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From Siloed Applications to National
Digital Health Ecosystems: A Strategic
Perspective for African Countries
Karl A. STROETMANN a,b,1
a Senior Research Associate, empirica Communication & Technology Research,
Germany
bAdjunct Assistant Professor, School of Health Information Science, University of
Victoria, BC, Canada
Abstract. Substantial investment in digital solutions for improved health services
has occurred in recent years in Africa. Digital Health provides for proven, beneficial
applications in many different areas of health systems. It supports the transformation
of healthcare delivery, and its potential is seemingly boundless. However, the
deployed systems are in silos, and interoperability and integration are largely
missing. There is no timely information for easy and quick decision making; there
is no ability to track service levels across the whole health sector. What is missing
is an integrated information system across all healthcare facilities nationwide. Such
a Digital Health Ecosystem, the holistic application of information and
communications technologies, services and applications, will support health
systems and improve healthcare delivery, coordination and integration across
providers. Based on global experience in resource-constraint contexts, core steps
necessary to develop and implement such an ecosystem are explored, and four
fundamental building blocks and their elements are d eveloped. The results presented
are succinctly integrated into six statements on lessons learned and
recommendations.
Keywords. Digital health, ecosystem, open platform, Africa, strategy, foundational
building blocks, interoperability
1. The Integration Challenge
Innovative digital solutions have become a major determinant for the improvement of
well-being and economic growth worldwide [1]. They help African economies to
overcome limitations and costs of physical infrastructure in important areas of social and
commercial life [2]. The health sector is also benefitting from this trend. Substantial
investment in digital technology solutions for improved health services has occurred in
recent years in Africa [3,4]. African leaders who gathered at the African Ministerial
Dialogue on Digital Health Leadership at the May 2017 World Health Assembly
affirmed their commitment to digital health and identified the pathway towards realising
strong Digital Health Ecosystems in their countries [5].
Digital Health provides for beneficial applications in many different areas of health
systems. It supports the transformation of healthcare delivery, and its potential is
seemingly boundless. E.g., the path-setting mHealth4Afrika application platform [6]
provides for more effective and efficient care provision through an open source,
multilingual digital health platform improving the quality of community based maternal
and newborn healthcare delivery in rural health service points of Ethiopia, Kenya,
1 empirica Gesellschaft für Kommunikations- und Technologieforschung mbH,
Oxfordstr. 2, D-53111 Bonn, Germany; E-mail: karl.stroetmann@empirica.com
Improving Usability, Safety and Patient Outcomes with Health Information Technology
F. Lau et al. (Eds.)
© 2019 The authors and IOS Press.
This article is published online with Open Access by IOS Press and distributed under the terms
of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0).
doi:10.3233/978-1-61499-951-5-404
404
Malawi, and South Africa. – Telemedicine makes specialist knowledge and improved
treatment accessible in rural areas: In Tanzania, for example, teleconsultation equipment
to support obstetric emergency care in rural and outmost areas was installed in ten
upgraded rural health centres, four rural district hospitals and one regional hospital [7].
– Mobile health (mHealth) makes use of cell and smart phones as well as other mobile
devices, a promising application field in Africa due to the relatively ubiquitous mobile
telecommunication connectivity when compared to other modes of communication.
Smart phones have been engineered to serve as local hubs or platforms to connect sensors
and electronic measurement devices, printers etc. at the local level, and to connect to
more complex systems at community centres and district hospitals. Worldwide known
applications focus on pregnant women, like the UNICEF-supported MomConnect
service in South Africa which links pregnant women and young mothers to healthcare
centres [8]. – Digital health also helps to better support administration and management
services. Triggered by the need to reduce endless waiting times for patients, in South
Africa the Western Cape’s Primary Health Care Information System [PHCIS] [9] focuses
on managing patient throughput in primary care clinics through electronically drawing
information on past clinic visits, creating electronic appointments, and providing patient
and facility management tools for reporting purposes. – Improving Public Health
surveillance is a core WHO goal for Africa [10]. Through the introduction of a mobile
“Electronic Integrated Disease Surveillance and Response [eIDSR]” application by
Sierra Leone’s Ministry of Health and Sanitation weekly disease reporting drastically
improved from occurring in 35% of health facilities to 96% [11]. – eLearning is another
highly relevant application field. The Tanzanian Training Centre for International Health
uses an audio teleconferencing service; and an online eLearning platform to teach health
workers and nurses in maternal and perinatal health-care in rural areas [12].
However, such isolated eHealth investments do not yet comprehensively meet the
needs of African countries. The core remaining challenge was neatly summarised in a
recent statement on the “Enhancement of Rwanda National Digital Health Care System
– ‘Smart Health’” by the Ministry of Health: “The earlier interventions only focused
more on routine reporting and disease surveillance systems. The deployed systems are
in silos and there is no system that is integrated with another. There is no timely
information for easy and quick decision making; there is no ability to track service levels
across the whole health sector. Due to the silos of systems patient records are only limited
to the health facility visited. … Multiple reporting systems impose a burden on health
workers and make it difficult to access data for evidence-based decision-making. An
increasing share of services delivered by the private sector, which does not report
systematically, means that a growing piece of the epidemiological situation is missing.
… There is no proper interoperability framework in place for all these systems. They
were developed on different platforms and data stored in legacy systems. This has
resulted in considerable duplication of effort and difficulty to access and consolidate data
for evidence-based decision-making. Terminology and technology standards need to be
implemented to ensure system interoperability” [13].
2. Objective
What is missing is a holistic information system integrating patient and other data across
all health system organisations and actors nationwide. We call this a Digital Health
Ecosystem, defined as
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems 405
the holistic application of information and communications technologies to
support and improve health services, their coordination, integration and
management across all actors in a given geographic domain (local, district,
national).
To meet interoperability requirements and be future-proof in resource-constrained
environments, it should rest upon an open digital health platform.
Based on global experience in resource-constraint contexts, the goal of this paper is
to sketch the core steps necessary to develop and implement such an ecosystem, and to
specify fundamental building blocks. Key problems and barriers encountered as well as
success factors and lessons learned will be discussed.
3. Methods
Methodologically, earlier work on describing, structuring and comparing national
eHealth policies has benefitted this work [14]. And it builds upon analytical research
undertaken, approaches developed and empirical surveys undertaken in the context of
Africa-related studies, inter alia, the “Interoperable eSystems for Africa Enhanced by
Satellites” Study for the European Space Agency’s (ESA) eHealth for Sub-Saharan
Africa (eHSA) Programme [15]. There an initial interoperability approach and roadmap
towards designing and implementing national eHealth platforms in Sub-Saharan Africa
(SSA) countries was developed, based on detailed statistical analyses of the respective
economic and health system situation in 48 SSA countries, as well as empirical surveys
with key decision makers in 24 countries. Further methodological and empirical input
was derived from detailed case studies of national or district eHealth platforms and
electronic health record (EHR) systems covering eight countries on five continents,
which – to render analysis results comparable – where structured and presented empirical
material in a framework similar to the one applied in the results section here.
Key methodological input is also derived from research on „Digital Health
Ecosystems for African countries - Integrated framework and approach” which was
undertaken for the Strategic Partnership Digital Africa (SPDA), Berlin/Germany, an
initiative of the German Federal Government and industry supported by the German
Corporation for International Cooperation (GIZ) [16]. A critical review of further
research, reports, papers, and literature were undertaken, too.
Reference is also made to eHealth strategy toolkits and guides as published by
WHO/ITU [17] and other organisations [18, 19].
4. Results
Concerning how to best move from siloed applications to national Digital Health
Ecosystems, these results can be summarised:
4.1 Responding to policy priorities and stakeholder needs
Successful national Digital Health Ecosystems respond to health policy priorities and
stakeholder needs. Establishing such an (open) platform is a complex, long-term and
never ending venture. Global experience suggests that starting with a focused approach
delivering early benefits to core actor groups is essential. Real benefits will convince
physicians and politicians alike to continue, expand and support further development of
digital health infrastructures. Such a needs-driven approach avoids a common pitfall of
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems406
digital health investments, namely technology push. “A lot of solutions have come from
technologists and engineers who are excited by the technology, but at times, they are not
starting with the true need. ... End-users must be central to the design. The problem with
African countries is that e-health systems are not integrated and are instead run by
different independent organisations” [20].
4.2 Four foundational building blocks for implementing a comprehensive Digital
Health Ecosystem
When planning, implementing and maintaining a resilient Digital Health Ecosystem, four
foundational building blocks need to be considered and analysed:
x Political agreement on an operational digital health strategy
x Development of a comprehensive roadmap translating the strategy into reality
and targeting long-term sustainability
x Implementation of the chosen Digital Health Ecosystem
x Monitoring and evaluation of outcomes and results achieved to guide further
progress.
Their logical relationship builds upon each other - respectively these blocks interact with
each other - as shown in Figure 1.
Figure 1. Four building blocks for a resilient Digital Health Ecosystem
Understanding these building blocks, their contents and the action steps involved, as well
as their logical relationship and how they interact with each other is mandatory for all
involved in planning, developing, implementing and maintaining the Digital Health
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems 407
Ecosystem – be they health policy decision makers, healthcare service providers, health
professionals, patients, industry involved in implementation, donors and financiers.
4.2.1 Agreement on an operational digital health strategy
Guided by health policy priorities, it is fundamental to reach agreement across all
stakeholders on an operational digital health strategy. Drafting together a strategic paper
builds trust across all stakeholders who are involved in or impacted by the development
of a Digital Health Ecosystem.
4.2.2 Development of a comprehensive roadmap
Drafting a digital health strategy is only a first, albeit necessary step towards establishing
and maintaining a Digital Health Ecosystem. Translating the strategy into an operational
roadmap with clear action steps and a realistic time frame is already a much more
demanding task, and ‘the proof of the pudding’ comes with concrete implementation and
continuous maintenance.
4.2.3 Implementation of a Digital Health Ecosystem
Six fields can be identified as particularly critical for successful implementations:
(1) Open digital health platform :
Open Digital Health Ecosystems implemented at the national or district level
will help to overcome the common barriers experienced when relying on
commercial system providers, like integrating new applications, transferring
patient data to other applications, or changing the software supplier completely.
An open approach allows apps and services from multiple vendors to work
together such that there is a many-to-many substitutability between applications
and services. This is based on common, open and standardised data models and
application programming interfaces (APIs). In this way, open platforms liberate
both data and applications making them portable and interoperable across
different platform implementations [21].
(2) Core starting services and applications
From the wide spectrum of open platform infrastructure services and digital
health applications and tools, a small set of priority services and application
should be explored when analysing the needs for and benefits resulting from a
national ecosystem. They may concern, e.g., essential eInfrastructure services
like electronic identification and cyber security, eAdministration, electronic
patient records (ePR) and other healthcare applications, eLearning, Public
Health/eSurveillance. Starting small, but assuring the ability to scale up should
be a particular concern [22].
(3) Interoperability framework
Interoperability must always be analysed in the context of the respective health
system. This implies that interoperability requirements cannot be identified ex
ante and as such, but rather need to reflect the data exchange and analysis needs
of health system actors to be supported by the electronic tools and applications
to be implemented. When planning and organising a comprehensive
interoperability framework and tools, five domains should be analysed:
x Policy domain
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems408
It is in the policy and strategy domain where high level decisions are
needed on which data should become interoperable for which health policy
needs, for which healthcare/clinical or public health purposes.
Implementation measures must be foreseen to assure that these
interoperability objectives are indeed reachable.
x Governance and legal domain
Interoperability is concerned with accessing and exchanging data.
Governance and legal/regulatory issues are core challenges when realising
a certain degree of interoperability within national Digital Health
Ecosystems. Usually it will be mandatory to clarify ownership and access
rights, privacy, confidentiality and system security to respond to increasing
challenges in this field, thereby strengthening trust and confidence of all
stakeholders, particularly patients and health professionals.
x Organisational domain
Securing interoperability is a long-term activity. eHealth interoperability
frameworks therefore require dedicated organisational support structures
and processes to not only guide and direct digital health infrastructure
investments and controlling in this sphere, but to also run daily
administration and production.
x Document format, data modelling and coding domain
Here three levels of interoperability may be discerned:
i. Technical interoperability (like correctly transferring a static paper
document electronically, e.g. in PDF-format)
ii. Structural interoperability (documents structured according to
standardised headings, which may allow for regrouping and
assembling information according to such headings)
iii. Semantic interoperability (information and data are presented in a
standardised clinical model and fully coded, thereby e.g. allowing for
safe translation into other languages if international dictionaries are
available)
x Data sharing domain
The issue to be solved here is whether data should be stored in a central (or
several linked, distributed) data repository(ies) where the authorised actors
can directly access the (patient) data whenever they need them, or whether
data are communicated via an exchange of messages, etc. Cloud storage of
such data is becoming another option.
(4) Leveraging the ‘open’ approach
Globally, support and engagement for ‘openSource’ software, ‘openData’
access, ‘openStandard’ availability and ‘openPlatform’ approaches has gained
great momentum, both in industrialised and resource-constraint environments
[21]. This “open” movement is now ubiquitous, recognized across public and
private entities as a fundamental course of action towards building interoperable,
easy to use infrastructure components, as well as a critical factor for driving
innovation in ‘vertical’ markets. The source code of software and tools
developed by the open source community is not proprietary, it can be freely
copied, modified and distributed; it is managed and continuously improved by
engaged participants.
(5) The need for change management
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems 409
Substituting hitherto paper-based recording and information exchange systems
by introducing digital services is not simply a means for improving the
efficiency of existing processes. A Digital Health Ecosystem with all its
potential for the health system to evolve towards safer, better health for all and
more efficient, integrated healthcare processes is quite different from what it
was before. It enables substantial change in the way health professionals and
others work together within and across organisational borders, share patient
data, manage the resources of their organisation, supervise and guide the
allocation of public funds, organise health system surveillance and quality
control. Eventually, a different health system will emerge.
To guide and direct this process of moving from one state of the system to the
other, professional change management is mandatory [23].
(6) Governance and legal framework
To function efficiently, reliably and amicably, open societies need a well-
designed governance and legal framework. This equally applies to the health
sector. What the term “governance” means is vague and disputed, and it has
variantly been located from civil society level laws and regulations – “rules that
guide the course of a system” or a country - to “rules of order” or procedures
for small group activities.
At the level of health system governance, WHO has recently proposed the
“TAPIC framework for analysing and improving health. [24]” It identifies and
defines five mutually exclusive attributes of governance that influence the kind
and consequences of decisions a health system makes:
x Transparency
x Accountability
x Participation
x Integrity
x Capacity
4.2.4 Monitoring and evaluation
An often neglected forth building block is monitoring and evaluation of outcomes and
results and the impact achieved. This is indispensible for updating and adapting the
ecosystem to changing and newly arising needs, i.e. it will support and help to guide
further progress [17].
5. Lessons learned and recommendations
The results presented can be succinctly integrated into six statements on lessons learned
and recommendations:
1) Digital health facilitates reaching health policy goals and Universal Health
Coverage (UHC)
When implemented appropriately, digital health is a great enabler towards better,
safer and more efficient healthcare and UHC.
2) Adopt the unifying approach of a national Digital Health Ecosystem
The reliable, sustained transformation of health systems through digital health
requires a holistic vision driven by focused health system priorities and a
unifying approach assuring that the deployed eHealth applications are
integrated through a national digital health infrastructure platform – a Digital
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems410
Health Ecosystem. Such an open Digital Health Ecosystem is vendor and
technology neutral and eliminates the expensive and much-dreaded vendor
lock-in. It facilitates innovation also by smaller companies and start-ups facing
lower barriers to market entry. It forces vendors to develop new business models
and compete solely on quality, value, and service.
3) Implementing a national digital health platform is a rather unique challenge
Implementing and sustaining digital applications in the health sector is more
demanding, complicated and time-consuming than in any other sector –
healthcare is an extremely complex undertaking. At the district or national level,
there is no one-size-fits-all platform solution readily available, each one has to
be tailored to local policy priorities, needs, capacities and resources.
4) Avoid Pilotitis – Focus on integration
Stand-alone eHealth implementations and pilot projects that rarely reach scale
and sustainability must be avoided. Focus on few healthcare and/or Public
Health priorities to guide nation-wide investments. Assure coordination and
integration across all actors and stakeholders, whether public/government
institutions, charities, foundations, development agencies, or private investors.
5) Four building blocks will guide towards successfully implementing a national
Digital Health Ecosystem
Just drafting a Digital Health Strategy will not do the job. Three further building
blocks are needed: An actionable, realistic roadmap how to move from the
strategy to implementation and long-term sustainability, six implementation
elements (national platform; core services; interoperability guidance;
leveraging the “open” approach – with respect to software, data models, APIs
etc.; change management; governance and legal framework), and finally
measuring impact to guide further development of policy and infrastructure.
6) Establish the role of governments, development partners, and industry
In a democratic society, national governments – controlled by parliament – are
in the driver’s seat concerning health system structures, regulation and
financing. They have to guide determining the needs, priorities and procedures
of investments in Digital Health Ecosystems. To avoid the disparate
development of siloed eHealth applications and thereby loosing many of the
potential benefits for improved healthcare, a national framework must set the
conditions and requirements within which development partners should act in
close coordination with public authorities. It follows that specifications in
national Calls for Tender to industry must fully align with the national digital
health strategy. A cooperative investment approach in which African
governments, donor and industry representatives join forces is strongly advised.
6. Acknowledgements:
Part of this research was financially supported by the German Gesellschaft für
Internationale Zusammenarbeit [GIZ] for the Strategic Partnership Digital Africa.
The work was undertaken in the context of the author’s affiliation with empirica
GmbH. Critical review and input by external experts and colleagues are gratefully
acknowledged.
K.A. Stroetmann / From Siloed Applications to National Digital Health Ecosystems 411
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