (2002) laid out these challenges in their report entitled Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. Short excerpts from the report are provided below along with discussion of the nature of each of the three key challenges.

Need for a Systems Approach

A systems approach to disaster planning implies discrete phases with clear inputs and outputs that build on each other through feedback loops that ensure iterative quality improvment. In other words, "Adequate mass casualty management and response require systems that achieve rapid, efficient expansion of capacity through local and regional coordination" (Barbera & Macintyre, 2002). The need to develop a comprehensive, systems approach to disaster planning represents a significant challenge for the health care delivery sector, a sector which operates as a loose network of separate entities that are themselves chronically burdened with daily operational stressors including hospital overcrowding, ambulance rerouting, nursing shortages, and many more.

Emphasis on National Planning vs. Local and Regional Planning

Since 9-11, great attention has been given to disaster planning and vulnerability assessment reforms at the national level (e.g. creation of the Department of Homeland Security, high-profile staff changes at FEMA, development of the National Incident Management System, etc.). In contrast, while many local health care delivery systems have also devoted greater attention to disaster planning – for example revising their own Emergency Response Plans – very little of this effort has been in concert with other resources at the local or regional level.

"Medical care and public health resources are primarily locally managed assets, yet much of the current national focus has been at a higher level of government or is being directed from that level. Most troubling is that progress in local and regional planning for mass casualty care falls far short of that made in other areas of emergency management and disaster response in recent years.... Individual components and capabilities for medical and health response exist, but they are not comprehensively addressed in an overall system. This has led to inefficiencies and confusion, risking organizational failure in a truly mass casualty incident.... Systems engineering research in emergency response demonstrates that if organizational and technological systems do not match the local reality created by an actual event, complete systems failure may occur, causing needless societal impacts" (Barbera & Macintyre, 2002).

This lack of coordinated disaster planning at the local and regional level represents a second critical challenge for health care delivery systems. Although more resources have begun to flow into efforts at the state and local levels, there is a dearth of leadership and coordination in applying them most effectively.

Necessity for Public/Private Collaboration

Because of the ecclectic nature of the economic, organizational, and regulatory models of health care delivery systems in the United States, the result has been a loose network of public and private interests that must collaborate and coordinate their activities in the event of a disaster to provide the best possible response.

"The strategy to implement these objectives requires close coordination of many diverse and only loosely connected health and medical entities. Preparedness for all-hazard mass casualty response is a complex undertaking, in part because medical infrastructure resides predominantly in the private sector, in many disparate resources.... Full community preparedness must involve the coordination of health and medical assets across both jurisdictional and public-private boundaries" (Barbera & Macintyre, 2002).

This need to coordinate the resources of public and private assets presents a third central challenge to effective disaster planning for health care delivery systems.