Digital Health in Ethiopia

Policy Framework Development for Private Sector Engagement

February 2021
 Contents

Abbreviations and Acronym iii

Acknowledgement iv

Executive Summary v
I. Introduction 1

Project Context 1

Objectives of the Study 1

Approach and Methodology 1

II. Rationale: what and Why of Digital Health 2

What is Digital Health? 2

Tools and Uses of Digital Health/Digital Solutions 2

Why is Digital Health Important? 2

The Unique Importance of Digital Transformation for Africa 3

III. Global Lessons: Key Pillars/Enablers of Digital Health 4

Key Findings: Review of Global, Regional and Country Level Documents 4

Key Findings: Enablers/Barriers Identified from Selected Country Case Studies 4

Summary: Key Enablers/Pilllars of Digital Health Identified from Review 4

IV. Key Findings: Ethiopia’s Current Digital Health Ecosystem 8

Ethiopia’s Socio-Economic Context for Digital Health 8

The Business and Investment Environment 8

The Healthcare System and Uptake of Technology 8

Enabling Environment, Policy, and Regulation of Digital Health in Ethiopia 9

Summary of Ecosystem-SWOR Analysis 10

V. Key Findings: Ethiopia’s Key Digital Health Policy Themes Identified 11

Ethiopia’s Stakeholders in Digital Health 11

Key Policy Themes Identified Through Key Informants Interviews 12

V. Recommendations and Proposed Policy Framework 15

Proposed Recommendations 15

Proposed Digital Health Policy Framework 17

V. High-Level Roadmap 19

Ethiopia’s Digital Health Priority Pillars and Roadmap 19

Annex 20

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Abbreviations and Acronyms

AfCFTA The Africa continental trade agreement

AI Artificial Intelligence

AU Africa Union

CHISU Country Health Information Systems and Data Use

COVID-19 Coronavirus Disease 2019

DH Digital Health

DHILC Digital Health Innovation and Learning Center

ECA The Economic Commission of Africa

EMR Electronic Medical Record

GTP Growth Transformation Plan

HDC Health Data Collaborative

CHS Comprehensive Health care Services

HRIS Human Resource Information System

HRM Human Resources Management

HSTP) Health Sector Transformation Plan

ICT Information Communication Technology

mHealth Mobile Health

MIT Ministry of Technology

MoFED Ministry of Finance and Economic Development

MOH Ministry of Health

PCI Precise Consult International

PFSA Pharmaceutical Funding and Supply Agency

PMO Prime Minister Office

PPP Public-Private Partnership

PPPH Private Partnership for Health

PSE Private Sector Engagement

SDG The sustainable development goals

SMEs Small-Medium Enterprises

STEM Science and Technology stream

UHC Universal Health Coverage

UHF Uganda Healthcare Federation

WHO World Health Organization

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 Acknowledgement

First and foremost, Precise Consult International PLC (Precise) would like to acknowledge that this
report is a result of collaboration and input from a great team of experts, group of advisors, and
stakeholders within the health sector.

We would like to sincerely thank our affiliated consulting firm, CHS Advisory, for putting its high
caliber professionals time, experiences, and expertise and came up with this report. Specifically, a
great appreciation for Dr. Maraki Fikre, Dr. Netsanet Fetene, and Kidist Nadew who are the
researchers and authors of this study.

Our deepest appreciation also goes to the Health Advisory Group of the Development Policy
Innovation Initiative for providing senior-level guidance on the study and feedback on the findings
and the recommendations.

Finally, we are immensely grateful to all of the individuals that have cooperated and shared their
insights during key informants' interviews and provided data during data collection phase. We are
also grateful to all stakeholders who participated in the validation workshops Precise organized.

Sincerely,

Henok Assefa

Managing Director, Precise Consult International PLC

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 Executive Summary

Introduction address key pillars and enablers identified for a

comprehensive DH ecosystem. Critical success factors
Digital Health (DH) is a new term that encapsulates and of other DH policy frameworks point to the key enablers
broadens the existing and simple concept of the use of including 1) leadership and governance; 2) integration
ICT for bettering health outcomes. Originating from and inclusive view of the ecosystem and recognizing
previous terms such as ehealth and mhealth, DH that stakeholders span, public, private, development
focuses its definition and scope to be outside of the partners as well as sectors outside of health such as
actual technology and DH solutions to its use and telecom, banking etc. are crucial; and 3) ensuring key
impact on health outcomes. Digital technology and its resources such as financial, technical (through human
various applications and use across the healthcare capacity and skills) and structural are enabled to support
value chain are varied but have shown influence and the DH ecosystem.
impact on the well-being and economic growth of the
population worldwide. Beyond these enablers, countries should have a
regionalization and global view of the ecosystem in
While high-income and developed economies such as establishing DH and ensure that policy and regulations
the US and Australia have differing appetite for DH incentive address the needs of all stakeholders to have a
technologies and adoptions of innovations and “patient-centric model” and ensure that end users and
solutions, mainly because of their already established consumers are empowered and can use the technology
legal and data protection frameworks as well as for better health outcomes.
generally well-performing health system, the imperative
Key Findings of the Current Landscape
and rationale for a DH agenda has more valuable and
quick impact for less “regulatory” heavy, and less
When reviewing the current landscape of Ethiopia and its
performing health systems and markets such as those
readiness for a successful and function DH ecosystem
in Africa where the opportunity for adoption and scale
and strategy, it is clear that Ethiopia has clear strengths
up may seem more “transformational” in nature. Indeed,
and opportunities in its inherent structures (e.g. clear
today a large majority of Africans still do not have
vision and leadership from government for a digitally
access to essential health services at primary level and
enabled economy; encouraging banking, telecom and
with the large population and youth across the
business sector reforms) but it also has significant
continent, there is more of an imperative for digital
limitations in its limited human expertise, digital literacy,
strategy as part of the agenda for economic
bureaucracy and most importantly the fragmentation and
transformation and job creation.
limited private sector engagement in a national digital
agenda.
This report summarizes key findings and proposes a
policy framework for DH in Ethiopia based on a deep-
Review of key policy documents in Ethiopia confirms that
dive analysis of the Ethiopian context, as well as
although Ethiopia has adopted a national digital strategy
enabling environment and barriers. In the study,
and encouraged private sector engagement in previously
extensive global, regional, and local documents were
public institutions such as telecom, banking, and others,
reviewed, and key informant interviews were conducted
DH as a key pillar for economic transformation is not
across a total of 20 stakeholders from private, public,
mentioned. Private sector is usually a sector that brings
development partners categories. Key findings from
finance, innovation, technical expertise, and efficiency.
the deep-dive analyses identified key themes relevant to
However, the sector is small and fragmented in Ethiopia
the DH ecosystem and were triangulated with findings
mainly due to lack of finances, funding and the
from country and regional learnings and case studies of
dependency of development partner funded
DH policy development.
programmatic areas for DH. The COVID-19 pandemic and
previous recognition that private sector dialogue and
The following highlights key findings across the
engagement is crucial to meet national goals have
specific analyses and major recommendations.
accelerated the organization of private sector and non-
Global Lessons and Country Case Reviews state actors under an umbrella (the EHF- Ethiopian
healthcare federation) but engagement, inclusive
Review of country case studies focused across the planning and data sharing especially under a digital
African continent showcased that most DH solutions agenda is not clearly stated under a policy or strategic
rolled out to date have limited sustainability and do not framework.

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 Key informant interviews further identified relevant • There is a need to develop a policy and strategic
barriers in the DH agenda. Key priority themes and plan for DH with government leadership and
barriers were identified and revolved around: limited based on health system needs rather than
human capacity and expertise; limited digital literacy of programmatic approach.
end users; limited financial incentives for growing
innovations and SMEs in DH solutions; other than key
Discussion and Conclusion
structural limitations in terms of infrastructure for
telecom, connectivity that is progressing but still
Key core messages and proposed DH framework for
remains a barrier to successful implementation. Most
Ethiopia revolve around: 1) DH policy and strategy
importantly, fragmentation of initiatives, lack of clear
development should be led by government and
governance and collaboration were identified as part of
support national SDG and UHC national health
the key limitations and barriers to a successful policy
priorities; 2) The establishment of a national DH
development for DH in Ethiopia.
ecosystem should be inclusive, integrated and should
keep regionalization initiative as a vision; 3) Ensure
Key Recommendations development partner funds to advocate and support
a ONE digital agenda and support financing and
• Need to align efforts with the government to ensure
incentivizing with a view to strengthen the healthcare
the digital agenda helps national priorities and
system and not a programmatic view; 4) Fostering a
strengthen the system. As mentioned, one of the
DH ecosystem needs key stakeholders such as
reasons for fragmentation and nature of DH
private sector and government to “self-organize” with
solutions in Ethiopia is the development partner
strong leadership and advocacy platforms to ensure
funds that incentivize market entry across specific
that the needs of end-users and consumers are at the
areas such as health and data management
core of the solution.
systems. Ethiopia needs to commit to the digital
agenda as part of any development-partner backed
Beyond the development of a DH strategy, and roadmap,
intervention and raise the need and urgency to DH
much attention needs to be given to the implementation
inclusion as part of key health interventions.
and ensuring relevant human and financial resources are
• A platform for dialogue and multi-stakeholder available for deployment. The implementation and roadmap
working groups focused on DH is crucial for Ethiopia should focus on low-hanging fruits and early benefits such
as currently the DH agenda is fragmented across as increasing the digital literacy of end-users for priority
selected government institutions. health services, training of developers, and health workers
to the use and analytics of DH data.

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 I Introduction

Project Context Specifically, the study focused on specific objectives to

understand:
Precise Consult International (Precise) recently
a. The rationale, what, and why of DH,
conducted a policy consultation to identify the
opportunities and challenges in private health sector b. Current DH ecosystem in Ethiopia including identification of
development particularly along with policy, regulations, barriers and opportunities for creating an enabling
standards, and procedural impediments for market entry environment,
and expansion of private enterprises in the health sector.
c. Current gaps as it pertains to other global and country
lessons (triangulation of results).
The consultative workshop conducted across key non-
state health actors held in Addis Ababa in September d. And develop a DH policy framework with key pillars,
2020, identified three key areas of interventions for recommendations and proposed roadmap for
deep-dive analyses, namely, (1) the need to review health implementation that will accelerate and enable the scale-
facility standards and licensing; (2) the need to develop up and effectiveness of DH solutions in helping meet key
a new standard for office medical practice such as health outcomes such as access, utilization, quality, and
“doctors’ plaza” and (3) the need to review and expand equity.
private sector engagement whilst leveraging on DH. The
consultation confirmed the fact that despite the Approach and Methodology
country’s significant progress across key health
indicators, the private sector in health remains small, The project was conducted across a rapid-4-week deep-
engagement remains limited, and more needs to be dive analysis of the current Ethiopian digital health
done given the known advantages of strategic private landscape as well as extensive document and case
sector engagement in other countries to support and study review of global and country case studies.
scale public health and government responses.
Key informant interviews (a total of 13) and informal
Ethiopia is among the first of many similar low-income consultative discussions (~7) were conducted across
countries to have acknowledged and actively sought to categories of relevant stakeholders to further
enable more inclusive private sector engagement as a understand key policy issues and barriers for the DH
key pillar across its national plans and response to the ecosystem of Ethiopia.
country’s healthcare challenges. Indeed, across its many
policies and proclamations such as the PPP framework In-depth interview guide was applied to understand the
of action and implementation plan, the Ethiopian current private sectors engagement in DH, opportunities
government, and the FMOH has acknowledged the fact and barriers and include experts’ recommendation for
that without engaging non-state actors in health, the better engagement in Ethiopia DH solutions. The
potential for scaling government plans remains discussion was recorded, thematically content analysis
underutilized and untapped. on the finding was conducted and presented in 13
themes.
This document outlines CHS advisory’s response to
Precise´s request for an independent consultant to Most of the stakeholders were from private companies
review, conduct deep-dive analyses, and develop a policy (8). Two participants were from International NGOs
framework for private sector engagement in the DH supporting digital technology, two from associations
stream of potential intervention. and one from government organization.

Objectives of the Study Informal consultative discussion (off record) was also
conducted with a number of leaderships, donors and
The main objective of this study is to conduct deep-dive policy makers currently working in Ethiopia and their
analyses to better understand the DH ecosystem in opinions and recommendations were also considered in
Ethiopia and provide Precise with an independent, the recommendation sections.
objective deep-dive policy review, analyses, and
framework development of the private sector in health
engagement across DH solutions in the Ethiopian
market.

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 II Rationale: What and Why of Digital Health

Digital technologies and accelerating technological changes will benefit the future of well-being and economic growth worldwide.

What is Digital Health? DH is not healthcare; it is what is done in and concerning

healthcare. DH is about health, not just the healthcare
delivery system. It is enabled by exponential increases in the
While DH is a simple concept — using technology to help
pervasion of ICT throughout economies and driven by
improve individuals’ health and wellness — it’s a broad and
individuals‘ demands to control their health and wellbeing
growing sector.
(Rawlands 2019).
The term DH is rooted in eHealth, which is defined as “the use “The practice of employing routine and innovative forms of
of information and communications technology in support of information communication technology (ICT) to address health
health and health-related fields”. Mobile health (mHealth) is a need.” WHO, 2019
subset of eHealth and is defined as “the use of mobile wireless
technologies for health”. More recently, the term DH was Tools and Uses of DH/Digital Solutions
introduced as “a broad umbrella term encompassing eHealth
(which includes mHealth), as well as emerging areas, such as There are a number of components or tools and uses of DH
the use of advanced computing sciences in ‘big data’, genomics today. There are several thousand different digital solutions
and artificial intelligence” (WHO 2019). across key categories of the healthcare ecosystem as below
(not intended to be exhaustive).

Components or tools of DH can cover everything from DH offers real opportunities to improve medical outcomes such
wearable gadgets to ingestible sensors, from mobile as quality, access, equity, and enhance efficiency. Some
health applications to artificial intelligence, from mobile examples of the use of digital technologies include:
medical applications and software that support the
clinical decisions doctors make every day to artificial • Digital technol-
intelligence and machine learning. ogies give pro-
viders a more
DH tools have the vast potential to improve healthcare holistic view of
professionals’ ability to diagnose and treat disease patient health
accurately and to enhance the delivery of health care for through access
the individual. to data and giv-
ing patients
DH technologies use computing platforms, connectivity, more control
software, and sensors for health care and related uses. over their health.
These technologies span a wide range of uses, from
applications in general wellness to applications as a
medical device. They include technologies intended for • Telemedicine, mobile health, and access to remote health
use as a medical product, in a medical product, as have improved access to communities far to reach.
companion diagnostics, or as an adjunct to other Technologies like 3D printing have changed the
medical products (devices, drugs, and biologics). They landscape for orthotics, prosthetics, and other medical
may also be used to develop or study medical products. device manufacturing.

• In recent years the use of machine learning has enabled

Why is DH Important? healthcare to predict public health emergencies and plan
management and service deliveries. The advent of mobile
Digital technologies are an essential component and an enabler of phones and digital technologies has also changed how
sustainable health systems and universal health coverage. individuals manage their health through free access to
health-related information.

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• Furthermore, digital technologies are being used to improve Digital technologies offer the expanding youth population the chance to
the training and performance of healthcare professionals unlock new paths for rapid economic growth, innova- tion, job creation,
and access to services that have been unim- aginable a few years ago.
as well as to address persistent low performance in health Africa has the opportunity to harness digital technology as a driver for
systems to develop a framework for improvement. economic growth.

The Unique Importance of Digital The digital divide between African countries has hindered the
Transformation for Africa fair and equal distribution and access to advanced technologies,
for example, while Kenya is averaging 89.9% Burundi is at 5.3%.
The second largest continent, Africa has 54 countries, one
• African leaders gathered at the May 2017 World Health
sovereign state, and an estimated population of 1.3 billion
Assembly to affirm their commitment to digital health and
combined. In recent years Africa has experienced rapid
the pathway to a holistic application of ICT to support and
urbanization and growth and transformation. At the same
improve health care delivery.
time, the majority of the population lives in rural and remote
communities with little or no connectivity. Some of the reasons • The African Union Agenda 2063 has put a strategy for eco-
for these barriers to improved connectivity include the nomic growth and industrialization to alleviate poverty and
location and landscape where these communities live, and improve the lives of people in Africa.
the poor return on investment.
• This is supported by the Digital Transformation Strategy
which was co-developed by the African Union (AU) and the
The growth of digital technology is mainly driven by the
Economic Commission of Africa (ECA) which has a focus
mobile phone revolution and related technologies have enabled
on supporting African countries’ efforts to capitalize on
millions of people in urban and remote areas to connect,
the socio-economic benefits of digitization and advanced
share information, create income generation activities, and
technologies.
improve their economic status. More than 80% of the African
population has at least one mobile phone subscription (Songwe Specific objectives of the digital strategy are:
2020 -URL).
• Build a secured digital single market in Africa by 2030
(based on the AfCFTA – the Africa continental trade
“Digital transformation is a driving force for innovative, includive and agreement) and this is relevant for pharmaceutical imports
sustainable growth. Innovations and digitalization are stimulating job and pooled procurement (see the African medical supplies
creation and contributing to addressing poverty, reducing inequality, plat- form (AMSP), a digital platform that allows African
facilitating the delivery of goods and services, and contributing to governments to “group” purchase items)
the achievement of Agenda 2063 and the Sustainable Development
Goals.” UNECA 2020 • By 2030, all Africa to be digitally empowered and able to
access safely,
Even though there is remarkable progress, bringing more • Harmonized enabling environment,
people online, Africa’s internet penetration is quite low
compared to the rest of the world (e-economy 2020). For • Entry into force by 2020 of the AU convention of
example, Africa’s internet penetration is at 39.6% compared to cybersecurity and personal data protection.
the global average of 62.7%.

Source: UNECA Digital Transformation Framework

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 III Global Lessons: Key Pillars/Enablers of Digital Health

The success of digital health depends on the accessibility, affordability, scalability, and sustainability of person-centric digital solutions to prevent,
detect, and respond to healthcare needs at the individual and population level.

Key Findings: Review of Global, Regional and • Fostering digital transformation for growth, entrepreneur-
Country- level Documents ship, job creation, and private sector empowerment,
especially technology start-ups and Small-Medium
The Sustainable Development Goals (SDG) acknowledge the Enterprises (SMEs), and innovative community initiatives
transformational impact that digital health technologies such using digital technologies.
as mobile health (m-health) will have in a context of continued • Expanding new solutions offered by digitization across
global population growth, inequitable access to health, increased other sectors such as health, agriculture, energy, e-
healthcare costs, and the limited number of healthcare workers. commerce, and electronic payment systems.

A review of the digital health ecosystem for Africa countries • Creating an enabling environment for good governance to
identified these core pillars of success: allow national stakeholders to manage digital risks and
coordinating the private sector. To support this, a legislative
1. Digital health supports the SDG and UHC (Universal framework known as the AU Convention on Cyber Security
Healthcare Coverage), and Personal Data Protection was established in 2014, for
member states to develop a national cyber security policy
2. The establishment of a national digital health ecosystem
and responsive actions against cybercrime.
should be based on an integrated framework (and not
individual pilots, today mainly supported by development • The strategy also acknowledges that the digital
partners and governments), transformation process cannot be the sole responsibility of
African governments; active participation from the private
3. There is no one-size-fits-all solution for digital health sector is crucial due to different financial conditions
4. Four building blocks: strategy, roadmap, implementation hindering large public investments in this area. Besides,
elements, and evaluation, the private sector can back the ecosystem through
knowledge, expertise, and finance.
5. Close coordination of all stakeholders with strong leader-
ship from governments, and
Key Findings: Enablers/Barriers Identified from
6. Needs a cooperative investment approach. Selected Country Case Studies
To realize their potential, digital health initiatives must be part The Eastern and Southern Africa (ESA) regulatory study ranked
of the more comprehensive health needs and the digital health sub-Saharan African countries in terms of their eHealth priority
ecosystem. It needs to be guided by a robust strategy that ranking: Tanzania, Rwanda, Namibia, and Kenya scored in the top 5
integrates leadership, financial, organizational, human, and places. Each country’s readiness and success for
technological resources and used as the basis for a cost implementation of a DH policy and strategy varies extensively
action plan which enables coordination among multiple across key pillars and structural factors and how well they have
stakeholders. understood the relevant ecosystem. Overall, the study identified
the following different pillars/enablers of this digital health
These initiatives should be led through strong governance ecosystem.
structures. The country’s digital health strategy should address
an approach that works across multiple health priorities
Key pillars/factors that need attention in the development of
under- pinned by standards and an architecture that enables
a country DH policy are:
this integration (WHO 2020).

The common AU Digital strategy is based on: 1. Organizational structural framework/Leadership and
Coordination
• Enabling the necessary digital infrastructure and enhancing 2. Infrastructure and Interoperability
3. Skills and Human Capacity
the capacity of transport and logistic activities for e-
4. Product standards, licensing, liability, and
commerce, complemented by the right investment climate
reimbursements
to attract private sector investment, 5. Data Security, Privacy, Confidentiality
• Developing digital literacy and skills particularly in Science 6. Information Quality
7. Funding/financing
and Technology stream (STEM),
8. Monitoring & Evaluation

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Selected pillars are further elaborated below in light of their Substantial investment in DH solutions in recent years has
relevance to Ethiopia: already shown improvements in health services. This has
demonstrated that there is both appetite and willingness that
Digital Infrastructure and Interoperability: At the core, the infra- can be leveraged, with the same potential for DH to play a
structure comprises an internet platform that offers digital crucial role in digital transformation. It focuses on leadership,
healthcare services. It promotes interoperability by allowing talent, and creativity on the part of stakeholders throughout the
intercommunication among healthcare profession- als. It private sector, government, and civil society to realize the
also enables the sharing of Electronic Medical Record promise of these new capabilities.
(EMR) for a 360-degree view of the patient’s health.
Digital Innovation & Entrepreneurship: Global DH Strategy
Interoperability is among the key focal areas of a new global outlines the vision for fostering an environment that supports
partnership known as the Health Data Collaborative (HDC) innovation to improve the experiences of consumers and
and the Principles for Digital Development (WHO). Interoperable clinicians and enhance their ability to improve health
systems can ‘speak’ to one another, and more importantly, outcomes for their communities through safer, more efficient,
share information to avoid duplication, reduce the burden on and effective healthcare delivery. Accelerating Innovation in the
healthcare workers and clients, and magnify impact through healthcare system means facilitating meaningful partnerships,
collaboration. working together to remove barriers, and learning from
successful products and projects, both locally and
internationally. Entrepreneurship is an additional component
“A digital health ecosystem is the holistic application of ICT to support
needed to pro- mote the progress of the emerging sector and
and improve health care delivery, its coordination and integration
across providers in a given domain (Local, regional, national).”
its contribution to economic development. Ensuring that there
Digital health ecosystem for African economies 2020 are sufficient, competent digital health workforce capabilities
across all disciplines is crucial to the success of the strategy.

Digital Skills and Human capacity: It is recognized that Selected Successes from Regional Country Case Review:
successful digital health needs new skills and approaches The development of multiple DH initiatives through the
for existing human resources, as well as new cadres of staff. collaboration with government, private (national and
Success needs two parallel strands. Firstly, hard components, international), and development partner sectors have facilitated
such as skills in ICT sciences, health sciences, and workforce the development and improvement of supporting and
management and development. Secondly, soft skills, such as collaborating sectors through infrastructure development and
culture, leadership, motivation, and change management help digital transformation. The following is a list of examples from
to ensure efforts are tailored to local needs and challenges. five African countries that have successfully piloted and scaled
up DH initiatives through government sectors and/or in
Africans have already eagerly embraced new technologies for collaboration with the private sector.
applications like digital cash, banking, e-commerce, and
governance.

Box 1: Rwanda Country Case Study

Overview: Although a much smaller country to Ethiopia, Rwanda is interesting as a country case study for digital health policy
framework due mainly to its strong and successful private sector engagement. Private sector especially in terms of human capital
development is well-integrated in national health priority planning and set up.

Key highlights: successes in PPD platform, Health financing and incentives for SMEs; other sectors relevant to DH are well
developed such as Telecom, banking and has a well-elaborated vision for a digital/smart city concept backed by strong innovation
and RnD “industrial park”.

Select DH Solutions: Jembi - Rwanda Health Information Exchange (RHIE); ZipLine - Blood Delivery by Drones; Babyl Rwanda -
Artificial Intelligence and Machine Learning; IntraHealth International - Integrated Health Service Delivery; TeleMedicine - Rwanda
Military Hospital.

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 Box 2: Uganda Country Case Study

Overview: Interesting lessons can be learned from Uganda in its application and use of ICT in achieving better health outcomes. For one,
Uganda has a similar large population, geography and decentralized health system that closely resembles the system in Ethiopia and its
governance. The country follows a similar focus to Ethiopia on local manufacturing and industrialization for economic growth. The private
sector is larger in Uganda than Ethiopia lending to key learnings on how to better organize a growing private sector in health.

Key highlights: The government chose to align the goals of digital health with a broader national health strategy. Uganda has a comprehensive e-
health policy and strategy for health information and digital health 2020-25. Key priority areas of intervention the strategy wants to address: Quality
of Care; HRH supervision, training, and communications; Community engagement and participation in health services; Availability and use of
relevant data. In Uganda, the Private Partnership for Health (PPPH) policy is operational and a PPPH health sector working group chaired by the
Uganda Healthcare Federation (UHF) which is the recognized Secretariat for the private sector healthcare providers that include
manufacturers, healthcare providers at all levels spread over the entire country. UHF is also the agency that is now working with WHO, The World
Bank, and Makerere School of Public Health to support the Ministry of Health in the development of the UHC roadmap. Uganda Healthcare
Federation (UHF) is an umbrella body that brings together all the private sector actors to harmonize service delivery, regulate the operations and
promote good governance and accountability of the health sector. UHF is comprised of all the medical bureaus, private for-profits providers,
professional bodies including the Uganda Medical and Dental Practitioners’ Council, Uganda Medical Association, Uganda Allied Health
Professionals Council, Uganda midwives and nurses’ council, insurance companies, health training institutions, and other bodies such as Uganda
manufacturers association, medical technologies and civil society.

Select DH Solutions: Through the PPPH node, a PPPH strategy was developed, and an online registration portal has been launched to foster
regulation and accountability for the stakeholders. This will enhance capacity building, regulate the market prices and mode of operation, but
also direct appropriate business areas for the private sector where the public system is still remote.

Box 3: Kenya Country Case Study

Overview: If we were to map investments and development of digital health solutions across the continent, we have seen that close to 40%
of digital technology investments and innovations are first implemented in Kenya. This is mainly due to Kenya’s open and easy business
environment, significant interest from development partners as well as reforms in the banking sector and strong academic sectors that has
allowed private sector innovations and technologies in the country.

Key highlights: Several notable digital health solutions are in Kenya. One of the key successes of Kenya in terms of Healthcare financing is
the M-Pesa and mobile banking that has revolutionized access to health information to consumers. Secondly, Kenya through its strong
education system has built significant “digital literacy” for end-users and awareness and use of social media platforms, and advocacy is an
important pillar for KenyaAnother pillar of the DH ecosystem that is well-developed in Kenya is in the digitization of health information
throughout (Afya Rekod is a health management medical data storage of patients’ health record).

Although there are several challenges, the pharmaceutical supply chain management is relatively more mature than in other African countries
and Kenya has a successful Pharmacy level digitization of information and health financing solution through M-pharma that offers a
pharmaceutical inventory management system by subscription.

Box 4: Ghana and South Africa Country Case Study

Ghana: Ghana is another African country, although smaller than Ethiopia and with a different healthcare system and readiness for Digital Health, has
some notable successes in digital health strategy and policy implementation and models that are worth a mention. Ghana has a very strong private
sector but also human capital capacity both in the local as well as in its diaspora population. Much of the healthcare investments today in Ghana are
either financed by diaspora investments or in health service delivery (big private hospital chains) but also through telemedicine and e-learning
platforms thus creating significant economic growth through its human capital. An example of a telemedicine initiative is ComHIP, an effective end-
user training for community-based hypertension improvement project. Other successes in Digital Health are in the logistics and pharmacy sector
similar to Kenya for its Pharma health management platform but also in logistics using Zipline prototypes in Rwanda for transporting key health
commodities.

South Africa: Within the Digital Health ecosystems, South Africa cannot be ignored for its significant innovations in health, manufacturing and a more
or less patient-centric model as its overall approach with numerous health management platforms and self-management and education platforms
and digitization of health information throughout its value chain. South Africa is somewhat an outlier as a significant proportion of health services
(some 70%) are today offered through the private sector but access is very expensive. South Africa has deployed several reforms in healthcare
financing (through the use of digital technology such as health fintech companies like Aligned to provide financial solutions for palliative care
patients) in order to achieve UHC vision for fair, equitable, quality and affordable access to health services but that is work in progress. Some notable
digital solutions in health are: MonConnect program in educating women to take care of themselves providing antenatal and postnatal service; mHealth
application for stock visibility system and workforce training and development. South Africa has a well-documented presidential health compact
supported by the WHO country office that involved the private sector in its drafting and specifically mentions engagement with the private sector as a
primary focus area for health improvement.

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 The use of digital technologies for functions such as supply-chain • Standards and interoperability: lay foundation for a local and
management, public health emergency, disease surveillance, regional interoperability.
electronic payment systems, data storage and sharing, e-learning
applications and telemedicine has shown how DH has influenced • Digital Innovation & Entrepreneurship: ensure relevant
the digital transformation within Africa. In some instances, it has financial resources availability and collaboration with
accelerated the progress of the implementation, scale-up, and academic sector to ensure sustainability and scale-up.
integration of digital technology and initiatives in other sectors. • Data Security, Privacy, Confidentially
One instance of acceleration is the current COVID-19 pandemic
that has facilitated the digitization of other activities but also • Funding/financing: include private funding for increased
accelerated private sector engagement through its financial, resources and buy-in.
technical and efficiency expertise to work more closely and • Digital Literacy, Skills and Human capacity: build required
align to national goals. capacity and literacy for end-users as well as developers.

• Services, Software, and Applications need a User-centered

program design development of reusable and interoperable
and IP protection issues for developers.

• To realize their potential, digital health initiatives must be

part of the more comprehensive health needs and digital
Summary: Key Enablers/Pillars of DH Identified from health ecosystem.
Review
• It needs to be guided by a robust strategy that integrates
leadership, financial, organizational, human, and
• Inclusive coordination of all stakeholders of the digital health
technological resources and is used as the basis for a
ecosystem: especially private sector integration and inclusion of
costed action plan which enables coordination among
end-users is paramount.
multiple stakeholders.
• Leadership and Governance: role clarity and capacitated
• These initiatives should be led through strong leadership
governance structure.
and governance structures.
• Enabling Environment, Policy, and Regulation: alignment to broader
health policy and national priorities is essential.

• Digital Infrastructure: create the technical global good that supports

all workstreams and regionalization of standard and interoperability.

7
 IV Key Findings: Ethiopia’s Current Digital Health Ecosystem

Ethiopia’s Socio-Economic Context for DH • The Ethiopian growth-oriented economic pol- icies
under the GTP II and encour- aging private sec- tor
engagement have created an attractive atmos- phere
• The Human Dividend- Ethiopia is the second-most popu-
for local and foreign investors, providing them with a
lous country in Sub-Saharan Africa and home to an esti-
number of investment incen- tives. Ethiopia’s
mated 105 million people in 2017 and growing, and pres-
economic devel- opment vision is summarized in the
ents, in virtually every sector, a sea of economic opportu-
Ethiopian government’s five- year Growth and
nities especially in this digital era.
Transformation Plan (GTP), 2010- 2015 and GTP II,
2015-2020. Three of the 16 reforms by EAC economies
• Focus on industrialization as the core of its economic
are in Sub-Saharan Africa; particularly, Ethiopia
growth -over the last decade and more, Ethiopia has made
introduced an on-line system to share credit
great strides economically and has sustained a GDP growth
information and allowed the debtor to review their data.
of about 10%, one of the highest in the region (Africa GDP
growth average is ~3%). The country’s per capita income of • Recently, regulations have allowed a joint venture partner-
470$USD is substantially lower than the regional average. ship with an international investor/operator for local health-
The government, however, aspires to reach middle-income care service providers in Ethiopia when it was not allowed
status over the next decade. Public investment has increas- previously and created significant barriers to access to
ingly played an important role in recent years. Industrial finance and quality.
development focused on agricultural, rural development
and infrastructure was an important component of the
Ethiopian Government’s national growth vision under the
The Healthcare System and Uptake of
Growth Transformation Plan I (GTP I) 2010-2015 that con- Technology
tributed to this growth. This is followed by Ethiopia’s sec-
ond-growth transformation plan GTP II (2015/16 – 2019/20) Despite scaling up health interventions and enormous pro- gress in
that rests on a vision to accelerate and sustain this growth health service delivery in terms of infrastructure, human resources, and
and “reach the level of lower-middle-income countries by service provision, the quality of health- care in Ethiopia, in terms of
2025 and middle-income by 2035”. patient safety, effectiveness and patient-centeredness remains limited
and unreliable.

The Business and Investment Environment The decentralized system is still highly dependent on external
donor sources: Even though the health sector has been
• Rapidly reforming business and investment environment- decentralized, the health bureau’s budget and activity plans are
the business and investment environment that is seeing based on the city’s strategic plan. The health sector receives
significant recent reforms (not currently publicized formally funding from the Ministry of Finance and Economic
but with key proclamations have been announced) shed- Development (MoFED) and international donors and partners
ding a more positive light to prospects of investment in the (such as USAID, DFID, UNICEF, USAID, WHO, etc.). The Ministry
country overall. Based on the International Monetary Fund of Health is responsible for developing policies, regulations, and
(IMF), the general annual consumer Price Index inflation programs. Service providing facilities are categorized into three
rate was 10.1% and the Ethiopian Birr is the official tiers: Primary, Secondary, and Tertiary, and each tier varies by
currency of the country´s foreign exchange market at capacity and type of service provided.
28.4/ USD in 2019.
Development partners support digital health: There is
• Doing Business, a World Bank Group measuring business promising support in Ethiopia’s DH from development
regulation, ranked Ethiopia at 132 out of 189 economies partners and donors. For example, the Ethiopian Ministry of
in 2015 (went down from 129 in the 2014 ranking). The Health (MOH), Saint Peter’s Specialized Hospital, and JSI
report found that despite Ethiopia ranking on the lower end Research & Training Institute, Inc. (with support from the Bill &
on the ease of doing business when compared to similar Melinda Gates Foundation) established the Digital Health
economies, it ranks a little higher than average. Significant Innovation and Learning Center (DHILC) in Addis Ababa. It is
efforts are currently underway in the country to improve envisioned to be a place where health professionals can
this ranking and Ethiopia taking benchmarks and learning design and validate DH tools, synthesize and promote best
from economies such as Rwanda in improving its practices, scale-up innovations, and to serve as a
business environment. clearinghouse for new DH tools that will be implemented in the
health system.

8
 The USAID’s Country Health Information Systems and Data • Human Resources Management (HRM): HRM
Use (CHISU) program also launched a DH program in functions remain traditional instead of playing a
collaboration with JSI Research & Training Institute, Inc. strategic role. Health workforce motivation and retention
for a five-year cooperative agreement with a budget ceiling of also remains a critical challenge.
$200 million. The program is designed to support
integration and harmonization of systems across health • Human Resource Information System (HRIS): the
areas, enhance the capacity of local partners to support national system is not effectively utilized to collect and
health ministries to improve data collection, analysis, and manage HR information and data thus there is a lack
use at national and sub-national levels. of planning.

• Increasing enablers for the private sector in health • Health workforce regulation: Capacities for regulation
engagement in Ethiopia: In 2015, the FMOH transitioned are not well-developed and require additional
to the Health Sector Transformation Plan (HSTP) which investments.
covers the timeframe between 2015 to 2020. Under this
HSTP, various health sector-specific strategies have been Enabling Environment, Policy, and Regulation of
developed and implemented to impact health service
delivery. The major strategic themes of the government
DH in Ethiopia
are to improve the quality of health service delivery,
enhance leadership, governance capacity, and develop As summarized from the global learnings section, the
health infrastructure and resources. Some examples of environment in which the digital healthcare initiative is intended
strategies and reforms developed are: to function needs alignment with broader healthcare policy as is a
sustainable funding that will support long-term growth. Equally as
• The Public-Private Partnership Reforms (significant important as the program, human and technical factors are key
effort to engage the private sector) pillars of the enabling environment. This includes:

• The Health Procurement Process reforms to improve • Sufficient financial allocation that enables long-term
key system hurdles such as pharmaceutical supply sustainable operations,
chain management and creating an enabling
• Regulatory standards and frameworks that ensure
environment for profes sional and resource
compliance with national health guidelines and strategies.
mobilization in this sector.
• Close collaboration with government stakeholders and
• Universal Health Coverage – Case Study and Health
other policymakers is useful to help inform emerging digital
financing strategy, 2015 that are a key cornerstone of
health policies and to provide information to technical
reforms and address “affordability” and access.
teams about regulatory changes on the horizon.
• Ethiopia e-health Strategy and Health information
Strategy that attempts to leverage on advancing Current enabling environment in terms of policy and
technology to create accountable and sustainable regulation of DH in Ethiopia was conducted through a
progress. review of relevant documents available in Ethiopia in
terms of DH. Please see Annex 2 for a summary of the
• Health Strategies and Implementation Plans.
review. Selected documents of interest are:
• National Drug and Pharma Policies and Plans.
• National Digital Vision – MinT and PMO
• Shortage and Low-skilled Workforce remains a challenge in
• National Health Financing strategy (not much mention of
Ethiopia: Strategic challenges and issues remain despite
DH)
the remarkable achievements stated above and some
relate to: • National ICT Policy

• National e-health strategy – the old one and now a

• Quality of Health workers’ education and training: the
concept stage new one being revised
rapid expansion was not matched with essential
inputs such as qualified faculty, skills, lab materials, • National HIS roadmap – FMOH IT department
libraries and resource centers.
• Other strategies such as the pharma, PFSA, and
• Geographical distribution and professional skills others do mention digitization, but it is not under
mix: Critical shortages of the selected health ONE document.
profession and low retention in remote and rural
areas.

9
 The key takeaway from the Ethiopia DH policy review is that Mentions and drafts of “ehealth and Health Information
although there are several mentions across key policy Strategies” have been developed but with little capacity to
documents about the need to focus on digital transformation implement and without a financial backing to ensure
and the need to further engage private sector, there is not sustainability.
ONE DH policy and strategy that encompasses the above key
enablers and sets a national framework of engagement.
Summary of Ecosystem-SWOT Analysis
Ethiopia today has a revolutionary vision for a digital
transformation with its newly launched national digital
The below SWOT analysis summarizes the current DH
strategy as a backbone for its economic transformations, but
ecosystem in Ethiopia and key opportunities and barriers to
health and DH is a missing core component of it although
mitigate.
recognized as a key economic pillar for transformations.

Strengths Weaknesses
• Human Dividend: High, young and growing population. • The national Digital Transformation does not put health at
the core although manufacturing.
• The country has significant leadership for Digital
Transformation – National Digital Strategy. • Small Private sector Innovation / limited engagement.

• Ethiopia is at the heart of regionalization agenda and • Fragmented systems – Public (within), private.
AU.
• Donor supported government (not private).
• Focus with committed resources (funds and
• Existing digital strategies are fragmented (see policy
infrastructure) on Industrialization and job creation for
review).
youth – IT park, Pharma park.
• Lack of skilled personnel, brain drain, low literacy.
• Rapidly reforming business and banking environment
– although has some way to go as compared to • Financial Commitment is limited especially domestically
others. for health and IT although growing.

• The healthcare sector status of the country has been • Data/Digital security not yet patient-centric – Very
improving especially for Access (primary care) government heavy.
although areas such as quality, financing, and
• Lack of standards, IT procedures but improving for Supply
workforce need improvement but are the focus today.
Chain Management.
• Mobile and Data IT infrastructure expanded
• Bureaucracy heavy: Customs clearance and regulatory
significantly.
hurdles and bureaucracy for logistics and supply chain.
Opportunities Threats
• Regionalization opportunity from its geographic • Health Data complexity: most medical information is
position -AU and AfCFTA. textual and not well-structured as in other industries.

• Travel hub with strong logistics infrastructure • Cultural complexity: a wide variety of actors, regionals,
(Ethiopian airlines). languages, religion.

• Industrialization vision and human dividend. • IT complexity and vendor lock-in.

• Health outcomes/access are still poor and NCD • Very rural population.
increasing that lend for digital tools/solutions to make
• Lack of trust: private sector amongst themselves as well
a bigger impact – leapfrog.
as lack of trust with gov entities.
• Covid-19 accelerated the PSE governance and PPD
platform.

10
 V Key Findings: Ethiopia’s Key Digital Health Policy Themes Identified

Ethiopia’s Stakeholders in DH

There are several global, regional, and local organizations that • Supply Chain actors: Pharmacies, Distributors, Importers,
are making a significant contribution to Ethiopia’s digital health or international supply chain players (Chemonics, Crown
ecosystem today. Some of the select ones are: agents).

• Government: MOH, MinT, MOE, Ethio Telecom, MOFEC.

• Global organizations: BMGF, World Bank/IFC, USAID.
• Civil Society/Consumers: Not much represented but an
• Innovators/SMEs: PITCH, coding, AI, and other innovators important category for health literacy and use of these
in product development (COVID test kits), etc. digital tools.
• Digital tech companies (local/global): Orbit Health, Perago
If we were to map them across the different areas of intervention
systems, Ali baba, SAP, IBM, etc.
of DH categories seen from the global lessons and the health
• INGOs/Local NGOs: AMREF, Path, CHAI, JSI, MSI, PSI. sector for the improvement of health outcomes, we would see
that there is a significant emphasis on Data health information
• Financing Institutions: Private Investors (PE, VC);
due to the high dependence on donor funds.
Philanthropists; banks (local/global) such as Abyssinia
or afriexim bank to enable loans and financing for soft-
Limited financial incentives have resulted in very small private
ware, etc.
sector innovation as compared to countries such as Rwanda or
• Academic institutions (global and national): John Hopkins, Ghana or South Africa that have significantly incentivized that
AAU pillar.
• Health Institutions (private/public): Different levels matter
(hubs vs. primary level/pro-poor); private (AMC, ICL) or Gov
such as St Paul’s, etc.

Global Digital Heath landscape – Patient Centric Stakeholder Map

Key Findings in Ethiopia:

• Limited private sector innovation,

• Fragmented systems,

• Donor supported government DH

ecosystem

• Existing digital strategies do not include the

full landscape of key pillars for DH ecosystem

11
 Key Policy Themes Identified through Key Nascent Public-Private dialogue and no private sector
engagement in planning: There are nominal collaboration
Informants Interviews efforts between pri- vate sector represent- atives and
government in the form of the steer- ing committee, work- ing
Formally and informally conducted interviews of key group as the form of the currently exist- ing HRH committee,
stakeholders of DH in Ethiopia have identified the following key etc. There is no sys- tem for a platform to engage the private
policy and strategic issues when it comes to DH ecosystem: sec- tors at the moment to work with the govern- ment in
digital health, but COVID has initiated the discussion. The
Limited Digital Literacy (consumers and end-users): The private Ethiopian Healthcare Federation was estab- lished as a
sector digital technology use is relatively ahead of the platform for private hospitals. Even though it is at its early
government’s current capacity and potentially has the stages, it can be used as a starting platform for stakeholders to
resources to support the progress of digital health. However, dis- cuss and identify chal- lenges and find solu- tions for
issues such as digital technology literacy, its use, and private sector engagement in digital solutions.
penetration in the country are a few of the concerns. Currently,
the demand for digital health by private and public sectors is No standardization and integration of digital innovations
limited; most settings stop the need for digital technology at across private and public: The private sector digital system
the patient registry, lab, and pharmacy orders level. There is a has no connection with the public system, raising sustainability
lot of resistance from health staff to use digital health due to concerns. The government has not taken the lead in
workload, capacity to use technology, and difficulty of the centralizing and linking information through digitization from
software itself. A large- scale fear of technology among the private sectors and public sectors. Systems, software, and
healthcare professionals is a problem that worsens in regional platform development in DH should be considered from the
and remote areas. The level of human resources capacity, customers’ perspective (end-user in mind) and interoperability
resistance, and fear to use technology, and lack of access to among each other.
technology equipment hinders people’s ability to be familiar
with and comfortable with using digital solutions. The absence of standardized tools and integrated platforms
makes private sector and government partnership incomplete.
Business Acumen of private sectors in digital health: There is
There is a need for an interoperable system to link the public and
the problem of availability and access to big software
private sectors for information and data sharing. At the moment
developing companies in Ethiopia, most are being developed
none of the systems link and talk to each other. Disease codes
locally on a small scale at an individual or group of individual
are not harmonized with standard WHO codes nor between the
level. There are more than 20 tech products in Ethiopia
private and government system. Private health facilities utilize
providing Digital health. All of these focus on one area rather
digital technology for service delivery, but they use different
than looking at the holistic approach and the bigger picture of
systems that do not interface.
digital health. Only a few technology providers and end-users
under- stand that Electronic Medical Record (EMR) is only one
At the beginning of COVID, shortage of reporting regulation
aspect of digital health.
made digitally shared and network reporting across sites
Digital health is becoming part of the healthcare business, difficult. The EPHI developed a directive for reporting and
so digital health developers and digital service users need to collabo- ration which is widely used at the moment. Due to the
have a better understanding of DH business ideas and growth. absence of digital technology import standards, the quality of
Currently, the focus of PS is on service development rather than digital equipment and accessories imported are poor and
business development. This is also highly influenced by avail- there are problems of maintenance capacity.
able funds that usually stem from development partners with
their own focus on certain aspects of digital health. Under-developed and limited understanding of use and value
of DH data: DH data is not properly used for health service
Limited private sectors platform for common voice: Private improvement purposes; patient information is not used for
sector actors do not have a strong collaboration platform within purposes like clinical decision making, the study of disease
their sector and are not unified in progressing the digital health epidemiology, and understanding the health markets. In
agenda. The private sectors do not have a collective voice, are another perspective, patient information is also not being used
competitive and everyone works in a silo. The private sectors to improve care through data analysis and research for digital
(service providers) are also not organized among themselves technology improvements. Currently, there is a huge gap in the
to be involved in governance and leadership at the moment. implementation of digital technology to support the delivery of
The private sector’s achievement in digital health so far relies quality healthcare; digitization of health centers and clinics at
upon individual efforts. zone and woreda level to improve supply chain management,
finance, and patient experience is not developed.

12
Underdeveloped digital technology infrastructures: banking and mobile money transfer in far reaching and
Infrastructures for enabling digital technology are underde- unbanked part of the community builds trust in using
veloped. Particularly internet availability and interruption, tele- technology. It also increases the culture of technology use.
communication services, electrical power, bureaucracy to set This has a spillover effect on health and other sectors as well
up and receive consistent services, access to good software as promoting digital health use and technological innovations.
and hardware, availability, accessibility and maintenance ser- Therefore, the private sector can play a big role here; especially
vices, and affordability of functional and user-friendly systems the banking and financial institutions. This also somehow
are challenging. There is a shortage of technology equipment increases the digital literacy of the community in the process.
for healthcare professionals at the woreda level. Lack of a
reliable local cloud or server storage system to store data is The current preparation to launch e-commerce via Alibaba cloud
another problem. platform could benefit health through engaging digital
technology and banking sectors. This will facilitate a digital
Limited technical skills and experience of human resource: payment system to settle bills and pay online and the
Human resource technical capacity and experience to development of a framework to establish and facilitate
implement the standards and policies even if they existed, is different digital discussion platforms.
limited across the country both in government and private
sectors. Trust in local capacity/well organized local company: The
local companies are concerned that government institutions
Government system; governance, transparency and are open and willing to work with foreign companies more than
accountability related issues: At the moment, governance is local companies. The local private sector often gets overlooked
solely carried out by the government. The private sector is not by government sector, engagement with foreign companies is
involved in the development of a digital health governance preferred over the local private sector. Government institutions
structure. The bottleneck is with the government’s focus on assume foreign companies know more. This could be a result
strategy and policy, not on its applications. The global of the knowledge of local decision-makers as well as lack of
experience shows progress in the use of digital technology communication of technology needs with the private sector.
forced policymakers in developing policies. The government
cannot implement and monitor while the private sector is not In the past two years, the government’s view of technology has
involved and the private sector can influence the government increased, and started to understand and access the private
to change its policies. sector technology and human power to support the
government systems. Private-public partnership in digital
The private sector engagement in government service is health is progressing in a piecemeal pattern between digital
commonly awarded based on connection rather than current solutions companies and referral hospitals; examples include
skills. When it comes to outsourcing services, the government Black Lion and Zewditu Hospital engagement with private sector
either does it to other government sectors or previous to improve health service delivery, quality of care provided,
connections and acquaintances. It is not based on transparent improving the use and efficiency of medical equipment.
competition based on capacity and current skills.
There is a lack of opportunity for collaboration and spillover
experience sharing from other private/public sectors in digital
Financial sectors engagement and investment opportunities: :
technology use. However, an organization like the International
There is a problem with the mindset at government and private
Clinical Laboratory (ICL) is an exemplary private sector currently
higher level as such the private sector’s role in digital health is a
providing lab services working closely with the government
donor fund driven project. Almost all initiatives are directed
public institutions (30 hospitals and EPHI) through developing
and withheld from progressing until donor funding becomes
reporting systems using digital networking.
available. Donor funding is not sustainable for ongoing work
forcing organizations to take on contextually inapplicable The private sectors also need to find out the areas of collab-
digital technologies instead of developing locally viable and oration with the government initiatives for outsourcing digital
sustainable technology to improve training and capacity health opportunities that strengthen their link. Currently, digital
building for the provision of better healthcare service. The health needs to support the licensing of healthcare
private sector has challenges with financial capacity in professionals through automation of CPD hours calculation,
accessing resources to purchase and import technology documentation and records for annual credentials, HR
equipment. There is difficulty in accessing foreign currency. capacity building through skills development and
accountability, healthcare financing management and scale-
Lessons from other African countries have shown that a up, etc.
developed finance system in the use of technology results in
spillover to other sectors. For example, the wide use of mobile

13
 Digital technology developers´ customer service: The service creates no trust and if the provider who developed the system
providers do not base their service on customer needs, so goes out of business the user will have to start all over again.
the system developed does not meet the customers’ needs. Ethiopia is lagging behind the global stage and the cost of the
Commonly they provide cheap software, systems, and platforms service does not consider service consumers, what is on offer
that break down, and poor quality of imported technologies and could be expensive. Most private sectors don’t focus on the use
equipment. The digital service user wants to use innovation for of data for decision making in improving customer service but
the service but due to the unorganized gap in service providers, are only interested in minimizing cost and maximizing profit.
they use fragmented services. The delayed delivery of service

14
 VI Recommendations and Proposed Policy Framework

Based on insights from the Key Informants Interviews and the • The private sectors should agree on a legal framework and
desktop research and global lessons, the below are proposed ethical participation between technology companies and
recommendations and policy framework for the development health facilities when it comes to the development, mar-
of a DH policy and ecosystem in Ethiopia. Although the initial keting, and sharing of software and systems.
scope of this project’s analyses was focused on the policy and
• Government regulations for DH should be encouraging the
enabling environment, it is very clear that all other “pillars” such
engagement of private sectors. The government should
as finance, private sector and others are interrelated and need
think about the solution for resource issues by prioritizing
to be addressed for a comprehensive framework.
DH over other needs such as other equipment.

Understanding the “readiness” of the country across those key • The governance strategy should link MOH, PS, MInT, tele-
pillars is primordial prior to developing a policy framework and com, and other relevant stakeholders for decisions in the
DH strategy for Ethiopia. development and improvement of infrastructure.

• Establish a regulatory standard on access to patient

Proposed Recommendations information as well as utilizing information for decision
making, research, etc. At the moment private sectors use
Recommendation 1: Develop policy and strategic road map
software that is vulnerable to hacking and gives
for Digital health
unregulated access to patient information.

• Development of an inclusive, bottom-up policy, strategy, Recommendation 3: Establish a strong digital health platform
and regulation for the implementation of digital health. This
should encourage its adoption in collaboration with • The government needs to start a dialogue with the private
relevant private sector and end user stakeholders. sectors and representatives from both sectors need to
Government to provide directives and guidance in the engage in a discussion to identify problems, develop
implementation, progress, and regulation. solutions, and create collaboration to develop ideas.

• The policy should look at what is required to digitize the • Create one strong platform for digital health transformation
health system and what are the key national priorities it through a collaboration of care providers, end users,
needs to address first and subsequently such as the cost, solution providers, and government and development
affordability, and access to digital equipment, software, agencies, to create a strong voice from each entity to
installation, administration, and maintenance. shape policy and develop the solution.

• Existing PPP policy needs to add and clarify directives and • The government as the leader together with the private
regulations in digital health use and recognize the sector needs to look at forming and supporting a strong
contribution of private and independent sectors in digital professional association for one voice on digital solutions.
solutions.
Recommendation 4: Integrate and standardize the digital
• The government in collaboration with the private sector innovations for health
should develop a strategy that embraces digital health
technology from early stages – school, university, etc. • Development of health facilities management standards
Digital technology use should be introduced in the (clinics and hospitals) incorporating guidelines for digital
education system to encourage familiarity and build health technologies both for PS and public services. MOH
confidence. should take the lead in collaboration with the PS and
develop a framework for standards of digital health inter-
• The PS involvement in strategy and policy development operable systems.
should go parallel with the implementation of digital
technology implementation and supporting the Recommendation 5: Cultivate the digital health financial sources
government. and investments

Recommendation 2: Pave a clear way for effective governance • Shift digital health financial support from donor funding to
in digital health technology a self-sufficient government and private sectors engaging
innovative and sustainable sources.
Build the foundational pre-work activities in a staged
approach for problem identification, developing strategy, and • Establish a link between banks, insurance agencies with
implementation to create a system that engages all patient digital health technologies like EMR under a
stakeholders for collaboration, clear direction, accountability, well-controlled system regulated by MOH and the Private
and transparency. sectors.

15
 • The private sector has to explore untapped areas that could • Regionalization: The policy and strategy developed needs
be supported by the private sector through government out- to consider regional frameworks and alignment for best
sourcing opportunities; examples, development of health integration. Dimensions of the digital health strategy to
software and systems contextualized for use in Ethiopia, consider alignment with:
platforms or systems for administration, data protection,
and security, installation and maintenance. ✓ Regional health surveillance and data-sharing
platform (e.g., COVID and others).
• Software and system developers must be supported to ✓ Setting policies that are aligned regionally for
organize themselves into larger IT solution companies technology use.
to have a competitive local capacity in the local markets.
✓ Developing a workforce.
Recommendation 6: Enhance the digital health capacity and ✓ Technology standards and interoperability
literacy
Recommendation 8: Develop a patient-centric DH ecosystem
• The private sector can provide teaching and clinical
placement support to healthcare professionals and • Healthcare service delivery has for long been
universities for skills transference and access to organization-centric. The providers were in the center,
technology. The positive relationship and collaboration of and the patients had to adjust. But recent trends in
the private sector with public healthcare facilities should healthcare delivery suggest a transition towards patient-
be encouraged and progressed on multiple fronts. centric care. This includes multidisciplinary teams and
• For Ethiopia, there is a strong linkage with diaspora and multiple care delivery settings working together to provide
universities in health (especially with the US and European patient care.
countries) that can be leveraged both for e-learning but • A digital healthcare ecosystem is an infrastructure that sup-
also digital literacy – some examples of programs could ports the shift from an organization-centric to a patient-
be mentorship and internship opportunities for students centric model of delivering healthcare services using
across countries to start exchanging information and digital platforms. The primary goal of this system is to
technical expertise and other that builds digital literacy. encourage cross-organizational, multidisciplinary, and
• The government should trust, test, understand, and give collaborative healthcare delivery. Placing the patient in the
priority to local companies to strengthen their capacity and center means focusing on prevention and wellness
create a competitive environment. Locally developed rather than only treatment. It includes addressing the
systems are sustainable and cost-effective– the overall social determinants of health such as the physical, mental,
cost of development, installation, administration, and spiritual needs of people.
maintenance, and pay is in local currency.

• End-use literacy is crucial and media channels and social

media platforms can be leveraged to encourage youth and
other segments of the population to understand how to
“improve” their health through digital technologies such as
mobile phones and others. Some platforms such as “hello
doctors” have started up in Ethiopia but not entirely
succeeded due to lack of literacy from consumers.

Recommendation 7: Align DH policy and strategy to Global,

Regional and National Goals

• Align to National Goals: Any policy framework and strategy

that is derived from this strategy should aim to address key
national health priorities and answer questions such as:
✓ Are we trying to increase quality? Of which priority
health sector? (E.g., pharmaceutical, delivery?)

✓ Are we producing a skilled workforce?

16
Proposed DH Policy Framework It follows extensive consultation with stakeholders, including
contributions from the private sector, and government
The proposed DH policy framework (see figure below) departments, whose perspective shaped the framework. The
incorporates all learnings from global, regional as well as objectives and principles contained in this framework will
current Ethiopian context. It is designed to portray the determine our approach to policy planning and strategy
complexity and the interconnected Ethiopian DH Ecosystem development. This Framework will remain consistent in the face
and the key pillars that policy and strategy development of new challenges as technological change accelerates and it
needs to address. contributes directly to the development and implementation of
a sustainable dig- ital ecosystem.

Below are some of the key principles of the proposed framework: Partnerships are essential to accelerate positive socio-eco-
nomic outcomes and implementation of enabling strate-
Inclusive/integration or private sector and other actors in the gies, particularly for improving communications infrastruc-
planning process to ensure strategy and policy alignment ture and creating digital public services. This collaboration
in the development of strategy and governance should
• The creation and implementation of a comprehensive not be restricted to a top-down approach and must also
digital health policy development and planning should include implementing partners but also consumers under
transcend the technology sector and embrace different the “patient-centric” model we strive to adapt.
sectors of society and the economy so that relevant
stakeholders such as the academic/education, telecom, Harmonization of standards and interoperability national and
and economic sectors should be included. regional initiatives and collaborators

• Key Principles -Adequate government structures, mainly Providing better care to help people healthier lives and live
regulatory in nature, are needed to manage the digital longer is the goal of governments and others delivering
transformation and to protect digital infrastructure, healthcare services in Ethiopia, the African region and globally.
services and data. Multi-stakeholder (Government, Connected care through interoperable systems is key to that
Private, Development and other sectors) collaborative ambition. Healthcare facilities across the globe have made
governance models are unique in their ability to address tremendous gains in shifting their record-keeping from paper to
the complexities of networked digital health, societies and computerized systems that support this.
economies.

17
 • Key Principles - The interoperability of clinical data and Safety and security through a robust approach to cybersecurity
healthcare related information is essential for high-quality,
sustainable healthcare. This means that patient data is • Cybersecurity plays a crucial role in supporting economic
collected in standard ways and that it can be shared growth and ensuring the safety of information collected
securely, in real-time and with a common meaning. Effective from patients and other individuals. Potential cybersecurity
interoperability of information is key to the attainment of threats do not just affect data and systems in government
the health-related Sustainable Development Goals and to and business, but also critical infrastructure, including
the improvement of the health and wellbeing of people emergency services, energy, health, transport, and water.
nationally and within the region, through the best use of
evidence-based digital technologies. • Key Principles - To protect the population’s information and
wellbeing, the government will work with the private sector
Interoperability is key to improving coordination of care and the operators of Ethiopia’s critical national
services, equity of access to them, as well as their infrastructure for investment in robust cybersecurity.
effective delivery. It improves prevention of Government itself must also be able to operate with
communicable and non-communicable disease and confidence in the digital environment, be trusted to
supports optimal responses to population health priorities. handle data, and remain capable of protecting
The government, in collaboration with relevant Ethiopians’ privacy. As society becomes more connected,
stakeholders, can take a coordinating role and ownership the government must also promote awareness of
to create a standard and guideline as well as a platform to cybersecurity and ensure people know how to stay safe
ensure interoperability of DH systems and platforms online.
across healthcare settings.
Efficient and convenient public service and well-maintained
Human capital development in digital skills and capacity the digital infrastructure
end-user both at provider and consumer level
• Including improved finance legislation, service
• Digital skills are vital for the growth of the digital sector infrastructures such as network, electricity, and
and increasing productivity across the economy. Enhancing availability, and access to affordable
digital skills at all stages of life will help to ensure that hardware/technology. Ethiopia’s digital infrastructure is in
consumers and service providers can access the benefits its infancy. Developing this digital infrastructure as both
offered by new technology. technology and consumer demand evolve will be critical
to achieving its digital health and national digital
• Key Principles - Digital skills are increasingly becoming strategy.
essential to society as a whole. Government, in
collaboration with the private, development, and other • Key principles -Government will make it a priority to engage
sectors, will support better understanding, at the highest the private sector and development partners, associations,
levels of business, of technology’s potential to transform and others to support projects that improve the reliability,
or disrupt established industries. The digital sector resilience, and affordability of Ethiopia’s infrastructure.
requires specialist skills, such as software development, Government policies will also look further to the future,
which should be provided through mainstream education, encouraging innovation and resilience in the
initiatives to promote reskilling and where necessary, by telecommunications sector, to ensure that next-generation
facilitating high-level support to local experts as well as services are available in Ethiopia in the long term. The
collaboration with regional experts. delivery of advanced digital infrastructure will be
supported by a telecommunications strategy that will
Government will ensure that students receive the describe the specific steps to be taken and improved
education they need to achieve digital skills in access to consumers to the range of services they
preparation for the work environment. As the require.
requirements of the industry evolve, links between
business and education providers should be developed to • The government will continue to encourage a
ensure that the supply of digital skills meets future competitive market that promotes affordability and high
demand. Through initiatives to promote and accelerate quality of products and services. The government in
digital literacy, the government should also provide support consultation with the relevant stakeholders will review,
to ensure users feel confident using technology in the adjust, and fast track the implementation of financial and
workplace and at home. tax legislation that is encouraging and conducive for
increasing access to goods and items essential for the
development of digital infrastructure including equipment
and software.

18
 VII High-Level Roadmap

While the above sets out the key principles of Ethiopia’s Digital Digital Literacy – one of the key barriers identified in the digital
Health Policy Framework it does not set out priorities of actions health ecosystem in Ethiopia is the limited human skills, capac-
for development and implementation. As per the proposed DH ity, and digital literacy. The average population being rural and
policy framework, establishing the DH ecosystem of Ethiopia with low literacy in general, beyond access to mobile, digital
needs to take account of several key pillars. literacy remains limited to the uptake of digital health
solutions. Factors such as awareness, data use, and
This section proposes the priority pillars of the proposed infrastructure barriers affect digital literacy.
framework that Ethiopia needs to consider enacting as a
priority given the level of readiness of Ethiopia’s DH ecosystem. Beyond the end-users, digital literacy of the workforce in
employment as well as skills and training and expertise in
Ethiopia’s DH Priority Pillars and Roadmap
software development of hardware use is also a big challenge.
The below figure depicts the priority pillars to address or enact
for Ethiopia’s digital health ecosystem policy and planning
process.

DH Policy &
Governance

Efficient DH
Platform

DH
Investment

Integration – The other priority pillar for Ethiopia is looking to And training of private sector innovation. Such funding can also
integrate the various fragmented DH initiatives across the pri- be allocated to the academic sector to encourage research
vate sector, within the public sector and encourage develop- and development and within that support and finance STEM
ment partners to support ONE integrated ecosystem rather and other incubators for innovations and local talent
than vertical support. Indeed, Digital health should intersect production.
and help strengthen at system level and avoid vertical or dis-
ease-specific support. Although the above figure depicts, based on the deep-dive
analyses, the 3 priority pillars, it is important to note that a cross-
Innovation – As a third pillar of priority for Ethiopia, we pro- cut- ting priority would be to set up the relevant leadership and
pose developing financing sources and investments that can governance structure. The governing structures would have
encourage SME and entrepreneurship and for the government different focus and technical advisory groups and divisions that
to “harness” through relevant financial incentives for some of will encourage the policy framing to allow the development of
the private sector innovations. Some of the ways to the digital health platform as well as encourage DH
encourage innovation may be ensuring that some development investments as part of the larger national vision and
partner funding is allocated directly to strengthening capacity strategy for digital transformation.

19
 Annex 1: Ethiopia DH Policy Documents

Ethiopia Strategic Descriptions Keynotes on DH and Private Sectors

Documents
• The National eHealth • The document that remained in a draft for a long is aimed at • The whole eHealth implementation
strategy of Ethiopia guiding and streamlining the Information and Communication was designed to be entirely led and
(2012-2015, Addis Technology (ICT) solutions in the healthcare sector focusing on governed by the FMOH.
Ababa ver.1. April Health and healthcare providers, Consumers of health, and Health
• The strategic document had fallen
2012), and healthcare service managers.
short of mentioning the private
• The vision of the strategy was to provide equitable, quality, and sector's critical roles in digital
timely health services through the use of digital technology. The health implementation, leadership,
strategic areas of interventions were identified to be adapting e- and governance.
health standards (Legal and Regulatory framework), implementing
the national ICT infrastructure for e-health (Infrastructure,
standards, and system for eHealth), establishing governance and
leadership for eHealth, educational promotion to all stakeholders
on e-health (financing and Investment as well).

• The 20-year health • Indicated the overall government direction about non-state actors • It recommended having a balanced
sector vision (private for-profit, local and international NGOs, civic and approach in which the public
document (draft 20- professional societies) and their contribution in the health sector facilities contracts with private
year health sector should be enhanced as the health sector’s needs cannot be sector providers (both for-profit
vision, version 2015) addressed by the public sector alone. Besides, health is generally and nonprofit) in areas where the
regarded as a public good demanding a concerted effort of all government sector is unable to fill
stakeholders’ Private health facilities including hospitals, clinics, the demand or where public-private
pharmacies, diagnostic centers, and other health sector partners, partnerships (PPPs) might be an
will increase access to services and leverage resources for health efficient way to improve quality
care. and access.

• Advised establishment of a
separate PPP unit in FMOH.

• Not specifically mentioned on

digital technology support of
private sectors.
• The Ethiopian Public- • Developed in 2017 through a series of in-country learning visits, • Its development did engage private
Private Partnership experience-sharing visits to other countries, and consultation with sectors for profits and
implementation various organizations of development partners, FMOH, and associations.
guide donors’ representatives.
• Even though the document did not
• PPPH highlights the need for collaboration between the public and mention the roles of the private
private sector in which both parties carry out a partnership based sector in digital health technology,
on agreed tasks, while each party retains its own identity and it encourages the private sector to
juridical responsibilities. provide high-end diagnostic
services (laboratory and imaging),
• The document prioritized the creation of effective platforms to
and high-end clinical services, such
address untapped opportunities, and facilitate the exchange of
as organ transplantation, cardiac
technology, knowledge, and practices between the public and
and orthopedic care, hemodialysis,
private sectors. The guide indicated the project development team
radiotherapy, neurosurgery, and
to use a strict flow chart for deciding to engage a public sector
rehabilitation.
institution to a project idea or receive project ideas from the
private sectors. The national PPP board, the management team • The document guides the
from FMOH, RHBs, CEOs decides based on the review team report. partnership of the private sector to
complement government public
health programs in terms of
coverage, standardization of
services, and improvement of
service quality.

20
 Ethiopia Strategic Descriptions Keynotes on DH and Private Sectors
Documents
• National Health • It is the joint work of stakeholders represented by directorates and • Again, the private sector for-profit
Information System agencies of Ministry of Health, central statistical agency, ministry and associations were not part of
road map (2012- of justice and core technical working group composed of CDC, the strategic document
2020) WHO, JSI/MEASURE Evaluation, Tulane University, Italian preparation. The eight-year plan
cooperation, USAID. envisioned timely, complete, and
accurate health and health-related
• There were five strategic objectives planned to achieve in the road
information from an integrated
map; to strengthen HIS governance, legislation, coordination, and
data repository made available and
Leadership, to improve, strengthen and institutionalize HIS
used for evidence-based decision
resources, to improve health data coverage, to improve health
making at all levels in the country.
data management and quality, and to strengthen and
institutionalize information use for evidence-based planning, • The road map outlined the
performance monitoring, feedback and action at all levels. importance of using Electronic
Health Record (EHR). The
• Under these objectives, 31 key interventions were identified for
document advises the importance
implementation but no mention of the role of the private sector in
of reviewing and harmonizing the
achieving these objectives as well as digitizing, harmonizing
various efforts that were being
standard indicators with private sectors. The road map admitted
applied in EHR use in different
the health services-based information system has not effectively
regions and levels.
brought together data from all private facilities. So far, only a few
aspects of the data on private facilities are covered in the annual • It stated the lack of coordination
publications. There is no national roster of public and private and standardization among various
sector health facilities and a limited human resource database and efforts and lack of a clear long-
system to track the number and professional mix both in the term plan to move the whole
public or private sector. system as a major concern. It
stated the adoption of information
technology in the health sector
EHR-Smart Care that has been
used by utilizing basic
telecommunication infrastructure
(Ordinary Phone or CDMA) and
computers to send and receive
reports and software updates.
• The draft ehealth • Developed by the Ministry, outlined the different components and • The Ethiopia eHealth Architecture
architecture the mechanisms of how components exchange data among is a conceptual framework that
document themselves. Concerning the technology that enables the depicts the information systems,
components to be interoperable, a landscape analysis was done data sources, and integrations that
to seek solutions that have been implemented in other countries the Federal Ministry of Health
and to choose the ones which fit our requirements. Based on the proposes to implement and
set criteria, the Ministry has selected Open HIM to pilot the data maintain to achieve its strategic
exchange between different systems. In light of this, FMoH is goals.
currently testing the interoperability layer using OpenHIM. In the
• The eHealth Architecture illustrates
reporting period, two use cases, DHIS2-MFR, and eCHIS-MFR were
how distinct IT components form a
selected for interoperability testing. The DHIS2-MFR
coherent and holistic national HIS
interoperability using OpenHIM has been tested successfully.
that provides an increasingly
sophisticated set of business
capabilities to the health sector.
The eHealth architecture is
designed to help guide decisions
about FMOH digital health
investments that support
improvements in service delivery
while ensuring alignment with the
broader strategic context.

• The e-health architecture did not

indicate the role and contributions
of the private sector.

21
 Ethiopia Strategic Descriptions Keynotes on DH and Private Sectors
Documents
• FMOH Annual • FMOH conducted a comprehensive, national inventory of • Did not mention of private sectors
health sector software applications. The inventory identified a total of role
performance 2019 228 apps being utilized at FMOH regional health offices,
private hospitals, and clinics. FMOH came up with its
own Digital Health Atlas (DHA) with custom attributes
included and published in WHO Digital Health Atlas
(WHO-DHA). FMOH believes this is a promising step
regarding standardization of the apps that are going to
be implemented in the country - and will also inform the
envisaged Ethiopian eHealth Architecture. Anyone can
visit the WHO-DHA site and get detailed information on
the published apps
• The Ethiopia HSTP • Outlined a strategic objective that involves enhancing the • This five-year strategic plan did
2016-2020 use of the existing technology, the introduction of new not indicate much on digital
technology, technology transfer and development, and technology and the private
the use of local technology. It also addresses finding sector's contribution to the area.
better ways of doing things through more effective
products, processes, services, technologies, or ideas. It
encourages the efficient and effective internal business
processes of the health system and self-reliance in
biotechnology, use of eHealth services (e-HMIS, EMR, M-
health), telemedicine, Tele education, and technology
transfer for vaccine and diagnostic materials production.
• The Information • Developed following the HSTP plan. It indicated the • There is no mention of the private
revolution road Woreda Network as a state-of-the-art ICT infrastructure sector's contribution to digital
map, 2016 deployed by the Ministry of Communication and health in the Information
Information Technology. It has high bandwidth revolution road map document.
connectivity between ministries and agencies for sharing
data, voice, and video communication throughout the
country.

• WoredaNet is mainly used to connect government

institutions that exchange sensitive data electronically.
WoredaNet has reached almost all woredas, which is a
cost-effective way to connect RHBs, ZHBs, WorHOs,
hospitals, health centers, health posts, and communities.
Moreover, since some major nationwide electronic
systems such as IFMIS (Integrated Financial
Management Information System) have already deployed
in the WoredaNet infrastructure, it will be much easier to
create interfaces and coordinate with national eHealth
systems. Therefore, WoredaNet will be one channel to
implement various eHealth systems during the
implementation of HSTP

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