A CONCEPTUAL FRAMEWORK FOR SUSTAINABLE eHEALTH IMPLEMENTATION IN RESOURCE-CONSTRAINED SETTINGS
South African Journal of Industrial Engineering
There is evidence that several eHealth pilot projects in developing countries could not progress to full-scale implementationsometimes referred to as the 'pilotitis' of the eHealth system. The sustainable eHealth implementation frameworks reported in the literature are linearly modelled, and fail to reflect the nonlinear and dynamic complexity of eHealth systems implementation. This study proposes a sustainable eHealth implementation framework to support the long-term sustainability of eHealth
... ability of eHealth systems in developing countries. The framework addresses the nonlinear and dynamic relationships among elements of the ecosystem in the implementation of eHealth through feedback systems by following a system dynamics method. A literature review and systems approach is used to understand the interactions between the elements of a sustainable eHealth system. System dynamics modelling is applied to develop a nonlinear and dynamic model of sustainable eHealth implementation. The study indicates that the long-term sustainability of eHealth depends not only on technological factors, but also on economic, social, and organisational factors. Moreover, the causal loop diagram highlights the dynamic interplay between the factors of a sustainable eHealth system through feedback loops. 133 INTRODUCTION Growth in the use of electronic systems to support healthcare services delivery can be seen in the increasing number of electronic health (eHealth) systems in developing countries  . Government and other stakeholders in the developing world are showing a strong desire to use information and communications technology (ICT) in the health sector to replicate the successful revolution of ICT systems in the financial and other sectors  . eHealth is defined as the use of ICT for health  . The successful implementation of eHealth technologies is believed to improve access, safety, quality, and performance of healthcare services delivery by improving healthcare data management, minimising costs, and reducing medical errors [4, 5] . eHealth technology can bridge the healthcare services delivery gap in developing countries, such as the burden of disease, scarcity of healthcare professionals, inequity of healthcare services delivery, and shortage of healthcare budget  . The implementation of an infectious disease reporting information management system (IDRIMS) in China improved disease outbreak detection from 30% to 90% by 2011  . Despite the highly anticipated benefits of eHealth technologies to strengthen healthcare services delivery, the success of eHealth implementation is low in developing countries  . Some of the eHealth implementation challenges are associated with high technology acquisition costs and ongoing maintenance costs [8, 9] , lack of computer skills by end-users , trust and privacy concerns  , poor ICT infrastructure [12, 13] , and lack of leadership and political support [8, 12] . Moreover, in the change management process, organisational, interoperability, psychological, social, legal, and ethical factors can be a barrier to the sustainable implementation of eHealth in developing countries [6, 8, 12, 13] . The success of eHealth implementation depends on the stakeholders' objectives and needs . Moreover, the determinants of success may vary over time as ICT advances . The successful implementation of eHealth is linked to the acceptance of technology by end-users , ; the long-term sustainability of technology ; and managing stakeholders' expectations . eHealth success factors are categorised into technological, organisational, financial, ethical, political, and training groups . The relevance and user-friendliness of a technology, the availability of funds, user involvement, executive support, and ICT infrastructure are some of the success factors that determine the long-term sustainability of eHealth .