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IST-Africa 2016 Conference Proceedings Paul Cunningham and Miriam Cunningham (Eds) IIMC International Information Management Corporation, 2016 ISBN: 978-1-905824-54-0

A Digital Health Innovation Ecosystem for South Africa Marlien HERSELMAN1, Adele BOTHA2 , Hannes TOIVANEN3, Jouko MYLLYOJA4, Thomas FOGWILL5, Ronell ALBERTS6 Meraka, CSIR, P.O. Box 395, Pretoria, 0001, South Africa & School of Computing, Unisa, Florida, 0001, South Africa 1 Tel: +09 12 8413081, Fax: + 09 12 8414720, Email: [email protected] 2 Tel: +09 12 8413265, Fax: +09 12 8414720, Email: [email protected] 5 Tel: +09 12 8413155, Fax: +09 12 8414720, Email: [email protected] 6 Tel: +09 12 8413936, Fax: +09 12 8414720, Email: [email protected] VTT Technical Research Centre, P.O. Box 5520, Laskut, 01051, Finland 3 Tel: +358 401863882, Fax: +358 20 722 7001, Email: [email protected] 4 Tel: +358 403545051, Fax: +358 20 722 7001, Email: [email protected] Abstract: The purpose of this paper is to provide an overview of how a digital health innovation ecosystem was conceptualised and validated for South Africa. Largely, we focus on defining strategies to build Digital Health Innovation Ecosystems in the context of developing countries, and pay particular attention to the challenges and potentials. Over a period of two years the conceptualisation was done by applying Design research as a methodology and the validation through two cycles of expert review feedback in order to improve the artifact. The conceptual digital health innovation ecosystem for South Africa portrays the inputs from research experts and practitioners in South Africa, Africa and Europe working in the Health domain. Feedback indicated that the conceptual digital health innovation ecosystem for South Africa is a good reflection of the realities of developing contexts where all role players and systems are indicated that affect digital health. This conceptualisation allows for the positioning of sub innovation ecosystems and related new products through applying an open innovation life cycle to improve the quality of life of ordinary citizens. Keywords: Digital Health, Open Innovation, ecosystem

1. Introduction Digitalization of Health Care processes is the norm today and regarded as one of the key phenomena in global health. As such it is an obvious central issue for every government concerned with the health and well-being of its citizens. No serious health policy maker or professional can have missed the call to Digital Health action because the reality is that social and demographic changes, the rise of chronic diseases, and the need to improve the quality and efficiency of health care delivery are challenges which every government is currently facing [1]. The question now is what is Digital Health and why is so much expected from it? The GBCHealth [2] defines Digital Health as an umbrella concept for the over-reaching digitalization of health care services and information. It often involves the addition of artificial intelligence and automation solutions for improved efficiency, coverage and accuracy of service provision. Digital Health is very much about moving away from the artisanal and analogue mode of organizing and providing health care, where economies of scale, access to and availability of care are constrained by the physical proximity and Copyright © 2016 The authors

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availability of skilled health personnel and sophisticated equipment. It is a ubiquitous phenomenon, impacting potentially all aspects of health care and opens up new avenues of cross-sectoral collaboration, especially between social security and health care sectors [2]. Digital Health thus implies significant expansion of the notion of health care and its provision in the society. It incorporates personalized and participatory health care models – including health monitoring, well-being practices and preventive care, and thus expands the organization and delivery of health related services and activities beyond professional health care organizations. This gave rise to personalized ICT devices, software and services, which have opened a new innovation platform for health related services. However, Digital Health is also related to health information systems, prompt convergence between social care and health care systems, affecting the organization, service delivery, and technological infrastructure. In short, Digital Health implies ubiquitous change throughout the existing health care system, as well as expansion and redefinition of its traditional boundaries between patients, consumers, citizen, health care professionals, innovators, organizations, sectoral policies, and so forth. The core argument of this paper is that the notion of Digital Health must incorporate the concept of Innovation Ecosystems. In order to build Digital Health Systems, they need to be adaptive, learning, and capable to improvise 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. The problem is that up to now the conceptualisation of a Digital Health Innovation ecosystem did not take place and this article is a way to tackle the problem and to develop and implement such an ecosystem for South Africa.

2. Literature Review of the Concept A brief review of key literature on Digital Health indicates that it is important to rapidly deploy new digital health solutions. The World Health Organization and International Telecommunication Union launched in 2012 the “National eHealth Strategy Toolkit” [3] 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 benefit of their citizens”. Focussing more on its rich country members, the OECD published in 2013 an overview report on strategic issues and analysis of expected benefits for Digital Health [1]. 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 ”[4], and more recently a report “Mobile Applications for the Health Sector” [5]. These reports and guidelines are all pointing to the dire need, indeed necessity, to move as quickly as possible to develop national eHealth strategies and implementation. In the Africa context, the need to deliver on the health related Millennium Development Goals (MDG) has been a central driver for the continent’s approach to Digital Health. As Haines and Caines [6] 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”. There have been plenty of strategy and policy papers on the issue. South Africa has made a strong case for adopting and developing eHealth to improve service delivery and to address the milestones of the national strategy of 2012. The strategy envisioned a roadmap for national eHealth development, as well as outlined the expected benefits [7]. However, as the strategy has been moving towards implementation, a set of more concrete issues concerning the implementation of the strategy, as well as operational issues have emerged and there is an increasing need to consider the eHealth within the broader South African context. In the developed countries like Canada, USA, United Copyright © 2016 The authors


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Kingdom and Finland the term Digital health has been used and applied [2], but in South Africa the term is relatively new. Although there is sufficiently convincing academic, policy and business literature to buttress the need, potential and importance of Digital Health, there are two important gaps. First, relatively little thought has been given to how health care systems should be transformed to incorporate the new objectives, functions, activities and organizations that are required to include creation innovations into Digital Health systems. Secondly, Digital Health Innovation Ecosystems have until now emerged mostly within the rich-country context. Here, we focus on defining strategies to build Digital Health Innovation Ecosystems in the context of developing countries in general and South Africa in particular, 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 specific issues must be addressed properly. These include [4]:        

Polarization of the health-care system between well-resourced private and underresourced public health care Fragmented health information systems (National, Provincial, public/private, etc); Build-up of the national health insurance system universal coverage health care Specific health challenges, such as HIV/AIDS, infant and maternal health, tuberculosis, violence, etc. Unsecure personal and digital identities, and other trust related issues. Lack of ICT infrastructure Territorial coverage in terms of isolated urban and rural areas Cost. Affordable access and use of electronic health services via mobile phones or internet, both for users and providers of digital health services.

For Digital Health to contribute towards improved health equality in the South African context, the above mentioned issues (and more) needs to be carefully considered. Reaching, engagement, and the empowerment of low-income population in urban and rural areas to deliver novel Digital Health services requires highly targeted measures, which will require careful consideration of relatively idiosyncratic conditions. The simple transfer of off-theshelf-technology or solutions will simply not work, resulting in a high failure rate. A successful Digital Health Innovation Ecosystem for South Africa will require [8]:   

Local, South African development of Digital Health solutions; A self-directed innovation ecosystem; An innovation ecosystem based on the common interest of all actors in a quadruple helix [9] (government, industry, users or community and universities or research entities);  Digital health solutions that are sensitive to local economic, social, cultural, and organizational factors; and  Digital health solutions that is adapted to augment the broader South African capabilities in Digital Health. In conceptualising a Digital Health Innovation Ecosystem for South Africa it was essential to contextualise it within the ICT Research, Development and Innovation (RDI) Implementation Roadmap for South Africa. This Roadmap was developed by Meraka Institute, CSIR in 2012 and accepted by Parliament as the plan to guide the implementation of national ICT research, development and innovation 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 significant player in Copyright © 2016 The authors


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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 [10]. The ICT RDI Implementation Roadmap provides a coherent, comprehensive and flexible 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 then function in support of the ICT RDI Implementation framework 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.

3. Methodology The purpose of this paper is to provide an overview of how a digital health innovation ecosystem was conceptualised and validated for South Africa. The methodology applied in the conceptualisation, refinement and validation, was Design Science Research (DSR). Design Science Research focuses on creation [11]. Design science addresses wicked problems in Information Systems or IS [12] and is fundamentally a problem-solving paradigm. Wicked problems, as explained by Hevner and Chatterjee [13], relate to the illdefined environmental contexts as well as the creativity and teamwork to produce effective solutions which is relevant to developing an innovation ecosystem. The research methodology is grounded in the philosophy of pragmatism; however, this study has also applied 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 [14]. The Design Science Research Process (DSRP) applied in this research included the following six steps: problem identification and motivation, objectives for a solution, design and development, evaluation and communication. The iterative nature of the Design Science Research Process, as introduced by Peffers, Tuunanen, Rothenberger & Chatterjee [15] was adapted for this study.

Figure 1: Design Science Research Process adapted from Peffers et al., (2008).

The artefact, the Conceptual Digital Health Innovation Ecosystem for South Africa, was conceptualised, refined and validated through three iterate phases (Figure 1): Copyright © 2016 The authors


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  

Phase 1: Conceptualization: Literature overview resulting in an initial Conceptual Digital Health Innovation Ecosystem Phase 2: Refinement: A Multiple Case study research strategy was applied to the exploration of digital health frameworks from Baltic Countries (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, African and European context to elicit feedback on proposed elements of the framework. Critical inputs from ehealth stakeholders, from both developing and developed context were incorporated. This process resulted in a validated 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 involves 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. Triangulation of results was also applied. Having provided a condensed result from Phase 1 in section 2 and outlined the Methodology used in this section, the following section provides a summary for Phase 2 (section 4) and Phase 3 (section 5).

4. Developments and Results of Baltic & Nordic Innovation Ecosystems The conceptualisation of a South African Digital Health Innovation Ecosystem was informed by the lessons learned from the Finnish and the Estonia digital health frameworks. Other countries were not considered as these were not the focus of this paper. These will be summarised shortly below as the main findings from the two case studies: Finland’s social welfare and health care system is founded on government-subsidised municipal social welfare and health care services. In addition to the public sector, many private enterprises and non-governmental organisations are providing services. Social welfare and the health care system in Finland is based on public, tax based funding [16]. For the citizens the social care services are public services but these are provided by private providers [17]. Finland can be considered as a strong digital health hub where social and health care technologies, devices and services can be effectively used for the benefit of individuals and societies. This is enabled by national strategies and a functional innovation ecosystem based on multidisciplinary co-operation and a good atmosphere [18]. In Finland the digital health ecosystem provides increased collaboration, coordination and better understanding on resource flows (finance, material, information etc.) between different stakeholders involved in the delivery of digital health services. And the stakeholders also include patients/users, user communities, technology providers, payers, regulators and policy makers simultaneously. Estonia is the smallest Baltic country where 70% of the population use the Internet [19]. Estonia is a democratic parliamentary republic and has belonged to the North Atlantic Treaty Organisation (NATO) and the European Union (EU) since 2004. Since regaining independence 1991, the political environment has been stable enough to implement various economic and social sector reforms [20]. There have been two significant health system changes since Estonia gained its independence. The first was shifting to a decentralized model from a centralized system. The second was replacing the state healthcare budget and financing 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 health care. The Estonian Health Copyright © 2016 The authors


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Insurance Fund is the main funding agency. Estonian e-Health Foundation (EeHF) was established in 2005 - and has acted in a role of leading the eHealth initiatives in the country. [19]. 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. Specialized care has increasingly been provided in outpatient settings [20]. In all, Estonia’s healthcare system has transformed a lot during the last twenty years and changes are to be continued. The EHR (Estonian Electronic Health Record) is a systematized collection of electronically-stored health information, in a digital format, about an individual patient or a population [21]. Within just twenty years, Estonia has renewed its information governance from multiple information systems (covering both paper based documentation and some early earchitectures) 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 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 field 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 few their files. 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 finding consensus, wider national expansions without proper user consultations etc.). However these systems were regarded as innovative products and services to support individual healthcare. Table 1: Finland and Estonia Digital Health Innovation Ecosystems Successful Digital Health Innovation Ecosystem Local development of Digital Health solutions A self-directed innovation ecosystem An innovation ecosystem based on the common interest of all actors in a quadruple helix [9] (government, industry, users or community and universities) Digital health solutions that are sensitive to local economic, social, cultural, and organizational factors Digital health solutions that is adapted to augment the broader localised capabilities in Digital Health.

Finland  

Estonia  













These findings and lessons learnt from exposure to and discussions with the developers of these systems in Estonia and Finland, informed the initial conceptualisation of the South African Digital Health Innovation Ecosystem. Phase 3 provided the opportunity to validate the stakeholders in Digital Health in South Africa and also what is understood by the concept. The following section provides the results from Phase 3 toward a validated conceptualisation of a South African Digital Health Innovation Ecosystem.

5. Results It is essential to understand the limitations of the transfer of Finnish or European experience and technical solutions to South Africa. The specification and definition of potential South African users and beneficiaries 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 look to transfer solutions from Europe to Africa. However, learning from other countries at the system level requires that attention is

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paid to how the emerging South African Digital Health System is adapted, integrated and coordinated with South Africa’s national innovation system. 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 which 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 a 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: 5.1 



5.2 

Context Digital health solutions that are sensitive to local economic, social, cultural, environmental and organizational factors: o Align ICT policy and government programs which should be linked with telecommunications regulations and develop a framework for data protection and privacy, o Inappropriate and unaffordable systems will not work and consider socio-technical 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 [4]. Also focus on contextualized appropriate content in solutions. Digital health solutions that is adapted to augment the broader localised capabilities in Digital Health. o Consider data security and building coalitions. These coalitions might include government, other health implementers, technology providers, mobile network operators and others. o Align with interoperability standards for mobile health based on the recent mobile health strategy and reflect on the South African Department of Health’s ehealth strategy [5]. o Governance (invest in infrastructure, rigorous decision-making, facilitated by data timing, systematic risk assessment where there is strategy and leadership o Consider technical requirements for scalability and be cognisant of client device neutrality. o 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) [6]. Innovation Lifecycle Local development of Digital Health solutions o Innovation opportunities and their uptake are not always organic and is often a facilitated process [9].



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

5.3 

o Applying foresight methodologies may propose a useful approach to construct shared understanding on future possibilities. o Local competencies and skills are essential and should be developed and incorporated or supported. o Economic sustainability requirements have to be considered for sustainability o Creative engagement platforms can help lower the barriers of entrepreneurship [6]. A self-directed innovation ecosystem o Allowing innovation to take place in an organic manner based on common interests of various stakeholders can allow for novel outcomes. o Bridgers and Curators help shape the ecosystem. Salmelin [22] 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 [9] (government, industry, users or community and universities) o Resources (allocation, management, availability), people, partners and technology need to work in a flexible system where there is a culture of innovation o 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.

6. Digital Health Innovation Ecosystem for South Africa The subsequent Conceptualised Digital Health innovative ecosystem as artefact is illustrated in Figure 2 and outlined below. 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) [23]. Here one has to be cognisant of the political and legal issues as it informs changes. It also involves issues like economic (monetary values of affordability and Return on Investment), social issues (empowering stakeholders, develop entrepeneurs), ethical (culture adaptations) and environmental (distance or geographical logistics). In the Digital Health Innovation ecosystem technology in the context plays a significant role as this is where innovation is triggered. Once innovation is triggered it has to then go through the Innovation Life-cycle which involves a process that moves from being a health innovative idea to become a concept, which is then developed to be deployed for uptake and use. This product is then evaluated or measured to determine if it needs more refinement or 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.



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Figure 2: Digital Health Innovation Ecosystem for South Africa

The users are thus all the stakeholders which represent the quadruple-helix components of government, industry, NGO’s and communities. Regulation comes after innovation and in innovation the focus has to be on adaptive technology, sustainability and the user in order 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 and 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 refine the true value.



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7. Conclusion For Digital Health to contribute towards improved health equality in the South African context, the specific challenges of implementing ehealth solutions needs 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 offthe-shelf-technology or solutions will simply not work, leading easily to high failure rates. Success will require local, South African, development of innovative solutions that are sensitive to local economic, social, cultural, and organizational factors, as well as are adapted to augment the broader South African capabilities in Digital Health. This can sometimes take years to develop. 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 health care 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. Implementing such solutions is a challenge, therefore the next steps will be to show evidence of implementation where mhealth innovation will be the target from July to October 2016 in Cape Town. Here the CSIR, Mlab and Demola will be involved to form teams consisting of mhealth industry partners, students and academia to co-create possible implementable innovations in mhealth. 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.

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