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  <front>
    <journal-meta />
    <article-meta>
      <title-group>
        <article-title>Strengthening Health Systems in Low-Income Countries: A Stakeholder Engagement Framework</article-title>
      </title-group>
      <contrib-group>
        <contrib contrib-type="author">
          <string-name>Diana Frost</string-name>
          <email>diana.frost@ntu.ac.uk</email>
          <xref ref-type="aff" rid="aff0">0</xref>
        </contrib>
        <contrib contrib-type="author">
          <string-name>Mufti Mahmud</string-name>
          <email>mufti.mahmud@ntu.ac.uk</email>
          <email>muftimahmud@gmail.com</email>
          <xref ref-type="aff" rid="aff0">0</xref>
        </contrib>
        <aff id="aff0">
          <label>0</label>
          <institution>Nottingham Business School, Nottingham Trent University</institution>
          ,
          <addr-line>Nottingham</addr-line>
          ,
          <country country="UK">UK</country>
        </aff>
      </contrib-group>
      <fpage>215</fpage>
      <lpage>222</lpage>
      <abstract>
        <p>Failures of e-Government projects in low-income countries are well-documented, though for many countries the adoption of information and communication technology presents the most effectual approach to overcoming some of the challenges faced in service provision. However, the long-term sustainability of e-Government projects may be hampered by an inadequate evaluation of the social and technical environment in which these solutions are placed, particularly with respect to the role of stakeholders during project design. This paper, therefore, proposes a strategic sector-specific exploration of the issues in the design and implementation processes of e-Government projects in low-income countries with a focus on the healthcare sector.</p>
      </abstract>
      <kwd-group>
        <kwd>e-Government</kwd>
        <kwd>Information and Communication Technologies</kwd>
        <kwd>Information Systems</kwd>
        <kwd>Healthcare Systems</kwd>
        <kwd>Citizen co-creation</kwd>
      </kwd-group>
    </article-meta>
  </front>
  <body>
    <sec id="sec-1">
      <title>1. Introduction</title>
      <p>
        Information and Communication Technologies (ICTs) are widely considered as playing a crucial
as a significant contributor to socio-economic development in advanced economic systems
        <xref ref-type="bibr" rid="ref19 ref6">(Erumban &amp; Das, 2016; Malaquias et al., 2017)</xref>
        . Low-income countries thus attempt to leverage on
the anticipated opportunities provided by these technologies in order to become effective
participants in an increasingly competitive global environment. ICTs have been used to advance
progress in key areas including: improvement of healthcare delivery
        <xref ref-type="bibr" rid="ref4">(Cecchini, 2018)</xref>
        , integration
into agricultural processes
        <xref ref-type="bibr" rid="ref5">(Dlodlo &amp; Kalezhi, 2015)</xref>
        , and use of mobile banking platforms
        <xref ref-type="bibr" rid="ref1">(Asongu
&amp; Odhiambo, 2019)</xref>
        . Yet, often insurmountable challenges such as poor physical infrastructure,
inadequate policies, and insufficient level of capacities (Gil-Garcia &amp; Pardo, 2005) , that are
particularly endemic in the implementation and sustainability of e-Government projects
        <xref ref-type="bibr" rid="ref11">(Heeks,
2002)</xref>
        , have resulted in high rates of project failure
        <xref ref-type="bibr" rid="ref9">(Lal et al., 2018)</xref>
        .
      </p>
      <p>
        Thus, long-term sustainability of e-Government projects in low-income countries are often
derailed not only by institutional procedures, policies and capacities, but also by extraneous factors
such as the availability of incomplete data, which has led to a modern data divide. Advanced
technologies such as big data analytics
        <xref ref-type="bibr" rid="ref16">(Luo et al., 2016)</xref>
        , artificial intelligence and machine learning
        <xref ref-type="bibr" rid="ref18">(Mahmud et al., 2018)</xref>
        therefore further underscore the disparities between those entities that collect
and/or own data, and those that have the capacities (and/or capabilities) to effectively analyse and
interpret this data.
      </p>
      <p>
        Additionally, the design of any e-Government project typically necessitates coordination among
a broad range of stakeholders including disparate Government ministries and departments, external
organisations and businesses, and other principal beneficiaries, including citizens. As such, possible
misalignment in stakeholder expectations
        <xref ref-type="bibr" rid="ref11">(Heeks, 2002)</xref>
        needs to be considered due to possible wide
government, local government, public service providers (both profit-driven and not-for-profit),
voluntary and community organisations and individual members of the public are rarely
et al., 2007). However, e-Government initiatives tend to emphasise the
technical aspects of delivery rather than the role of stakeholders and their participation in project
design
        <xref ref-type="bibr" rid="ref15">(Longford, 2000)</xref>
        . Therefore, given the resource constraints faced by low-income countries,
an integrated approach to e-Government project design which considers key issues such as
resourcesharing and stakeholder participation, needs to be considered.
      </p>
      <p>
        This paper therefore discusses an integrated and consistent approach to the design and
development of e-Government projects in low-income countries, building on existing research in the
conceptualisation of a framework for adoption
        <xref ref-type="bibr" rid="ref9">(Frost &amp; Lal, 2019)</xref>
        . The framework highlights a
multi-dimensional approach to e-Government design with a focus on the engagement of
stakeholders for successful implementation and the capitalisation of available resources. This paper
examines the possible application of this framework to an e-Government project. Human
development projects (such as healthcare systems) however tend to be at the focal edge of
eGovernment initiatives in low-income countries, with more attention paid to those projects
time or money to pay government bills, or to comply with taxes and other dues, or to obtain a
        <xref ref-type="bibr" rid="ref17">(Madon et al., 2007)</xref>
        . Therefore this paper discusses a possible approach to
application of the framework within the healthcare sector, prompted by current ongoing research
within two selected regions - Africa and Bangladesh. It is anticipated that the future results of this
research project will contribute to the dialogue on e-Government project design, and further the
debate in the adoption of ICTs by the public sector in low-income countries.
      </p>
    </sec>
    <sec id="sec-2">
      <title>2. Methodology</title>
      <p>
        Previous research
        <xref ref-type="bibr" rid="ref9">(Frost &amp; Lal, 2019)</xref>
        , explored the core underlying components for success in
eGovernment project design and proposed a framework within which relationships among the
components could be more effectively investigated. A thorough search of the literature identified
key compoents in the design of e-Government projects, namely:
1) Information networks: characterise the individuals, technologies, and processes that facilitate
information and knowledge exchange within the system;
2) Policy frameworks: encompass the policies (to include ICT and other sector-specific policies)
and other regulations and standards; and
3) Capabilities/capacities: describe the existing capabilities within the system and the potential
capacities to exploit the benefits of the implemented system.
      </p>
      <p>This research also identified three supporting factors for e-Government project design in low income
countries as:</p>
      <p>Social capital: refers to the levels of social cohesion that are formed within communities or that
support vertical linkages with external formal institutions;
Human capital: broadly refers to the ability of actors such as individuals, groups,
organizations, institutions and countries to perform specified functions, solve problems, set
and achieve objectives within the system; and
Infrastructure: specifically, within an e-Government context, this is the underlying
telecommunication networks or the ICTs that facilitate access to the system.</p>
      <p>The developed framework (Figure 1) therefore highlights the key dependencies within the system
that should be considered during e-Government project design and which are critical to long-term
sustainability. Specifically, these primary relationships were identified as:
the role of the underlying infrastructure in supporting information and knowledge exchange,
and in defining the types of policies to be created to support access;</p>
      <p>Capacities/Capabilities: This describes the
individuals and communities that support the development of the network through creation
of the requisite policies (e.g., within Government agencies) and the individual or collective
capabilities of a society or community for exploiting the opportunities offered by the system;
-dependency
underscores the pivotal role of social capital in facilitating and enhancing information and
knowledge exchange among individuals and/or organisations, making it easier for people to
collaborate and develop requisite capabilities.</p>
    </sec>
    <sec id="sec-3">
      <title>3. Application in the Healthcare Sector</title>
      <p>
        Ongoing research therefore further examines the applicability of this e-Government framework to
the healthcare sector to examine how technologies can more effectively support and enhance the
inter-relationships among stakeholders in a health system. In many low-income countries healthcare
projects have been predominantly facilitated and controlled by government agencies, therefore this
research offers some generalisations for other sector-specific e-Government projects. Additionally,
with the increased use of technologies in the sector to support healthcare provision (e-Health) and
information exchange, and recent research pointing to the growing importance of data- driven,
evidence-based healthcare
        <xref ref-type="bibr" rid="ref20">(Ong et al., 2018)</xref>
        an exploration of these components in the sector will
contribute to the growing literature on the use of technologies for strengthening health systems.
Therefore focus is given to enhancements and interactions among the proposed framework
(WHO, 2007).
      </p>
      <p>
        Consideration was given to the differentiation of the framework within a healthcare context, and
the specific issues that may contend. Borrowing from the information systems literature to
complex systems to meet their deadline, costs, and stakeholder expectations are not, by and large,
failures of technology. Rather, these projects fail because they do not recognise the social and
organisational complexity of the environment in whic
        <xref ref-type="bibr" rid="ref2">(Baxter and
Sommerville, 2011)</xref>
        . Therefore it can be argued that an adopted
top
      </p>
      <p>
        - that is to develop and implement the system without a full understanding
of the context within which the system will operate - is more likely to lead to failure. Thus in
considering the applicability of the framework to the healthcare sector, the researchers decided that
a more stakeholder-centric approach is needed where the current and desired outcomes of the
project are made explicit
        <xref ref-type="bibr" rid="ref7">(Grimsley et al., 2007)</xref>
        , and anticipated contributions - in the manner of
available resources and capabilities - of all participating stakeholders are also clearly defined.
      </p>
      <p>
        The evaluation of multiple stakeholder interests in the design of e-Government initiatives
public service providers (both profit-driven and not-for-profit), voluntary and community
organi
        <xref ref-type="bibr" rid="ref7">(Grimsley et al., 2007)</xref>
        .
However identified stakeholders in e-Government projects may necessarily include Government
agencies, citizens, and businesses, but can also extend to those stakeholders such as voluntary and
community organisations that may be misplaced on the periphery of e-Government design
processes
        <xref ref-type="bibr" rid="ref3">(Bowles &amp; Gintis, 2002)</xref>
        . Therefore, the refined framework for the healthcare sector
highlights the role of stakeholders - individuals or groups that affect (or are affected by) realisation
of the project goals or outcomes
        <xref ref-type="bibr" rid="ref8">(Freeman, 2010)</xref>
        - in the design and development of the
eGovernment project (Flak &amp; Rose, 2005). The refined framework is based on the supposition that the
health system is implemented: (i) as an e-Government project with mandatory use by end-users; (ii)
as a service provided by health workers in the public sector, but may also extend to private
healthcare practitioners; and (iii) is supported by an underlying telecommunications infrastructure
where service provisioning may be from private (non-Government) agencies.
      </p>
      <p>
        Figure 2 illustrates the proposed primary roles of each group of stakeholders within the general
framework, where the following groups are proposed as the primary stakeholders in the health
system
        <xref ref-type="bibr" rid="ref20">(Ong et al., 2018)</xref>
        :
      </p>
      <p>Service receivers: This group of stakeholders includes individual beneficiaries and
communities, highlighting the use of technologies by these stakeholders to facilitate the
creation or enhancement of information networks. The development and sustainability of
these information networks are dependent on having access to the relevant underlying
infrastructure such as a mobile network, and on the existence of sufficient levels of social
capital exist to support trust in the created information networks.</p>
      <p>Service providers: Service providers include for example community healthcare workers and
other healthcare professionals that possess the capacities and capabilities for health service
provision to communities. Underlying this is the skills or knowledge that these providers
possess (human capital) and, it can also be argued, that social capital facilitates the
development of trusted relationships for information and knowledge exchange.
Government agencies: Government agencies are typically the principal regulators responsible
for the design of requisite policies. The types of policies may be defined by the underlying
infrastructure such as the selected technologies, and these agencies having the relevant human
capital to create effective policies.</p>
      <p>Ongoing research therefore examines the application of the framework within the healthcare
sector, with specific focus on the role of stakeholders and their engagement within the project. Some
of the key research aims therefore include:
a) To understand the dynamics of the specific relationships among stakeholders within the
framework during project design and development;
b) To investigate, through comparative analyses between the two regions, the socio-cultural
factors in the implementation of the project;
c) To understand the key factors that may impact sustainability of the project.</p>
    </sec>
    <sec id="sec-4">
      <title>4. Conclusion and Future Directions</title>
      <p>This paper explores the application of a framework to understand the inter-relationships among key
components and stakeholders for the implementation of an e-Government project, specifically a
health system in a low-income country. The framework presents a multidimensional approach to
understanding these issues, that may help in identifying misalignment between stakeholder needs
and requirements, and the technologies used within that system. Ongoing research will focus on the
collection and analysis of data from two low-income countries on the use of technologies within a
selected health system. By adopting a structured-case method approach, the longitudinal studies
will facilitate more in-depth research on the application of the e-Government framework within a
specific sector.</p>
      <p>The sector-specific application of the framework is not without its limitations, as it omits
extraneous factors such as the pervasiveness of political corruption, measures that are difficult to
encapsulate within the current framework. However, the results of this ongoing research between
the two selected regions - Africa and Asia - will serve as a broad starting point to discussion of these
issues and bring focus to sector (and possibly regionally) specific issues that impact long-term
sustainability of the implemented systems in low-income countries. Additionally, the results of the
research will contribute to debates on approaches to stakeholder engagement in the implementation
of e-Government projects in low-income countries.
Gil</p>
      <p>E-government success factors: Mapping practical tools to theoretical
foundations. Government Information Quarterly, 22(2), 187 216
Flak, L.S., &amp; Rose, J. (2005). Stakeholder Governance: Adapting Stakeholder Theory to E-Government.</p>
      <p>Communications of the Association for Information Systems, 16(1), 642-664.
About the Authors
Diana Frost
Diana Frost is a member of the teaching faculty in the Nottingham Business School, Nottingham Trent
University (NTU). She worked as a private management consultant for fifteen years before starting her
academic career at NTU in 2016. Her continued primary research interests are in the areas of e-Government,
particularly in small economies, and more generally the application of information technologies for
development. Diana has a PhD in Computer Science (Tufts University), MSc in Computer Science (University
of Oxford), and BSc in Computer Science and Mathematics (University of the West Indies).
Mufti Mahmud
Mufti Mahmud received his PhD degree in information engineering from the University of Padova, Padua,
Italy, in 2011. He is currently a Senior Lecturer with the Department of Computing and Technology,
Nottingham Trent University, Nottingham, UK. With over 80 peer-reviewed research articles, his current
research focuses on application of artificial intelligence (AI) in healthcare systems to improve healthcare
delivery at low-resource settings. His research interest includes AI applied to healthcare, (big)data analytics,
the Internet of healthcare things, and trust management in cyber-physical systems. He was a recipient of
the Marie-Curie Fellowship. He also serves at various capacities in the organisation of leading conferences,
including the Coordinating Chair of the local organization committee of the IEEE WCCI2020 conference and
General Chair of the Brain Informatics 2020 conference. He serves as Editorial Board Member of Cognitive
Computation (Springer-Nature) and Big Data Analytics (BioMed Central) journals, and Associate Editor of the
Brain Informatics (SpringerOpen) and IEEE Access (IEEE) journals.</p>
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