Conceptualising of a South African Digital Health Innovation Ecosystem

Abstract

Digitalisation of Healthcare Information Systems in South Africa could have an impact beyond access to and
delivery of health services; it should also contribute towards the Conceptualisation of a South African Digital
Health Innovation Ecosystem.
• South African investments in digital health, when conceived and managed as social, technologically
and economically sustainable innovation, can have implications beyond economic policy, requiring new
approaches in public management.
• The planning and building of national infrastructure for digital health ought to take stock of international
experiences of building integrated systems. Yet, substantial effort is required to plan and build a distinctly
South African digital health culture that accommodates the country’s diverse needs appropriately.
• Success will require innovative solutions that are sensitive to local economic, social, cultural and organisational
factors, and that are adapted to augment the broader South African capabilities in digital health.
• Adoption and acceptance of digital health infrastructure and solutions by healthcare professionals,
organisations and patients is challenging and is critical for success. A clear evaluation framework to monitor
unsuccessful and successful adoption and acceptance of digital health solutions, as well as to trigger adaptive
and corrective measures, must be designed from early on.
• The Digital Health Innovation Ecosystem involves three interactive, complementary modules: context, the
innovation lifecycle and the users/stakeholders. The context builds on the typology of Social, Technological,
Economic, Environmental, Political and Value-based issues (STEEPV).
• Stakeholders should be considered in an expanded form. Stakeholders include, for example, patients, user
communities, technology providers, payers, regulators and policymakers.
• Technology should cover systemic views on elements of interoperability, standards, and integration of infrastructure.
It should include privacy elements, big data, and focus on analytics and storage, and control of access.
• In a digital ecosystem, the user must feel or experience trust. They must feel that they can control and increase
their own access to a system. Their uptake and use are essential for such an ecosystem to work or to be regarded
as a sustainable solution.
• For sustainability to work, the value of a system has to be shared across groups where there are partnerships,
capacity building, good leadership and governance.
• Reaching, engagement and empowerment of low-income populations in urban and rural areas to deliver novel
digital health services require highly targeted measures, which will require careful consideration of relatively
idiosyncratic conditions.
• The build-up of digital health in South Africa is not only about improving the availability, access and delivery
of healthcare services, but essentially about enhancing a country’s strategic capabilities to create, adapt
and implement novel digital health solutions within and by the public and private sectors.
• Platforms, technologies and solutions implemented also have to be flexible for future needs. Foresight
methodologies may propose a useful approach to construct shared understanding on emerging possibilities.
Including often facilitated social processes, foresight methodologies propose a reforming platform for a self-
directed innovation ecosystem to emerge. Innovation is considered to occur in an organic manner based on
common interests of various stakeholders and, consequently, allowing novel outcomes. In a local form these
creative platforms can support the rise of an innovation-favourable culture, and help lower the barriers of local
entrepreneurship.

Full text

Conceptualising of a
South African Digital
Health Innovation
Ecosystem
Jouko Myllyoja, Hannes Toivanen
VTT Technical Research Centre of Finland
Marlien Herselman, Adele Botha, Ronell Alberts,
Thomas Fogwill
CSIR Meraka Institute
2016

1
Contents
EXECUTIVE SUMMARY ...................................................................................2
PREFACE ........................................................................................................3
DIGITAL HEALTH SYSTEMS AND DEVELOPMENT .......................................4
TECHNOLOGICAL UPGRADING AND SOCIETAL
TRANSITION MANAGEMENT .......................................................................... 9
EVALUATING SUCCESS AND FAILURE IN DIGITAL HEALTH ......................13
DIGITAL HEALTH INNOVATION ECOSYSTEMS ............................................24
TOWARDS SOUTH AFRICAN DIGITAL HEALTH
INNOVATION ECOSYSTEM ............................................................................. 34
DISCUSSION AND CONCLUSIONS .............................................................. 49
REFERENCES ............................................................................................... 52

2
EXECUTIVE SUMMARY
• Digitalisationof Healthcare Information Systems in South Africa could have an impact beyond access to and
delivery of health services; it should alsocontribute towards theConceptualisationofaSouthAfricanDigital
HealthInnovationEcosystem.
•
South African investments in digital health, when conceived and managed as social, technologically
andeconomicallysustainableinnovation,canhaveimplicationsbeyondeconomicpolicy,requiring new
approaches in public management.
• Theplanning andbuildingof nationalinfrastructure fordigitalhealth ought to take stock of international
experiences of building integrated systems. Yet,substantialeffortisrequiredtoplanandbuildadistinctly
SouthAfricandigitalhealthculturethataccommodatesthecountry’sdiverseneedsappropriately.
•
Success will require innovative solutions that are sensitivetolocaleconomic,social,culturalandorganisational
factors, and that are adapted to augment the broader SouthAfricancapabilities in digital health.
•
Adoption and acceptance of digital health infrastructure and solutions by healthcare professionals,
organisationsandpatientsischallengingandiscriticalforsuccess. A clear evaluation framework to monitor
unsuccessful and successful adoption and acceptance of digital health solutions, as well as to trigger adaptive
and corrective measures, must bedesigned from early on.
• The DigitalHealth Innovation Ecosystem involves three interactive, complementary modules: context,the
innovationlifecycleandtheusers/stakeholders. The context builds on the typology of Social, Technological,
Economic, Environmental, Political and Value-based issues (STEEPV).
• Stakeholdersshouldbeconsideredin an expanded form. Stakeholders include, for example, patients, user
communities, technology providers, payers, regulators and policymakers.
•
Technologyshould cover systemicviewsonelements of interoperability, standards, and integration of infrastructure.
It should include privacy elements, big data, and focus on analytics and storage, and control of access.
•
In a digital ecosystem, the usermustfeelorexperiencetrust. They must feel that they can control and increase
their own access to a system. Their uptake and use are essential for such an ecosystem to work or to be regarded
as a sustainable solution.
•
For sustainability to work, the valueofasystemhastobesharedacrossgroups where there are partnerships,
capacity building, good leadership and governance.
• Reaching,engagementandempowerment of low-income populations in urban and rural areas to deliver novel
digital health services require highlytargeted measures, which will require careful consideration of relatively
idiosyncraticconditions.
• Thebuild-upofdigitalhealthinSouthAfrica is not only about improving the availability, access and delivery
of healthcare services, but essentiallyaboutenhancingacountry’sstrategiccapabilitiestocreate,adapt
andimplementnoveldigitalhealthsolutions within and by the publicandprivate sectors.
•
Platforms, technologies and solutions implemented also have to be exible for future needs. Foresight
methodologies may propose a useful approach to construct shared understanding on emerging possibilities.
Including often facilitated social processes, foresight methodologies propose a reforming platform for a self-
directedinnovationecosystemtoemerge. Innovation is considered to occur in an organic manner based on
commoninterestsofvariousstakeholders and, consequently, allowing novel outcomes. In a local form these
creative platforms can support the rise of an innovation-favourable culture, and help lower the barriers of local
entrepreneurship.

3
PREFACE
ThisreportisanoutcomeofcollaborativeeffortbetweentheCouncilforScienticandIndustrialResearch(CSIR)
and VTT Technical Research Centre of Finland. It is funded and supported by the Finnish Ministry for Foreign Affairs.
The project “Digital Health Future – Roadmapping South African Strategy” has focused on two key issues: First, it
has worked to broaden the Finnish and South African capabilities for strategic planning of digital health innovation
ecosystems, and secondly, undertaken practical and targeted work to analyse and conceptualise digital health
innovation ecosystem issues in the South African context.
The project was launched with a planning phase in 2013, and implemented as a full project since 2014. From VTT,
the project team included Jouko Myllyoja, Hannes Toivanen, Kari Kohtamäki, Torsti Loikkanen and Maria Lima
Toivanen. From the CSIR, the team comprised Marlien Herselman, Adele Botha, Ronell Alberts and Thomas Fogwill.
Implementationoftheprojecthasbenettedfromthesupportandhelpofmanypeopleandorganisations,andthe
project team would like to extend its gratitude to especially the following: Aki Enkenberg and Tuomas Pollari from the
Ministry for Foreign Affairs of Finland, as well as Laurens Cloete and Matthew Chetty from the CSIR and Jeanette
Morwane from the Department of Science and Technology (DST).
This report, and the project itself, has been part of an extended collaboration between South African and Finnish
experts working on innovation and challenges of global development. This dialogue has been and is important for
our ability to learn how technologies can be deployed to address society-wide challenges. It is also a testimony to
the importance of two-way learning between Finland and South Africa.

4
DIGITAL HEALTH SYSTEMS AND DEVELOPMENT
The promise and perils of Digital Health
Digitalisation of healthcare processes is one of the key phenomena in global health, and as such an obvious central
issue for every government concerned with the health and well-being of its citizens.
National strategies, initiatives, funding, projects, as well as consultant briefs and academic literature on the topic
are increasing rapidly. Practically no serious health policymaker or professional can have missed the call to digital
health action because of “social and demographic changes, the rise of chronic diseases, and the need to improve
efciencyandqualityofhealthcaredelivery”(OECD2013).
What is digital health and why is so much is expected from it? Digital health can be summarised as an umbrella concept
fortheover-reachingdigitalisationofhealthcareservicesandinformation,andoftenitinvolvestheadditionofarticial
intelligenceandautomationsolutionsforimprovedefciency,coverageandaccuracyofserviceprovision.Itisverymuch
about moving away from the artisanal and analogue mode of organising and providing healthcare, where economies
of scale, access to and availability of care are constrained by the physical proximity and availability of skilled health
personnel and sophisticated equipment. It is a ubiquitous phenomenon, impacting potentially every aspect of healthcare
and opening up new avenues of cross-sectoral collaboration, especially between social security and healthcare sectors.
Importantly,digitalhealthimpliessignicantexpansionofthenotionof‘healthcare’anditsprovisioninthesociety.Firstly,
the emerging digital health systems incorporate personalised and participatory healthcare models – including health
monitoring, well-being practices, preventive care, etc. It thereby expands the organisation and delivery of health-related
services and activities beyond professional healthcare organisations. This is in particular relevant to the rise of a new range of
personalised ICT devices, software and services, which have opened a new innovation platform for health-related services.
Secondly, digital health and, in particular, related health information systems, stimulate convergence between social
care and healthcare systems, affecting the organisation, service delivery, and technological infrastructure of two large
publicsectors.AtoneextremeofthisconvergenceistheEstonianmethodwhichhaspioneereda‘DigitalCitizenship’
approachthatintegratesacitizen’spublicservicesandinformationintoacohesivedigitalinfrastructure.Withinthis
infrastructure, digital health constitutes only one sector. However, in the context of healthcare, the new ways of
gathering, storing and retrieving information is redrawing boundaries between social care, social security and health.
In short, digital health implies ubiquitous change throughout the existing healthcare systems, as well as expansion and
re-denitionofitstraditionalboundariesbetweenpatients,consumers,citizens,healthcareprofessionals,innovators,
organisations, sectoral policies, and so forth. Given the pervasive nature of the impeding change, it is necessary to
conceptualise the future change processes – something that lies at the core of this report.
Today there is no need to convince people that digital health is an important emerging technology. Nor is it necessary
toamassyetanotherseriesofdocumentationaboutexpectedbenets.Someofthemostimportantargumentsfor
digitalhealthhavebeenputforwardbytheOECD(2013):IntheU.S.“therearesignicantgapsbetweenthehealthcare
thatpeopleshouldreceiveandwhattheyactuallyreceive”(OECD, 2013,p. 22).Given itspivotal importance,all
theworld’sleadingorganisationsforhealth,innovation,ICTsanddevelopmenthaveputforwardwhatamountstoa
library of strategies, guidelines and evidence.
Expanding the notion of Digital Health
The core argument of this report is that the notion of digital health must incorporate the concept of ‘innovation
ecosystems’.Successfuldigital healthsystemsneedtobeadaptive,learning,andcapableofimprovisingasnew
problems, challenges, and objectives emerge.
To be able to achieve this, digital health systems must include strong capabilities for local problem analysis and
innovation, or, in other words, credible innovation capabilities. Public strategies, business briefs and academic
literature on digital health are abundant, yet much of the literature continues to be focused on sectoral implementation.
We argue that the approach they embody must be extended to include stronger effort to build-up local innovation
capabilities, and that this extension enhances the success and potential impact of digital health initiatives.

5
Indeed, a brief review of key literature and strategies on the topic underlines that much of it stresses the importance
of rapid deployment of new digital health solutions, and are focused on providing sectoral implementation advice. The
WorldHealthOrganizationandInternationalTelecommunicationUnionlaunchedin2012the“NationaleHealthStrategy
Toolkit”(WHO, 2012)torespondto the“needsof countries,atevery level ofdevelopment,who seektoadapt and
employthelatestinformationcommunicationtechnologies(ICT)inhealthforthemeasurablebenetoftheircitizens”.
Focusingmoreonitsafuentcountrymembers,theOECDpublishedin2013anoverviewreportonstrategicissues
andanalysisofexpectedbenetsfordigitalhealth.TheWorldBankhasissuedaseriesofpolicybriefsandpolicy
frameworkpapersontheissue,including“ImprovingHealth,ConnectingPeople:TheRoleofICT’sin theHealth
Sector of Developing Countries. A Framework Paper” (Chetley et al. 2006), and more recently a report “Mobile
Applications for the Health Sector” (Zhenwei, Qiang et al. 2012). These reports and guidelines are all pointing to the
dire need to move as quickly as possible to develop national eHealth strategies and implementation.
In the African context, the need to deliver on the Millennium Development Goals (MDGs) on health has been a central
driverforthecontinent’sapproachtodigitalhealth.AsHainesandCassels(2004)havepointedoutintheiranalysisof
health MDG goals in Africa: “Improving health outcomes will not be possible without major improvements in healthcare
delivery systems”. Thus, there have been plenty of strategy and policy papers on the issues. The World Bank, as part
of a six-report series on the transformational use of ICTs in Africa, issued a guideline report “ICTs for Health in Africa” in
2006.Inaddition,abackgroundpaperfortheUnitedNations-sponsoredmeetingofAfricanministersin2009(ECOSOC,
2009) concluded that “eHealth has enormous potential to help strengthen health systems in Africa and achieve the
MDGs.”TheAfricanHealthObservatory(AHO),operatingundertheWorldHealthOrganization,tracksandmonitors
eHealthprogressonthecontinent,aswellasanalysesmajorbottlenecksandchallenges(seeAHO,2016).
SouthAfrica has made a strong case for adopting and developing eHealth to improve the country’s delivery of
healthcare services. A particular milestone is the national strategy of 2012 (Department of Health, 2012). The
document envisioned a strategy and implementation roadmap for national eHealth development, as well as outlined
theexpectedbenets.However,asthestrategyhasbeenmovingtowardsimplementation,asetofmoreconcrete
issues concerning its implementation and operational issues have emerged and there is an increasing need to
consider eHealth within the broader South African context.
Although there is convincing academic, policy and business literature to motivate for the need, potential and importance
of digital health, two important gaps exist. Firstly, relatively little thought has been given to how healthcare systems
should be transformed to incorporate the new objectives, functions, activities and organisations that are required to
facilitate creation innovations into digital health systems. This report pays particular attention to the question of how to
build Digital Health Innovation Ecosystems that not only are capable of deploying and using new digital technologies,
but also foster environments and practices that give rise to new technologies and innovations. As such, emerging Digital
Health Innovation Ecosystems have the potential to contribute beyond the health and social care sectors, and play a
pivotal role in pioneering completely new avenues of innovation as well as to contribute to the economic vitally of regions.
Secondly, Digital Health Innovation Ecosystems have until now emerged and been conceptualised mostly within the
resource-richcountrycontext.Here,wefocusondeningstrategiestobuildDigitalHealthInnovationEcosystems
in the context of developing countries – South Africa – and pay particular attention to the challenges and potential
in that context. For digital health, not to mention Digital Health Innovation Ecosystems, to succeed, several South
Africa-specicissuesmustbeaddressed.Theseinclude:
• Polarisation of the healthcare system between well-resourced private and under-resourced public healthcare;
• Fragmented health information systems (national, provincial, public/private, etc.);
• Proposed national health insurance system;
• Specichealthchallenges,suchasHIV/AIDS,infantandmaternalhealth,tuberculosis,violence,etc.;
• Security of personal information;
• ICT infrastructure challenges;
• Territorial coverage in terms of isolated urban and rural areas; and
• Affordable access to electronic health services for users and providers of digital health services.

6
For digital health to contribute towards improved health equality in the South African context, the above-mentioned
issues (among others) need to be taken into account. Reaching, engagement and empowerment of low-income
populations in urban and rural areas through novel digital health services require highly contextualised interventions.
Simple transfer of off-the-shelf-technology or solutions will not work and can lead to high failure rates (as discussed
below). Success will require local, South African development of innovative solutions that are sensitive to the relevant
economic, social, cultural, and organisational factors, and which are adapted to augment the broader South African
capabilities in digital health.
For this reason, we propose that the notion of Digital Health in South Africa be expanded to include innovation
ecosystems. The conceptualisation of digital health in South Africa is not only about improving the availability, access
anddeliveryofhealthcareservices,butessentiallyaboutenhancingacountry’sstrategiccapabilitiestocreate,adapt
and implement novel digital health solutions within and by the public and private sector.
This will contribute towards the emergence of a Learning Digital Health Innovation Ecosystem capable of identifying
andanalysingproblemsastheyemerge,aswellasproducingnovelsolutionsaddressinglocallyspecicchallenges.
A comprehensive systems approach will also contribute towards the build-up of an important part of the broader
SouthAfricanknowledgeeconomycomponent,andenhancethecountry’soverallinnovationcapacity.
It is the core argument of this report that a narrow implementation and use perspective on digital health should be
abandoned, and that a broader strategy, mixing improved healthcare provision and innovation capacity, of a Digital
HealthInnovationEcosystembuild-upshouldbedenedandfollowed.
Transformative Digital Health Technologies: Contrasting Health with Wellness
The potential of new digital technologies holds a promise for innovative digital healthcare. In many respects, this is
due to the maturation of ICTs and their increasing diffusion to a wide range of application areas, health being central
among these.
Digitalisation has also pronounced the contrast between “digital health” and “digital wellness” technologies. Whereas
the healthcare professions, organisations and practices have been deeply affected by digitalisation at all levels,
so have the ways in which people and populations take care of their wellness. Health and wellness are admittedly
interlinked, but they are also contrasted.
‘Wellness’isaboutpeopleactivelymaintainingtheirhealthandoverallphysicalandmentalstateinagoodandhealthy
condition,whereas‘healthcare’isaboutattendingtopeoplewhosehealthneedsactivetreatment.
Thebenetsofdigitalhealthunfoldalsodifferentlyinthesetwospheres.Whereasdigitaltechnologiesinhealthcare
areaboutimprovingthecoverage,access,accuracyandcost-benetofhealthcare;inawellnesscontext,thebenets
come primarily from preventive care. As costs in healthcare increase rapidly with the intensity of the care, there is a
lot to be gained by reducing the demand for healthcare services by improving the wellness of people.
Digitalisation is impacting healthcare and wellness in several ways and levels, but it is important to classify and
conceptualiseitsimpacts.TherecentOECDreporton“ICTsandtheHealthSector”(OECD,2013)arguedthatits
impacts and potential can be summarised in six main policy priority and research areas:
• Integrated health and social care;
• Participatory care and personally controlled health records;
• Personalised medicine;
• Convergence of technologies and health innovation;
• Privacy and security risks; and
• Big data and health.

7
For the focus of this report, important topics are the integration of health and social care, participatory care, as well
as the convergence of technologies and health innovation.
The emerging “smart” and “intelligent” health systems constitute the core platform for national and broader digital
health systems. They will embody the digital and physical infrastructure of new types of information systems, which
will integrate services beyond health, such as social security, and, as discussed later in the Estonian case, all
informationrelatedtoone’scitizenshipandlife.
Itis importanttoconsider thatsuch‘smart’ systemsarean opportunitytobuild broader‘digitalhealth innovation
systems’,anditwouldbeamistaketodevelopthemforthenarrowneedsofonlyhealthcareorprovisionofsocial
security services. In addition, these systems will play an enabling role for increasing the participation of individual
people in administering their own health, social security and wellbeing. Such empowerment will also transform
boundaries between health and wellness, and as this transformation unfolds, new types of innovative technologies,
solutions and services can be envisioned, developed and implemented. Not all will be possible through the central
authority of national, regional or municipal authorities, but much could be unleashed through the private sector. This
is where the Digital Health Innovation Ecosystem may play a pivotal role.
Muchinnovationcanemergefromthepersonalisedandparticipatorydigitalhealth,especially‘M-Health’and‘UHealth’.
This is the area that directly empowers patients (healthcare), but also people caring for their own wellbeing or wellness.
The empowerment of patients, consumers and citizens is one of the most potent areas of digital health. The wave of
new digital health technologies has and continues to transform the traditional roles of patients, consumers, healthcare
professionals, as well as many of the established institutions. It changes the ways in which healthcare is delivered
and where it can be delivered and empowers people to act about their health and wellness.
Critically, this change is also transforming the boundaries of health and wellness, enabling new approaches and
solutions, and thereby providing new opportunities for innovation. Therefore, it is essential that the emerging digital
health systems and policies are built to support and sustain new waves of innovation.
A central issue in building Digital Health Innovation Ecosystems is to enable further innovation. This means that the
new public policies, governance structures, IT infrastructure, and new practices and approaches are all harnessed
to carry out their main tasks in healthcare, social security and wellness, and that they also actively encourage and
enable new digital innovations.
This is the key message of this report, analysed and considered from various perspectives. Digital health systems
are not systems to be built and completed, but they should become evolving organisations, in short, Digital Health
Innovation Ecosystems.

8
The second key message of this report concerns the ways in which South Africa and other developing countries can
learnandbenetfrominternationalexamplesandexperiences.AsSouthAfricamobilisessophisticatedtechnologies
and knowledge to address the country’s healthcare and social security needs, there are many opportunities to
discoverthemostbenecialstrategiesofplanningandimplementingdigitalhealthsystems,andthatlearningfrom
othercountriesatthe‘system’or‘innovationecosystem’levelisimportant.
It is essential to understand the limitations of the transfer of Finnish or European experience and technical solutions
toSouthAfrica.ThespecicationanddenitionofpotentialSouthAfricanusersandbeneciariesofdigitalhealth
systems, or the adaptation of the cost structure of solutions would probably be the traditional focus areas when
considering the value of European examples for South Africa. Indeed, failure to appreciate the local context and
user needs is a typical failure when people transfer solutions from Europe to Africa. However, learning from other
countries at the system level requires that attention is paid to how the emerging South African digital health system
isadapted,integratedandcoordinatedwithSouthAfrica’snationalinnovationsystem.
The call to consider is to acknowledge that the primary purpose of digital health is to deliver healthcare and social
security services, and to also draw attention to the possibility that it forms part of a new type of innovation ecosystem.
In this perspective, the report offers detailed case studies from two countries, Finland and Estonia, with the aim to
illustrate how digital health systems can be conceptualised and implemented within a broader context.
Infobox:SouthAfricanM-HealthInnovation:HearScreen-Low-CostApptoDetectHearingLoss
Figure1.HearScreenintheeld.Illustratinglow-costandmobilehearingtest
(Source:https://www.facebook.com/hearscreen/)
HearScreen is a smartphone solution that removes traditional barriers for identifying and addressing hearing loss.
ItconsistsofsoftwaredevelopedbyscientistsattheUniversityofPretoriaforhearingtests,andsubsequently
adapted to be used on smartphones. As such, it offers a low-cost hearing test equipment and software.
Approximately 4% of South Africans suffer from hearing problems, and the development of HearScreen was
closely linked to the objective of better reaching a wider part of this population. A focus was to make the hearing
test easier, using a low-cost solution: Prof. De Wet Swanepoel, a co-developer of the HearScreen technology:
“We’relookingfor asolutiontomakehearingtestsavailable atgrassrootslevel.Testinghasalwaysbeenan
isolated service, and we wanted to make use of current trends in smartphone technology.”
HearScreen has received considerable international acclaim.
Sources: https://www.facebook.com/hearscreen/, “Hearscreen. Low-cost health solution for affordable health access and
linkage,” CoFounder Magazine Winter 2015, 93, http://allafrica.com/stories/201510131097.html, http://www.hearscreen.co.za/.

9
TECHNOLOGICAL UPGRADING AND
SOCIETAL TRANSITION MANAGEMENT
Foresighting was applied in this project to understand the future and determining what will be important components
for a Digital Health Innovation Ecosystem for South Africa. Roadmapping was used to understand the interrelations
of different stakeholders and to plan ahead when conceptualising such an ecosystem.
This project also made use of Design Science as its main methodology to develop the Digital Health Innovation Ecosystem
as it went through various phases of conceptualisation and during these phases both foresighting and roadmapping
were applied (see Figure 8 below on Design Science process as deliverables from each iteration are provided).
Thebackgroundofforesightgoesbackthe1950sand’60swhenitwasnarroweddowntoanticipatenewtechnology
areas.Effortsweremainlycalled‘forecasting’withtheprobabilisticassessmentsofwhatislikelytohappeninthe
future. Creative and consultative methods such as Delphi, scenarios, brainstorming and expert panels were already
used. In 1970 some unpredictable events (such as the oil shock) cast doubt on the reliability of forecasting, increasing
understanding that the future is not just an extension of the past. In the 1980s the foresight could be characterised
throughtheimpressionof‘multiplefutures’topointoutwiderframesofuncertaintiesinvolvedintheworldandsociety.
During the 2000s, mainly due to increased complexity of societies, the scope and focus of foresight activities have
widened to cover a wide variety of issues. This has led to the emergence of emphasising process aspects in foresight,
stressing the possibilities that the participatory nature of foresight process may enable. There seems to be a need
to develop foresight approaches towards systemic direction, where understanding an increasingly interconnected
and interdependent world, in a higher speed functioning society, could be increased (Saritas, 2013).
In so-called systemic foresight methodology (SFM, see Figure 2), foresight is seen as an inclusive activity, including
interaction with different stakeholders to provide different perspectives, and to aim at longer-term effects. All phases
of the SFM are systematically interrelated; each is building on the previous, culminating in policies, strategies and
actionsforthedesignofafuturesystem.Informationandactionowbetweenthephasesarenotnecessarilylinear.
Phases can be iterated more than once until the outputs and process outcomes planned are achieved. The phases
are linking back to create a full circle of foresight as a continuous loop. It is important to highlight that the process can
be as important as the outcome, and that the commitment to the process by participants is essential (Saritas, 2013).
Phases Intelligence Imagination Integration Interpretation Intervention Impact
Functions
Scoping
phase
Creative
phase
Ordering
phase
Strategy
phase
Action
phase
Evaluation
phase
Themestrand
(which)
Specicareasintechnologiesorsectorsasthefocusofenquiry
Worldviews/goal
strand(why)
The values, worldviews and discourses between different stakeholders
Futuresstrand
(when)
Systematic exploration of trends, projections, scenarios, wild cards, and policy responses
Capacitybuilding
strand(who)
Systematic development of shared learning, networking, collaboration and intelligence
between all stakeholders involved
Institutions/
structures
strand(what)
Factors in the regimes, institutions and organisational structures
Strategicplanning
strand(how)
Panels, workshops, conferences, training courses, dissemination, awareness raising,
surveys, interviews
Foresightagenda
Foresightprocessorientation
Figure2.ArchitectureoftheSystemicForesightMethodology(Saritas,2013)

10
In all, the SFM views foresight methods as the tools to be used as part of the means to explore ideas, acquire
information and data, clarify situations and negotiate solutions. Foresight is not only considered as a methodologically
systematic activity, but an activity that creates its own methodological approaches with the consideration of the
nature of the issue in question. Instead of putting the methods at the forefront of investigation, the SFM suggests
amore conceptual andexibleprocess orientation,whichstarts fromachievingacomprehensive understanding
ofsituations.Methodswillbeused,modiedortailoredwheneverneeded.Newmethodswillbecreatedtohandle
theuniquerequirementsofsystemsunderinvestigation.TheSFMbenetsfromapoolof availableforesightand
forecasting methods and other planning tools (Saritas, 2013).
Methodological approach: Roadmapping
Technicalroadmappingrepresentsoneapproachormethodologyintheeldofforesight.Originallyitwasconsidered
as a systematic and detailed step-by-step progress towards a goal, such as starting the process to develop a new
productormakingincrementaldevelopmentsinanexistingproduct.Emergingtraditioncouldbecalled‘diversied
strategicroadmapping’–initiatedbyRobertPhaalfromtheUniversityofCambridge,thenfurtherappliedattheVTT
Technical Research Centre of Finland, among many others (Ahlqvist & Myllyoja, 2011).
Technologyroadmappingisaveryexibletechniquethatiswidelyusedwithinindustrytosupportstrategicandlong-
term planning. It provides structured means for exploring and communicating the relationships between evolving
and developing markets, products and technologies over time. The scope of roadmaps is often broad, covering a
number of complex conceptual and human interactions. The use of roadmaps can be approached from either a
company or multi-organisational perspective. In a company, roadmaps may allow technology developments to be
integrated with business planning. In a multi-organisational context, their primary contribution may take place in the
formofcapturingtheenvironmentallandscape,threatsandopportunitiesforaspeciedgroupofstakeholdersina
technology or application area (Phaal et al., 2004).
Technology roadmapping represents a technique for supporting technology management and planning, especially
for exploring and communicating the dynamic linkages between technological resources, organisational objectives
andthechangingenvironment.Asaexibletechnique,roadmapscantakevariousforms,rangingfromtechnology
push (divergent, covering opportunities) to market pull (for example a customer product) (Phaal et al., 2004).
The particular feature of technology roadmapping is a time-based structure, comprising a number of layers that typically
include both commercial and technological perspectives. With this dimension of time involved, the roadmapping can be seen
to draw key themes from the technology strategy and transition literature together. Certain types of roadmaps that contain an
extended planning horizon are utilised to support long-range planning. These are often performed at the sector or national
level (foresight), and can act as a radar to identify potentially disruptive technologies and markets (Phaal et al., 2004).
Onewaytoapproachroadmapsistoviewthemasvisualnarrativesthatdescribethe mostcritical elementsand
future development paths of the focal topic. In wider societal and business contexts they function as a strategic
lens with a certain information structure and graphical style (Phaal & Muller, 2009), or as a blueprint that visualises
and describes the core strategic issues (Blackwell et al., 2008). This special visual emphasis makes it possible to
use roadmaps as crystallised strategy pictures that open up perspectives on both overall macro-level impressions
and selected micro-level developments. They could be seen in terms of kaleidoscopes that give a grand vision of
the future, identify critical paths on different levels such as drivers or enabling technologies, and link large-scale
societaldriverstomorespecicmicro-scaleproductandsolutiondevelopment(Ahlqvist&Myllyoja,2011).Thisvisual
emphasis of technology roadmapping also makes roadmaps closely related to other graphical planning approaches
such as PERT and the Gantt planning tool (Phaal et al., 2004).
Transition management
Transitions are conceptualised as system innovations, in other words, a change from one sociotechnical system to
another. Systems innovations are co-evolution processes that evolve technological changes, as well as changes in
other elements. The multi-level perspective (MLP) is a key concept in transition management literature (see Figure
4). The MLP distinguishes three analytical and heuristic levels to understand system innovations: sociotechnical
landscape, sociotechnical regimes and technological niches. A sociotechnical landscape refers to aspects of the wider
exogenous environment, which affect sociotechnical development (globalisation, environmental problems, cultural
changesetc.).Landscapesarebeyondthedirectinuenceofactorsandcannotbechangedatwill(Geels,2005).

11
Figure3.Adynamicmulti-levelperspectiveonsysteminnovations(Geels,2005)
The meso level is formed by sociotechnical regimes. They are not only referring to a social group of engineers and
rms,butalsoothersocialgroups.Theiractivitiesreproducetheelementsandlinkagesinsociotechnicalsystems.Each
social group has its own distinctive feature and environment, which means that they all have relative autonomy. At the
same time, the groups are interdependent and interacting with each other. The micro level is formed by technological
niches,thefocusforradicalinnovations.Theradicalnoveltiesemergein‘protectedspaces’.Thesenichesactas
‘incubationrooms’forradicalnovelties.Nichesalsofunctionaslocationsforlearningprocesses.Furthermore,niches
provide space to build the social networks that support innovations, e.g. user-producer relationships (Geels, 2005).
The logic of three levels is that they provide different kinds of coordination and structuration of activities in local
practices. The work in niches is often geared to problems of existing regimes. Different actors work in novelties that
would eventually be used in a regime or even replace it. Existing regimes may, however, have existing entrenchments
to slow down the progress. These may cover, for example, institutional, organisational, economical or cultural issues.
Radical novelties often have a mismatch with the existing regime and do not easily break. Even so, niches are
crucial for system innovations, because they provide seeds for the change. The key point of the MLP is that system
innovations occur as an outcome of linkages between developments at multiple levels.
Another important aspect of the MLP is to distinguish systems innovations from simple causalities. Instead, simultaneous
processes occur at multiple dimensions and levels. System innovations occur when processes link up and reinforce
each other (Geels, 2005).
Severalphasescanbeidentiedintransitions(Geels,2005):
1. Novelties emerge in niches in the context of existing regime and landscape developments. There may be various
technical forms competing with each other, actors improvise and engage in experiments to work out the best
designandndoutwhatuserswant.
2. The novelty is used in small market niches, which provides resources for technical specialisation. Gradually, different
actors direct their activities to the improvement of the new technology. The new technology also improves as a
result of learning process. As users interact with the new technology, they gradually explore new functionalities.
Landscape
developments
Socio-technical
regime
Technology
niches
Time
Landscape developments
put pressure on regime,
which opens up on multiple
dimensions, creating windows
of opportunity for novelties.
ST-regimeis‘dynamically
stable’.Ondifferentdimensions
there are ongoing processes.
Newcongurationbreaksthrough,taking
advantageof‘windowsofopportunity’.
Adjustments occur in ST-regime.
Elements are gradually linked together,
andstabiliseintoanewST-conguration
which is not (yet) dominant. Internal
momentum increases.
Articulation processes with novelties on multiple
dimensions (e.g. technology, user preferences, and
policies). Via co-construction, different elements are
gradually linked together.
New ST-regime
inuenceslandscapes.

12
3. Breakthrough of the new technology, wide distribution and competition with the established regime occur. There
are internal drivers for breakthrough, for example; price/performance improvements and actors with interests that
pushforfurtherbreakthroughs.Thelatterdependonexternalcircumstancesand‘windowsofopportunity’.Pressure
for change may come from the landscape level or there may be internal technical problems in the regime, which
cannot be met with the available technology.
4. The new technology replaces the old regime, which is accompanied by changes on wider dimensions of the
sociotechnical regime. Creation of a new sociotechnical regime often takes time. The new regime may eventually
inuencewiderlandscapedevelopments.
Implicitly, to apply the aspect of development aid, the donor-driven projects are intended to stimulate local initiatives
and experiments that can lead to a system innovation. Transformative change depends on localinitiatives functioning
as models for further development. Projects are being implemented on various levels – they either function as
niche level experiments or intervene directly on the regime level. Immediate landscape effects are rare. Transition
management does not only highlight the multi-level dimension of transition, but also emphasises the importance of
coordination, interaction and learning that are needed to scale up results from niche experiments.
Transition management may also provide a framework to understand how local interventions can be scaled up
to change the broader regime context, or it may help to identify key stakeholders that are relevant for scaling up
experiences (responsibilities, resources, interests etc.). At the same time, it may reveal patterns of cooperation
between stakeholders to increase the likelihood of scaling up. Transition management provides a framework to better
understand the relation between niche projects and their broader (regime and landscape) context (Marquardt, 2015).
Synthesis:SFM–roadmapping-MLP
Genericobservations Reectionsinpracticalsense
Systemic
Foresight
Methodology
• Createsanadaptiveandwideplatformforbuilding
an appropriate approach.
• Includesloopsofphasesincludingpotentially
different methodological approaches integrated.
Dynamic on its characteristics, customised to be
the aims and needs of a foresight project.
• Involvementofstakeholdersisakeyissue.The
process is concerned on building interaction
between them.
• Cancreateanovel,openplatformforalearning
and change.
• Projectresourcingmaynotenablelongterm
process with various approaches involved.
• Mayconfrontchallengesrelatedtopoliticallyand
cultural reality and mind set (e.g. hierarchies,
openness).
• Canbeexperiencedas“farfromthereality”kindof
operation.
Strategic/
Technical
roadmapping
• Representsoneforesightapproachamongothers
• Shouldnotbeconsideredasatooltocreatecausal
pathfromspecicstartingpointtoadesiredstatein
a future. Can include them, however.
• Shouldbeconsideredasaexibletechniquethat
enables holistic modelling of a theme / phenomena
of interest.
• Enablesthinkinginalongertimehorizonandwith
wider phenomena (drivers) to observe.
• Createsdifferent“mixes”betweendrivers,markets,
solutions and technologies.
• Worksasbestinacollectivesense,i.e.when
constituencies a wide are participating in a process.
• Canbeusedasmethodologicalapproachorasa
practical tool – depending on the scope.
• Enablesopeningupthinkingtomoreholistic
direction, including long term perspectives.
• Canactasamapastoidentifyareasofstrategic
interests and priorities for various actors
simultaneously.
• Longertermideagenerationcansometimes
be experienced as “not rational enough” kind of
thinking.
Multi-level
perspective
• Depictsasystemicmodellingforunderstanding
sociotechnical change.
• Representsfutureoriented,holisticapproach.
• Includescoordination,interaction,learningand
informationow–aspectsbetweendifferentsocial
groups.
• Buildsconnectionsbetweenlocalinnovationwith
the regional / national regimes.
• Contributespositivelyinstrivingsystemicchange
into a desired directed.
• Concretisesthesignicanceoflandscapedrivers
in pursuing strategic activities in different levels of
societies.
• Concretisesthelinkagesbetweenlarger
phenomena and local action.
• Underlinesthesignicanceoflocalinnovationand
experimentation.
• Canbeconsideredasatoolforachieving
understanding on complexity.
• “Amplifyingandtransformingsocialactivities
towards powerful drivers of development”.
Figure4.DepictingcharacteristicsofSFM,roadmappingandMLPconcurrently

13
EVALUATING SUCCESS AND FAILURE IN
DIGITAL HEALTH
Failure is an important problem for digital health planning, strategies and implementation. This reality has been
difculttoadmitatalllevelsofengagement:fromgovernments,industry,IT-professionalsandhealthprofessionals
to academics, donors, and so forth. Indeed, a clear success bias (Heeks 2006) exists in both academic literature
assessing and reporting digital health projects, as well as the discussion within the broader stakeholder community
that comprises governments, healthcare administration, IT professionals, health professionals, and, especially in
developing countries, donors.
Broad review of failure and success of health IT projects reported that at least 40% of generic IT projects are either abandoned
or failed to meet business requirements, less than 40% of large systems acquired from vendors delivered as expected, and
some sources report that, more broadly, even up to 70% of health IT implementation projects can be assessed as failures.
An industry-wide estimate is that about half of all health IT projects fail to meet designed goals and objectives, and that a
similar number of projects exceed their planned cost or timeframe for implementation (Kaplan and Harris-Salamone, 2009).
In his review of failure in health IT systems projects, Heeks noted that “The best estimate…is that most Health
Information Systems fail in some way” (Heeks 2006). Nevertheless, failures offer a great opportunity for learning
andimprovement,andthereareimportantinsightsfromthe‘failureliterature’toimprovethelikelihoodsofsuccessful
adoption and acceptance of digital health systems.
The so-called design-reality gap model (Heeks 2006) captures the central issues and dimensions for failure in digital health
projects. Its central claim is that planning of digital health information systems (HIS) fails to consider the practical realities
framing and constraining adoption and acceptance of new digital health systems. In short, what looks straightforward and
greatatan engineer’sdrawing boardasaplangetsstuckinallkindsofchallengeswhenconfronted withrealpeople,
organisationsandreality.The‘messiness’,orcomplexity,oftherealitysimplyexceedstheimaginationofmostplanners.
It is important to understand that the design-reality gap does not emerge because of the refusal or opposition of implementing
level people and organisations. The design-reality gap, and the risk of failure, emerge typically because the planning
stage has failed to investigate and analyse deeply enough the social, cultural, organisational, economic and technological
preconditions for adoption and acceptance of new digital health solutions. Proper and deep understanding of the users
goes beyond analysing the user needs that the digital health solutions must satisfy, and should extend towards change
management where careful attention is paid to the preconditions on which users can adopt and accept new solutions.
Thus, as Richard Heeks proposes, successful implementation of new digital health solutions requires adaptive
implementation. As the roll-out of an ambitious digital health projects begins, its management should be prepared to
adapt,reviseandimprovisetheoriginalplansastheimplementationproceeds.Or,asHeekswrites:“…theamountof
changebetween‘wherewearenow’and‘wheretheHealthInformationSystemswanttogetus’iscentraltohealth
information system success and failure” (Heeks 2006).
In the South African context, a number of issues may expound the challenges, lending extra weight to the importance
to adaptive and improvised change management. It is important to appreciate the distinct features of the South
African society, as well as those of its social and healthcare services. The social and healthcare services remain
fragmented in different layers and sectors, and the initial technological level of different regions and organisations
varysignicantly.Allthisislikelytocontributetotheemergenceofadesign-reality gap, underscoring the importance
of the style and philosophy of change management for successful development, adoption and acceptance of new
digital health solutions.
Furthermore, in the broader African and development country context, another set of sources for failures arise.
Many digital health projects are created as donor-initiated pilots with a relatively small lifespan or poor sustainability.
Inthissectionandthefollowingsub-sections,webrieysketchsomekeyissuesforchangemanagementandevaluation
framework for Digital Health Innovation Ecosystems in a South African context, as well as develop perspectives on
management solutions for managing the roll-out of digital health solutions in South Africa.

14
Success and Failure in Digital Health Innovation Ecosystems
Whatis the proper framework to assess success and failure in digital health? Whatspecic metrics and which
dimensions of implementation of digital health impact and outcomes should be accounted for to evaluate success
and failure in digital health? As digital health is designed as ubiquitous, penetrating through all layers of activity
in health and social care, so the range of its impacts – and failure – is extremely broad. When we add to this the
notion of Digital Health Innovation Ecosystems, the complexity increases, but so too do the impact and outcomes
of digital health.
There are numerous ways for failure or incomplete success for digital health. It is important to note that the extent
of failure varies between complete and zero failure, with most projects demonstrating varying degrees of partial
failure. Thus, failure and success are not binary concepts, but should be assessed as multi-dimensional features of
a digital health project, especially if we are to contribute towards a constructive evaluation framework in support of
improved Digital Health Innovation Ecosystem planning and implementation.
Thehealthcarecontextexpoundsthemeaningof‘failure’,asbesidesadditionalcostanddelays,alsoinvolving
possibleadverseeffectsonpatienthealthcareandpublichealth.Whilenancial,technicalandcontractualfailures
are relatively easy to detect, issues become more complex once we turn our attention to failure to deliver impact and
outcomes. Yet, in the context of health, it is essentially the last category of impacts that matter for success and failure.
The same holds true if digital health initiatives are supposed to contribute to the enhanced innovation capacity of
rms,researchanddevelopmentorganisations,universities,hospitals,healthclinics,andsoforth.Theimpactand
outcomes from digital health initiatives to innovation capability are usually affected by indirect channels and a time lag.
Thus, we propose a three-tier conceptual framework to monitor and act upon management challenges in the context
of digital health, and use it to consider possible impact and outcome metrics for Digital Health Innovation Ecosystems.
Tier one, project failures, focuses on project implementation or operational issues, such as cost or scheduling issues,
ortechnical problemsassociated withtheendproject.Assuch, itis connedtofocusonlyon operationalissues
related to the implementation of a health IT initiative.
Tier two, impact failures, focuses on expected impacts of a health IT initiative. Such projects impact on management
of health systems, execution of physician or nurse work at clinics, the direct impact on patient safety (e.g. problems
caused by faulty software when failing to notify patients of appointments), and so forth.
Tierthree,outcomefailures,addressestheexpectedbenetsofdigitalhealthasbroadercommunity-orsociety-wide
outcomes. Broadly, this can be translated into improved availability and delivery of health services, or better health.
In practice, it should be broken down into more impact level phenomena that consist of practical outcomes from the
vantagepointofahealthsystemasanimprovedcost/benetrationofhealthcare,improvedaccesstohealthcare,
or even delivering targeted metrics, such as improved infant care or vaccination rates.
Tier-related discussion points include:
• Projectfailures:
»Budget exceeded;
»Delayed implementation;
»Partial or incomplete implementation; and
»UnderperformanceofhardwareandsoftwaretotheextentthattheITsystemcannotbeadoptedforintended
use or it fails in terms of interoperability with other relevant IT systems.
• Impactfailures:
»IT failures that adversely affect management of health systems;
»IT failures that adversely affect administration of care;
»IT failures that adversely affect patient safety; and
»IT failures that adversely affect collection and analysis of public health information.

15
• Outcomefailures:
»Access to healthcare services
› Expanded service area/clientele;
› Vaccination rates; and
› Health monitoring of targeted diseases or population.
»Availability of healthcare services
› Improvedcost-benetrationofhealthservices.
These points for consideration are not exhaustive: The point is that digital health, like all complex projects, should
have proper metrics to assess and evaluate. Furthermore, as discussed below, it is essential to develop perspectives
to conceptualise metrics to assess impact on the innovative capacity.
Towards an Evaluative Framework of Digital Health Innovation Ecosystems in
South Africa
In developing a framework for digital health for South Africa, it is essential to focus on the ICT Research, Development
and Innovation (RDI) Implementation Roadmap for South Africa. This Roadmap was developed by the CSIR Meraka
Institute in 2012 and accepted by parliament as the plan to guide the implementation of a national ICT RDI strategy.
The Roadmap is driven by the potential to deliver socio-economic impact, and presents a sound case for increased
public and private investment in ICT RDI. It serves as an anchor point for attracting increased public and private
investment in ICT R&D, including from multinational corporations.
ThisdigitaladvantagewillenableSouthAfricatobecomeasignicantplayerintheglobalICTRDIarena;provide
more targeted engagement with industry; focused international collaboration; more comprehensive and transparent
monitoring of investment and achieving impact, such as jobs and business creation, contribution to GDP, societal
impact and positioning South Africa for strategic advantage (Mjawara, 2012).
TheICTRDIImplementationRoadmapprovidesacoherent,comprehensiveandexibleten-yearimplementation
framework to coordinate and manage ICT research and technology development nationally, regionally and in relation
toourinternational partners. Oneofthekey priorities articulatedintheICT Roadmap documentisthe focus on
mobile health as a form of digital health.
The principal impact, in line with the MDGs, is to improve the quality of life through better and more convenient access
to healthcare. Mobile enablement is concerned with making services accessible via mobile platforms.
Betteraccesstorelevantinformationdrivesmoreefcientconsumptionofservices,bothpublicandprivate.Moreand
stronger interaction between individuals and organisations stimulates economic growth. Development and delivery of
new mobile applications drives the emergence of new mobile-service oriented businesses, including in rural areas.
To make this a reality, it was decided to develop a Digital Health Innovation Ecosystem for South Africa based on
what was found to be effective in the Scandinavian countries.
The Design Science as an Applied Methodology
The methodology applied in the exploration and design of the framework, was Design Science Research (DSR).
Design Science Research focuses on creation and the purpose of design being “to change existing situations into
preferredones”(Simon,1996).Designscienceaddresses‘wickedproblems’ininformationsystems(IS)(Rittel &
Webber, 1984) and is fundamentally a problem-solving paradigm. Wicked problems, as explained by Hevner and
Chatterjee(2010,p.11),relatetotheill-denedenvironmentalcontextsaswellasthecreativityandteamworkto
produce effective solutions.
The research methodology is grounded in the philosophy of pragmatism but the study has also applied interpretivism to
understandthefeedbackduringspeciccasestudies.Toadesignscienceresearcher,realityissocio-technologically
enabled and knowledge is gained through the process of artefact creation (Vaishnavi & Kuechler, 2013).

16
HevnerandChatterjee (2010)indicatethatanartefact isaman-madeobjectcreatedtosolveaspecicproblem,
as opposed to naturally occurring objects. The artefacts created in DSR could be in the form of one of the following
(Hevner & Chatterjee, 2010; Hevner et al., 2004; Vaishnavi & Kuechler, 2013):
• Constructs: A construct is the term that is used to describe a problem or solution. Constructs establish the
specialised language and shared knowledge of a discipline that arises during the conceptualisation of a problem
andtheyarerenedthroughouttheDSRcycle.
• Models: A model is a set of propositions or statements that describes the relationships between constructs. It
could also refer to an abstraction and representation of a problem or solution. The focus of models in DSR is on
their usefulness or utility. It can also include frameworks and guidelines.
• Methods: A method is a set of steps that guides the performance of tasks. Methods also represent the plan of
action aimed at achieving a goal. In DSR, a method that is aimed at solving a previously known problem in a
more effective way is deemed valuable.
• Instantiation: This is the actualisation of a construct, model or method. Instantiations demonstrate the feasibility
and effectiveness of the constructs, models or methods in an environment. The digital health framework is an
example of this.
•
Bettertheories: The DSR can contribute to the formulation of better theories, or to the development of new ones.
The development or evaluation of an artefact, which results in a better understanding of the relationships between
its elements, could potentially lead to the development of a new design theory for the artefact.
Basedonthesedenitions,theartefactknownastheDigitalHealthInnovationEcosystem,whichwasconceptualised
in a developing context in this project, is an instantiation. The construct (Digital Health Innovation Ecosystem) was
actualised by demonstrating its effectiveness in a developing context (South Africa).
Hevner,MarchandPark(2004)weretherstauthorstoprovideaninformationsystemsframeworktoshowwhere
DSRtsin. This framework waslaterimprovedby Pirinen (2009) as wellasWangand Wang(2010). Figure 5,
adapted from Hevner et al., (2004) and Pirinen (2009), indicates the relevance and rigour of DSR in information
systems. It is also used as the theoretical framework which informs this initiative.
Figure 6 borrows the IS research framework found in Hevner et al., (2004) and overlays a focus on three inherent
research cycles – relevance, rigour and design – with creativity and how each of these contributes to the knowledge
base of foundations and methodologies. People, organisation and technology are three components of the environment
of design research. Business needs are the driving force for design research so that it remains relevant. Design
researchmustaddto theknowledge basesothatitcanberigorous.ThespecicISDSRcyclesthat havebeen
applied, are illustrated in Figure 6.

17
ENVIRONMENT
CYCLICAdherence THEMATIC
PEOPLE
•Roles
•Capabilities
•Characteristics
ORGANISATIONS
•Strategiesandculture
•Processes
TECHNOLOGY
•Infrastructure
•Applications
•Communications
•Architecture
•Development
•Capabilities
FOUNDATIONS
•Theories
•Frameworks
•Instruments
•Constructs
•Models
•Methods
•Instantiations
METHODOLOGIES
•Dataanalysis
techniques
•Formalisms
•Measures
•Validationcriteria
ISRESEARCH
LINEAR
RELEVANCE
RELEVANCE
Business
Needs
Applicable
Knowledge
Additionstothe
KnowledgeBase
Applicationsinthe
appropriateenvironment
DEVELOP/BUILD
•Theories
•Artifacts
JUSTIFY/EVALUATE
•Analytical
•Casestudy
•Experimental
•Fieldstudy
•Simulation
RIGOR KNOWLEDGEBASE
Access Rene
CYCLIC
CREATIVITY
Figure5.InformationSystemFramework(Hevneretal.,2004;Pirinen,2009)
Environment
RELEVANCE
CYCLE
PROBLEMS&
OPPORTUNITIES
EVALUATE/OUTCOME/
REFLECTION
What&why,forwhom,in
whichcontexts?
EXPERIENCE&
EXPERTISE
DESIGN
CYCLE
RIGOR
CYCLE
ApplicationDomain
DesignScienceResearch
Hypothesis(technologicalrules)
KnowledgeBase
Foundations
•People
•Organizationalsystems
•Technicalsystems
•Hypothesis(technologicalrules)
•Builddesignartifacts&processes
What might work
› for whom
› In which contexts
› And why?
•Scientictheoriesandmodelsof
IS interventions, IS, or IT artefacts
(Design Products / Design Processes)
?
•Requirements
•Observations,testing
•Multi-mediadata
collection:
Mechanisms
Context
Outcomes
•Grounding
•AdditionstoKB
•BasedonExisting
assessment of:
Mechanisms
Context
Outcomes
Figure6.Informationsystemsdesignscienceresearchcycles(adaptedfromCarlsson,2010,andHevner,2007)

18
Relevance Cycle
The Relevance Cycle initiates DSR with an application context that not only outlines the requirements for the research
(e.g.theopportunity/problemtobeaddressed)asinputs,butalsodenesacceptancecriteriafortheultimateevaluation
of the research results. The output from the DSR must be returned into the environment for study and evaluation in
the application domain (Hevner, 2007).
The digital health framework can inform other developing countries in similar initiatives where appropriate. The
framework would be developed for the resource-constrained context as contextualised by individual literature
studiesofrelevantcasestudiesandpositionpapers.Identiedrequirementswerepeerreviewedbyexperts,orin
peer-reviewed publications, for validation and to ensure the artefact designs had a solid foundation. The individual
component requirements provided the input for the design cycle and were used to collect data and evaluate the artefact.
Rigor Cycle
The Rigor Cycle provides existing knowledge to the research initiative to ensure its innovation. It is contingent on the
researchers to thoroughly research and reference the knowledge base to guarantee that the designs produced are
research contributions and not routine designs based on the application of well-known processes (Hevner, 2007).
Additions to the knowledge base, as a result of the DSR, will include any extensions made during the research, the
newartefact(framework)andallexperiencesgainedfromperformingtheresearchandeldtestingtheartefactin
the application environment (Hevner et al., 2004; Hevner, 2007).
For the knowledge base, this study applied relevant existing digital health frameworks from other Scandinavian
countries to inform the development of the framework for South Africa.
Design Cycle
The internal Design Cycle of research activities iterates more rapidly than the Relevance and Rigor Cycles between
the development of technological rules, the construction of an artefact, its evaluation and subsequent feedback to
renethedesignfurther(Carlsson,2006;Hevner,2007).Simon(1996)describesthenatureofthiscycleasgenerating
design alternatives and evaluating the alternatives against requirements until a satisfactory design is achieved. In
this study, the design cycle involves the development and evaluation of the artefacts.
Design Science Research Guidelines
The seven guidelines to perform DSR in an information systems discipline, as described by Hevner et al., (2004),
follow and include (see Table 1): design as an artefact, problem relevance, design evaluation, research contributions,
research rigour, design as a search process and communication of research (Wang & Wang, 2010).
Table1.DesignScienceResearchGuidelines(Hevneretal.,2004)
Guideline Description ApplicationforDigitalHealthFramework
Guideline 1: Design as
an Artefact
Design science research must produce a viable
artefact in the form of a construct, a model, a
method or an instantiation.
A research-related artefact (frameworks) was
developed based on knowledge gained from
the application of technologies and resources in
digital health in other countries.
Guideline 2: Problem
Relevance
The objective of design science research is to
develop technology-based solutions to important
and relevant business problems.
Based on the ICT Roadmap it was necessary to
develop a digital health innovation ecosystem to
guide the implementation of health systems in
South Africa.
Guideline 3: Design
Evaluation
Theutility,quality,andefcacyofadesign
artefact must be rigorously demonstrated via
well-executed evaluation methods.
The artefact was evaluated by experts in the
digital health domain at various workshops
during 2015.
Guideline 4: Research
Contribution
Effective design science research must provide
clearandveriablecontributionsintheareasof
the design artefact, design foundations, and/or
design methodologies.
The relevant ecosystem is a novel contribution
to assist health system implementers to
considerspeciccomponentsrelevantto
digital health. There are also some theoretical,
methodological and practical contributions which
the ecosystem can have for ehealth in South
Africa.

19
Guideline Description ApplicationforDigitalHealthFramework
Guideline 5: Research
Rigor
Design science research relies upon the
application of rigorous methods in both the
construction and evaluation of the design
artefact.
Rigor will be achieved through the use of the
researchers or practitioners from industry and
academia to evaluate the relevance of the
Digital Health Innovation Ecosystem. Additions
to the knowledge base have assisted in the
development of the ecosystem.
Guideline 6: Design as a
Search Process
The search for an effective artefact requires
utilising available means to reach desired
ends while satisfying laws in the problem
environment.
The researchers from South Africa and Finland
scanned the digital health literature and used
the already existing digital health literature
and architectures from Finland and Estonia to
develop the ecosystem for South Africa. It was
also important to know what existed already in
South Africa. The design science process was
followed to develop the ecosystem, which was
then evaluated through a workshop.
Guideline 7:
Communication of
Research
Design science research must be presented
effectively, both to technology-oriented as well
as management-oriented audiences.
Various presentations at various forums,
conferences and workshops were done to
communicate the ecosystem and to get inputs
fromexpertsintheeldofdigitalhealthbothin
South Africa and from Finland.
Design Science Research Process
The Design Science Research Process (DSRP) applied in this research is consistent with prior literature (Hevner et
al.,2004;Hevner,2007;March&Storey,2008)andincludethefollowingsixsteps:problemidentication,motivation,
objectives for a solution, design and development, evaluation and communication. The iterative nature of the DSRP,
asintroducedbyPeffersetal.,(2008)andadaptedforthisstudy,isillustratedinthefollowinggurebythearrows
between the various steps (see Figure 7).
CommunicationEvaluationDemonstration
Design
and
Development
Objectives
ofthe
Solution
Entrypointfor
thisresearch
Problem-
centered
approach
Deneproblem
andaim
Conceptualise
adigitalhealth
innovation
ecosystemfor
SouthAfrica
Thedesign
involvedthree
specicphases
wherethe
learningfrom
eachphase
informedthe
development
ofthe
conceptualisation
oftheecosystem
Involvedspecic
phases
Phase1:
Literature
studiesand
foresightingwith
roadmapping
Phase2:Case
studiesof
Estoniaand
Finland
Phase3:
Workshopsand
expertreviews
Thenal
conceptualised
ecosystemwas
evaluatedby
expertsfrom
SouthAfrica,
Africaand
Finlandforits
relevanceand
utility
Scholarly
publications
Professional
publications
Objective-
centered
solution
Design&
Development-
centered
approach
Observing
thesolution
Problem
Identication
andMotivation
Inference
Theory
How-toknowledge
Analysis&metrics
knowledge
Disciplinary
knowledge
Figure7.DesignScienceResearchProcessadaptedfromPeffersetal.,(2008)

20
Thefollowingguredepictsthephasedimplementationasiterations:
Communicate
Results
ofPhase1
Communicate
Results
ofPhase2
Communicate
Results
ofPhase3
Objectives
ofthe
Solution
Communication
Communication
Communication
Evaluation
Evaluation
Evaluation
Demonstration
CommunicationEvaluationDemonstration
Demonstration
Demonstration
Initial
Conceptualisation

fromLiterature
Intermediate
Conceptualised
DigitalHealth
Innovation
Ecosystem
Final
Conceptualised
DigitalHealth
Innovation
Ecosystem
Initial
Conceptualisation
withfuture
locallyrelevant
Healthand
Wellness
Innovations
horisons
Initial
Conceptualised
DigitalHealth
Innovation
Ecosystem
Problem
Identication
andMotivation
Phase1a:LiteratureoverviewofDigitalHealthSystems
Phase1b:ForesightingtoidentifyrelevantfutureHealthand
WellnessInnovationsandroadmappingtowardsfuturehorizons
Phase2:CaseStudy,FinlandandEsatoniaHealthSystems
Phase3:Workshopsandexpertconsultationandreview
Informs
Figure8.DesignScienceResearchprocesswiththe multiplecase studiesand thedeliverable fromeach
iteration
The Digital Health Innovation Ecosystem was thus developed through three phases as depicted in Figure 8:
Phase 1: Involved the literature review on digital health as well as a foresight exercise to identify relevant future
health and wellness innovations and roadmapping towards future horizons.
Phase 2: Covered the case studies where Finland and Estonia health systems were addressed and where experts
working on these were interviewed to get relevant feedback on architectures and challenges.
Phase 3: Involved workshops and expert consultations to validate and review the conceptualised Digital Health
InnovationEcosystemforittobecomethenalecosystem.

21
At the end of each phase, the Digital Health Innovation Ecosystem was at a different level of conceptualisation. At
the end of level one it was an initial ecosystem, at the end of phase two it was an intermediate ecosystem and the
endofphasethreeitwasthenal,conceptualisedDigitalHealthInnovationEcosystem ascan beseen fromthe
nalexplanationofhowthisecosystemlookslike.
Data collection
To ensure data accuracy, a variety of sources were used. These included observations, interviews (both one-on-one
and focus groups) and audio-visual material (photographs, text and video recordings).
Sampling
The participants for the interviews in Phase 2 and Phase 3 were selected using purposive and snowball sampling.
Withpurposivesamplingtheresearcherusesher/hisjudgmenttoselectspecicparticipantswhocancontributeto
an understanding of the research problem and phenomena central to the investigation to meet the purpose of the
research(Creswell,Plano&Clark,2011;Oates,2006).Snowballsamplingidentiesresearchparticipantsthrough
achainreactionasaresultofwordofmouth.Researchersndonepersonwhocomesfromthetargetgroupand
then ask him/her to recommend additional participants who can contribute to the study. Having gathered data from
these participants, the researchers then ask them to recommend additional participants (Creswell, Plano & Clark,
2011;Oates,2006).
Data verication
Tofurtherensuredataaccuracy,corroboratethendingsandenhancetheirvalidity,varioustypesoftriangulation
wereused(Oates,2006):
• Data triangulation involves the use of a variety of data sources in a study. In this study the sources included
participants (digital health developers in Finland and Estonia and experts in South Africa and Finland in digital health)
and existing documentation relevant to the study and external experts in ICT4D, technology and health domains;
• Theory triangulation in which multiple theoretical perspectives – critical and design – were used to interpret the
data collected; and
•
Method triangulation entailed the use of multiple data-generation methods, namely ethnographic reports,
observations, interviews, photographs, and anecdotal stories.
Data analysis techniques
As interpretivism is the philosophy which has been applied under the different case studies of each phase of the
development, the hermeneutic analysis technique was applied. Hermeneutics is based on the interpretative paradigm
(Walsham, 1995). Gadamer (1998, p. 196) points out that the hermeneutic analysis is “logically a circular argument
in so far as the whole, in terms of which parts…” or otherwise put “we must understand the whole in terms of the
detail and the detail in terms of the whole” (Gadamer, 1998). Hermeneutics therefore analyses the various sections
of the text while considering the complete picture. It also analyses the complete picture while looking at the various
separate texts that contributed to the whole picture. This is done through the hermeneutic circle.
Hermeneutic cycle
The analysis of this research was based on four stages, which make up the hermeneutic circle. They are the following:
• Stages 1 and 2: Study of the literature review based on the hermeneutic cycle to produce initial artefacts; and
• Stages 3 and 4: Conducting multiple case studies which included Finland and Estonia health systems and having
workshops.
Klein and Myers (1999) propose a set of principles to conduct and evaluate interpretive case research, which are
based on the philosophical perspective of hermeneutics and which mostly apply to studies of this nature. Table 2
indicates these principles and how they guided the research study as a whole.

22
Table2.Principlesforconductingandevaluatinginterpretiveresearch
Fundamentalprincipleforconductingandevaluating
interpretivestudies
Howandwhereappliedinthisstudy
1. The Fundamental Principle of the Hermeneutic Circle.
This principle suggests that all human understanding is achieved
by iterating between considering the interdependent meaning
of parts and the whole that they form. This principle of human
understanding is fundamental to all the other principles.
DataanalysisusingCreswell’s(2007,p.75)within-
case, cross-case and holistic-case analysis template.
Triangulation.
2. The Principle of Contextualisation.
Requirescriticalreectionofthesocialandhistoricalbackground
of the research setting, so that the intended audience can see
how the current situation under investigation emerged.
AppliedwhenhighlightingthesettingofSouthAfrica’s
public health system.
3. The Principle of Interaction Between the Researchers and the
Subjects.
Requirescriticalreectiononhowtheresearchmaterials(or
‘data’)weresociallyconstructedthroughtheinteractionbetween
the researchers and participants.
The role of the researchers and digital health experts
during the interviews and workshop is evidence of this.
4. The Principle of Abstraction and Generalisation.
Requires relating the idiographic details, revealed by the data
interpretation, through the application of principles one and two to
theoretical, general concepts that describe the nature of human
understanding and social action.
It is envisaged that the resulting ecosystem will be able
to be replicated and applied in other provinces in South
Africa or other developing countries thus generalisation
willbepossibleifthecontextspecicsaretakeninto
consideration.
5. The Principle of Dialogical Reasoning.
Requires sensitivity to possible contradictions between the
theoretical preconceptions guiding the research design and actual
ndings(‘thestorywhichthedatatell’)withsubsequentcyclesof
revision.
The interpretations of the data were done in light of the
literature and visiting and interviewing the Finnish and
Estonia health systems developers and experts.
6. The Principle of Multiple Interpretations.
Requires sensitivity to possible differences in interpretations among
the participants as are typically expressed in multiple narratives
or stories of the same sequence of events under study. Similar to
multiple witness accounts, even if all tell it as they saw it.
Interpretations from the researchers from both South
Africa and Finland were useful to ensure that differences
are addressed.
7. The Principle of Suspicion.
Requiressensitivitytopossible‘biases’andsystematic
‘distortions’inthenarrativescollectedfromtheparticipants.
Data collected from participants were done anonymously.
Multiple sources for data collection and multiple
measures for data collection were employed.
The principle of the hermeneutics circle and multiple interpretations require the researcher to understand and examine
situations in parts, and as a whole, and to assign explanations to them.
In summary, the following was applied to guide the development of the artefacts:
• Philosophy: The philosophy chosen for the study is mainly pragmatism to guide the design and development of
the artefacts, but interpretivism was also applied to the results from the phases and case studies, which were
part of the phase iterations of the design science cycle.
•
Methodology: The methodology used was DSR, which was informed by qualitative multiple case study methodology
as well as foresight and roadmapping.
• Approach: The data were analysed through both inductive and deductive means.
• Research strategy: The strategy used in the study is the multiple case study approach.
• Data collection techniques used: The data collection techniques used included primary data, in the form of the
validations from the experts, and secondary data, sought from literature reviews.
•
Data analysis: Employed hermeneutics, descriptive statistics techniques to make meaningful examinations of the
collected data as well as within, cross and holistic case analysis. Triangulation of results was therefore applied.
The methodology section explained the design of the digital health framework. The next section explains the possible
contribution that this framework can have for South Africa.

23
Theoretical contribution
The literature and existing digital health systems from two Scandinavian countries allowed for insight and foresighting
toplayasignicantroleindevelopingthe DigitalHealthInnovationEcosystemfor SouthAfrica.Itwillalsoinform
health strategies and systems development of future health systems for the country. The design theory recalibrated
the DSR approach to better accommodate the needs of the digital health environment of South Africa. For the
purpose of this initiative, the resulting artefacts can guide the implementation of similar initiatives in similar contexts.
Contribution to research methods
ThechallengingenvironmentinwhichthedigitalhealthsystemshavetobeimplementedinSouthAfrica,providesforspecic
challenges relating to the environmental, community and physical challenges. Making use of an in-depth comparative case
study, within the design science iterations, this project applied multiple data-gathering methods as well as multiple data sources.
Data-gathering methods included expert and participant interviews, focus groups and observations. Following an iterative
data-gathering process over a period of two years enabled an in-depth understanding of the social reality of the participants.
Practical contributions
Onapracticallevel,thisinitiativeprovidedthefollowing:
• AnalconceptualisationofaDigitalHealthInnovationEcosystemthatspecicallysuitstherequirementsofthe
health system in South Africa;
• Processes, operational and procedures with guidelines; and
• Recommendations and advice.
Conclusion
ThissectionprovidedanoverviewofthescienticmethodologicalperspectiveofhowtheDigitalHealthInnovation
Ecosystem for South Africa was developed.
The way in which foresight and roadmapping were applied during the DSR methodology process was also provided.
The DSR methodology is grounded in the philosophy of pragmatism; however, this study also applies interpretivism
within the evaluation and validation through various workshops.
To a design science researcher, reality is socio-technologically enabled and knowledge is gained through the process of
artefact creation (Vaishnavi & Kuechler, 2015). The DSR process applied in this research included the following six steps:
problemidentication,motivation,objectivesforasolution,designanddevelopment,evaluationandcommunication.
The iterative nature of the DSR process, as introduced by Peffers et al. (2008), was adapted for this study.
Theartefact,theconceptualDigitalHealthInnovationEcosystemforSouthAfrica,wasconceptualised,renedand
validated through three iterate phases:
•
Phase 1: Conceptualisation: Literature overview resulting in an initial conceptual Digital Health Innovation Ecosystem
and also using foresight to ensure that all possible future digital health and wellness innovations and possibilities
are taken into account. Roadmapping was also part of this phase.
• Phase2:Renement:Amultiplecasestudyresearch strategy wasappliedtothe exploration of digitalhealth
systems from Finland and Estonia resulting in an intermediate conceptual Digital Health Innovation Ecosystem.
• Phase 3: Validation: A multiple case study research strategy was applied through two workshops in a South
African and African context to elicit feedback on proposed elements of the ecosystem. Critical inputs from ehealth
stakeholders, from both developing and developed contexts were incorporated. This process resulted in a validated
andnalconceptualDigitalHealthInnovationEcosystem.
The data collection techniques used included primary data, in the form of the validations from the experts, and
secondary data, sought from literature reviews. It also involved the use of foresight methodologies. Data analysis
was done through the application of hermeneutics, descriptive statistics techniques to make meaningful examinations
of the collected data as well as within, cross and holistic case analysis. Results were triangulated.

24
DIGITAL HEALTH INNOVATION ECOSYSTEMS
This section offers a brief review of the Finnish and Estonian digital health cases. This section also involves Phase
2 of the DSR methodology process as depicted earlier and in Figure 9:
Communicate
Results
ofPhase2
CommunicationEvaluationDemonstration
Intermediate
Conceptualised
DigitalHealth
Innovation
Ecosystem
Phase2:CaseStudy,FinlandandEsatoniaHealthSystems
InitialConceptualisedDigitalHealthInnovationEcosystem
Figure9.Casestudiesasapartoftheresearchprocess
Itisourintentiontodrawlessonsfromthesedifferentsystemsandcase-specicdevelopmentpaths.Inshort,within
just twenty years, Estonia has renewed its information governance from multiple information systems to integrated
system level architecture serving society both vertically and horizontally. Finland, on the other hand, has been running
an ongoing reformation process for years, struggling with a lack of vision and consensus in political decision-making
and stagnated situation in ICT context.
Inourapproachweapplyanecosystemperspectivebyidentifyingeldactorsandtheirrolesasenablersofchange.
We also present some existing modelling on key infrastructure and information sharing dynamics on these two
systems. In a research context, it is our intention to create understanding on elements of health information ecosystem
and wider, to create insights for structuring digital health paradigm change towards an ecosystem way of operation.
Finnish Digital Health Efforts
Background – Social and Health IT in Finland
The Finnish welfare state is characterised by a universal right to social welfare and healthcare services. Preventive,
equalprimaryhealthcare and speciedmedicalcareservices as wellasenvironmentalhealthcare are essential
elements of the system. The objective of the Finnish social welfare and healthcare system is a socially sustainable
society. As a part of this process, everyone is entitled to be treated fairly, social inclusion and participation are
encouraged,everyone’shealthandfunctionalcapacityarepromoted,andsupport andservices areavailable. To
achieve a socially sustainable society, welfare and health inequalities between citizens must be reduced and the
status of the most vulnerable improved (Ministry of Social Affairs and Health, 2013a).
Reformingthestructureandcontentofsocialwelfareandhealthcareserviceswillbeoneofsociety’smostimportant
goalsincomingyears.Thisprocessisaimedatensuringmunicipalitiesremainsufcientlystrongtobeabletooffer
high-quality services to citizens on an equal basis in all parts of the country. The objective is to divide the provision
of services between larger regions serving a higher number of citizens. This is the only way to ensure that citizens
receive services of equal quality regardless of where they live and that service providers are not overburdened
nanciallyby individual,expensivetreatment andservicedecisions. Municipalitiesthatare unabletoprovide the
necessary services alone can form joint social welfare and healthcare regions.
Another simultaneous aim of the reform is to lower the boundaries between primary healthcare and specialised
medicalcare.Socialwelfareandhealthcareservicesarenotenoughtosolvetheproblemsassociatedwithpeople’s
lifestyles and living environments. Population health is also affected by decisions relating to community structure,
exercise and education (Ministry of Social Affairs and Health, 2013a).
Health technology research and development activities are long term and expensive. The high costs and slow progress
oftheresearchanddevelopmentactivitiesarepartlyduetoincreasingregulation.InFinland,especiallyEUregulations

25
and directives have an impact on the development and implementation of health technology innovations both directly
and through national legislation. Taking a look at pharmaceuticals, for example, a marketing authorisation for new
innovationsis usually requestedthroughouttheEU in aso-calledcentralised procedure. Inpractice,introducing
health technology products to the market requires compliance with the European harmonised standards (TEM, 2014).
Overview on health challenges in Finland
In general, it can be observed that many traditionally common diseases are decreasing but new kinds of health
problems are increasing. This includes, for example, lifestyle-related diseases such as overweight among adolescents.
Inthisregard,thenumberofobeseindividualshastripledduringthepast30years.Onlyoneinthreegetsenough
exercise. The most common endemic disease is diabetes with more than half a million people suffering from it.
Type 1 diabetes is more common than anywhere else in the world and type 2 diabetes is also found in children. The
most common musculoskeletal diseases are back problems, hip and knee osteoarthritis, rheumatoid arthritis and
osteoporosis. The number of cancer patients has increased slightly, but the prognosis has improved continuously.
Deathsresultingfromaccidentalinjuriesatworkandtrafcaccidentinjurieshavedecreasedbutdeathsresulting
from home and leisure accident injuries have become more common. Allergies and dementia are growing health
problems. Approximately one in four people aged 75 and over will need care due to dementia in the coming years
(Ministry of Social Affairs and Health, 2013a).
Mental disorders are among the most common reasons for disability for work. Approximately one in two people
on a disability pension are unable to work due to mental disorders and diseases resulting from substance abuse
(2010). The most common reason is depression. Alcohol consumption has grown since the tax cut in 2004 and the
abolishment of import restrictions, which is why alcohol-related problems and deaths have increased. Smoking has
decreased slightly among young people and the working-age population, but differences between socio-economic
groups are substantial (Ministry of Social Affairs and Health, 2013a).
OneofthesubjectspursuedbytheEuropeanUnionisactiveandhealthyageing.Finlandisalsofacingthisperiod
of rapid large-scale demographic change. In the 1940s and 1950s, there was a heavy post-Second World War baby
boom. Consequently Finland now has a bigger ageing population. It has been estimated that by 2050 Finland may
have a 10% addition to its social expenditure. This also impacts the labour force in healthcare. It the municipal level,
there are more and more people working in specialised healthcare, and fewer people in primary or elderly care.
Simultaneously, the average age of people working in the sector has been maturing and many employees will be
retired shortly. These are some of the reasons to introduce more effective ways of providing health and care services
through ICT tools and services (Schug & Whitehouse, 2013).
System view on healthcare services
Finland’ssocialwelfareandhealthcaresystemisfoundedongovernment-subsidisedmunicipalsocialwelfareand
healthcare services. In addition to public sector, many private enterprises and non-governmental organisations
are providing services. The social welfare and healthcare system in Finland is based on public, tax-based funding
(Ministry of Social Affairs and Health, 2013a). Citizens have guaranteed access to care, and have to wait between
three and six weeks for treatment, depending on the type of illness (Schug & Whitehouse, 2013).
Primary healthcare is provided in municipal health centres. Every municipality has to belong to a hospital district and
they have the responsibility to choose which one. Hospital districts are part of the public system and are owned by
the municipalities. State revenues are given by the central government to municipalities and can be used for primary
or secondary care. (See Figure 10)
FouroutofvehealthservicesareprovidedpubliclyinFinland.Insomeareasof socialcare, municipalitiesmay
purchase many services from private providers instead of having their own public health provider organisations.
Therefore, for the citizens the social care services are public services even though the services are offered by private
providers (Schug & Whitehouse, 2013).

26
STAT E
Funding,guidanceandsupervision*
SOCIALINSURANCEINSTITUTION
Healthinsurancereimbursements
Parliament
Government MSAH MinistryofFinance
MUNICIPALITIES/LOCAL
GOVERNMENTJOINT
SERVICESAREAS**
Medicines
Insurers
Healthcentres
(publicsector
primaryhealthcare)
Privatehealthservices
PUBLICSECTOR
SERVICEPROVIDERS
State’sfunding
contribution
Funding
Health and other insurance contributions
Client fees for service use
Employer fees for services
Reimbursements
Central
government
transfers to local
government for
running costs
PRIVATESECTOR
SERVICEPROVIDERS
Hospitaldistricts(public
sectorspecialised
medicalcare)
NGOs
Employers’own
occupationalhealthcare
clinics
Taxes
POPULATION
Employers
Project funding
and specialised
government
transfer for
training
Specialised
government
transfer for
research
Slot Machine
Association
grants
*The Regional State Administrative Agencies, National Supervisory Authority for Welfare and Health (Valvira) and the Finnish
Medicines Agency (Fimea) supervise healthcare. The following expert institutes are in charge of information guidance: the National
Institutefor Healthand Welfare(THL),theFinnishInstitutionofOccupationalHealth(TTL)andSTUK–RadiationandNuclear
Safety Authority, Finland.
**Municipalities are responsible for organising the health services required by the population. Primary healthcare should be arranged
inmunicipalities,orlocalgovernmentjointservicesareas,withatleastaround20,000inhabitants.Infulllingitsresponsibilityfor
organising specialised medical care, each municipality must belong to a hospital district.
Figure10.Organisationfundingprovisionand supervisionof healthcareservices (MinistryofSocialAffairs
andHealth,2013a)
Nearly 200 different municipal organisations are responsible for organising and providing social welfare and healthcare
services. According to a government decision communicated in November 2015, a new service structure will be
based on 18 autonomous regions in the country, of which 15 will organise healthcare and social services in their area
themselves. The remaining three regions will provide the services with the support of one of the other autonomous
regions. As a consequence, the number of joint statutory organisations would be markedly reduced. The intention is
that each autonomous region will provide the services itself, together with other autonomous regions, or in cooperation
with the private or third sector (Finnish Government, 2015). This process has immediate effects on resources required
for new innovation, but structural changes are likely to contribute savings in the long run. At the same time, health
sector research activities in the industry are in a transitional stage: closed innovation models are being transformed
into open models or entirely different models. There are differences between the various technological, diagnostic and
pharmaceutical research operations, but cooperation with healthcare providers and the academic research community
will be central to all operators (TEM, 2014).

27
E-health development path
Inthe1980s,Finlandstartedtodeveloplocalelectronicpatientrecords.FinlandhashadanofcialeHealthstrategy
since 1996. It necessitated experimental legislation which permitted the sharing of data. Finland has been working on
eSocial services since 2004. However, the country does not yet have any legislation on it, and the work has so far not
moved towards an implementation phase. In 2006, a political decision was taken to develop a national IT architecture
and in 2007, the Finnish National Archive of Health Information (KanTa, see Figure 11) legislation was passed. As
a result, the Social Insurance Institution of Finland was selected as the hosting organisation and technical provider
forthenewdigitalservicestothewholeofFinland.UntiltheKanTasystemisinfulloperation,patientdataexchange
willtakeplaceina‘businessasusual’wayonaregionallevel,butwithnonationaldataexchangepossibilities.After
upcoming legislationhas been introduced in Finland, patients will be able to visit and use services in other hospital
districts. This will necessitate patient data exchange (Schug & Whitehouse, 2013).
Othernationalservices
Publichealthcareproviders Kantaservices
ePrescriptionservice
Pharmaceutical
database
Kantamessaginglayer
Patientdata
repository
Nationalcodeserver
Certicationservices Healthcareprofessionalsregister
Logs
DispensationsPrescriptions
Metadata
Radiology
DICOM
studies
Web
services
for HCPs
My Kanta
pages
SwedishepSOSNCP
Health care professionals
Citizens (> 5 000 000)
Hospital districts (20)
Primary care org. (192)
Private healthcare
providers (4000)
Pharmacies (~800) Logs
Health records,
structured (CDA R2 L3)
Health records, legacy
(CDA R2 L1)
Patient summary management
Patientdatamanagementservice
Diagnoses Vaccinations
Lab
Health and care plan
Procedures
Risks
Radiology
Physicalndings
Code lists and terminologies
Mainstandards
• HL7V3:CDAR2Level3and
Medical Records
• IHEIT-IProles
• W3CXMLDSig
• WSAddressing,WS-I
• TLS,X.509
Form and document structures Pharmacies register
Healthcare and social care
organizations register
Medication
OtherNCPsnotyetconnected
epSOSNCP
IHEXDS
PersonalHealth
andSocialRecord
APPS
mHealth
OwnCare
SelfCare
Figure11.TheFinnishNationalArchiveofHealthInformationKanTa(Hämäläinen,2015)
Asobserved,theFinnishhealthsystemisgoingthroughasignicantchangeprocess.Criticalquestionsreecting
on future developments include (Schug & Whitehouse, 2013):
• Howis‘opendata’relevanttotheFinnishnationalrepository?
• IsinformationexchangefeasiblebetweenKanTaandpeople’spersonalhealthrecords?
• What happens if data are sold to a third party or a company?

28
• Canusabilityandprocesssupportbeguaranteedintermsofelectronicmedicalrecords(e.g.withbothofcial
data and also patient-entered data)?
• Is it possible to shift from available data and information to knowledge management?
• CanhealthprofessionalsactuallybesatisedwithIT?
Anotherrelateddevelopmentpathconcernscitizens’increasingroleintakingresponsibilityfortheirownwell-being
andprevent varioushealth problems.The Internethas asignicant enablingroleinthis.Itwillinvolve theuse of
virtual medical examinations, personal data to create instructions, or the provision of treatment programmes that
promote health and well-being. It will also encourage citizens to follow instructions and offer them rewards in terms
of the positive monitoring of follow-up and results. A virtual service instructor would guide a citizen to the appropriate
service provider on the basis of the need for service, quality and comparative data (Schug & Whitehouse, 2013).
Quantiedinformationandbigdatacancreatesupportfordiagnosisandrevealnewinformationoncasesofdifferent
illnesses. Finland has good possibilities in this area as background systems are quite well established, but legislation
regulating research and innovation activities must consider in greater detail the context where the data are used and
personal information included (TEM, 2014).
In all, Finland has long been involved in the development of eHealth systems and services, starting from a mainly
localisedapproachtowardsamorenational-levelapproachthatmaximisesthebenetsoflocalownershipandexibility,
but operates within an inclusive structure of information sharing and standardisation (Schug & Whitehouse, 2013).
Positively, Finland can be considered as a strong digital health hub where social and healthcare technologies,
devices and services can have increasing potential also on a global scale. The core is that health information will be
effectivelyusedforthebenetofindividualsandthesocieties.Thisisenabledbynationalstrategiesandafunctional
innovation ecosystem based on multidisciplinary cooperation and a positive atmosphere (Pere & Toivainen, 2015).
Atthesame time, Finland shouldhavethecourage to makedecisionsinspecic areas of competencethatare
believedtogeneratefuturedemandforinventionsandderivedinnovations;also,sufcientresourcesshouldbeleft
foropen,‘bottom-up’fundinginthefuture(TEM,2014).
Towards ecosystem modelling
TheFinnishITinnovationlandscapecanberoughlydescribedasatwo-foldsystem,consistingofofcialhealthcare
andsmallercompaniesoperating beside this ofcial system.Thisofcialsystemcontains certain stable players
such as IT service providers (patient safety systems in particular), and can be described as resource intensive in its
characteristics.Inachievingbettersystemefciencyandinnovationcapability,thesetwoworldsshouldcommunicate
better, wherein developing modularity and interfaces between the systems are vital. Larger health technologies are
acknowledged as a key growth area for Finland and funding for this area is increasing.
The TEM strategy document (2014) presents one way to identify and integrate the sections in the health sector.
Themodelstressesthebusinessdevelopmentviewpoint.Asimplieddescriptionoftheinnovative healthsector
ecosystem model is presented in Figure 12.
Baseofcompetences
Creationofinnovations
Fundingof
R&Dactivities
Marketand
demand
Denitionsof
policyand
legislation
Networks
Creationof
innovations
Figure12.HealthInnovationEcosystem(TEM,2014)

29
Thesepresentedareascoverfollowingspecications:
•
Base of competences (education and research in polytechnic institutions and universities and in various research
institutions).
•
Funding for research and innovation activities (the Academy of Finland, Tekes, Sitra, Finnvera, Industry Investment,
stateresearchfunding[formerlyresearchEVO],internationalorEUresearchfunding[includingIMI,EIT],foundations,
private investors, capital investors and industrial funding).
•
Infrastructures and networks (universities, Biocenter Finland, university hospitals, other healthcare operating units
carryingout researchactivities,sectoral organisations, INKA,SHOKactivities [andinthe future,TeamHealth
Finlandandspecialisedareasofresponsibilityrelatedtosocialaffairsandhealth]).
•
Denitionsofpolicy,legislationandtheattitudesofpublicoperators(STM,TEM,OKM,Fimea,Valvira,theNational
Institute for Health and Welfare, hospital districts, Tekes, the Academy of Finland).
• Markets and demand (public and private healthcare operators as purchasers, patients and individuals working
to promote health).
Itisessentialthatthecorrectstakeholders,whohavesufcientmotivationandauthority,areidentiedfromthestart
of the ecosystem modelling process to ensure that any challenges to adopt digital health are addressed. This may
notbeeasy,asthebenetsareoftennotseenbyanyparticularstakeholder,butmorewidelyinthesociety.Another
challengeisthatthesebenetstendtohavealong-termnatureand do not yield immediate results.Therefore,
the strategic change toward digital health needs to be a national priority, strongly supported by the government.
To succeed, digital health implementation needs strong and visible advocates who provide leadership and build
enthusiasm among stakeholders.
Primary contribution and lessons learnt
The utilisation of modern ICT-based solutions and services has the potential of improving the cost-effectiveness, quality
andaccessibilityofhealthcare.Therealisationofthesebenetsis,however,notstraightforward.Theoutcomesof
many promising digital health projects remain limited to small-scale pilots, without longer term impact on healthcare
delivery.Thishastodowiththesystemicnatureoftoday’shealthcarechallenges.Tohaveapermanentimpact,itis
notsufcienttojustdevelopbettertechnologiesandsolutions–theseactuallyoftenexist,butarenotusedeffectively.
The development of regional pilot activities and testing environments is a matter of priority, and equally important is
having dynamic mechanisms for larger scale implementations.
In addition to technology, the digital health paradigm change happens in two other dimensions: processes and people.
Adding new technologies on top of existing processes seldom yields good results and may even increase the cost of
care. What is needed is a renewal of the way care is provided to citizens, by re-engineering care processes in such
a way that technology can be utilised effectively. As a parallel action with developing digital health processes, there
is also a need to motivate both healthcare providers and citizens in adopting new ways of care. This also relates to
the changing role of citizens. It involves a major change in empowering people in taking care of their own health,
instead of being passive objects in healthcare delivery. This enables healthcare to become more personal, proactive
and cost-effective. By using ICT-based tools such as health information systems, remote monitoring solutions, mobile
health services and point-of-care diagnostic tools, digital health brings care closer to the people.
ThescatteredFinnishinnovationlandscapewithitsdiverseeldoperatorsmakesitchallengingtocreatecommon
elements,includinge-services.Incomparison,thehealthcaresystemintheUSAiscriticisedforitslackofequality;
however, e-services in that country are working well. To a large extent, this is because insurance companies also
covermedical care, forming a kind of integrative operator’spositionwith the apparent system optimisation and
efciencypossibilities asan outcome.Thiskindoforganisational restructuringmay notbeeasy toapply,but the
digital health paradigm change towards an ecosystem way of operation creates a platform for change. It enables
increasedcollaboration,coordinationandbetterunderstandingofresourceows(nance,material,informationetc.)
between different stakeholders involved in the delivery of digital health services. In addition, the paradigm change
does not concern only healthcare providers but also patients/users, user communities, technology providers, payers,
regulators and policymakers.

30
Various stakeholders can form an ecosystem that brings together all the necessary parties to create an environment
whichis favourable to the provision of efcient digital health services. In Europe, severalnationaldigital health
ecosystemshave beenestablished,including intheUK, DenmarkandFinland. Thesepioneeringeffortsarestill
like‘test beds’ratherthannationaldeployments,but theydemonstrate thestrategicvisionandleadership bythe
local government, co-evolution of the value network for digital health as well as technological capabilities deployed
in a real-life environment.
Social and Health IT Innovation Landscape in Estonia
About 1.34 million people live in Estonia, which makes it the smallest of the three Baltic countries formerly belonging
totheSovietUnion(Doupietal.,2010).Approximately17%ofthepopulationareyoungerthan14years,and16%
are 65 and older. Life expectancy at birth is about 71. Cardiovascular diseases are the main cause of death. Infant
mortality is steadily declining.More than 70% of the population use the Internet (ProeHealth, 2012).
Estonia is a unitary and sovereign democratic republic. Its central government consists of 11 ministries and various
centralofces.Alllocalissues aremanagedandresolved autonomously bythelocal authorities, whichhavean
independent budget. State tasks may be imposed on local authorities only pursuant to law or under an agreement
withthem. Estonia isademocratic parliamentaryrepublicand hasbelongedto the NorthAtlanticTreatyOrgani-
sation(NATO)andtheEuropean Union(EU)since2004.Since regainingindependencein1991,the politicalen-
vironment has been stable enough to implement various economic and social sector reforms (Doupi et al., 2010).
There have been two signicant health system changes since Estonia gained its independence. The rst was
shifting to a decentralised model from a centralised system. The second was replacing the state healthcare budget
andnancingmodelwith social insurance contributions. Family practitioners are the core of the health service.
The whole system is under the umbrella of the Ministry of Social Affairs, which can be considered as a main policy
developer in healthcare. The Estonian Health Insurance Fund is the main funding agency. The Estonian e-Health
Foundation (EeHF) was established in 2005 and has led the eHealth initiatives in the country (ProeHealth, 2012).
The current Estonian healthcare system is built around countrywide primary care relying on family medicine. The
primary care is supported by ambulant services available all over Estonia. Specialised care has increasingly been
providedinoutpatientsettings.Thecareinvolvinghightechnologyhasbeencentralisedtofewerinstitutions.Over
theyears,availabilityofandaccesstopharmaceuticalshasincreasedsignicantly(Doupietal.,2010).
Estonia’shealthcaresystem hastransformed alotduringthepasttwentyyearsandchangescontinue.Technical
concerns relate especially to the development of the Health Information Exchange (HIE) platform (ProeHealth,
2012). In terms of proving health services, more emphasis will be put on quality of care, which is visible in different
initiatives. The coordination of and approach to tackling chronic conditions create a continuous concern. There are
also several other topics in need of further attention, most noticeably patient empowerment, self-care, development
of further home care as well as long-term care services (Doupi et al., 2010).
E-health development path
Estonian health system reforms can be roughly divided into four development phases: the early 1990s, the mid-1990s,
thelate1990s/early21stcentury,andthedevelopmentsincethen.Thersttwoperiodsintroducedaradicalnew
direction for the health system and laid the foundation for the organisational structure – including basic regulation
onhealthnancingandserviceprovision.
The reforms were conducted within a short preparation time and implementation deadlines. Reforms were not
plannedindetail,leavingconsiderablespaceforne-tuningandregionalinnovation.However,duetothesmallsize
of the country, this did not result in unmanageable chaos – rather, it contributed to case studies from which to learn
in preparation for developing uniform national procedures from 1994 onwards.
The third phase was focused more on incremental development, aiming to clarify and strengthen the regulatory
framework, setting the strategic objectives, clarifying the functions and responsibilities of various stakeholders and
exploring different ways of working. Generally, the reforms were planned in greater detail at this point. After that,
systemefciencyandtransparencyissuesstartedtogainincreasingattention.Thisculminatedintheearly2000s
whenlegislationwasupdatedintermsof,forexample,healthnancing,serviceprovisionandpharmaceuticals.

31
The last phase was characterised by multi-perceptiveness or individual knowledge views pertaining to the activity
model. Further development concerned issues such as access to healthcare, responsiveness, quality and accountability
(Doupi et al., 2010).
The Estonian Electronic Health Record (EHR) offers a positive example of a systematised collection of electronically-
stored health information about an individual patient or a population (Gunter & Terry, 2005). First an open procedure
for the procurement of Health Information Exchange (HIE) infrastructure was established. Compliance with the
standardssetbytheEstoniane-HealthFoundation(EeHF)wasthemainspecicationfortheprocurement.Aspart
of the development of the National Health Information System (HIS), the EHR was introduced in 2008 (see Figure
13). Between 2008 and 2010, the EeHF delivered the basic infrastructure. From 2011, infrastructure services were
purchasedfromaprivateserviceprovider. One ofthekeyfunctionalitiesoftheEHRis that it gives doctors the
possibilityto see adenedselectionof a patient’shealth information. Italsoprovides time criticalinformationto
ambulance services (ProeHealth, 2012).
Planning
initiated
Project
preparation
(2003–2005)
X-roadrst
service
Electronic
healthrecord
Digital
images
Digital
prescription
Digital
registration
NationalHIS
18.12.2008
eHealth
Foundation
established
eHealth
Projects
(2006–2008)
ePrescription
01.01.2010
2000 2004 2006 2008 2010
2002
FundingdecisionbyMinistryof
EconomicAffairs
Figure13.BuildingEstonianHealthInformationSystem(Novek,2015)
System view on provision of healthcare services
eGovernmentinEstoniawasinitiatedbydevelopingafunctionalarchitecturethatincludedX-Roadforsecuredata
transport, distributed information systems functionality and different hardware and software components like portals,
elementsofpublickeyinfrastructure,governmentaldatabasesandinformationsystems.TheX-Roadprojectwas
originally initiated for interconnecting Estonian governmental databases to enable common data resource accessibility
overtheInternet.Afterprovensuccessfulindataenquiries,theX-Roadenvironmentwasexpandedforsharingall
kindsofXMLdocuments.Atthesametime,X-RoadstartedtobecomeaskeletonofalleGovernmentservices(see
Figure14)(Kalja,2006).X-Roaddoesnotdependonthetransitionofalldatabasestosomelargerdatamanagement
system,butinthecreationofunieduserinterfacesfordifferentdatabases.Citizensandinstitutionscanjoinanduse
theX-Roadfreeofcharge.IdenticationofthepersonisbasedonthecompulsoryID-cardissuedbythestate.The
ID-cardisusedbothforidenticationoftheuserandfordigitalsigningofdocuments(Doupietal.,2010).X-Road
providese-Servicestocitizens,tocivilservantsandtoentrepreneurs(EstonianInformationSystem’sAuthority,2013).

32
Population
Register
Health
Insurance
Register
Vehicle
Register
Document
record
management
systems
Documents
repository Energy
X-GIS
Administrative
systemof
thestate
information
system
https://riha.
eesti.ee
ID-card&
MobileID
Telecom Banks
Central
serverI
HelpDesk
Central
monitoring
X-road
certicationcentre
Central
serverII
Publicsector Privatesector
Userinterfaces X-RoadCentre CerticationCentre
Adapter
server
Security
server
Security
server
Security
server
KIT
Citizen
view
EIT
Enterpriser
view
AIT
Public
servant
view
Security
server
Security
server
Security
server
Security
server
Security
server
Security
server
Security
server
Security
server
Adapter
server
E-institution–institutionview
E-country–countryview
GovernmentalPortal–YourEstonia
Stateportalwww.eesti.ee
Adapter
server
Adapter
server
Adapter
server
Adapter
server
Adapter
server
Adapter
server
Adapter
server
Adapter
server
InternetX-ROAD
Figure14.InfrastructureforeGovernmentservices(Novek,2015)
TheHIEplatformutilisesexistingstateinfrastructuresuchaselectronicIDcardsandX-Roadsecurityandcommunications
(seeFigure15).TheHealthInformationAct2008speciedthecontentofinformationstoredcentrally.Legalregulations
specify the security requirement for the EHR and its access. All healthcare providers must send agreed data to the EHR
(ProeHealth, 2012). The system also compiles data for national statistics, so the relevant ministry can measure health
trends, track epidemics and make sure that its health resources are being spent wisely. Patients have access to their
own records, as well as those of their children. By logging into the Patient Portal with an electronic ID card, patients
canreviewtheirpastdoctorvisitsandcurrentprescriptions,controlwhichdoctorshaveaccesstotheirles,andeven
receive general health advice (E-Estonia.com, 2015).

33
STATEAGENCYOFMEDICINES
-CodingCentre
-Handlersofmedicines
PATIENT
PORTAL
2009
2013v2
DOCTOR
PORTAL
2013
X-ROADGATEWAY
SERVICE2009
PHARMACIESAND
FAMILYDOCTORS
SOCIAL
INSURANCE
BOARD
PORTAL
2012
X-ROADGATEWAY
FOREMERGENCY
SERVICES2014
EMERGENCY
SERVICEMOBILE
WORKSTATITIONS
HOSPITALS
2009
HEALTHCAREBOARD
-Healthcareproviders
-Healthprofessionals
-Dispensingchemists
FAMILYDOCTORS#
2009
POPULATIONREGISTER
PHARMACIES
2010January
PRESCRIPTIONCENTRE
2010January
NATION-WIDEHEALTH
INFORMATIONSYSTEM
2008December
X-Road,ID-card,StateISServiceRegister
BUSINESSREGISTER
SCHOOLNURSES
2010September
HEALTHINSURANCE
FUNDREGISTER
ANONYMIZED
HEALTH
DATAFOR
STATISTICS2013
STATISTICS
PORTAL
2013
Figure15.EstonianeHealtharchitecture(Novek,2015)
Primary contribution and lessons learnt
Within just 20 years, Estonia has renewed its information governance from multiple information systems (covering
both paper-based documentation and some early e-architectures) to integrated system-level architecture serving
society both vertically and horizontally. In a way, Estonia can be observed as a case study that may provide learning
onwhatcanbeperformedwithinashortperiodoftime.Oneshouldkeepinmindthatreformationofthiskindisa
unique result of multiple simultaneous factors comprising historical issues, technological restrictions and possibilities,
motivationsofeldactors,governance’sfundingstatus,andtheappointmentofcapablepeopleinfavourablepositions,
etc. Consequently, the primary contribution may more likely be in achieving understanding of system and change
dynamics,ratherthantoconsideritasacaseofanidealisticsector’srenewal.
Morebroadly,regulationsandstandardisationhavebeendeningthedirectionoftheEstonianITreformationprocess.
In particular, these guiding actions have been creating stability for change. Looking at the Estonian history, one
shouldnotunderestimatethesignicanceofactors’willingnesstocommittoaprocess.Inevitably,therehasbeen
strong motivation away from old socialistic ways of operations and governance. Estonia has also been successful
inacquiringinternationalnancingfrombothEUandotherinternationalfunders.Ithasbeenconsideredasanew
developing economy with great potential and evidence of successful implementations.
In Finland there has been a lot of public critique towards the price of social and health IT systems change. Quite
oftenthisdiscussionincludescomparisonswiththeEstoniansystemreformationconductedwithsignicantlyless
money. Clearly, there have been many challenges related to the speed of the Finnish political decision-making
processandndingconsensusonappropriatetechnicalsolutionstoapply,amongotherissues.However,processes
and systems should not be compared directly. Where Estonia has been able to start with a rather clean slate and
benettedfromsomethingthatcouldbecalledthe‘economyofsimplicity’,theFinnishsystemdevelopmentstruggled
with a situation where system providers and a large number of different sub-systems have not changed or adapted
in the way they integrate.

34
TOWARDS SOUTH AFRICAN DIGITAL HEALTH
INNOVATION ECOSYSTEM
To conceptualise the Digital Health Innovation Ecosystem for South Africa it was important to understand the
literature on the existing situation of health in South Africa as well as to investigate some case studies which explain
the way in which digital health was applied or used to demonstrate how it can support the health system of this
country. This all forms part of Phase 1 of the Design Science Research Methodology (DSRM) process but also
involvessomeaspectsofPhase3aswillbeseenlaterinthissection.AllthisisnecessarytogettothenalDigital
Health Innovation Ecosystem. Figure 16 features Phase 1 of the conceptualisation of the Digital Health Innovation
Ecosystem for South Africa.
Communicate
results
ofPhase1
Communication
Communication
Evaluation
Evaluation
Demonstration
Demonstration
Initial
conceptualisation
fromliterature
Initial
conceptualisation
withfuture
locallyrelevant
healthand
wellness
innovations
horisons
Phase1a:LiteratureoverviewofDigitalHealthSystems
Figure16.ProcessviewforconceptualisationoftheDigitalHealthInnovationEcosystem
Statistics South Africa (2014), in its mid-year 2014 report, estimates that South Africa has a population of 54 million,
with a life expectancy of 59.1 years for males and 63.1 for females. These realities fall short of the MDG target of 70
(UNDOEconomic,2008).StatisticsSouthAfricareportsaninfantmortalityrateof34.4per1000livebirths(2014),
wellabovetheMDGtargetof18(UNDOEconomics,2008).
Healthcarein SouthAfricais divided betweenthepublic and privatesectors,and there aresignicantinequities
evident between the two systems. According to the National Health Insurance Green Paper (NDoH, 2011), almost half
of the national expenditure is in the private sector, which only covers 16.2% of the population, while the remainder
of the population is served by the under-resourced public health sector. Stucler et al. (2011) state that, in South
Africa, the provinces with the least economic resources and the largest populations receive the smallest share of
national public healthcare funds.
This inequity in the health system is seen as a major inhibitor slowing progress towards universal health coverage
in South Africa (Marten et al., 2014). As a result of this inequity, and despite high national expenditure on health
(8.5%ofGDPin2011againstaWorldHealthOrganizationrecommendationof5%),healthoutcomesinSouthAfrica
remainspoorincomparisontoothermiddleincomecountries(NDoH,2011;Albertsetal.,2015).Obstaclesinprimary
healthcareaswellasintheuseifICTinhealthinSouthAfrica(Ouma,2013),includethefollowing:
i. Shortage of healthcare workers and inequality of resource distribution.
ii. Wrong drug suppliers.
iii. Useoffaultyequipment.
iv. Shortcoming of leadership in the public health sector.
v. HIV and AIDS pandemic.
Phase1b:ForesightingtoidentifyrelevantfutureHealthandWellness
Innovationsandroadmappingtowardsfuturehorizons
Initial
conceptualised
DigitalHealth
Innovation
Ecosystem

35
vi. Reliable network connectivity.
vii. ICT infrastructure. Cost of acquisition and maintenance of ICT infrastructure and hiring of ICT technical staff.
viii. Concernsregardingcondentialityofhealthcarerecords.
ix. Automation or integration of systems requiring technical expertise.
x. Interoperability and standards of healthcare systems.
xi. Providingabudgetfore-healthsolutions(nancialandeconomicsustainability).
xii. Stakeholder engagement does not take place through establishing provincial health information systems
committees.
xiii. The type of evaluations that are done on e-health.
xiv. The lack of policies with implementation guidelines.
The key challenges that have been noticed in implementing the district health information systems include (English
et al., 2011):
•
Getting the right human resources skills to troubleshoot and maintain the health information systems in addition to
experts who can act as developers and managers who can create, link and extract integrated data from various
sources of the information systems; and
• Lack of control on the versions of the health information systems used within the provinces.
Despiteitspotentialbenets,theadoptionofe-healthhasbeenveryslow.Someofthechallengestotheadoption
of e-health can be related to the development of integrated HISs and include high costs of acquisition; lack of ICT
skills,especiallyindevelopingcountries;andconcernsforthesecurityandcondentialityofelectronichealthcare
information (Anderson, 2007; Karisa et al., 2014; Meingast et al., 2006).
To address these challenges in the delivery of health outcomes, the South African health system is being reformed to
have a greater focus on primary healthcare and preventative care through the use of community outreach programmes,
andsupportedbyanationalhealthinsurance(NDoH,2011).Thestrategyistobringhealthcareclosertopatients’
homes through the use of dedicated teams, including (Alberts, et al., 2015):
• An integrated, district-based team of clinical specialists, initially including an obstetrician and gynaecologist, a
paediatrician, a family physician, an anaesthetist, a midwife and a professional nurse;
• School-based primary care and health promotion services (e.g. immunisation, physical and mental health and
well-being, family planning, etc.), delivered by teams led by professional nurses; and
•
Municipal ward-based primary healthcare workers who work with allocated households to identify health problems
and to promote active involvement in good health practice by communities.
Stakeholders involved in the National Health System of Innovation in South Africa
The following table is a summary of all the current stakeholders involved in the National System of Innovation (NSI)
for health in South Africa (Table 3).
Table3.StakeholdersintheNSIforhealth
Stakeholder Role
National Department of Health Per National Health Act:
“74. (1) The national department must facilitate and
co-ordinate the establishment, implementation and
maintenance by provincial departments, district health
councils, municipalities and the private health sector of
health information systems at nation & provincial and local
levels in order to create a comprehensive national health
information system.”
Provincial and District Departments of Health Responsible for procurement, implementation and support
of health information systems.

36
Stakeholder Role
National Health Information Systems of South Africa
Committee
Committee of health IT staff across all levels of the DoH
Local Government Implementation(workingwithdistricthealthofce)
Health Information Systems Programme Responsible for development and deployment of the
District Health Information System (DHIS)
Health Systems Trust Performs health research and responsible for
rationalisation of health registers (data collection
guidelines)
Medical Research Council Currently focused on research to address burden of
disease; may fund some eHealth related work
Health Professionals Council of South Africa Regulates health professionals
SITA Hosting of public sector infrastructure and data; Public
sector ICT procurement
Strategic Health Innovation Programme DST vehicle for funding of strategic health innovation
Universities Various aspects of research into eHealth; Also source of
staff
Jembi Health information systems integration and standards
mHealth solution providers Mobile data collection and health services (cell phones,
digital pens, portable diagnostic devices)
Commercial Integration vendors Provide IT integration services and tools
CSIR Implementation and development body tasked by the
Department of Health to develop interoperability standards,
Hospital registration system with a patient registration
system as well as a future clinic. The CSIR collaborates
with all the above stakeholders to achieve these goals.
The Health Landscape of South Africa
In South Africa there are nine provinces and each province is divided into several districts and each district is divided
intosub-districts.Thefollowinggureexplainstheoutlineofhowdataaretransferredfromthecommunity(wherea
community health worker captures the data) to the provincial hospital. In this way primary data can rather be regarded
assecondarydata(Wright&Odama,2012).Thedataareusedtocalculatethevalueofauthority,administrationas
wellasmedicalandcarefunctionsforpatients(Wright&Odama,2012).
Inthisgure,theNationalDevelopmentPlan(2012)hasoutlinedthehealthlandscapeandchallengesintheSouth
African healthcare system. It also explains the different levels evident in the public health sector, the role of each of
the primary health centres, the community worker and the home-based care that falls under the revitalised primary
care (Chetty, 2013).

37
HealthLandscapeandChallenges:TheHealthcareSystem
(for National Planning Commission National Development Plan Vision 2030)
Quaternary/CentralHospital
RegionalTertiaryHospital
SecondDistrictHospital
NationalHealthLabService
PHC–PrimaryHealthCare
CHW–CommunityHealthWorker
HBC–HomeBasedCare
PHCTeam
PHCCentre/Clinic
CHW/HBC
PublicHealthSector
ModernisedtertiarycareRevitalisedprimarycare
Evidence suggests multiple system failure across
a range of programmes, including maternal and
child health, HIV/AIDS, tuberculosis and others,
with a devastating combined impact. At the
hearth of this failure is the inability to get primary
health care and district health system to function
effectively. (NPC National Development Plan)
Primaryhealthcaretobeconsolidatedasthe
primarymodeofhealthcaredelivery
(Minister Motsoaledi, Health Budget Vote Policy
Speech, 2011)
Figure17.NationalDevelopmentPlanoutliningthehealthlandscapeandchallenges
These challenges have resulted in the drive to re-engineer the primary healthcare in South Africa and the following
gureprovidesthedetailoftheDepartmentofHealth’sprioritiesregardingprimaryhealthcare(Chetty,2013):
Re-engineeringprimaryhealthcareinSouthAfrica
NationalDOH
Policy, Strategy & Budgetary Allocation
NHLS
Pathology & Diagnostic Services
ProvincialDOH
Implementation & Service Delivery
ServiceProviders
Quaternary
Hospital
Regional
Hospital
District
Hospital
Clinic
Population
PrimaryHealthcareSpace
Cascading resources down to primary healthcare
Community focused preventative healthcare
DoHprioritiesforre-engineering
primaryhealthcare
Quality and accessibility of infrastructure
Health information systems and
processes
Human resources for health
Quality of healthcare service delivery
Access and equity
Community focused healthcare
Figure18.Re-engineeringprimaryhealthcare

38
Even though the use of ICTs in the healthcare domain has evolved from supporting patient administration and billing
processes in the mid-1960s to HISs which can support collection, storage and transmission of clinical records,
including discharge summaries, referral notes, laboratory test results and radiology images (Wager et al., 2009),
theinvestmentsintothepublichealthsectors’ICTandHIShavenotmaterialisedintheexpectedhighinvestment
returns. ICT and HIS within the public health system have not, up to now, adequately supported business processes,
resulting in the inability to effectively monitor and evaluate the performance of the South African national health
system(Geldenhuys&Botha,2015).Oneoftheidentiedproblemsisthelackoftechnologypolicyframeworksand
regulations to support ICT procurement and management processes (Kirigia et al., 2005; South African National
Department of Health, 2010).
There are also currently several application areas of e-health. Some of these are EHR systems, electronic medical
record systems, clinical decision support systems, electronic prescribing, mobile health and telemedicine (Adebesin,
2014).The adoption ofe-healthoffers severalbenets,includingimproved patientsafety,moreaccurateclinical
data, better legibility of healthcare documents and a reduction in overall costs of healthcare services (Cohen et al.,
2013;Wageretal.,2009;WHOandITU,2012).
Therefore, the NDoH (2011) has embarked on several initiatives to address the aforementioned challenges. These
initiatives include for example, the Integrated Health Programme for the Primary Healthcare (PHC) facility. This
comprises the installation of hardware, connectivity, deployment of the Health Patient Registration System (HPRS)
andDHIS,rationalisationofregistersinPHCsandtheintegrationofidentiedeHealthapplicationstotheHIE.The
CSIR has been tasked by the NDoH to address these initiatives.
Fragmentation of Systems
As part of the mandate of the CSIR to support the NDoH to address the challenges and priorities in Figure 18, it
wassoonrealisedthatHISsarenotcapableofexchangingpatients’healthcareinformationasandwhenrequired.
Fragmentation and the inability of HISs to share and exchange the relevant patient healthcare information make
itdifculttocoordinatehealthcareservices.The fragmentation of HISs is largely due to silo implementations in
South African hospitals (from district to provincial) which have hampered the investment into HISs with low returns.
Healthcare providers and facilities typically implement their own proprietary-based HISs, many of which are incapable
ofexchanginginformationwiththesystemsimplementedbyotherprovidersorfacilities(ITU,2012a).
Fragmentation in the HISs currently being used in South African public health facilities was evident during a 2013
assessment of HISs (NDoH and CSIR, 2014). The study, conducted by the CSIR on behalf of the NDoH showed
that different systems from different vendors were implemented across the country. The study also revealed that
31% of the 42 systems were unable to exchange patient information (Adebesin, 2014).
The problem of fragmentation has been exacerbated by a lack of coordination of HISs implementations, especially
at national level. In many instances, the implementation of HISs is driven by donor-funded vertical programmes that
focusonspecice-healthinitiatives,suchasthemonitoringandevaluationofHIV/AIDSprogrammes.Thesemaynot
necessarilytwellwithacountry’soverallnationale-healthinitiatives.AcomparativeanalysisonICTusetosupport
healthcare in African countries revealed that many of the implementations are pilot projects, which made scale-ups
difcult(Pankomera &VanGreunen, 2014;Spies&Muwanguzi,2014). Manyof theprojectsinvolvedtheuse of
mobile phones by healthcare workers to retrieve basic healthcare information for patients and the dissemination of
educational health information to patients using text messages (Spies & Muwanguzi, 2014).
Thus a major ICT problem in the health system in South Africa is fragmentation of health information systems
andthe lackofinteroperability.Thiswas conrmedinthe SouthAfricaeHealthStrategy,2012-2106byDrAaron
Motsoaledi, Minister of Health. Therefore, the South African NDoH has approved the implementation of its National
Health Normative Standards Framework for Interoperability in eHealth (HNSF) in a Government Notice signed by the
Minister of Health in April 2014 (Motsoaledi, 2014). The HNSF recommends a set of baseline standards to support the
interoperabilityofHISsacrossthecountry’spublichealthcarefacilitiestoensureaseamless,secureandtrustworthy
integration and exchange of health information/data across devices, systems, components and business processes.
The National eHealth Strategy of the South African Department of Health (2012) outlines a comprehensive and
integrated ICT health system to be implemented by 2017. This eHealth Strategy is a roadmap to guide the public health
sector from the current situation to a more improved health information system (South African National Department

39
ofHealth,2012).TheeHealthStrategyadoptstheWorldHealthOrganizationdenitionforeHealth,thatistheuse
of ICT for health to, for example, treat patients, conduct research, educate the health workforce, track diseases and
monitorpublichealth(WorldHealthOrganisation,2015).
TheeHealthStrategydenes10strategicpriorities:
1. Strategy and leadership.
2. Stakeholder management.
3. Standards and interoperability.
4. Governance and regulation.
5. Investment, affordability and sustainability.
6. Benetsandrealisation.
7. Capacity and workforce.
8. eHealth foundations.
9. Applications and tolls supporting healthcare delivery.
10. Monitoring and evaluation.
The focus of the eHealth Foundations strategic area (no. 8 above) is to build capability for eHealth and all future
eHealthactivities.ThekeyareasoftheeHealthFoundationsstrategicareaasdenedintheeHealthStrategyare
(South African National Department of Health, 2012):
• Infrastructure;
• Connectivity;
• Registration of patients, facilities and providers; and a
• Basic national electronic health record.
eHealth Interoperability
To address the problem of fragmentation and lack of interoperability between eHealth systems, the NDoH requested
the CSIR to conduct a study into applicable standards for eHealth interoperability and to select a set of standards to
be applied in the South African context to support interoperability of healthcare information systems. As a result, the
HNSFwasdevelopedandgazettedin2014.TheHNSFdenedasetofIHE(integratingthehealthcareenterprise)
prolesapplicabletoselectedinteroperabilityproblemsandassociatedbasestandardstobeappliedandadhered
to by health systems in the South African health environment to achieve eHealth interoperability. The HNSF also
includedaproposed structure for a centralisedsharedelectronichealthrecord system. Thisstructuredeneda
number of technical components required to enable interoperability between eHealth systems compliant with the
denedeHealthstandards.Thesecomponentscoverhealthinformationexchange,sharedregisters,sharedclinical
repositories, health analytics, security and auditing services, and third party healthcare applications.
The technical components for a centralised shared electronic health record system which has to comply to eHealth
standards include:
• An HIE enables the electronic exchange of health-related information between disparate healthcare information
systems while preserving the meaning of information being exchanged. The purpose of information exchange is to
facilitate interoperability by providing access to and retrieval of health-related and clinical data to support improved
qualityandcontinuityofpatient-centredcare.TheHIEimplementsthenormsandstandardsasdenedbythe
HNSF through controlling and mediating standard-based messages between compliant consumer applications
and shared registers and repositories.
• Shared registers are used to store, manage and provide access to master demographic and other information of
entities required for interoperability, including patients, healthcare providers, facilities, etc.

40
•
Shared clinical repositories will be used to store and provide controlled access to clinical information of patients related
to healthcare encounters. Shared clinical repositories will provide the ability to construct a longitudinal health record or
medical history over different encounters at different facilities using different standards-compliant eHealth applications.
• The health analytics component provides access to appropriate anonymised or aggregated data for the purpose
of analysis, decision support, business intelligence, surveillance and research. Current implementations in this
area are the DHIS, responsible for the calculation of the National Indicator Data Set; and the National Health
Information Repository and Data Warehouse.
• The security and auditing services component will provide services to ensure the privacy, security and integrity
of information exchanged and stored within the infostructure.
•
Useraccountabilityisprovidedthroughanaudittrail.Theaudittrailneedstoallowasecurityofcerinaninstitutionto
auditactivities,toassesscompliancewithasecuredomain’spolicies,todetectinstancesofnon-compliantbehaviour,
andtofacilitatedetectionofimpropercreation,access,modicationanddeletionofprotectedhealthinformation.
• Any third-party healthcare application to be integrated through the HIE for the purposes of interoperability is
requiredtobecomplianttothestandardsasdenedbytheHNSF.Third-partyapplicationswillinteractthrough
the infostructure via standards-based messages orchestrated by the HIE.
The Patient Registration System
Toaddresstheabovestrategicehealthpriorityno8andspecicallytheregistration of patients asidentiedinthe
eHealth Foundations strategic priority area of the NDoH (2012), the CSIR embarked on developing an electronic
HPRS towards a national HPRS for South Africa.
Implementing an electronic system for the registration of patients at healthcare facilities across South Africa will not be
completed without challenges and obstacles. Most South African healthcare facilities do not have adequate infrastructure
and Internet-connectivity (Geldenhuys & Botha, 2015). Adequate infrastructure and Internet connectivity is considered an
important objective in delivering on the eHealth strategy. These lie within the mandate of the Infrastructure and Connectivity
key initiatives of the eHealth Foundations strategic area. This mandate extends to include the procurement and installation
of adequate infrastructure at health facilities (e.g. computers, printers, uninterrupted power supplies as well network
infrastructure equipment) and the implementation of the Internet (South African National Department of Health, 2012).
In many cases health facilities are located in rural areas in South Africa which are far from cities and when facilities
dorequiretheexpertiseoftechniciansto xInternet-relatedproblemsonsite,itcouldtakedaysto resolvethese.
In addition, depending on the contract agreement with the service provider, data bundle limitations (e.g. 1GB per
facility per month) could also cause problems for any electronic system dependent and requiring access to a central
server via the Internet (Geldenhuys & Botha, 2015).
Within the South African context, the design and implementation of any patient registration system ought to also
consider the following policies and regulations affecting eHealth as outlined in the eHealth Strategy (2012) as well
as relevant industry standards. The relevant policies, regulations and industry standards implications and detail
discussions are beyond the scope of this paper, but are listed here for further reference (South African National
Department of Health, 2012):
• State Information Technology Agency Act 88 of 1998;
• The Minimum Information Interoperability Standards;
• Promotion of Access to Information Act, Act 2 of 2000;
• The Minimum Information Security Standard;
• The National Archives and Record Service of South Africa Act, Act 43 of 1996;
• ThePolicyofFreeandOpenSourceSoftwareUseforSouthAfricanGovernment;and
• The National Health Normative Standards Framework for Interoperability in eHealth in South Africa.
The requirements and conceptualising of a proposed electronic HPRS towards a national HPRS for South Africa
was initiated during joint application design sessions where the project team was formed and which included
members of the CSIR, NDoH, Statistics South Africa, and the National Department of Home Affairs. Daily operations

41
and business processes at clinics were discussed and included in the requirements for a proposed health patient
registrationsystem.Theresultingrequirementswereconrmedandrenedthroughasitevisittotwopurposefully
chosenclinicsinGautengandtheEasternCape.Therenementextendedtoincludeadministrativeprocessesas
well as the information required from patients upon visiting facilities (Geldenhuys & Botha, 2015).
The design of the patient registration system architecture considered six main technological and business areas that
would result in an effective solution (Geldenhuys & Botha, 2015):
• Possible intermittent and/or slow Internet responses at clinics;
• Promptly available aggregated patient information to provincial and national management;
• Minimal cost to maintain system version at clinics;
• Implementation of open source technologies as far as possible to minimise licensing cost;
• The patient registration system must be able to respond instantaneously to requests from approximately 10 000
users from over 4 000 clinics across South Africa; and
• Security and privacy requirements.
The patient registration system architecture consists of multi-tiered client-server architecture – (i) client tier, (ii)
presentation tier, (iii) business tier, and (iv) data tier (Van Zyl, 2015). Figure 20 outlines the physical implementation
model for the patient registration system solution (Geldenhuys & Botha, 2015).
Figure19.Patientregistrationsystem
HANIS
National,
district,
sub-district
ofce
Health
facility
HTTPS
HTTPS
HTTPS
HTTPS
HTTPS
SSL
HTTPS
HTTPS
Web application server
Internet
Desktop
HPRS
web
app
Data
sync
server
Database server
Central
hosting
provider
Thirdpartyapp
Centralserver
Data sync
client
Database
Virtual machine
HPRS web
application
Designated
server machine
HTTPS

42
Geldenhuys and Botha (2015) indicate that the patient registration system consists of the following main implementation
environments:
• Central server;
• Health facility implementation;
• National,districtandsub-districtmanagementofces;
• HomeAffairsNationalIdenticationSystem(HANIS);and
• Third-party application.
Each of these will now be explained:
Central server environment
The central server environment is the core component of the patient registration system and consists of the web
application server and the database server. The web application server contains the web application and the data
synchronisation server. The web application is responsible for responding to HTTPS requests from external sources,
forexamplearequestfromaclerkataclinictosearchforapatient’sdemographicinformation.Thesynchronisation
server listens for incoming requests from synchronisation clients residing at health facilities. Synchronisation requests
are requests from health facilities to synchronise data with the central server. These requests are communicated to
the central database server. The database server consists of a relational database using open source PostgreSQL
version 9.3 and is responsible for centrally storing patient demographic information for health facilities across South
Africa. It is also responsible for handling requests from the web application server via secure protocols.
Health facility implementation
The health facility implementation environment includes (i) desktop computers, (ii) facility LAN router, and (iii) the
designated server machine at health facilities. Desktop computers are any Windows-compatible computer at the health
facility that is connected to the local network via the facility router. The patient registration system is mainly accessed
from desktop computers located in the reception areas of health facilities. In addition, desktop computers in the reception
areasofpilothealthfacilitieshaveabarcodeordriver’slicencescanneraswellasangerprintreaderconnected.
Thebarcodescannersassistclerks toscanthebarcodeonapatient’sidenticationdocumentation.Alternatively,
ifpatientsprovidetheirSouthAfricandriver’slicencecard,theclerkusesthedriver’slicencescannertoscan the
PDF417codecontainingthepatient’sidenticationnumber.The ngerprintreaderisusedtoscanthepatient’s
ngerprintandisdisplayedonthepatientregistrationsystemuponasuccessfulscan.Thepatient’sngerprintimage
andSouthAfricanidenticationnumberwillbesenttotheSouthAfricanHANISforidentityverication.TheHANIS
environment is discussed in more detail in one of the following sections.
The facility router is the gateway to designated server machines and the Internet for health facility computers. Thus,
if the facility router is unavailable or faulty, computers in the facility would be unable to access the patient registration
system on the designated server machine. The facility designated server machine actsasthe‘local’serverhosting
a virtual machine consisting of the patient registration system web application, database, and a data sync client.
Desktop computers in health facilities are set up to access the patient registration system on the virtual machine
residing on the designated server machine. The main advantage of accessing the patient registration system locally
via the virtual machine is that this architecture approach limits the dependency on slow and intermittent Internet
access. Thus, patients would spend less time waiting for clerks to retrieve their patient information from the patient
registration system. The data sync client is responsible for checking if a good Internet connection is available and
initiating a data synchronisation request with the central server. Alternatively, data synchronisation requests are also
automaticallyinitiatedbythecentralserveratpredenedperiodsduringtheday.

43
Department of Health ofces
Authorisedusersatnational,districtandsub-districthealthofcesarepermittedtoaccessthepatientregistration
systemreportsaswellastoviewinrealtimethenumberofpatientsvisitingclinicsacrossSouthAfrica.Usersonly
have access to facilities where they are assigned. Thus, districts are not permitted to view reports for another district
or view real-time patient visiting totals.
Usingsupportedbrowsers(e.g.ChromeandInternetExplorer),usersatDepartmentofHealthofcesmayaccessthe
patient registration system on the central server after a successful authentication. Access for users at national, district and
sub-districthealthofcesispermitteddirectlyviatheInternetwithouttheuseofarouter,asisrequiredbyhealthfacilities.
HANIS
TheSouthAfricanHomeAffairsNational Identication Systemisrequested by thepatientregistration system to
verifytheidentityofpatientsvisitinghealthfacilities.Theidentityofpatientsisveriedusingthepatient’sidentication
numberandanimageofthepatient’sngerprintasminimumcriteria.Therefore,ifapatientdoesnotprovideproof
ofidentication(e.g.RSAidentitydocument,driver’slicencecard) theidentity maynot beveried viathe HANIS
system.Visitsbypatientswheretheidentitycouldnotbeveried,aremarkedas‘unveried’patientvisits,alternatively,
wheretheidentitycanbeveried,thevisitsaremarkedas‘veried’patientvisitsbythepatientregistrationsystem.
Third party application
The third party application environment refers to any external system requiring access to the national patient register.
For example, health facilities that have existing healthcare information systems to manage patient demographic
information and record patient visits would access the national patient register directly via an application programming
interface (API) hosted on the central server. Future work will include iterations of implementation, evaluation, design
and development towards enabling a long and healthy life for all South Africans (South African NDoH, 2012).
Case study: MomConnect
MomConnect is an NDoH initiative to use cellphone SMS technology to register every pregnant woman in South Africa.
Once registered, the system will send each mother pregnancy stage-based messages to support her and her baby
during the course of her pregnancy, childbirth and up to the child’s rst birthday (see Figure 20). The system will also be
used to provide feedback (rating, compliments and complaints) about public health services to a central communication
centre. MomConnect aims to strengthen demand and accountability of maternal and child health services to improve
access, coverage and quality of care for mothers and their children in the community. (MomConnect, 2015)
Figure20.MomConnectininteractionwithmothers(NationalDepartmentofHealth,2014a)

44
MomConnect is an inclusive, mobile health service for pregnant women that was launched nationally in August 2014.
MomConnect was established relying on local experiences achieved in the MAMA project. Through this project, a
free SMS program was offered through six inner-city clinics in Johannesburg. MomConnect began as a Praekelt
Foundation,UNICEFandDepartmentofHealthprojectin2012inKwazulu-Natal(theprovincewiththehighestHIV-
prevalence in South Africa) (MAMA, 2015). Targeted at all South African pregnant women and mothers of children
not yet a year old, it provides stage-based advice and information on pregnancy. There are approximately 1.2 million
women who fall pregnant every year in South Africa – one million of them are using public sector services and 200
000theprivatesectorservices(SANGONeT,2014).MomConnectisSouthAfrica’srstnationallevelm-healthproject.
It provides data collection tools, supports clinical care, and builds the national pregnancy registry, both at individual
level and at aggregate district level, to feed into the District Health Information System (Waldman & Stevens, 2015).
MomConnect removes the need for multiple registration of pregnant women on various systems (see Figure 21) and
it alleviates the need for clinic sisters to assist pregnant women to register on MomConnect on their mobile phones
(which is proving to be a tedious process, given the wide range of these phones).
Community health worker (CHW)
identify potential pregnancy during a
household visit
- CHW completes the pregnancy
related questions for the woman
on the household assessment
application (e.g. Mezzanine)
- CHW advises the woman to go to
the clinic
Responsible doctor views results
ofUmbiowtestsusingthe
Cellnostics system
Decision makers, managers
and researchers view reports
and analyse data regarding
pregnancy and ante-natal follow-
ups (using data warehouse over
an integrated dataset)
Woman with potential
pregnancy visit the clinic (1st
visit and follow-up visits)
Clinicadministratornds
patient on the national patient
register (HRPS)
- If not found, registers the
patient on the national
patient register (HPRS)
Ifthisisarstvisit
- Clinic nurse performs pregnancy test
-Ifpregnancyisconrmedclinicnurseregistersthe
patientonMomConnect(registrationissimplied
through integration with HPRS)
-Ifconrmedpregnancyandgestationalage>24
weeksclinicnurseperformsUmbiowtest
ClinicnurserecordsUmbiowtestoutcomeon
UmbiowUI(dataintegratedHIEviaCellnostic
back-end)
IfaproblemisdetectedthroughtheUmbiowtest,
patient is referred to the hospital
If no problem detected, patient is advised to come
for a follow-up visit
If a problem is detected
throughtheUmbiow
test, patient is referred
to the hospital
Umbiow
Figure21.Supportingmaternalhealth
The aim of MomConnect is to encourage pregnant women to start antenatal care early and simultaneously, to enable
testing for hypertension, HIV/AIDS and diabetes very early in the pregnancy. The service enables healthcare workers to
plugintopatients’historybylinkingtheexistingmedicalregistrytoanelectronicdatabasethatcanbeaccessedfromall
MomConnect clinics (Bateman, 2014). At the same time, the NDoH is creating a national pregnancy registry. The central
database is to provide mothers with valuable services that will improve maternal health indicators and provide better
statistical data with which to inform governmental decisions around maternal health. MomConnect is not a compulsory
serviceandmothersdon’tnecessarilyhavetogivetheirIDorpassportnumber(NationalDepartmentofHealth,2014b).

45
Figure22.MomConnecttechnicalservicestructure(UNICEF2013)
The system ensures that health workers are informed to follow up when patients miss important appointments. It
updates medical records in real time, ensuring that women can be tracked even if they do not return to the same
facility where they signed up. MomConnect communicates any important messages with regards to a particular woman
tohealthworkers(UNICEF2013).ByusingthemobilemessagingandinformationdeliveryabilitiesoftheMobi4D
platform,earlywarningsignsofnon-communicablediseasescanbeidentiedandaffectedpeople,communityhealth
workers and clinics can be appropriately alerted (see technical service structure in Figure 23).
The Praekelt Foundation is one of the key technology partners in MomConnect. It has worked together with Jembi
Health Systems, provided the project architecture and process ow for the programme. MomConnect contains
threekeyelements:apregnancyregistry,stage-basedmessagingandahelpdeskformothers.TheUSSD-based
registrationsystembeingusedintheMomConnectprojectrunsonPraekeltFoundation’sopensource,cloud-based
platform, Vumi. The platform connects with all four South African mobile operators, ensuring that registered pregnant
women receive stage-based, culturally sensitive SMSs in their language of choice. Help Desk gives users the ability
to rate the service they received at public health facilities in South Africa. It also enables women to send questions,
feedback, or enquiries to search information about pregnancy, HIV, feeding etc. (Praekelt, 2014).
MomConnect’suseoftheVumiplatformmeansthattheprogrammehasthepotentialtoreacheverypregnantmother
inSouthAfrica.WithoutrelyingonsmartphonetechnologyorInternet-enableddevices,USSDisatechnologythat
works on every phone in the country. In addition, the reverse-billing being contributed by the four major mobile service
providers (MTN, Vodacom, Cell C and Telkom Mobile), together with additional funding from Johnson & Johnson,
means that all registered MomConnect users will receive messages via free SMS. Praekelt has also created marketing
andtrainingmaterialfortheprogramme,includingposters,yers,andtheopt-inbooklet(Praekelt,2014).
MomConnect has not been without challenges. The challenges include, for example, the funding partnerships with
phone operators; dynamics and priorities between and within government departments; and the content of the SMS
messages.Concerninggovernmentdynamics,somerespondentsmentionedtheNDoH‘barriersandpersonalities’
asachallenge,demonstratingpartlythatakindof‘siloed’approach exists.It wassuggested thatm-health could
be a mechanism for cross-cutting work and helping to understand broader structures (Waldman & Stevens, 2015).
Related to contents of SMSs, considerable effort was devoted to tailoring text messages that comprise only 160
characters.Achallengewastondanappropriatebalancebetweentechnical,medicaljargonandcolloquiallanguage.
MomConnectalsoafrmswomen’sdependent,domesticandchild-rearingrole.ItoffersMaternalandChildHealth
(MCH) enhancement without addressing critical political issues around rights, about control of fertility and around
women’sroleorpositioninsociety(Waldman&Stevens,2015).ThePraekeltFoundationhasworkedtogetherwith
the Wits Reproductive Health and HIV Institute and BabyCenter, who has helped to create and deliver these twice-

46
weekly-sentmessages.MessaginghasnowalsobeencombinedwiththeNDoH’smessages.MAMASouthAfrica
plays a complementary role to MomConnect with an increased focus on interactive, community platforms, such as
theMAMAmobi site.More than90% ofMAMASouthAfrica’s450000usersengagewiththesechannels, which
allow users to interact with a community of pregnant women and moms of infants (Praekelt, 2014).
Future work of MomConnect will include (1) the deployment and assessment of the mobile health monitoring system
intheeld;and(2)theuseoftheMobi4Dplatformforotherhealth-relatedcommunicationservicessuchasSMS
reminders of appointments at clinics, SMS reminder services for medication adherence and mobile health information
services for health education and awareness (Alberts et al., 2015). Future extensions are also meant to cater for
illiteratemothersbyanintegratedvoiceprogramme.Otherfutureplansincludecoveringall11ofciallanguages(now
onlyEnglish,Afrikaans,Zulu,Xhosa,SothoandSetswanaarecateredfor)(NationalDepartmentofHealth,2014b).
Case study reections
Referring to the wide expansion of the service and large amount of users involved in MomConnect today, it can be
concluded that there has been an apparent need for the service. However, the successful implementation is a result
of many factors. Identifying the user needs and their different characteristics creates one basis. To build up a network
of actors with capabilities and motivations is another key starting point. Funding arrangements and governmental
support in different levels enable the development work more generally.
Piloting on a smaller scale gives an opportunity to test and develop a service in a more manageable context. This
is emphasised in particular when developing a novel service in circumstances where there are no comparable
experiences or when constructing a service in an environment with many unforeseeable factors.
Participatory process design plays a key role in the development of a MomConnect-like service. Involvement covers
manyconstituenciessuchasusers,technologyproviders,healthprofessionals,andexpertsfromvariousotherelds.
Integrationofscientic,medical,socialandlocalknow-howintextmessagingisagoodexampleofsuch;simple-
looking text messages constitute an aggregate outcome enabled by cooperation between various constituencies.
ItisalsousefultolookatsomeserviceattributesandtechnicalspecicationsofMomConnectfromalargerperspective.
Toll-free usability has inevitably been a crucial issue to achieve inclusiveness. Inclusiveness has also been supported
fromthetechnologicalpointofview.DuetotheVumiplatform’scompatibilitywithallmobileoperatorsandchoiceof
extensiveUSSDmessagingprotocol,theservicecanbeusedbyalltypesofmobilephonesinacountry.Inaddition,
the helpdesk, feedback system and marketing material have all had an additional, supportive role in achieving
acceptance among users and other constituencies.
Finally, to gauge whether a successful innovation is also proof of a functional ecosystem, the following issues can be
observed based on a review of MomConnect: i) an enabling infrastructure and appropriate technical solutions exist to
establish a nationwide service; ii) there are contributing mechanisms to enable expansion from local experimentation
to national implementation; iii) there are emerging cross-organisational possibilities, i.e. multi-actor operation can
beestablishedinm-healthwithparticipatingactorsworkingtogetherfromgovernment, privatesector,NGOsand
other relevant foundations.

47
Key Finding from Workshops in South Africa and Tanzania
This part involved the last phase of the DSRM process as depicted below (Figure 23):
Communicate
results
ofPhase3
Finalconceptualised
DigitalHealth
InnovationEcosystem
Phase3:Workshopsandexpertconsultationandreview
CommunicationEvaluationDemonstration
IntermediateConceptualisedDigitalHealthInnovationEcosystem
InitialConceptualisedDigitalHealthInnovationEcosystem
Figure23.TowardsconceptualisedDigitalHealthInnovationEcosystem
Two workshops were held, one in South Africa (August 2015) and one in Tanzania (November 2015) where health
experts and researchers from all over the world provided inputs into the development of the Digital Health Innovation
Ecosystem.
The workshops represented various stakeholders from different institutions and included academics from South
Africa(RhodesUniversity,Unisa,NorthWestUniversityandUniversityofCapeTown);researchersfromGermany,
Namibia, Zimbabwe, Spain, Zambia and Tanzania and the Innovation Centre at Groote Schuur Hospital in Cape
Townas wellasan NGOfromCape Town.This allowedfora unique combinationofstakeholders whoprovided
valuable feedback and inputs to the Digital Innovation Ecosystem for South Africa. Their feedback offered additional
insights into the initial understanding and subsequently expanded the conceptualisation of a successful Digital Health
Innovation Ecosystem to include the following:
Context
•
Digital health solutions that are sensitive to local economic, social, cultural, environmental and organisational factors:
»Align ICT policy and government programmes which should be linked with telecommunications regulations
and develop a framework for data protection and privacy.
»
Inappropriate and unaffordable systems will not work. Consider sociotechnical requirements where you
choose appropriate technologies sensitive to resource constrained environments (context, culture, politics)
and environmental constraints (low literacy, older technologies). There should also be a focus on poor-user
techniques and capitalise on available technological capabilities (mobile phones) and facilitate equitable access
to information services. Also focus on contextualised, appropriate content in solutions.
• Digitalhealthsolutionsthatisadaptedtoaugmentthebroaderlocalisedcapabilitiesinthiseld:
»
Consider data security and building coalitions. These coalitions might include government, other health
implementers, technology providers, mobile network operators and others.
»Alignwithinteroperabilitystandardsformobilehealthbasedontherecentmobilehealthstrategyandreect
ontheSouthAfricanDepartmentofHealth’sehealthstrategy.
»
Governance (invest in infrastructure, rigorous decision-making, facilitated by data timing, systematic risk
assessment where there is strategy and leadership).
»Consider technical requirements for scalability and be cognisant of client device neutrality.
»Allow for access-technology agnostic (support for information and service delivery media convergence so that
digital content and services are accessible and delivered to end-users regardless of the access technologies
used by the end-user).

48
Innovation lifecycle
• Local development of digital health solutions
»Innovation opportunities and their uptake are not always organic and is often a facilitated process.
»
Applying foresight methodologies may propose a useful approach to construct shared understanding on future
possibilities.
»Local competencies and skills are essential and should be developed and incorporated or supported.
»Economic sustainability requirements have to be considered for sustainability.
»Creative engagement platforms can help lower the barriers of entrepreneurship.
• A self-directed innovation ecosystem
»Allowing innovation to take place in an organic manner based on common interests of various stakeholders
can enable novel outcomes.
»
Bridgers and curators help shape the ecosystem. Salmelin (2015) describes curators as focusing on sustaining
and enriching the quality of the innovation for reuse or adaption by bridgers to other disciplines. He describes
bridgers as socially well-connected stakeholders, with a broad knowledgebase, who are able to link various
aspects of the innovation in spontaneous and unusual ways with other stakeholders or innovations.
Users/stakeholders
• An innovation ecosystem based on the common interest of all actors in a quadruple helix (government, industry,
users or community and universities) (Salmelin, 2015):
»Resources(allocation,management,availability),people,partnersandtechnologyneedtoworkinaexible
system where there is a culture of innovation.
»For solutions to work in a digital health space the technologies and people will have to be able to adapt to
changes and to focus on a mind-set where capabilities are important to think differently and where opportunities
exist for co-creation.

49
DISCUSSION AND CONCLUSIONS
Developments and Results of the Baltic and Nordic Innovation Ecosystems
The conceptualisation of a South African Digital Health Innovation Ecosystem was informed by the lessons learnt
from the Finnish and the Estonia digital health frameworks.
To begin with Finland: Its social welfare and healthcare system is founded on government-subsidised municipal social
welfare and healthcare services. In addition to the public sector, many private enterprises and non-governmental
organisations are providing services. Social welfare and the healthcare system in Finland is based on public, tax-
based funding (Ministry of Social Affairs and Health, 2013b). For the citizens the social care services are public
services but these are provided by private providers (Schug & Whitehouse, 2013).
Finland can be considered as a strong digital health hub where social and healthcare technologies, devices and
servicescanbeeffectivelyusedforthebenetofindividualsandsocieties.Thisisenabledby nationalstrategies
and a functional innovation ecosystem based on multidisciplinary cooperation and a good atmosphere (Pere &
Toivainen, 2015). In Finland the digital health ecosystem provides increased collaboration, coordination and better
understandingofresourceows(nance,material,informationetc.)betweendifferentstakeholdersinvolvedinthe
delivery of digital health services. Stakeholders include patients/users, user communities, technology providers,
payers, regulators and policymakers.
Estonia is the smallest Baltic country and 70% of the population use the Internet (ProeHealth, 2012). Estonia is a
democraticparliamentaryrepublicandhasbelongedtoNATOandtheEUsince2004.Sinceregainingindependence
in 1991, the political environment has been stable enough to implement various economic and social sector reforms
(Doupietal.,2010).TherehavebeentwosignicanthealthsystemchangessinceEstoniagaineditsindependence.
The rst was shifting to a decentralised model from a centralised system. The second was replacing the state
healthcarebudgetandnancingmodelwithsocialinsurancecontributions.Familypractitionersarethecoreofthe
health service. The whole system is under the umbrella of the Ministry of Social Affairs, which can be considered as
a main policy developer in healthcare. The Estonian Health Insurance Fund is the main funding agency. The Estonian
e-Health Foundation was established in 2005 and has led the eHealth initiatives in the country (ProeHealth, 2012).
The current Estonian healthcare system is built around countrywide primary care relying on family medicine. The
primary care is supported by ambulance services available all over Estonia. Specialised care has increasingly been
provided in outpatient settings (Doupi et al., 2010).
Within just twenty years, Estonia has renewed its information governance from multiple information systems (covering
both paper-based documentation and some early e-architectures) to integrated system-level architecture serving
society both vertically and horizontally. In a way, Estonia can be observed as a case study that provides learning on
what can be performed within a rather short period of time. However, reformation of this kind is a unique result of
multiple, simultaneous factors which include historical issues, technological restrictions and possibilities, motivations
ofeldactors,governance’sfundingstatus,andtheexistenceofcapablepeopleinfavourablepositions.Still,this
system allows ordinary citizens access to their electronic health records and they are informed if any intruder (with
noaccess)wantstoviewtheirles.
Both Finland and Estonia have evidence of collaborations with various stakeholders to develop their own personalised
digitalhealthecosystems,butthesewerealsoplaguedwithvariouschallenges(notndingconsensus,widernational
expansions without proper user consultations, etc.). Nonetheless, these systems are regarded as innovative products
and services to support individual healthcare.
Digital Health Innovation Ecosystem for South Africa
Findings from Finnish and Estonian case studies informed the initial conceptualisation of the South African Digital Health
Innovation Ecosystem. Workshops in South Africa and Zanzibar, Tanzania, provided the opportunity to validate the
stakeholders in digital health in South Africa and also clarify what is understood by the concept. The following section
provides the results toward a validated conceptualisation of a South African Digital Health Innovation Ecosystem.
The subsequent conceptualised Digital Health Innovation Ecosystem as artefact is illustrated in Figure 24.

50
Figure24.DigitalHealthInnovationEcosystemforSouthAfrica
Based on the study done, it is suggested that a Digital Health Innovation Ecosystem involves the three interactive,
complementary modules: context, the innovation lifecycle and the users/stakeholders. The context builds on the
typology of Social, Technological, Economic, Environmental, Political and Value-base issues (STEEPV) (Miles,
2015). Here one has to be cognisant of the political and legal issues as these inform changes. It also involves issues
like economic (monetary values of affordability), social issues, ethical and environmental (distance or geographical
logistics).ThecontextplaysasignicantroleintheDigitalHealthInnovationEcosystemtechnologyasthisiswhere
innovationistriggered. Once innovationistriggeredit has togothroughthe innovation life-cyclewhichinvolves
a process that moves from being a health innovative idea to becoming a concept, which is then developed to be
deployedfor uptakeand use.This productisevaluatedormeasured todetermine ifitneedsmorerenement or

51
improvements. The users are involved in the context and in the innovation lifecycle and play a pivotal role to provide
feedback and to identify innovative health ideas. Largely, foresight methodologies/futures studies propose herein a
potential approach to create and to construct shared, holistic understanding in different timeframes.
The users are thus all the stakeholders which represent the quadruple-helix components of government, industry,
NGOsandcommunities.Regulationcomesafterinnovationandininnovationthefocushastobeontechnology,
sustainability and the user to streamline a digital ecosystem. The user must feel or experience trust, have to change
behaviour, feel that they can control and increase their own access to a system. Their uptake and use are essential
for such an ecosystem to work or to be regarded as a sustainable solution. Technology should include elements
of interoperability, standards, integration of infrastructure, include privacy elements, include big data, focus on
analytics, storage and control of access. For sustainability to work, the value of a system has to be shared across
groups where there are partnerships, capacity building, leadership and governance and where measurement can
renethetruevalue.
FordigitalhealthtocontributetowardsimprovedhealthequalityintheSouthAfricancontext,thespecicchallenges
of implementing ehealth solutions need to be addressed. Reaching, engagement and empowerment of low-income
populations in urban and rural areas to deliver novel digital health services requires highly targeted measures, which
will require careful consideration of relatively idiosyncratic conditions. Simple transfer of off-the-shelf-technology or
solutions will not work, but will lead to high failure rates. Success will require local, South African development of
innovative solutions that are sensitive to local economic, social, cultural and organisational factors, as well as are
adapted to augment the broader South African capabilities in digital health.
It is for this reason we are arguing for the notion of an Innovation Ecosystem. The build-up of digital health in South
Africa is not only about improving the availability, access and delivery of healthcare services, but essentially about
enhancingacountry’sstrategiccapabilitiestocreate,adaptandimplementnoveldigitalhealthsolutionswithinand
bythepublicandprivatesector.Thiscanalsoenhancethecountry’soverallinnovationcapacity.Inthiscontext,it
is also about processing shared understanding on future possibilities in a systematic way. Platforms, technologies
and solutions implemented today should also be aware and open for needs of tomorrow.
Finally
In conceptualising a Digital Health Innovation Ecosystem for South Africa it was essential to contextualise it within
the ICT RDI Implementation Roadmap for South Africa. This Roadmap was developed by the CSIR Meraka Institute
in 2012 and accepted by parliament as the plan to guide the implementation of a national ICT RDI strategy. The
Roadmap is driven by the potential to deliver socio-economic impact, and presents a sound case for increased
public and private investment in ICT RDI. It serves as an anchor point for attracting increased public and private
investment in ICT R&D, including from multi-national corporations. A digital advantage will enable South Africa to
becomeasignicantplayerintheglobalICTRDIarena;providemoretargetedengagementwithindustry;focused
international collaboration; more comprehensive and transparent monitoring of investment; and achieving impact,
such as jobs and business creation, contribution to GDP, societal impact and positioning South Africa for strategic
advantage(Mjawara,2012).TheICTRDIImplementationRoadmapprovidesacoherent,comprehensiveandexible
ten-year implementation framework to coordinate and manage ICT research and technology development nationally,
regionally and in relation to our international partners.
A Digital Health Innovation Ecosystem for South Africa would function in support of the ICT RDI Implementation
Roadmap supporting further innovation. This implies that new public policies, governance structures, IT infrastructure,
practices and approaches should be aligned to strengthen the implementation framework, in addition to actively
encourage and enable new digital innovations.
Finally, it is essential to highlight the limitations of the transfer of Finnish or European experience and technical
solutionstoSouthAfrica.ThespecicationanddenitionofpotentialSouthAfricanusersandbeneciariesofdigital
health systems, or the adaptation of the cost structure of solutions, would probably be the traditional focus areas
when considering the value of European examples for South Africa. Indeed, failure to appreciate the local context
and user needs is a typical mistake when people look to transfer solutions from Europe to Africa. However, learning
from other countries at the system level requires that attention is paid to how the emerging South African digital
healthsystemisadapted,integratedandcoordinatedwithSouthAfrica’snationalinnovationsystem.

52
REFERENCES
1. Adebesin, T. (2014). A method for the selection of e-health standards to support interoperability in healthcare
informationsystems.UnpublishedPhDthesis,NelsonMandelaMetropolitanUniversity.
2. Ahlqvist, T. & Myllyoja J. (2011). Part II. Ch 3.: Roadmapping – Multilateral Support of the Strategic Work. In:
M&AasaStrategic Option–FromOpportunitiestoNewBusinessCreation.EditedbyRaukko,Räikkönen&
Rantala.Teknologiateollisuusry.TeknologiainfoTeknovaOy.
3. AHO(2016).AbouttheAfricanHealthObservatory.Retrieved21March2016,from:http://www.aho.afro.who.
int/en/about-african-health-observatory
4. Alberts, R., Botha, A. & Fogwill, T. (2015). Channel Agnostic Healthcare for resource constrained environments.
Journal of Network and Innovative Computing ISSN 2160-2174 Volume 3 (2015) pp. 060-067 © MIR Labs, www.
mirlabs.net/jnic/index.html.
5. Anderson, J. (2007). Social, Ethical and Legal Barriers to E-health. International Journal of Medical Informatics,
76(5–6): 480-483.
6.
Bateman,C.(2014).Usingbasictechnology-andcorporatesocialresponsibility-tosavelives.In:SAMJ:South
African Medical Journal, December 2014, Vol. 104, No 12.
7.
Blackwell, A., Phaal, R., Eppler, M. & Crilly, N. (2008). Strategy roadmaps: new forms, new practices. In Stapleton,
G., Howse, J. and Lee, J. (Eds.). Diagrams 2008. Springer-Verlag, Berlin/Heidelberg,127–140.
8.
Carlsson, S. (2006). “Towards an Information Systems Design Research Framework: A Critical Realist Perspective”
1st International Conference on Design Science in Information Systems and Technology: Claremont, pp. 192-212.
9. Carlsson, S. (2010). Design Science Research in Information Systems: A critical realist approach in Design
ResearchinInformationSystems.Springer:US,p209-233.
10. Chetty,M.(2013).PresentationtoVTTontheFutureclinic’sproject.13June2013.
11. Chetley, A. (2006). Improving health, connecting people: The role of ICT in the health sectors of developing
countries a framework paper. InfoDev.
12.
Cohen,J.,Bancilhon,J.andJone,M.(2013).SouthAfricanPhysicians’Acceptanceofe-PrescribingTechnology:
AnEmpiricalTestofaModiedUTAUTModel.South African Computer Journal 50(July): 43-54.
13.
Creswell,J.(2007).Qualitativeinquiry&researchdesign-choosingamongveapproaches(2nded.).California:
Sage Publications.
14. Creswell,J.,&Plano Clark,V.(2011).Designing andconductingmixed methodsresearch.Thousand Oaks,
California: Sage Publications.
15. CSIR(2012).SupportforruraleducationinComvaba.Unpublishedreport.
16. CSIR & VTT (2015). Building Digital Health Innovation Ecosystems – Strategies, Approaches and Experiences,
Pretoria, South Africa: CSIR, VTT collaboration.
17. Department of Health (2012). eHealth Strategy South Africa. Pretoria, South Africa.
18. Doupi, P., Renko, E., Giest, S., Heywood, J. & Dumortier, J. (2010). E-health strategies – Country brief Estonia.
EuropeanCommission,DGInformationSocietyandMedia,ICTforHealthUnit.
19. ECOSOC(2009).Backgroundpaper “eHealth: useofinformationand communication technologyinhealth”.
Africa Regional Ministerial Meeting Accra, Ghana, 10‐11 June 2009.
20. English,R.,Masilela,T.,Barron,P.&Schönfeldt,A.(2011).HealthInformationSystemsinSouthAfricaSouth
African Health review. South Africa: Health system trust.
21. E-Estonia.com (2015). Cited 2015 July, from: https://e-estonia.com/component/electronic-health-record/.

53
22. EstonianInformationSystem’sAuthority(2013).X-Road.
23.
Finnish Government (2015). Government decision on next steps in reform package on healthcare, social welfare
andautonomousregions. Cited 2016 March; From:http://valtioneuvosto./artikkeli/-/asset_publisher/hallitus-
paatti-sote-uudistuksen-jatkosta-ja-itsehallintoalueista?_101_INSTANCE_3wyslLo1Z0ni_groupId=10616&_101_
INSTANCE_3wyslLo1Z0ni_languageId=en_US
24. Geels,F.G.(2005).Processesandpatternsintransitionsandsysteminnovations:Reningtheco-evolutionary
multi-level perspective. Technological Forecasting & Social Change 72 (2005) 681–696.
25. Geldenhuys,P.&Botha,A.(2015).OnthedesignofanelectronichealthpatientregistrationsystemforSouth
Africa. Proceedings of the 9th IDIA conference, IDIA2015, Nungwi, Zanzibar: 202-216. ISBN: 978-0-620-68395-1.
26. Gunter,T.&Terry,N.(2005).TheEmergenceofNationalElectronicHealthRecordArchitecturesintheUnited
States and Australia: Models, Costs, and Questions. Journal of Medical Internet Research 7 (1).
27. Haines, A. & Cassels, A. (2004). Can the millennium development goals be attained? British medical journal,
2004, 329 (7462): p. 394.
28. Heeks, R. (2006). Implementing and Managing eGovernment, Sage Publications, London.
29.
Hevner, A. (2007). A Three Cycle View of Design Science Research, Scandinavian Journal of Information
Systems, 19(2):87-92.
30. Hevner, A. & Chatterjee, S. (2010). Design Research in Information Systems. Integrated Series in Information
Systems, 2010, Springer. p. 9-22.
31. Hevner, A. R., March, S. T., & Park, J. (2004). Design science in information systems research. MIS Quarterly,
28(1), 75 – 105
32. ITU(2012a). E-health Standards and Interoperability: Published by International TelecommunicationUnion.
Retrieved09May2013,fromhttp://www.itu.int/dms_pub/itu-t/oth/23/01/T23010000170001PDFE.pdf
33. ITU(2012b).JointITU-WHOWorkshopone-HealthStandardsandInteroperability:PublishedbyInternational
Telecommunication Union. Retrieved 31 October 2013, from http://www.itu.int/en/ITU-T/Workshops-and-
Seminars/e-Health/201204/Pages/default.aspx
34.
Kalja, A. (2006). Estonian example of integration e-government services. Presentation in 2nd Conf. on eServices
in E. C. R. Available from: http://www.docstoc.com/docs/29867400/eGovernment-in-Estonia-Best-Practices
35. Kaplan, B. & Harris-Salamone, K. (2009). Health IT Success and Failure: Recommendations from Literature
and an AMIA Workshop Journal of the American Medical Informatics Association Volume 16 Number 3 May /
June 2009.
36. Karisa,A.J.,Sissine,M.,Ngibuini,G.,Oiro,J.,Medeiros,D.andJefferson,B.(2014).Bending the Cost Curve
in Implementing Electronic Medical Record Systems: Lessons Learnt from Kenya. Proceedings of the IASTED
African Conference on Health Informatics (AfricaHI 2014) Conference.
37.
Kirigia, J., Sambo, L., Nganda, B., Mwabu, G., Chatora, R., & Mwase, T. (2005). Determinants of health insurance
ownership among South African women, BMC health services research, 5(1), 17.
38.
Klein, H. & Myers, M. (1999). A set of principles for conducting and evaluating interpretive eld studies in
information systems. MIS Quarterly, 23, 67-94.
39. MAMA(2015).Thepowerofhealthineverymama’shand.Availablefrom:http://www.mobilemamaalliance.org/
mama-south-africa
40. March, S. T., & Storey, V. C. (2008). Design science in the information systems discipline: an introduction to the
special issue on Design Science Research. MIS Quarterly, 32(4), 725 - 730.
41. Marquardt, J. (2015). How transition management can inform development aid. Environmental Innovation and
Societal Transitions 14, 182-185.

54
42.
Marten, R., McIntyre, D., Travassos, C., Shishkin, S. Longde, W., Reddy, S. and Vega, J. (2014). “An assessment
of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS),” The
Lancet, vol. 384, pp. 2164-2171.
43.
Meingast, M., Roosta, T. and Sastry, S. (2006). Security and Privacy Issues with Health Care Information
Technology. Proceedings of the 28th Annual International Conference of the IEEE Engineering in Medicine and
Biology Society Conference.
44.
Miles, I. (2015). Fundamentals of scenario building, in Foresight: Exploring the future, shaping the present. 2015
Courseworkbook.,R.Popper,etal.,Editors.2015,UniversityofManchester,Manchester.
45. Ministry of Social Affairs and Health (2013a). Health Care in Finland. Brochures of the Ministry of Social Affairs
and Health 2eng (2013).
46. Ministry of Social Affairs and Health (2013b). Social welfare and health care reform, Finish Ministry of Social
Affairs and Health, Editor 2013: Finland.
47.
Mjawara, P. (2012). ICT Roadmap. Assessed: 02 June 2015, available from: http://www.meraka.org.za/ictroadmap/
sites/default/les/Roadmap%20-%20DEV12.pdf.
48. MomConnect (2015). Available from: http://www.rmchsa.org/momconnect/
49. Motsoaledi, A. (2014). National Health Act (61/2003): National Health Normative Standards Framework for
Interoperability in eHealth. Government Gazette 37583 (Government Notice 314).
50. NDoH National Department of Health (2011). National Health Insurance in South Africa: policy (Green) paper,
Pretoria, Republic of South Africa.
51.
National Department of Health (2014a). MomConnect Booklet. Available from: http://www.rmchsa.org/wp-content/
uploads/2014/08/MomConnect-Booklet.pdf
52.
National Department of Health (2014b). Momconnect - Frequently Asked Questions For Healthcare Professionals
at Clinics.
53. NDoH and CSIR (2014). South African National Health Normative Standards Framework for Interoperability in
eHealth:CompleteVersion.PublishedbySouthAfricanNationalDepartmentofHealthandCouncilforScientic
and Industrial Research (CSIR GWDMS Number: 240075).
54. Novek, A. (2015). PowerPoint presentation 13 February 2015 related to VTT and CSIR-Meraka delegation visit
to Estonia.
55. Oates,B.(2006).Researchinginformationsystemsandcomputing.LosAngeles:SAGEPublications.
56. OECD(2013).Healthata glance: OECDindicators.Availablefrom:http://www.oecd.org/els/health-systems/
Health-at-a-Glance-2013.pdf
57. Ouma,S.(2013).M-health user experience framework for the public healthcare sector (PhD). Nelson Mandela
MetropolitanUniversity.
58. Pankomera, R. and Van Greunen, D. (2014). Comparative Analysis of the Status of ICT Usage in Healthcare:
South Africa, Tanzania, Malawi. Proceedings of the IASTED African Conference on Health Informatics (AfricaHI
2014) Conference.
59. Peffers, K., Tuunanen, T., Rothenberger, M. & Chatterjee, S. (2008). A Design Science Research methodology
for information systems research. Journal of Management Information Systems, 24(3): 45 - 77.
60. Pere,A.& Toivainen,E. (2015).BitsofHealth - Business from Digitalisation. PresentationrelatedtoTekes’
Programmelaunchseminar11.3.2015.Availablefrom: https://tapahtumat.tekes./uploads/a9a1d585/5_Auli_
Pere_Eero_Toivainen_Bits_of_Health-8489.pdf
61. Phaal, R., Farrukh, C. & Probert, D. (2004). Technology roadmapping – A planning framework for evolution and
revolution. Technological Forecasting and Social change 71, 5-26.

55
62. Phaal, R. & Muller, G. An architectural framework for roadmapping: Towards visual strategy. Technological
Forecasting & Social Change e 76 (2009) 39–49.
63. Pirinen, R. (2009). Research framework of Integrative Action. In: Fifteenth Americas Conference on Information
Systems. An Fransicso, California, August 6th-9th 2009.
64.
Praekelt (2014). Praekelt Mobile Technology Powers Groundbreaking South African Department of Health
Maternal Health Service. Bloq release. Available from: http://blog.praekeltfoundation.org/post/95353223077/
praekelt-mobile-technology-powers-groundbreaking
65. ProeHealth (2012). Estonian EHR Case Study.
66.
Qiang, C., Yamamichi, M., Hausman, V. & Altman, D. (2011). Mobile applications for the health sector. Washington:
World Bank.
67. Rittel, H., Webber, M. (1984). Planning problems are wicked problems. N. Cross (Ed.). Developments in Design
Methodology (pp. 135-144). John Wiley & Sons, New York.
68. Salmelin, B., Open Innovation 2.0 creates a new innovation space, in Open Innovation 2.0 yearbook2015,
European Commission: Italy.
69.
SANGONeT - The Southern African NGO Network. (2014). MomConnect Empowers Pregnant
Women and New Mothers in South Africa. Available from: http://www.ngopulse.org/blogs/
momconnect-empowers-pregnant-women-and-new-mothers-south-africa
70. Saritas,O. (2013). Systemic Foresight Methodology, Book chapter in “Science, Technology and Innovation
Policy for the Future: Potential and Limits of Foresight Studies” (pp. 83-117), eds. D. Meissner, L. Gokhberg,
A. Sokolov, 330p.
71. Schug, S. & Whitehouse, D. (2013). Peer Review: eHealth Strategy and Action Plan of Finland in a European
Context. Workshop report version 0.16/10 of 26 May 2013.
72. Simon,H.(1996).TheSciencesoftheArticial.Cambridge,Mass:MITPress.
73. South African National Department of Health. (2010). Negotiated Service Delivery Agreement for Outcome 2: A
long and healthy life for all South Africans. Pretoria: South African National Department of Health.
74. South African National Department of Health. (2012). eHealth Strategy for South Africa 2012-2016. Pretoria.
75. Spies, C. and Muwanguzi, M. (2014). Comparison Study on ICT in the Healthcare System of Developed and
Developing Nations. Proceedings of the IASTED African Conference on Health Informatics (AfricaHI 2014)
Conference.
76.
Statistics South Africa (2014). “Mid-year population estimates: 2014.,” Statistics South Africa, Pretoria, South Africa.
77. Stuckler, D., Basu, S. & Mckee, M. (2011) International Monetary Fund and aid displacement. Int J Health
Services, 41,67–76.
78. TEM (2014). Health Sector Growth Strategy for Research and Innovation Activities. MEE reports 16/2014.
79. U.N.D.o.(2008).Economic,The Millennium Development Goals Report 2008.UnitedNationsPublications.
80. UNICEF(2013).Supportingpregnantwomen’sjourneytomotherhood.Availablefrom:http://www.unicef.org/
southafrica/media_14102.html
81. Vaishnavi,V.andKuechler,W.(2013).DesignScienceResearchinInformationSystems.Onlineavailableat:
http://www.desrist.org/design-research-in-information-systems/. Accessed: 17 December 2014.
82. Vaishnavi, V. and Kuechler, W. (2015). Design science research methods and patterns: innovating information
and communication technology 2015: CRC Press.
83.
Van Zyl. (2015). Architecture Blueprint for the Health Patient Registration System (CSIR Meraka, Trans.). Pretoria:
CouncilforScienticandIndustrialResearch.

56
84. Wager, K., Lee, F. & Glaser, J. (2009). Health Care Information Systems: A Practical Approach for Health Care
Management, 2nd edition. San Francisco, CA: John Wiley & Sons, Inc.
85.
Waldman, L. & Stevens, M. (2015). Sexual and Reproductive Health Rights and Information and Communications
Technologies: A Policy Review and Case Study from South Africa.
86.
Walsham, G. (1995). Interpretive Case Studies in Is Research: Nature and Method. European Journal of
Information Systems, 4:74 - 81.
87. Wang, S. & Wang, H. (2010). Towards Innovative design research in Information Systems. Journal of Computer
Information Systems. Fall, 2010.
88. WHO(2012).NationaleHealthStrategyToolkit.Cited2015October;From:https://www.itu.int/dms_pub/itu-d/
opb/str/D-STR-E_HEALTH.05-2012-PDF-E.pdf
89.
WorldHealthOrganisation(2012). National eHealth Strategy Toolkit.[cited2015October];Availablefrom:https://
www.itu.int/dms_pub/itu-d/opb/str/D-STR-E_HEALTH.05-2012-PDF-E.pdf.
90.
Wright,G.,&Odama,A.(2012).Healthdataownershipanddataquality:clinicsintheNyandeniDistrict,Eastern
Cape, South Africa. Engineering Management Research, 1(2), 146.
Interviews
JaakkoLähteenmäki(Principal Scientist, VTT).Background:E-services, self-care, software basedsolutions,EU
co-operation, projects for municipalities and private sector concerning ICT utilization in healthcare. IT in health
innovation system.
Niilo Saranummi(Senior Principal Scientist, VTT). Background: One of the best-known Finnish developers for
healthcare systems with strong expertise for several decades. Worked for example as a laboratory leader for hospital
technology; worked for the Academy of Finland.
Matti Penttilä(Senior Scientist, VTT). Background: Mathematics & Philosophy. Experienced in software development
and project management for healthcare among other substance areas. Moved to 1988 Nepal, where lived for 2,5
yearsbuildingphonecenter.WorkedinTKKforveyears.Since1995inVTT.20yearsasachairforFinlandNepal-
friendship association.

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