A proportional interoperability framework as an appropriate growth strategy for eHealth in sub-Saharan Africa

The objective of our work was to improve healthcare services supported by eHealth applications in sub-Saharan Africa (SSA) by proposing interoperability that is proportional, in terms of costs and benefits, to immediate demands and is capable to enable future scenarios of growth. (e)Health represents a very complex system with many stakeholders, services and technologies, varying objectives and forces that play out on separate hierarchical levels with inconsistent and sometimes even contradicting prerequisites as well as requirements. To provide individual patients with the integrated care they need and to meet the distinct however interrelated interests of the other primary stakeholders and society alike, interoperability guidance is required. To improve effectiveness and efficiency of eHealth in SSA, interoperability solutions that stimulate and consolidate cooperation on various levels (e.g., local, district, national, international) and in different dimensions (e.g., social and political, regulatory, organisational, technical, semantic, financial) is key. To that end, we have conducted research towards a flexible interoperability framework that can cope with various demands from these different levels and dimensions, and facilitates different operational models of cooperation while preserving interoperability. Since a top-down approach too often results in unworkable, one-size-fits-all paradigms, and a bottom-up approach generates heterogeneous, non-interoperable islands of operations, we propose a value-driven, hybrid approach with intense user involvement and incremental steps towards higher levels of interoperability. By building on successful initiatives on any level, with proven cooperative solutions in at least one dimension, and guiding further development by addressing dimensional issues at each level proportionally, interoperable centers of cooperative eHealth emerge that are governed by African ownership towards future growth, yet remain proportional to current demands and flexible to future scenarios.