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Final Report eHSA Governance Study - ESTEC Contract No. 4000104924/12/NL/AD

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eHSA Programme

Governance Study

Final Report

The work described in this report was done under ESA contract. Responsibility for the contents resides in the author or organisation that prepared it. The copyright in this document is vested in Logica, now part of CGI. This document may only be reproduced in whole or in part, or stored in a retrieval system, or transmitted in any form, or by any means electronic, mechanical, photocopying or otherwise, either with the prior permission of Logica, now part of

CGI or in accordance with the terms of the ESA Contract N:4000104924/12/NL/AD


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African Health for African Vitality in African Hands

Contents

1 Introduction ............................................................................................................................................................. 2

1.1 Purpose of the document ............................................................................................................................... 2

1.2 Acronyms and abbreviations .......................................................................................................................... 2

2 Background .............................................................................................................................................................. 3

2.1 Motivation ...................................................................................................................................................... 3

2.2 The eHSA Programme .................................................................................................................................... 3

2.3 The Governance study .................................................................................................................................... 4

2.4 Logica Consortium .......................................................................................................................................... 4

2.5 Approach to the Governance Study ............................................................................................................... 5

2.6 Study Logic ..................................................................................................................................................... 6

3 Main findings and output of the Governance Study ............................................................................................... 7

3.1 The need to strengthen Healthcare Systems ................................................................................................. 7

3.2 Engineering health processes to strengthen healthcare systems .................................................................. 8

3.2.1 eCare process ........................................................................................................................................ 9

3.2.2 eLearning process................................................................................................................................ 10

3.2.3 eSurveillance process .......................................................................................................................... 11

3.2.4 National Health Assets Map Management Process ............................................................................ 12

3.2.5 Supply Chain Management Process .................................................................................................... 13

3.2.6 Financial Management Process ........................................................................................................... 14

3.2.7 Infrastructure Management Process................................................................................................... 15

3.2.8 Performance Management Process .................................................................................................... 16

3.3 Addressing the needs for eServices: The service catalogue ......................................................................... 17

3.4 Fundamentals for a proposition of governance for eHealth services .......................................................... 19

3.4.1 Stakeholders’ analysis ......................................................................................................................... 19

3.4.2 Ensuring African Ownership ................................................................................................................ 20

3.4.3 Understanding the differences in health financing practices.............................................................. 21

3.4.4 Introducing the question of performance ........................................................................................... 22

3.4.5 Lessons learnt from eHealth experiences ........................................................................................... 22

3.5 The Four Block Governance Model for eHealth in SSA ................................................................................ 25

3.5.1 Governance of Stakeholders: National eHealth Cooperative.............................................................. 26

3.5.2 Governance of Finance: National Financing Pooling ........................................................................... 27

3.5.3 Governance of Services: Public Private Partnership............................................................................ 28

3.5.4 Architecture for a One Stop Shop for eHealth in Sub Saharan Africa ................................................. 29

3.6 Consolidation of the Governance Model ..................................................................................................... 30

3.7 Implementation Roadmap ........................................................................................................................... 32

3.8 Services Implementation Simulation ............................................................................................................ 34

3.8.1 Sample Results: Impact of eCare on Primary Health Care in Ethiopia ................................................ 35

3.8.2 Conclusions from the Simulations ....................................................................................................... 39

4 Conclusion ............................................................................................................................................................. 40


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1 Introduction

1.1 Purpose of the document This document is the Final Report for the Governance study which is part of the Satellite-Enhanced

Telemedicine and eHealth for sub-Saharan Africa Programme. The study has been managed by ESA, with

funding from the European Union Africa Infrastructure Trust Fund, and the Government of Luxembourg

through the Luxembourg Agency for Development Cooperation. This programme will hereafter be referred to

as the eHSA programme.

This report provides an overview of the three main volumes that document the outputs of the study, and

covers non-exhaustively the work packages in the statement of work. It presents more specifically:

The main findings and output of the study;

The key recommendations from the consortium;

The conclusions and perspectives.

1.2 Acronyms and abbreviations

AIDS Acquired Immunodeficiency Syndrome

CAPEX Capital Expenditure

CHW Community Health Workers

ESA European Space Agency

EHR Electronic Health Record

FAO Food and Agriculture Organisation

FBO Faith-Based Organisation

GDP Gross Development Product

GIS Geographic Information System

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HR Human Resources

ICT Information and Communication Technology

IDSR Integrated Disease Surveillance and Response

IHR International Health Regulation

IMF International Monetary Fund

ITF European Union-Africa Infrastructure Trust Fund

LuxDev Luxembourg Agency for Development Cooperation

MDGs Millennium Development Goals

MoH Ministry of Health

MHealth Mobile Health

NEPAD New Partnership for Africa’s Development

NGO Non-Governmental Organization

OPEX Operation Expenditure

PHC Primary Health Care

PPP Public Private Partnership

REC Regional Economic Community

SSA Sub-Saharan Africa

UN United Nations

USAID United States Agency for International Development

WHO World Health Organisation

4BGM Four Block Governance Model


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2 Background

2.1 Motivation

eHealth is the use of Information and Communication Technologies for health. These tools and services can be used by patients or by healthcare professionals, and serve to improve the quality and efficiency of current healthcare services.

Presently, Sub-Saharan Africa has:

25% of the world’s communicable disease burden

3% of the world’s health workforce 1% of global expenditures on

healthcare a population exceeding 840 million people 60% of its population living in rural areas.

As eHealth can be delivered from a distance, it is ideal for rural communities and those in isolated areas where it is difficult for patients to obtain medical attention. Sub-Saharan Africa is one such example where healthcare delivery is a real challenge due to the high population and disease burden when compared to healthcare expenditures and the number of healthcare professionals.

2.2 The eHSA Programme

The goal of the eHSA programme is to develop pan-African eHealth services, enabled by satellite, to benefit the sub-Saharan Africa region. These services are to be focused on education, clinical services, surveillance and management to the citizens and health workers in that region. The eHSA programme has been set up by the European Space Agency (ESA), working in collaboration with the Luxembourg Agency for Development Cooperation (LuxDev), and with the co-funding of the Government of Luxembourg and the European Union - Africa Infrastructure Trust Fund.

The six year long programme has been designed to meet the challenges, and to exploit the opportunities, presented by the healthcare situation in SSA. The programme focuses on activities towards the delivery of sustainable services on a scalable infrastructure. Prior to service implementation, four horizontal studies will be conducted across four thematic areas as illustrated in the Figure.

The four horizontal studies are cross-thematic and are considered fundamental to the success for the eHSA Programme. They address key issues critical to the successful implementation of any eHealth and telemedicine service. They will provide the backbone of the programme, and emphasise sustainability of infrastructure and services as the major goal. The infrastructure will also be open for services beyond eHealth and, in this way, contribute to the knowledge economy of the region.


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2.3 The Governance study

Governance generally comprises a wide range of tasks, including financial administration, aggregation and reporting of administrative data. Governance is concerned with quality, programme outcomes, informed decision making, efficient steering of multiple projects through continuous access to timely information, public relations, dissemination strategies, and advocacy for the new services.

The governance study aims at examining the basic conditions for implementing, by the governments or by private parties, eHealth and telemedicine services in sub-Saharan Africa.

Key tasks within the governance study include:

Analysing the required interaction among all the local authorities at district, country, and regional level;

Identifying the role and responsibility of stakeholders on various levels of the healthcare system, and, if needed, other entities;

Identifying and proposing a suitable governance model to manage the infrastructure from the thematic areas funded by the programme (eCare, eLearning, eGovernance, and eSurveillance).

The governance study is the very first stage of the eHSA programme. Its purpose is to pave the way for the successful delivery of the overall programme - i.e. to enable the development of a satellite-enhanced eHealth and telemedicine infrastructure for the sub-Saharan African region.

2.4 Logica Consortium

The Consortium for the eHSA Governance Study consists of a core team with expertise in Sub-Saharan health systems evaluation and governance of health systems. This is led by Logica who have expertise in all the required domains and a vision for the future implementation.

The core team combines extensive practical experience across the majority of countries in Sub-Saharan African, and scientific expertise from an ongoing academic research programme in health governance. The team also has links to key players in policy development and funding.

In addition, the consortium also has other partners who have extensive experience on the ground within Sub-Saharan Africa. These partners bring real case studies, as well as having links to private and public stakeholders and the wider African eHealth community.

Logica, is now part of CGI, a global IT and business process services provider delivering business consulting, systems integration and outsourcing services. With 72,000 professionals operating in 400 offices in 40 countries, CGI fosters local accountability for client success while bringing global delivery capabilities to clients’ front doors. CGI applies a disciplined and creative approach to achieve an industry-leading track record of on-time, on-budget projects and to help clients leverage current investments while adopting new technology and business strategies. As a result of this approach, our average client satisfaction score for the past 10 years has measured consistently higher than 9 out of 10.

Alter Santé Internationale et Développement, is a consulting firm created in 2000 by a group of health professionals with extensive experience in clinical and public health as well as health economy and socio-anthropology.

ESCEM is a French Grande Ecole of Management. ESCEM’s student population is around 2900 students

for MSc and BSc programmes with 70 permanent faculty members, 500 partner businesses and 13800

graduates.


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The African Medical and Research Foundation (AMREF) is an international African health development organisation. It consists of 500 professionals working with research, consulting and training across 37 African countries.

UNISA - the University of South Africa - is a higher education institution founded in 1873, with quarter of a million students from 130 countries, driving research in Governance and in Health partnerships in Sub-Saharan Africa.

CIDMEF is the International Conference of Deans of Francophone Medical Schools. Founded in 1981, it comprises approximately 140 Faculties of Medicine in 40 French speaking Countries. 27 of these universities are in Sub-Saharan Africa.

Le Kinkeliba is a non-governmental organization founded in 1995 and dedicated to providing medical, educational and economic aid to Eastern Senegal. They have created two health centres providing close to 15 000 consultations every year.

Merlin is a Charity which focuses on improving health in fragile states taking a long term approach. Merlin supports 1136 health facilities in 16 countries, including 10 African countries.

The RAFT (Réseau en Afrique Francophone pour la Télémédecine) is a telemedicine network that was developed by Geneva University Hospitals and that covers 17 African countries, including 15 in Sub-Saharan Africa.

2.5 Approach to the Governance Study The development of collaborative governance models was supported by Nobel Prize winning work carried by

Ostrom called “Governance of the Commons”. This is a branch of game theory that has been applied

successfully to create win-win outcomes where groups with differing individual interests must agree how to

use common resources. This approach has helped us ensure that public and private health service actors can

work together by identifying the reasons why previous governance models have failed before, and assist in

constraining adopters to accept and adhere to the agreed code of governance designed to maximise outcomes

for everyone.

Participation of African healthcare experts on a weekly basis has allowed to test and to validate the approach.

A community workspace was created as a repository for collected feedback and the results of stakeholder and

country-by-country health system analysis. It acts as a gateway to the tools used by the project team. This

portal is primarily intended to support the project team but it can be expanded and used in the future by the

eHSA community.

Baseline electronic models have been delivered with live toolsets giving an ability to enhance and expand these

baseline models for each country. The intention was that the community should be able to use and adopt these

models as open source templates for eHealth satellite enhanced processes, and that they will adapt, tailor and

take these forward for the future via a portal.

The adopted approach was designed to mitigate the risks and barriers to success:

On-the-ground understanding rather than a conceptual study: strong African participation of first movers and involvement of African stakeholders has prevented the risk of a purely conceptual study which is unlikely to deliver useable results;

Address the problem not the implementation issues: deep understanding of the technical complexities in eHealth systems, IT infrastructure, satellite communications, methodologies and modelling across the interlinked domains has allowed us to focus on the problem as well as to see a way forward for implementation;


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Gathering information sensitive to the wider political and financial issues: knowledge of the wider political considerations in crossing national and regional policy divides and the conflicts this may bring, has allowed us to extract the right information sensitively and confidently, reducing the risk of increasing the problem;

Understand local priorities to ensure take-up: good understanding of local level priorities has been key to addressing them at the appropriate level;

Consider the different players and drivers to ensure buy-in and appropriate governance: the consortium understood the drivers that public, private and charitable players have in this space and also appreciated the ongoing development of health in SSA. It was important to include all parties in order to ensure comprehensive buy-in.

Generic reference models for healthcare governance were captured formally in a business modelling tool and

iteratively refined and extended throughout the study, using real case studies provided by partners and the

results of questionnaires and workshops conducted with stakeholders. An agile development methodology was

applied, tightly bounding each task and work-package by “sprints” to ensure focus.

2.6 Study Logic In the first part of the study, referred to as Volume 1, an analysis of the current governance models and the

lessons learnt from these has been undertaken. This has provided a comprehensive and detailed analysis of

what is required in order to provide effective governance of eHealth in the view of strengthening health system

programmes in Sub-Saharan Africa.

In the second part of the study, Volume 2, the different aspects of Governance required to ensure African

Ownership has been analysed, and a number of different governance mechanisms has been evaluated to meet

these requirements.

In the third volume of the study, each of these different mechanisms has been brought together into a

consolidated governance model for eHealth in SSA that is aimed at supporting universal health coverage. The

aim was to provide a governance ‘framework’ that if instantiated with country-specific parameters and

executed correctly, can be used to ensure successful eHealth projects.


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3 Main findings and output of the Governance Study

3.1 The need to strengthen Healthcare Systems In SSA, most national health authorities face difficulties in operating health systems due to financial,

administrative, and management bottlenecks. Their regulatory role is also constrained by the multiplicity and

financial power of important stakeholders (donors, NGOs, private sector, etc.), and a generally insufficient

capacity to enforce regulations. SSA health systems are challenged by some financial, administrative, and

organisational distortions that constitute the main barriers to equitable and efficient healthcare service

delivery.

It is nevertheless increasingly recognized internationally that improved health status depends on the

development of equitable and efficient health systems and on better social protection of the population. As a

consequence, after a decade of disease targeted funding, many international initiatives and donors have

shifted priority to strengthening health systems in their most recent strategies.

Reference model for Healthcare system strengthening

Health systems have for a long time been a topic of analysis and research, and consequently analytical

frameworks are numerous. Our proposed eHSA health system reference model was previously developed by

Alter, based on the Building Blocks developed by the WHO in 2007, integrating a dynamic between blocks

inspired by the classic Donabedian model from 1966. It also takes into consideration recent recommendations

by the United Nations General Assembly and commitment by UN member countries, notably recommendations

from the 2010 United Nations General Assembly.

The figure below shows the attributes that should apply to health systems, which are:

• Legitimacy and equity of resource allocation; • Coherence and transparency of resource mobilization; • Responsiveness and continuity of service provision; • Quality, efficiency and coverage of health services outputs; • Health outcomes will only be achieved if synergistic policies are developed, and strong coordination is

established with other sectors.


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The section below summarizes the bottlenecks that were identified through the analysis of SSA healthcare systems.

Policy Making • Lack of harmonization due to aid fragmentation • Lack of national leadership and ownership • Unrealistic norms and planning • Lack of Regulation (private health sector mapping) Funding Mobilised • Underfinanced sector • Unpredictability of international aid • Imbalance between investments and recurrent costs needs • Important transaction cost due to aid fragmentation • Catastrophic health expenditures in households budget • Insufficient strategies to increase fiscal space to health Resources Mobilised • Lack of motivation of existing HR resources due to poor working conditions and inadequate salaries • Health worker migration or attrition • Uneven repartition or HR shortage • Lack of knowledge and skills adapted to local needs Services delivered • services (diagnostic accuracy, quality of care,) • Essential drug shortages due to poor management • Informal payment • Infrastructure and equipment maintenance problems due to lack of standardization/money/knowledge • Lack of accuracy, relevance and use of data collection • Lack of timeliness, responsiveness and integration of surveillance system Outputs produced • Low utilisation of public health available services (high costs, quality)

3.2 Engineering health processes to strengthen healthcare systems Process models were developed in which eServices form a central backbone, and support the strengthening of

healthcare systems. There were two main phases of design for every model relevant to this study:

• Understanding the issues, exploring the options for the design, and recommending a design to address the

health situation;

• Translating and documenting the recommendation from the initial design, ensuring that everything is

captured.

The eServices Value Chain

The Value Chain approach is aimed at:

• Aligning activities with the health sector with the agendas and drivers of all stakeholders;

• Lowering the barriers to eHealth by delivering benefits and externalities to enable the mobilisation of

resources.

The Value Chain consists of four core services that will achieve health outputs within eHealth services, along

with four support functions that support these main services. The following figure illustrates these services.


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eHealth Value Chain

The following sections describe the Process Identity Cards that were developed for each of these services.

3.2.1 eCare process

In Sub-Saharan Africa, most national health policies rely mostly on the Primary Health Care (PHC) strategy, which aims at offering an essential health care package to the population, at first contact and referral levels. Although costly, referral hospitals also play an important role in health care delivery, the organisation of staff training, and the delivery of priority programmes such as HIV/AIDS treatment and prevention. In all cases, care processes should go through a process of registration, assessment, diagnosis, testing, treatment, and referral as required. Regarding the referral level, which corresponds to secondary or tertiary hospitals, there is no agreed international definition of which specific services should be provided in developing countries.

At all levels of the health pyramid, there are important areas of quality improvement. The model should be adaptable to specific implementers, such as Non-Governmental Organisations, faith based health networks, private health providers in urban areas, or big companies providing healthcare services to their employees. These other stakeholders have indeed developed their own pathways in parallel to the public one, and may have their own objectives and policies. To help them target their own objectives while being as consistent as possible with the national policies would be exemplary in terms of good governance of health systems.

eCare Process Identity Card

Objective of the eCare process: To deliver better quality of health services and coverage

Principle: Patient centred remote expertise. The patient centred approach is defined as healthcare organized

around the needs, capabilities and desires of patients, with the goal of optimizing care, in part through greatly

improved use of data.

Input: The eCare process is triggered by patients consulting a care provider. A patient centred model may imply

that individual health information is available, and that critical information can be tracked through a patient

record system.

Output: Accurate patient diagnosis and prescription.

Key Performance Factors (KPF):

• Health guidelines availability

• Inter-connecting health practitioners,

• Drug availability

• Data confidentiality


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• Provider regulatory compliance

• Economic access to essential care package

• Trust and socio-cultural adherence

Key Performance Indicators (KPI): The following KPIs can be directly measured from the health facility routine

data recorded by the system:

• Availability of up-to date patient records, especially for chronic diseases (HIV, tuberculosis, diabetes, etc.)

but also pregnancy follow-up

• Treatment success rates (tuberculosis, AIDS, etc.)

• Percent of chronic cases (HIV, tuberculosis, others) or priority programmes (immunization, pregnant

women) “lost to follow-up”

• Percent of children with complete immunization coverage

• Hospital re-admission rate

• Case fatality rate for specific diseases

• Post-surgery infection and complication rate

• Rational use of drugs (use of national protocols, dosage, duration)

3.2.2 eLearning process

In order to improve population health outcomes and contribute to the universal access to healthcare, WHO and the Global Alliance for Health called, in 2008, for the scaling up of health workforce education in terms of quantity, quality, and relevance. In SSA the shortage of qualified health professionals is more acute than in any other region, and most qualified health workers are concentrated in urban areas where more opportunities are present. The expected output of eTraining is to improve the health workforce in terms of quantity, quality, and relevance, thereby contributing to the goal of health system strengthening. eLearning could help make the best of the scarce human resource, especially through task shifting from qualified staff to available mid-level workers, Community Health Workers (CHW) and in some cases, to patients themselves. The most important shift implies moving from centralized workshops to local eLearning. This strategy could contribute to lower absenteeism and improve continuity of care. The e-strategy for health workforce capacity building should account for key related human resource management issues (staff motivation, workload and organization of work), so as to be efficient and sustainable for the health system as a whole. eLearning cannot replace traditional training pathways (surgery for instance needs hands-on training, with a mentor’s physical presence). Last but not least, mobile phone use is spreading rapidly, with Africa exhibiting the quickest growth in the world. This provides an opportunity for mHealth applications at a large scale, including eLearning for quality patient self-care (self-medication, home treatment).

Educational and Learning Processes Identity Card

Objective: To increase relevant knowledge and skills among personnel involved in delivering health care or healthcare support services, thereby enhancing the overall performance of care delivery. Principle: Task shifting. The WHO definition of task shifting is: “the name now given to the process whereby specific tasks are moved, where appropriate, to health care workers with shorter training and fewer qualifications.” Input: The eLearning process is triggered i) by the decision at the strategic level of a MoH to update the knowledge of (a subset of) the health workforce, and ii) by the decision at an authorized training institution to provide educational content online. Output: The main output of the eLearning workflow is the certification that users (trainees) have successfully completed the course online. Key Performance Factors (KPF): While eLearning may help remove some barriers to learning (trips, costs, lack of trainers), some current barriers can hamper the development of eLearning. These include:


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• Staff motivation: The willingness to learn and to teach should be maintained by adequate accompanying incentive measures. Motivating health staff to learn may include financial incentives, or at least a scheme that would replace remuneration loss due to no longer receiving workshop per diems;

• Support to staff: Availability of training equipment, availability of appropriate infrastructure, availability of teachers and lecturers for eLearning programmes;

• Staff learning capacities: cultural barriers, staff literacy and limited command of training languages such as English or French, inadequate initial and basic training, health workers age pyramid, etc. can hamper the health workforce’s ability to adopt distance learning;

• Work organisation, time management, and workload have to be addressed at the same time, to ensure that eLearning is feasible and not detrimental to other important tasks if carried on-the-job. Time saving is a key issue.

Key Performance Indicators (KPI): • Number of eLearning programmes availed by national institutions • Number of trainees completing eLearning programmes: for priority interventions, for emergency

preparedness (link with eSurveillance), in specialist care and for healthcare key support functions (drug management, public health, accountancy, planning, etc.)

• Trainee satisfaction after eLearning sessions (gathered by feedback forms).

3.2.3 eSurveillance process

Communicable diseases remain the main burden of illness and cause of death in SSA countries. However, non-communicable diseases such as diabetes are already of great concern (a situation known as the African double burden of disease). At the same time, emerging or re-emerging diseases with pandemic potential first occur in developing countries. For global public health reasons, there is a growing interest among international donors to strengthen surveillance systems in resource-limited countries. Early detection of disease outbreaks of international concern is an opportunity for SSA countries to strengthen their surveillance systems for their own good, although substantial effort needs to be made to streamline the existing and often parallel data surveillance systems. The International Health Regulation (IHR) 2005, adopted during the World Health Assembly provides WHO member countries with the regulatory binding framework to organize their disease surveillance. To adjust for SSA specificity, the AFRO Region has adopted the Integrated Disease Surveillance and Response (IDSR) framework as a standard, with a technology level appropriate to the development of countries. Surveillance systems in most SSA countries lack integration because they have been mostly funded on a vertical programme basis. Conversely, routine surveillance through the health system has remained neglected. During the past decade though, the need to strengthen the routine data system has been widely recognized and increasingly supported. Strengthening the routine data system at all levels of the health pyramid, based on the national priority diseases list is a key to the development of robust surveillance. In addition, it would be of great added value to enhance multi-sectoral coordination, including putting into practice the “One world, one health” principle promoted by WHO, FAO, World Bank, and Unicef in 2010, as well as enhancing regional and international coordination. There is a need for more timely data collection, analysis, and response based on routine data systems. Networking sentinel sites with simultaneous use of appropriate ICT can enhance responsiveness of surveillance systems, and allow compliance with IHR requirements.

eSurveillance Process Identity Card

Objective: To provide information for early warning and successful intervention.

Principle: Integrated and timely surveillance. Timeliness is critical to allow rapid and effective response, especially for epidemic prone diseases. ICT enables timely data collection, analysis, and response.

Input: The process starts either from a clinical record or a lab record in a sentinel health facility, when a suspect or confirmed case of a disease monitored by the national surveillance program is reported. This can be either human, when records are compiled manually in health facilities, or automatic, when electronic medical records or registers are in place.


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Output: The system compiles cases, allows database formatting and data export to statistical software (e.g.

Epiinfo ®, SPSS ®, etc.), and generates alerts when thresholds are breached. Alert processing is human.


• List of epidemic diseases published (International Health Regulation requirement); • Epidemic thresholds defined and updated;

• Availability and accessibility of lab tests at different levels, including through a safe sample shipping

mechanism (IATA certified if air transport required) ;

• IHR compliance certification.

Key Performance Indicators (KPI):

• Reporting of notifiable diseases makes use of modern communication technology, and reporting of statistics from district to national level is web-based;

• At least 90% of health facilities/districts submit timely, complete, accurate reports to national level;

• All notified outbreaks communicated to WHO surveillance unit (IHR requirement).

3.2.4 National Health Asset Map Management Process

National health asset map management includes the development and presentation of a database, as well as managing decision making processes. The management of the national health asset map addresses the need to regulate the scale of the health system, thereby enhancing the pertinence and equity in asset and service distribution, ensuring their compliance with regulation, and steering their development or scaling-up. This enables an effective information system, mapping public and private healthcare providers and the assets they avail to their patients. The required information relates to location, population served, resources, assets, activities, and health outputs. A government requires good knowledge of health assets and their locations in order ensure equity in the distribution of services where discrepancies in availability already occur. Satellite imaging can be used to obtain fairly realistic population estimates when censuses cannot be conducted. The combined use of geographic information systems, maps and satellite imaging can help optimize the location of new health facilities, or implant new services in existing facilities based on population densities, relief, and natural obstacles.

National Health Asset Map Management Process Identity Card

Objective: to capture and rationalize/regulate the national health assets and services map. The purpose is (i) to

regulate the national health asset map to maximize equity in availability of the desirable combination of

facilities / beds, equipment, personnel, according to national policies and plan, and (ii) to plan the most

adequate location of new health infrastructure or services.

Principles: Harmonised management of health assets to develop a consistent health facility network.

Input: This process is triggered by:

• Periodic health facility reports on assets and staff;

• Reports and recommendations by MoH periodic inspection services;

• Reports by specific boards on facility accreditation;

• Decisions by relevant authorities on license to operate;

• Decisions by relevant authorities to scale-up national programs in a given area.

Output:

• Dynamic up-to-date health service database, possibly presented using GIS;

• Information on availability of assets and services to population;

• Data export feature for cross-matching e.g. with financing;

• Health facility served area analysis, based on topography and population location (provided via interface with adequate GIS).

Key Performance Factors:


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• Population data are reliable;

• Standards for National health assets are up to date;

• Health facilities regularly report on staffing levels;

• MoH health inspection services are functional;

• MoH has capacity to enforce decisions on license to operate;

• MoH planning department has the capacity to use GIS.

Key Performance Indicator

• Availability of health resources or key services (facilities, equipment, human resource, broken up by profession) per 10,000 pop, stratified by geographic / administrative area, with maps readily available to planners and regulators;

• Web presentation of key data up to date and for the largest part accessible by the public.

3.2.5 Supply Chain Management Process

Health care administration involves the management of consumable stocks, particularly drugs, medical, and lab supplies. Most public health facilities in sub-Saharan Africa suffer from poor management of consumable stocks. The context is characterized by: a multiplicity of financing pathways (in cash or kind); a disharmonious combination of “pull” and “push” logistics leading to frequent essential drug and consumable shortages; a lack of accountability towards the patients and to some extent institutional players; a lack of management capacities or willingness in relation to the importance of informal payments.

Improving healthcare administration in many public health facilities is thus a key challenge to delivering quality care. The proposed model has to account for the complexity of financial pathways and human resources constraints (capacities, incentives, etc.). The final objective is to enable a harmonised and well-managed flow of assets at the health facility level, in order to deliver quality services and accountability. In doing so it should streamline the existing processes, link activity data to financial data, and build a robust stock management system.

Supply Chain Management Process Identity Cards

Objective: Enabling a harmonized and well-managed flow of funds and commodities at health facility level to deliver quality services and transparently account for resources availed.

Principle: Streamlining the processes to link activity data (electronic registers as well as electronic patient records) to financial data and stocks. This can enable transparency, performance assessment as well as budget planning.

Input: This process is triggered by:

• Stock movement recording; • Payment recording; • Facility stock report requirement; • Facility financial report requirement.

Output:

• Accurate and regular reports on medical stock levels and shelf life by batch; • Drugs and Services delivered to Patients in timely fashion; • Accurate and regular reports on services delivered and value of those; • Accurate and regular report on facility income, and outstanding debts; • Accurate and regular report on budget situation; • Generation of regular report to authorities on assets, stocks, and finances.

Key Performance Factor (KPF)

• Standardized nomenclature for health acts available and updated; • Availability of at least two computers, one for finance, one for stocks. Finance and stock software can be

commercial provided that interoperability with platform is secured; • Availability of a terminal with virus security;


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• Availability of Internet with sufficient bandwidth at appropriate hours of the day to transfer data as required;

• Ongoing electricity supply to power the whole set.

Key Performance Indicator (KPI)

• Timeliness of health facility report on activity, assets, finances, and stocks; • Data accuracy showed by coherence of reported data with physical information obtained through audits.

3.2.6 Financial Management Process

Tracking financial flows from the different funding sources ensures that the national health plan is actually funded, and controls the scope of health services. In addition, tracking allocations across different sources may contribute to the reduction of funding fragmentation. This may incentivise sector contributors to pool funding, enhancing efficiency and compliance with the Paris Declaration. Similarly, linking expenditures to services or activities in the plan may not only contribute to improving transparency and accountability, but also to tracking the actual implementation of activities against plans. The implementation of the national health plan, once funding and resources are availed to implementers, is broken-up into periodic work programmes related to milestones in time. Monitoring the implementation of the national health plan entails benchmarking completed tasks against the time and level they were planned, and deciding whether related activities should be adjusted in scope, scale or time. A consolidated dashboard presenting the progress in implementation and expenditure to decision makers at the different levels, and flagging areas with deviation against a plan, is likely to enhance implementation of national health plans. Financial Management Process Identity Card

Objectives: The specific objective is to track funding flows from different sources from pledge to commitment and finally disbursement, and timeliness of those against plans. The general objectives are to better control fragmented funding systems, enhance fund pooling, promote alignment of aid, and coordinate implementation. Principles: Transparency, accountability, alignment of aid, efficiency of allocation, benchmarking Input: This process is triggered by: • Financiers (Ministry, donor, NGO…) pledging funding;

• Financiers committing funds according to calendar;

• Financiers disbursing funds;

• Health decentralized authority, implementing agent, or facility receiving funds from a given financier;

• Periodic work programmes in line with disbursement plan are entered into system by implementers and

validated by supervisory level;

• Adjustment is made to work programmes when deviation against plan is flagged.

Output:

• Periodic reports on pledges, commitments, disbursements, and their linking with planned activities or

services are available on line to principals, financiers and the public;

• Consolidation of plan and expenditure is made on the different domains of the plan;

• Transaction costs resulting from multiple agents in expenditure chain are highlighted;

• Dashboard flags deviation from revenue and expenditure plans in time or volume.

Key Performance Factors:

• Donors are willing to share their financial data with the system;

• Web based financial reporting in place at facility level (eAdministration) and with health plan

implementers;

• Plan funding recipients / implementers (public and private) adhere to presenting their funding requests

and expenditure reports in a standardised format;


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• Plan implementers at all levels can access activity update system with capacity to consolidate from paper

documents, and in particular district supervision;

• Significant funding in support to the national health plan is conditional to the use of the system, as a

demonstration of the political commitment to move towards e-governance.

Key Performance Indicators:

• Periodic reports on pledges and commitments (half-yearly), and disbursements (quarterly) are available

online to financiers, decision makers, and the public;

• Reports progressively include all funding sources.

3.2.7 Infrastructure Management Process

African health sector development records show that Governments were more successful in mobilizing funding

for investment in health, whilst mobilizing resources to run the system remained a challenge and increasingly

relied on users’ fees. This situation resulted in a CAPEX/OPEX imbalance leading to deterioration of health care

provision, and a decrease in health care utilisation. This means that it must be designed to be low cost in order

to be funded from the sale of medical services to the public. This low cost applies to all parts of the service

including the communications, computer infrastructure, software etc. Sustainability also implies balancing the

expenditure towards OPEX and away from CAPEX in order to support an easier and faster uptake of the service,

providing larger volumes and therefore lower cost. Infrastructure, databases and other components have to be

delivered as eHealth services.

There is really only one service framework that can realistically be considered to support this service delivery,

and that is Information Technology Infrastructure Library (ITIL) (APM Group Ltd). ITIL is a public framework that

describes best practice in IT service management. It provides a framework for the governance of IT, the ‘service

wrap’ that is focused on the continual measurement and improvement of the quality of IT service delivered,

from both a business and a customer perspective. It is used to manage the services, infrastructure on site,

hosting infrastructure, and remote monitoring of the in-country equipment.

Infrastructure Management Process Identity Card

Objective:

To deliver eHealth services to Sub-Saharan Africa.

Principle:

Deliver services from a pre-defined service catalogue based on the ITIL process model.

Input:

Access to eHealth service centre from eHealth staff and patients

Output:

• Delivered eHealth Services;

• Invoices and bills to medical staff and patients.


• Pay as you go model;

• Price of eHealth services including communication costs;

• Bandwidth availability for locations with a need;

• Usability and usefulness of the services – measured by promoting surveys via Portal;

• Availability of services;

• Responsiveness of service centre.

Key Performance Indicators (KPI):

• Service Availability;


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• Service Uptake;

• Service Prices;

• Service Complaints/Feedback;

• Service Response Time;

• Geographical distribution of services;

• Rejected Orders.

3.2.8 Performance Management Process

Launched at the turn of the millennium to pave the way to end poverty, the Millennium Development Goals

(MDGs) became the central development paradigm of the first decade. For health, the 2010 UN General

Assembly (United Nations General Assembly, 2010) adopted a more comprehensive approach, stressing the

need for social protection and the central role of health systems complementing the previous disease focus. If

the MDG related indicators are possibly insufficient or insufficiently relevant to assess the benefit of a health

project/program, the MDG spirit remains. Drawing lessons from the past and being aware of the strength of

the principle “what gets measured gets done”, health systems assessment and eHSA governance both require a

balanced mix of process indicators, so as to benchmark the development of a virtuous health system. In

coherence with the health system reference model developed in parallel to this one, a set of systemic

indicators is proposed, inspired from the most recent WHO-UN-World Bank joint reference document and from

literature review. The proposed monitoring framework can be used to assess both health systems

strengthening progress and eHSA relevance, hence complying with the Paris Declaration requirements. The

MDG-relevance model has been thus refined into a performance management process model.

Performance Management Process Identity Card

Objective: To monitor contribution to Health systems strengthening

Principles: National authorities need a responsive tool conduct a pilot of their national health strategy in a

timely manner. Despite a long list of desirable indicators often demanded by donors, governments have a

tough time instituting an accurate, standardized National Health Management Information System based on a

responsive routine health data system. This is partly due to a coexistence of several reporting pathways.

Inputs: Activities performed through others processes and associated key performance indicators.

Output:

Online dashboards, reports

Key Performance factors:

Baseline data to measure progress;

Data accuracy and timeliness;

GIS availability;

Data security and confidentiality

Key performance indicator:

Timeliness and accuracy of reports


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3.3 Addressing the needs for eServices: The service catalogue A number of process models were developed in which eServices form the central backbone. These processes

identify each eService and, through its context in the diagram, the type of service that it delivers. From these

process models an initial service catalogue could be extracted summarising each of these services and

categorising them based on their delivery mechanism. Each service is defined in order to support part of the

medical process.

The summary services are designed such that they can be costed and priced. Some services may be free, others

may be charged to the medical centre or hospital on a usage basis. In order to create a sustainable system, the

charges for many of the services may be passed down by the medical centre to the patient or medical worker.

These services have been expanded through the definition of the underlying functions that they support.

Distilling a Service Catalogue from the process models

Service Catalogue Functions

The section below provides a more detailed expansion of the functions in each service group. How these map

on to each service will be determined closer to implementation. This will be dependent upon the business

model and the way in which services are charged.

eCare

Patient identification, registration, and medical file management (Patient eRecords)

Appointment booking

Consultations and test requests recorded in a the department register

Capture and up load the patients’ test results (radiology, dermatology, cardiology, lab and pathology)

Off line / asynchronous remote second opinion or diagnosis from specialist sharing patient records

On line / synchronous remote support on consultation with audio or video conferencing sharing patient records

Send dispensing records, prescriptions to laboratories and pharmacies

Checking of prescriptions against good practice standards

Patient self-management of programme with mobile support (maternal care, chronic care etc.)

Patient satisfaction survey

Update of Programme registers

eLearning

Patient preventative educational care and disease management broadcasting accessible from health centres

Patient psychosocial support through social networking and/ or call centre service

Degree and skills training programmes for community health workers


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Health Workers social networking around practices

Degree and skills continuous training programmes for medical workforce

Degree and skills continuous training programme for administrative staff

Skills training programme for practitioners

Remote access to high-quality health information including current literature.

Scientific databases used by healthcare professionals for continuous medical education and research.

eSurveillance

Mobile capture and notification of tracked event

Notification of tracked events from e-records (mobile, register etc.)

Early warning systems (EWS) based on collected health & remote sensing m-data.

Real-time epidemiological analysis (epidemic charts) and threshold alert

Alert and response tracking system (signal-action / surveillance performance monitoring)

District morbidity and facility mortality notification (from patient or lab e-records or manual)

District morbidity and facility mortality regular reporting

Public health and disease reporting using GIS

National Health Asset Map

District population databases, based on census projections and operations e.g. vaccination campaigns.

Health Centre asset registration ( facilities, equipment, human resources, stock )

Human resources skills and degree management

Partners’ asset mapping using GIS

Budget Planning

What if scenario development

Health Centre and partners’ connection management

District health assets inventory using GIS

Case study and good practice data base

Financial Management

Service pricing and invoicing management

Mobile Payment

Cashier Management

Billing and accounting interface with accounting software

Interface with aid health projects settlement

Interface with national health budget / pooling and settlement

Interface with insurance / third party payer settlement

Interface with money transfer

Performance Management

Facility activity reporting based on department e-records or manual

Facility Process KPI management (dashboard comparing KPI in time)

Facility activity and resource use reporting

District Process KPI consolidation and management (dashboard comparing KPI in time and across facilities)


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Supply Chain Management

Stock Management with pharmaceuticals as first priority (see Initial spreadsheet)

Reporting on stock level and expiry

Automated warning or order when stock threshold reached

Shared stock management

Central purchasing

Infrastructure Management

Provisioning ICT infrastructure: VSAT, Wi-Fi, devices, etc.

Safe power supply (see Initial spreadsheet)

Broadband communications

Initial Training and online training

User Forum

Helpdesk

Maintenance of ICT infrastructure

Services Catalogue and Level management

Internet access

3.4 Fundamentals for a proposition of governance for eHealth services

3.4.1 Stakeholders’ analysis

Stakeholders can be defined as any group or individual who can affect, or is affected by, an organization or its

activities. This concept was developed as part of the discourse on Corporate Social Responsibility. A

stakeholder analysis is a technique or tool used to identify and assess the importance of key people, groups of

people and institutions that may influence the success of an activity or project. A stakeholder analysis for the

eHSA programme will enable the identification of everyone with a concern or interest in the programme.

The identified stakeholders’ categories are listed below:

Advocators are stakeholders who may not be affected by or involved in the project but have an interest in the outcome of the project. The main advocators for eHealth are WHO and ITU. Those organisations have jointly issued in 2012 a National eHealth Strategy Toolkit.

Financiers are involved in the managing and funding of health activities. These stakeholders are concerned with resource allocation in health activities. The main financiers for health in developing countries are the development agencies for international cooperation of the G20 countries. Those agencies are acting in bilateral aid for development or joining multilateral initiatives.

Regulators are policy makers and government agencies that can devise, pass, and enforce laws and regulations that may either fulfil the goals of the project or directly cancel them. They are involved in the drafting of existing and new legislation with regards to the project. The Ministry of Health is the domain regulator and policy maker. This should not lead to underestimate the importance of Ministries of Finance and Telecommunications

Suppliers are stakeholders who enhance access to essential medical supplies and services. The obvious suppliers for a satellite enhanced infrastructure are Satellite Operators including those with existing or future Ka-Band proposition. Key mobile operators are also to be considered to capture points of competition, or synergy, with the operational services from mobile banking and mobile health.

Beneficiaries include patients, patient communities and patient interest groups. This group of stakeholders will

be served by the project and stand to gain something such as services, skills, money, goods, and social

connections as a direct result of the project.


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Implementers are involved in the day-to-day operations and implementation of the project. They are also

directly involved with or responsible for the beneficiaries. They coordinate national activities in health projects

and hold official positions relevant to the project. Examples of implementers include nurses, doctors and

hospitals.

A fragmented power In the general context of health financing in Sub-Saharan countries it is important to note that each stakeholder has a piece of the fragmented power.

Stakeholders Piece of the power to develop and implement of a eHealth policy

Advocators Guidelines for health and eHealth policy

Financiers Grants and loans to finance the development of infrastructures

Regulators License to operate for health providers

Suppliers ICT resources to deliver eHealth services

Implementers Human resources to deliver the health services.

Beneficiaries Revenue to pay for health services

3.4.2 Ensuring African Ownership

The concept of ‘African ownership’ is rooted in the discourse on international cooperation and aid for

development. Consequently, this framework was used as a reference to conduct this part of the study. In

particular, reference was made to the international declarations on Aid Effectiveness which were signed in

Paris, Accra and Busan, respectively in 2005, 2008 and 2011. Donors and receiving countries have agreed on a

set of principles that are aimed to ensure effectiveness of development aid in achieving economic or human

development. Based on these principles, Requisites for African Ownership were established and applied to our

Governance Model for satellite-enhanced eHealth services.

RfO 1: The Governance Model for satellite-enhanced eHealth services must support the implementation of

existing national Health and eHealth policies.

RfO 2: The Governance Model for satellite-enhanced eHealth services must enable Sub Saharan African

countries to take a joint responsibility for the implementation of such services.

RfO 3: The Governance Model for satellite-enhanced eHealth services must facilitate the mobilisation and

utilization of national and local resources, people-knowledge-money.

What does Ownership means for each stakeholder category?

• For advocators, the African ownership consists in designing the eHealth platform to be a vehicle for

providing the guidelines for Sub Saharan Africa advocators;

• For Regulators the African Ownership consists in designing the eHealth platform to be a regional health

policy integration tool, and therefore, could be presented to the REC’s as such;

• For Financiers, African Ownership consists in pooling African and foreign sources of funding to finance a

health point of services;

• For Suppliers African Ownership consists in local sourcing to provision the health point of services;

• For implementers African Ownership consists in turning the current heterogeneity of health care providers

into regional federations of eHealth platform communities of users;

• For beneficiaries African Ownership consists in having local communities taking responsibilities in the

implementation of eHealth platform and governance.


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3.4.3 Understanding the differences in health financing practices

Developing appropriate services for eHealth to respond to the challenges that SSA countries are facing requires

a better understanding of their existing health systems. Although there is an undoubted acceptance of the

importance of eHealth in all these countries, its extent, forms, and related practices, may vary across countries

because of the different situations. At the moment, a systematic classification of health profiles in SSA is

lacking. It is, however, important to allow for relevant comparisons and avoid misleading generalizations.

Consequently, three country profiles were defined depending on their health financing practices. These

financing profiles are determined by the ratio of public expenditures and private expenditures for health.

Countries coloured in blue in the map below, have a public-oriented financing profile. A ratio of 70 / 30 %

(public / private) characterizes these countries;

In this second group of countries, coloured in red, this ratio is reversed. Private-oriented profiles clearly

show in the data on health expenditures;

The last group of countries, coloured in green on the map, is the largest group obtained. The ratio between

public and private expenses is here balanced, characterizing a mixed profile.

Differences in Health Financing Practices (2010)

Between 2009 and 2010, there is a global move of sub-Saharan countries towards mixed practices (green). It

can be explained by the fact that the WHO performed better data collection, but it also highlights a strategic

and key evolution in SSA countries. Health care systems are evolving towards more collaborative practices,

where public and private partnership may more and more be developed. Consequently, these countries could

be considered as good candidates for the adoption of a common e-service that is intentionally drafted for

them. Another interesting result of this comparison is that private and public models seem to form geographic

clusters. Public models are located in Central Africa, and private models in Southern Africa.


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3.4.4 Introducing the question of performance

Looking at the Human development index provided by the United Nation Development Program helps

understanding SSA countries levels of economic and social development. According to the African Economic

Outlook, sub-Saharan Africa’s gains in improving lives seem to come from all three dimensions of human

development. As a consequence this indicator has been chosen as a first measure of performance in the

countries studied.

The mapping provided in the figure below is crossing information concerning health funding practices, total

expenditures on health, external resources on health, household expenditures and human development.

Looking at the results obtained with this analysis, it seems that health funding practices can be significantly

associated to human development in SSA countries. The results obtained showed that public-oriented

practices, but also mixed practices are associated to high levels of development. Whereas private- oriented

practices are associated to weak levels of human development. Moreover, countries where external resources

to health are dominant will have more difficulties to reach high performance levels.

Health funding practices vs. Human Development

3.4.5 Lessons learnt from eHealth experiences

This part of the study draws learning from eHealth past experience, especially in developing countries, and

identifies eHealth best practice examples of good governance to guide the eHSA project’s future

implementation. The health systems reference model and attributes, introduced previously, were used as an

analytic tool to screen the best practices candidates. Case studies were assessed in terms of (i) adequacy with

the national policy making (legitimacy and equity), (ii) financial coherence and transparency enabler, (iii) in


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terms of responsiveness and continuity of eHealth services, (iv) in terms of quality, coverage and efficiency

enabler, and (v) in terms of health outputs and outcomes produced.

All in all, our analysis methodology assessed more than 120 eHealth case studies either through published

articles or through available eHealth reviews.

Output from the literature analysis

The following table synthesizes the review of literature analysis from this governance perspective.

Governance

criteria Governance analysis

Legitimacy

Most reviewed eHealth projects have adopted a narrow point of view (medical specialty,

specific disease) and not from a HSS point of view especially at early stage of

telemedicine development;

Most telemedicine projects are often driven by out-of-the country stakeholders (lack of

national ownership);

The majority of eHealth projects are at pilot stage, no scaling up;

Projects are mostly donor or aid –broker driven, with a lack of country-led process;

There is no structured knowledge transfer to influence decisions or policy making to

influence future eHealth implementations.

Equity

Most long running telemedicine projects are medical specialty related and have little

impact on general population;

The focus on PHC activities is a more recent and rising trend though, thanks to the

alignment on MDGs;

There is a risk of resource shift.

Coherence

We see duplication of efforts, investment fragmentation, overspending and no

interoperability;

eHealth and mHealth services are mostly donor driven pilot projects;

Multiple financers and stakeholders are difficult to harmonize.

Transparency

There is a lack of financial data in most pilot projects;

Synergies between mobile financial services and health are emerging and could bring

more transparency (e.g. tracking of health financial flows).

Sustainability

Almost all projects are facing financial sustainability problems: even some of the more

successful pilot projects are dropped because of a lack of continuous funding;

The first generation of telemedicine projects that were developed and tested were too

expensive to be widely adopted in resource-poor settings;

There is no evidence of sustainability for the most recent mobile technologies, which are

still at an early stage of implementation.

Responsiveness

The first generation of eHealth projects mostly dealt with hardware and faced

implementation problems;

The mHealth revolution is enabling better conditions for success, with the development

of technologies that are more flexible, less expensive and that require less maintenance;

The human resource management aspect for ICT user’s acceptance should not be

underestimated.

Continuity Most telemedicine projects have used asynchronous technology due to low bandwidth


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Governance

criteria Governance analysis

constraint, while users call for synchronous;

We see interoperability issues;

There is a dependency on energy source to power IT.

Quality

The proliferation of Health Information Systems, brings about the duplication and

incompatibility of collected data;

eCare: the first generation of solutions using hardware and technology are too complex

or not adapted to local conditions;

eLearning: there is a problem of inadequate learning content;

eSurveillance: the increased workload related to data collection is a problem in a context

of health workers shortages.

Coverage

Acceptability from both providers and patients is a challenge. This is linked to habits,

cultural barriers and human resources competencies;

Low network and bandwidth availability is often a problem.

Efficiency There is no evidence of cost-effectiveness benefits;

eProcesses are time consuming and may shift time from provision of health services.

Health outputs Only theoretical benefits are established but there is little evidence of effective outputs;

There is an estimated 30 to 80% of failure for ICT projects;

There is a lack of sound evaluation and planning;

There is a lack of dissemination of findings.

Health outcomes There is no real assessment attempted by eHealth project;

We see difficulties to provide evidence of health outcomes.

Highlights

• First and regardless of governance criteria, it is noticeable that there is a high failure rate in eHealth/ICT

projects in both developed and developing countries;

• A very important number of eHealth projects are being carried out, especially in low and middle income

countries, but, there is still no or little evidence of health outputs or health outcomes;

• Mobile technology is booming in SSA. This is promising for the health sector, as it is likely to provide huge

opportunities to overcome some of the previously identified health systems difficulties, such as lack of

infrastructure, lack of maintenance, difficult medical referrals, lack of competences, etc. However, some

difficulties, such as workforce shortage may turn out to be more of a barrier than an opportunity if not

properly addressed;

• Many reasons for ICT projects failures are actually not health sector-specific, but are related to

implementation difficulties, especially due to underestimating the human factor;

• What is most striking is undoubtedly a lack of financial sustainability of almost all eHealth projects, even

when successful. Financial sustainability is indeed a critical issue in a chronically and deeply underfinanced

health sector, when compared to the population needs, and to other sectors (e.g. business, industry, etc.);


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• As a consequence, systemic thinking is necessary to build useful, effective, scalable and sustainable

eHealth solutions. In a context of a generally narrow-minded plethora of eHealth pilot projects, the added-

Value of eHSA program may lie in a systemic intervention, even though this is to be piloted.

Stemming from literature review, the major recommendations for the governance of future eHealth Services

are the following

• Adopt a Health System Strengthening point of view;

• Carry out a e-readiness assessment and do not underestimate the risks for failure;

• Respond to health providers and patients priority needs by starting with a needs assessment;

• Avoid shifting time and scarce human resources to the detriment of essential healthcare services;

• Give immediate and high priority to financial sustainability;

• Do not miss the opportunities in relation to the rapid growing of mobile technology;

• A simple solution is more likely to succeed;

• Keep focus on measurable health outputs, starting with a baseline assessment;

• Establish and prioritize within-country eHealth networks in articulation with regional or international

networks;

• Be aware of the unavoidable difficulties inherent to the important number of stakeholders and the highly competitive market.

3.5 The Four Block Governance Model for eHealth in SSA

The following part introduces our proposition for a National eHealth Governance. This proposition is built on

the analysis of SSA Health Systems and has been enriched with the lessons learnt from past eHealth

experiences. It was designed to address national goals for Health.

Our proposed approach aims at guiding the implementation and governance of national eHealth Strategies

across Sub-Saharan Africa, focusing on strengthening the health system to achieve national health coverage,

while ensuring a strong local anchorage and African ownership.

The model is founded on four building blocks that are to be implemented in each country for a transition

toward universal coverage supported by eHealth. The four governance components that are addressed are:

Governance of ICT

Governance of Service

Governance of Finance

Governance of Stakeholders

The Four Block Governance Model


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The strategy will consist in implementing those blocks along a roadmap. Each block is grounded by a tangible

governance mechanism to operate in the country reality.

3.5.1 Governance of Stakeholders: National eHealth Cooperative

The mechanisms and organisational structures that are to be used in order to co-ordinate the Stakeholders

were defined so that they can govern the eHealth services within a country. The model is based on a

cooperative society which is a model that can deliver collective action and local ownership. The characteristics

of the cooperatives make them strongly anchored in the communities. They can represent a powerful lever for

the participation of communities in health development.

As members of the national eHealth Cooperative, healthcare providers would manage the common use of the

satellite-enhanced eHealth platform, as a national common asset. This means defining collectively a strategy

and a pricing model, and orienting the evolution of services provided in the Services Catalogue.

More precisely, some the National eHealth cooperative will have the following characteristics:

• It objective is to manage the collective usage of the common e-Health production asset;

• The general assembly is the main decision organization, with the principle: 1 member= 1 vote;

• The members are represented through regional clusters and cluster delegates;

• The active participation, sharing of information, and responsibility are conditions for membership;

• External stakeholders such as industrial leaders, financiers, suppliers, advocators, regulators and

beneficiaries, are consulted via the Stakeholders Consultation Forum;

• Adopting a set of common Values and Principles, and complying with a Code of Governance.

Proposed organization for the national eHealth Cooperative


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3.5.2 Governance of Finance: National Financing Pooling

In order to develop a sustainable service it is important to determine how the OpEx required to pay for the

eHealth services will be secured. Governance of Finance is the mechanisms for securing the OpEx funding from

Governments and from private organisations in country. Securing revenue to support OpEx is therefore

imperative in providing a sustainable service. So providing a mix of OpEx and revenues from different sources

will provide the best opportunity for success.

Pivotal to the governance model is the existence and the use of National Health Financing Pool. The National

Health Financing Pool will be the body used to collect Opex from public private partnership to subsidise the use

of eHealth Platform and support a national health policy formulation and implementation.

The figures below illustrate the proposition for the Governance of Finance.

OpEx Flow Revenue flow generated from regulated pricing

The OpEx provided from development aid and public money is part of the mechanism to achieve sustainability

of the model. The main long-term source of revenue for the financer is the revenue derived from delivering the

service. Patients and Health workers will continue to pay directly to the local health provider on a cost-sharing

basis for regulated eHealth services. The local Health providers will pay per use for the eHealth services

delivered to patients (care and learning) and to health workers (learning). The sustainability of the structure

and the long-term business case requires that all pricing must be regulated to provide competitive pricing and

visibility for Financers. All of this is to be organised in line with the National government.


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3.5.3 Governance of Services: Public Private Partnership

With the stakeholders in place, and the OpEx secured, the service will need to be developed, rolled out and

delivered. To do this a number of companies and suppliers will need to be put in place together with the CapEx

funding to procure the assets and start up the services. Allied to these companies is a governance structure

that flows down risk and finances in a controlled manner. The structure will support the raising and securing of

CapEx together with the revenue streams that will allow a return on this investment to be generated.

Since CapEx will need to be raised and secured it is important that a tried and tested industrial model is used to

deliver the services. In fact, this is the only mechanism that will be tolerated by the financiers. The model used

for service delivery is shown in the figure below.

The Service Delivery Approach

This ownership model fits well with a Public Private Partnership (PPP) funding model. The Special Purpose

Company secures the finance and owns the relationship with the financial organisations. The ring fencing of

risk provided by this model is often a prerequisite of financial organisations investing in PPP.


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3.5.4 Architecture for a One Stop Shop for eHealth in Sub Saharan Africa

The delivery of services is through a mixture of people, process and technologies which also need a Governance

framework which is described here. Our proposition is to design, build, implement and operate a common

decentralised satellite enhanced ICT infrastructure for health to deliver a ‘one stop shop’, ’pay per use’, ‘e-

services catalogue’.

A One Stop Shop would provide:

• Communications and IT;

• Services and Applications;

• Interoperability;

• Community (users’ network);

• Usage based payment.

The benefits for this would be a lower cost, a more widespread use, standardisation, improved health

outcomes as well sustainability. In order to make it simple, robust, secure, evolutionary and at a low cost, the

following design features are proposed for the technical architecture;

An initial physical architecture has been designed and is shown below.

Physical architecture


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3.6 Consolidation of the Governance Model Consultative meetings in Nairobi, Kenya and in Dakar, Senegal, initiated a phase of workshops where the

developed model was presented to the stakeholders. The aim of this phase was to consolidate and firm up the

4BGM against stakeholder’s drivers and objectives.

A method was developed to rationalise the consolidation by checking the features of the 4BGM with each of

the stakeholders. Where necessary the model was the refined from the. However, in the health financing

context of sub Saharan countries this method would miss an important finding: each stakeholder has a piece of

the power to develop an eHealth policy, as listed below. The fragmentation of the power to consistently

develop a policy is correlated with the economic situation of the countries: 40 Sub-Saharan countries are

eligible to international development aid (based on per capital income and lack of creditworthiness criteria).

Hence an effective way to consolidate the 4BGM was to check with representatives of each stakeholder

category that it contained incentives to trigger their support.

Advocators: The 4BGM was introduced to the WHO’s department in charge of eHealth: Department of Knowledge Management and Sharing. The 4BGM is complementary and would be part of a National eHealth action plan. Those organizations were invited to our consultative meetings. Financers: The 4BGM was introduced to representatives of United States Agency for International Development, Canadian International Development Agency, French Development Agency, Department For International Development (UK) and African Development Bank. Regulators: Representative for Kenya and Senegal Ministries of Health joined the consultative meeting in Nairobi and Dakar. Some Regional Economics Communities are developing coordination in the area of health: East African Community and Economic Community of West African Countries. The representative of East African Community joined the Nairobi consultative meeting. Suppliers: Satellite Operators with existing or future Ka-Band proposition were approached to introduce the concept of developing a virtual network for eHealth. At the same time, the key mobile operators in West and East Africa were approached to capture points of competition, or synergy, with the operational services from mobile banking (financial transactions through a mobile device) and mobile health (practice of medicine and public health, supported by mobile devices). Suppliers and Implementers are part of the consortium. Beneficiaries’ representatives were not approached as they were not in the scope of the study. The result of this consultation is summarised in the following table listing the expected benefit for the

stakeholders’ category and the associated enabling component of the 4BGM.

Stakeholders Expected Benefit Enabling Component of the solution

Advocators A channel to spread Guidelines Service Catalogue to broadcast best practices

Financiers An instrument for country’s structural reform

PPP to manage governmental commitment

Regulators A ready to use health policy implementation tool

Satellite enhanced infrastructure and stakeholders forum to manage collaboration

Suppliers Providing low risk business opportunities

A guaranteed pricing to secure business

Implementers Accelerator of the implementation of projects.

Low cost and country large services to support operations

Beneficiaries Universal Health coverage National health pooling to develop third party payment mechanism.


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However a consultation is not committing. A real case of implementation is seen as the best means to validate stakeholder’s attitudes asking for an official corporate position and commitment. As a consequence the table below suggests a way to test the willingness of the stakeholders to support a trial period of the model in a country.

Stakeholders Attitude Test of willingness to support

Advocators Positive as long as the project objective an deliverables are adding to the plea and not crossing existing actions

Propose to join a fertilisation project as

observers attending to the steering

committee of a country trial project. Ask to

provide guidelines to be used by a

fertilisation project

Financiers Positive as long as the project is demonstrating its integration with the country strategy and the request is coming from the country with strong socio economic rational.

Propose to fund a trial and join the project steering committee.

Regulators Positive as long as there is a third party funding and the MoH is seating at the steering committee of the trial.

Propose to suggest a panel of health centres for the trial and fund a dedicated team to the project management.

Suppliers Positive as long as the cost of business case development is supported by the trial and promote new or existing product development.

Propose to a panel of Satcoms to contribute in kind to the trial project in their region of competitive advantage.

Implementers Positive as long as the trial is supporting the development of operations and not creating long term dependency.

Propose to join the trial project in association with public sector.

Beneficiaries Not covered in the scope of the study. Propose to representatives of the communities covered by the trial project to the steering committee as consultative stakeholders.

Apart from Consultative Meetings with countries representatives, and one-to-one meetings with selected

stakeholders, the process of consolidation also included a sanity check of the model with the Sub-Saharan

countries situations, and lessons learned from existing eHealth initiatives.

Output from the consolidation process The consolidation process did not change the structure of the model; it allowed it to be clarified, refined and

completed.

It has aligned the 4BGM to enable universal coverage for a country willing to reform its health system. It does

this by providing geographical and financial access to health services.

The national eHealth cooperative, and the national health pooling, contribute to lowering the barrier to health

by regulating pricing for health services and developing payment mechanisms.

The national common infrastructure and the public private partnership, contribute to lowering the barrier to

health by setting up an infrastructure allowing the health sector to develop.

The major changes that were applied to the model during the consolidation process:


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• The national health financing pooling, initially designed to be a tool for monitoring activities based

funding, is extended to mobile payments and third party payments;

• The national eHealth cooperative, initially designed to be a collaborative tool for members enforce the

role of the stakeholder’s forum, is now also used to support the Ministry of Health to manage the

eHealth strategy implementation and regulation;

• The national common infrastructure, initially designed to mobilise CapEx to finance infrastructure and

subsidise the use to break even, is now also seen as a mechanism to pass ownership to the country on

a time frame depending on the economic situation.

The 4BGM has been developed to support the governance of a national eHealth strategy for sub-Saharan

health systems.

The consultation process helped to understand that the governance model has to be deployed and used in a

country of each targeted Regional Economic Community for a trial period. This is reflected in the section

presenting the implementation roadmap.

3.7 Implementation Roadmap

The recommend four blocks governance model is an instrument to reform the various national health systems

towards universal health coverage. Therefore, an implementation roadmap was created to capture the various

emerging or ongoing national health strategies. Furthermore, this implementation roadmap will help

leveraging or to create stronger synergies between the Regional Economic Communities (REC) health policy

development. RECs are natural and realistic paths for addressing Sub-Saharan Africa. The nature of the

governance model structures the implementation strategy.

Developing a RECs strategy

If one takes on the RECs’ road, the approach consists of developing a repeatable regional approach. This

consists of starting with the selection of a country for the initial trial and then roll-out to the adjacent countries

for the dissemination of the governance model. Dissemination strategy is all about the creation of a reference

success story - a show room, with a first country and to stimulate adjacent borders stakeholders to apply this to

be rolled out into their own countries: developing a regional strategy. The dissemination strategy is about

triggering the desire of the countries to adopt the governance model as a result to create a dynamics of

adoption amongst stakeholders. The figure below illustrates the suggested scheduling for a regional adoption.

5 year regional adoption plan

Year 1 Year 2 Year 3 Year 4 Year 5

3 years Regional Trial

Country 1 Regional Roll Out

Country 2 Regional Roll Out

RECs’ Scheduling


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Addressing Sub-Saharan Africa

The aim is to create specific regional eHealth fertilisation experiences that respect the cultural diversity and the

various socio economic conditions of the RECs. The baseline governance model is subject to regional

adaptation and to countries’ readiness to manage a common infrastructure. Therefore, it may not achieve the

same goals at the same time frame: setting ambitions. The countries’ diversity will set the level of regional

goals. However the selection of the best suited countries for the trial is a key success factor in addressing Sub

Saharan Africa.

For each REC a country ranking is provided. The ranking indicates the most likely country to start with a trial to

properly develop a RECs adoption. The ranking methodology consisted in evaluating the “regional” impact of

implementing the governance model in that country and the adherence of the country to the governance

model.

• The impact factors are those that amplify the impact of the Trial in the region. For example, a high impact

country is the one that: has the largest population, the lowest human development indicator, the largest

international aid, the deepest digital divide and the better World Bank public rating;

• The adherence factors are those that will make the implementation of the governance model easier. For

example, a high adherence country is the one that: has already his health strategy assessed, has an

international aid pooling in place, has a governmental eHealth strategy, a broadband strategy formulated,

it has an eHealth society and a mixed (public and private) health financing system.

The selected countries for regional trials are:

RECs Countries for

Trial

Population

(000)

% pop >50km

fibre node

Language Religion Health

System

Horn of Africa Ethiopia 82,950 46 English Orthodox Mixed

Great Lakes Tanzania 44,841 44 English Muslim Public

Southern Africa Mozambique 23,391 39 Portuguese Catholic Public

Indian Ocean Madagascar 20,714 51 French Indigenous Public

Central Africa DRC 65,966 81 French Catholic Private

West Africa Burkina Faso 16,469 50 French Muslim Public

Creating events along the service introduction phase

Operating at Sub-Saharan Africa scale requires an overall coordination to impulse RECs strategies and to

manage international stakeholders. Major events must be organised and planned across various RECs with key

milestones for a Sub-Saharan dissemination strategy. The programmatic approach commands a centralised

communication and animation toward pivotal stakeholders. The following picture illustrate that event to create

will be feed by the campaign milestone.


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Three Year Dissemination Campaign

3.8 Services Implementation Simulations

In order to provide reality based service implementation simulations, it has been necessary to carry out initial

desk research in order to gain real information of situations faced by each country being selected for regional

trials. Using information such as the organisation and state of the country’s health system, the organisation of

the healthcare delivery system, distances between facilities and staff numbers at each facility has allowed

baseline ‘as is’ simulations to be run. The models are run for two separate years – Yr 0 is the ‘as is’ state, and

yr3 is an expected state 3 yrs after implementing eHealth services.

As Yr3 figures are projecting forward to a situation that is not yet in place, there have been assumptions made

in order to run the simulation. These are clearly stated, and the parameter values that have been used to

operate the simulation are available within the appendices. Partners within the consortium have been used to

validate the scenarios and assumptions where possible.

All Simulation models are being run on Bonitasoft Open Solution v5.7.2, and the simulation models are based

on v2.6 of the agreed models.

Partial view of a simulation model on Bonitasoft

Year 1 Year 2 Year 3

SSA eHealth Campaign Kick Off

Announcement of the first country

trial

Opening the first National eHealth

Portal

Regional for Purpose Holding

National eHealth Cooperative

National eHealth Pooling

RECs Scheduling Review

Announcement of the first country roll

out

SSA eHealth Regional

Conference

Announcement of the second country

trial

Ongoing participation to SSA eHealth related events and communities animation


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Simulation parameters

Gateways: For each gateway, there are exit points, and in terms of the simulation, probabilities are assigned to

these for which way the workflow would exit. For example, in the first step of eCare, there is a gateway for the

patient going either to the community or the primary health facility. For Tanzania, this is set at 50% for each

option, as this is a reflection of what could happen. For Ethiopia, however, there are a small number of health

outposts and so it would be more likely for the patient to go to the Primary Health Facility, therefore the

possibility is set at 10% for Community and 90% for Primary Health Care Facility.

Tasks: There are two aspects of tasks that can be parameterised: durations and resources. The duration of a

task is set to estimate how long the actual task will take. The number of resources assigned to that task does

not necessarily decrease the time taken, but do allow more parallel tasking to take place.

Timers: Timers are events that are placed between tasks that allow a delay to be introduced between the

completion of the previous task and the commencement of the next. This allows simulations to be more

accurate, for example, for the time taken to travel between the various centres in the health system.

Load profile parameters: Parameters can also be set against different load profiles. A load profile is a way of

injecting the expected number of scenario instances into the simulation.

The results obtained by the simulations are presented in terms of graphs that show process time, process

execution time, and utilisation levels of the resources used in the simulation parameters. The following graphs

are shown:

Instances Execution Time: execution time in hours vs. date;

Time by Instance: minimum, average, and maximum execution times calculated over all iterations;

Resource Utilization by instance: minimum, average, and maximum resource consumption or usage by

percentage, as compared to the total available.

3.8.1 Sample Results: Impact of eCare on Primary Health Care in Ethiopia

Scenario

Dangila Health Post, Ethiopia

This scenario concentrates on the Ambassel Woreda (121,889 inhabitants) in the Amhara Region (154,709 sq

km and 17,221,976 inhabitants). Within the Amhara Region, there are 17 hospitals, 520 Health Centres and

2,941 Health Post. The scenario focuses on the Dangila Health Post in the town of Dangila. It is supported by

the Bahir Dar Health Centre in Bahir Dar, which is a 15 hr walk away. The referral hospital, Felege Hiwot, is also

situated in Bahir Dar and is 2.2 Km from the Health Centre. The nearest Zonal Hospital is in Addis Ababa, which

would be over 5 day-walk away. There is one Community Health Worker at the Dangila Health Post, but there

are no Health Extension Workers, as this has not been implemented in this region as yet. Within the Health

Centre at Bahir Dar, there 8 Nurses, 2 midwives, 1 pharmacist and 2 lab technicians.

Year 0 assumption: The baseline Yr0 simulation is assumed to take place at the start of the Region looking to

implement eHealth Services, and a baseline being run to establish metrics against.

Year 3 assumption:

• eCare: Patients records are now held electronically, and synchronised twice a day with the Bahir Dar

Health Centre.

• eSurveillance: Broadband links are established between the lower levels and highest levels in the health

system. Workflows and business logic are implemented into the laboratory systems, and non personalised

electronic health records are sent regularly.


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• eLearning: The course is now being delivered electronically. It assumes that the nurse still works during the

day, and completes the course in her own time.

• National Health Assets Maps: Paper records are still kept by the Health Post, but these are double keyed

into the electronic system at the Health Centre once a week. Both Bahir Dar and Felege Hiwot are now

connected, and are sharing electronic health records, pharmacy stocks and asset lists.

Simulation Results

This simulation focuses on Bahir Dar health centre and the Referral Hospital.

Year 0, with focus on doctors, nurses and lab technicians

As expected, there are a number of areas where resources are being utilised to their maximum, which provides

a good indication of the real state of the Ethiopian health workforce. It is important to note that in all of these

simulations, there is a dip at the end of the utilisation graphs, where the preset number of instances is

completing, and therefore utilisation is dropping. In reality, it would be expected that the utilisation patterns

would mirror those in the main part of the graphs.

The Doctor’s utilisation follows a familiar pattern as well, in that the simulation is started ‘clean’ i.e., there are

no tasks already in progress. As the simulation runs on, however, the more tasks and the more patients the

doctor is required to see, and it becomes clear that there is no space capacity. Indeed, with the flat line at the

100%, this indicates that the doctor is over utilised.

The same pattern emerges for the Laboratory Technicians, in that although there are spikes in utilisation, they

become over utilised by the end of the month.

However, what is interesting about the Nurse’s utilisation figures is that it appears on this scenario, the nurses

are only half utilised, and there is spare capacity. This would be one area to bear in mind, as it shows that

nurses could be trained to perform more duties, and relieve some of the burden without requiring more staff –

the notion of task shifting.


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As it can be seen from the time factor, the increase in time taken to execute the process increases in a linear

fashion, as resources become over-utilised. This is also borne by the fact that the simulation took 336 days to

complete the 1000 instances. This is, in part, due to the simulation parameters that take into account all

options open in the workflow.

Year 3 with focus on doctors, nurses and laboratory technicians

In this simulation, eHealth Services have been implemented for two and a half years. The first difference to

note is that, almost without exception, the utilisation for the resources has decreased to manageable levels.

This now allows future HR planning to be carried out for how best to use this capacity, but one clear option is

the change to increase the number of patients seen.

The second point of note is that the resources still show the dip at the end of the simulation, this is more

pronounced with the utilisation levels being more manageable. This is still attributed to the limitations of the

simulation rather than what would be expected in reality.

The utilisation for the doctors has decreased to manageable levels without increasing the headcount at the

facility. It is believed that the following aspects of the eHealth Service contributed to this in the simulation by

changing the parameters:

Electronic Referral systems using broadband to obtain a second opinion from peers;

Reduced time in writing prescriptions;

Reduced time having to run the same tests, as EHR’s have the information on screen for all previous

interactions;

Task shifting, with nurses being able to carry out more administrative tasks


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The utilisation for laboratory technicians has decreased due to Remote Diagnosis being introduced to be able

to images to specialists quicker.

Although this time for running the processes overall is increasing, it is increasing at a much slower rate than at

Yr0. In addition, with more capacity within the health centre now, it would normal for HR planning to be

introduced in order to forward plan, use the resources more effectively and reduce further the time taken to

complete. The time taken to complete the processes has reduced substantially to 120 days. This means that

there is potential for more patients to be seen.


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3.8.2 Conclusions from the Simulations

As can be seen from the results, the main interventions and enhancements that can be measured as outputs

are the reduction in utilisation of existing resources and reduction in time for the current processes. These

benefits, in turn, allow more planning and proactive services to the community and the eHealth

implementations progress, they are expected to be continually monitored, reviewed and adjusted as necessary.

As has also been demonstrated are those outputs that are not able to be simulated through a business process

toolset. Areas such as the joining of information thought Electronic Health Records, removal of areas of

potential error, such as double keying paper based records into computerised systems, and remote diagnostics

are all benefits of the eHealth Service Implementation.

What will be crucial to the implementation of the eHealth services are not only the selection of the correct

services to implement, but also the correct order to implement it, with the full understanding of the benefits

expected for that particular implementation. For example, in the case of Tanzania, the implementation of

EHR’s and Remote Diagnostics do not, by themselves, suddenly produce a large decrease in utilisation.

However, by implementing EHR’s, then data quality and better information flows through the systems are

started, upon which eSurveillance can be implemented at a later date. It is the synergy of the services together

that provides their strength. The models that have been constructed during the Governance Study are now

able to be used to realistically model implementations within specific regions in countries. The parameters

used are able to be changed in order to more realistically represent the situations that are required to be faced

in implementations.

This work is a successful demonstration of a tool and associated mechanisms to perform impact simulations of

eHealth services at a very low level of granularity. To take these impact simulations at a next level, there is a

need for gathering real improvement parameters and using a higher number of scenarios to be collected on the

field. In other words, the limit of the “laboratory” study has been reached, which clearly motivates the

initiation of a trial period projects.


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4 Conclusion

E-Health for Sub-Saharan Africa: Taking up the challenge with satellite technology.

The journey of the governance study started with a number of key questions:

How can satellite skill up 3% of the world’s health workforce?

How can satellite bridge the health divide for 60% of the SSA population living in rural areas?

How can satellite grow the SSA share of only 1% of the global expenditures on healthcare?

How can satellite serve a population exceeding 840 million people?

The answer is not about technology, it is about people and systems. The approach is not about implementing a

new age solution; it is about stimulating structural reform to produce effective health output. The governance

study works out the best use of satellites to synergise Sub Saharan Africa stakeholder’s collaboration towards

universal health coverage. The Governance Model introduces commons themes in a national health system to

start the transformation process:

An eHealth Cooperative;

A Health Financing Pooling;

A Public Private Partnership; and

A common ICT infrastructure.

The recommendation is grounded by the understanding of the last decade of health system evolution in Sub-

Saharan Africa, the review of eHealth projects, the understanding of aid for development and finally from

consultation with the stakeholders. The service catalogue for beneficiaries is engineered from real cases and

practice.

Satellite can be a game changer and will provide, enhanced

with the governance model, an equitable geographic and

economic access to health services. Regulation and

interoperability will support the implementation strategy.

The strategy consists of creating a political will for a satellite

enhanced infrastructure. The framework will deploy the

governance model as part of the project insuring the reform

mechanism. The sustainability of the reform is seated in

turning the existing flow of aid for health into a capital share

of a satellite enhanced eHealth asset generating 15 to 25

years pay back hedged by government. Regional trial would

be designed to change the stakeholders’ perspective. A

special purpose holding company owning the dissemination

strategy, and an associated Regional Desk executing the

strategy, are pivotal to deliver the ambition.

Let’s take up the challenge with satellite technology!

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