Building a Digital Health Innovation Ecosystem
Framework through Design Science Research
Gloria E. Iyawa Marlien Herselman
Department of Informatics
Namibia University of Science and
Technology University of South Africa
Windhoek, Namibia Pretoria, South Africa
gloria.iyawa@gmail.comline 1 mherselman@csir.co.zain
Abstract— Digital Health Innovation Ecosystem is a relatively
new concept, with studies describing it as an ecosystem that
allows patients and other healthcare stakeholders take part in
the healthcare delivery process using digital health technologies
with the inclusion of innovation principles. This paper presents
findings of a study which aimed at developing a contextualised
Digital Health Innovation Ecosystem framework for the
Namibian context. The use of Design Science Research (DSR) in
developing the framework is demonstrated through a case study
of the development of a Digital Health Innovation Ecosystem
framework for Namibia. The study adopted DSR in three
evaluative phases which covered the literature study, Delphi
method, local and global expert reviews. Through DSR,
processes such as literature review, building components and
infrastructure for the Namibian context are unearthed. The
Digital Health Innovation Ecosystem framework facilitates the
use of various existing approaches in a logical manner that
incorporates the needs of a specific country, also taking into
consideration that each is country context is unique and
different, hence, permitting flexibility. The findings of this paper
provide useful insights into how a Digital Health Innovation
Ecosystem framework may be developed.
Keywords—Digital health, innovation, digital ecosystems,
design science research, Digital Health Innovation Ecosystems,
framework.
I. INTRODUCTION AND BACKGROUND
Information and communication technologies (ICTs) have
been present in the delivery of healthcare services over the
past few years [1], with the use of different terms to describe
its relevance in healthcare; for example, electronic health (e-
health) [2], mobile health (m-health) [3], telemedicine [4], and
most recently, digital health [5-8]. Digital health has become
a trending topic recently [5] [8-12], with different studies
emphasizing the need for the implementation of digital health
[9] [13] in which patients can take part in the proactive
management of their own health [5-6]. Lupton [6] further
suggests that patients can facilitate the management of their
health with digital health technologies.
This study focuses on a unique setting, Namibia. Namibia
is a developing country and “classified as an upper middle-
income country” [14]. Namibia is located in the Southern part
of Africa and became independent in 1990 [15]. In the recent
literature, it is highlighted that paper-based health records are
still in use within the healthcare sector in the management of
healthcare services within the Namibian context [16-17]
health information systems have also been implemented in
public health institutions [17] and as such, the Namibian
healthcare sector is constantly changing. However, there are
more efforts that need to be put into consideration to ensure
that these systems work efficiently which a digital health
platform can provide [11]. With digital health, patients can
facilitate the healthcare delivery process [6], doctors can
communicate with patients at distant locations [4] and it is
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Adele Botha
CSIR, Meraka CSIR, Meraka
& &
University of South Africa
Pretoria, South Africa
abotha@csir.co.za
possible for doctors to monitor patients from a distant location
[18-19], leading to better healthcare supervision for patients.
The current healthcare infrastructure in Namibia does not
facilitate sharing of information among healthcare
practitioners as well as with patients [16-17]. Furthermore,
there is currently no platform in which patients can directly
take part in the healthcare delivery process. As a result, there
is a need for digital health to be established within the
Namibian healthcare paradigm. The implementation of digital
health is not only important to healthcare practitioners, but
also important in the management of health and wellbeing of
patients [5-6].
Digital health has been implemented in developed
countries [9]. However, the discussion on digital health in
developing countries is starting to take shape [20-22] [9]. The
problem within the Namibian public healthcare sector is that,
despite the recent uptake of ICT in its processes [17], there is
still dependence on paper-based records which hampers the
efficient sharing of health information among practitioners
and between health institutions. Furthermore, there is no
opportunity for patients to participate in the healthcare
delivery process to facilitate healthcare innovation. Kanstrup
et al. [23] reveal that patient innovation is important in the
healthcare delivery process. Additionally, information sharing
among healthcare practitioners and health institutions can be
hampered by many factors such as organizational policies,
competition among healthcare practitioners and healthcare
institutions.
There are different platforms which have been highlighted
in literature to improve information sharing using digital
technologies such as digital ecosystems [24] [25], also in the
healthcare setting, concepts like digital health ecosystems
have been discussed [7] [26]. The concept of digital health
ecosystems suggests the need to share information among
healthcare practitioners and health institutions to aid the
delivery of healthcare services to patients in a digital platform
[7]. The concept of Digital Health Innovation Ecosystems
promises better utilisation of digital technologies in the
healthcare delivery process by involving patients in the
healthcare process [27]. The need for incorporating innovation
within a digital health ecosystem is important as Herselman et
al. [9] argue that it is necessary to have “innovation
ecosystems” when incorporating digitalisation into healthcare
services, hence, the concept of Digital Health Innovation
Ecosystems. The potential of Digital Health Innovation
Ecosystems to support innovation within the healthcare
paradigm is therefore of keen interest.
Iyawa et al. [27] define a Digital Health Innovation
Ecosystem as a “network of digital health communities
consisting of interconnected, interrelated and interdependent
digital health species, including healthcare stakeholders,
healthcare institutions and digital healthcare devices situated
in a digital health environment, who adopt the best-
demonstrated practices that have been proven to be successful,
and implementation of those practices through the use of
information and communication technologies to monitor and
improve the wellbeing and health of patients, to empower
patients in the management of their health and that of their
families.”
The definition provided by Iyawa et al. [28] suggests that
a Digital Health Innovation Ecosystem consists of concepts of
digital health, innovation and digital ecosystems. A Digital
Health Innovation Ecosystem has the potential to enable the
interaction, sharing of information among healthcare
practitioners, healthcare institutions, patients and facilitate
patient involvement in the healthcare delivery process within
the Namibian context. Digital Health Innovation Ecosystems
can also enable patients participate in the management of their
own health as Curley and Salmelin [29] suggest that
innovation ecosystems facilitate participants to work as
collaborators rather than competitors. Furthermore, Digital
Health Innovation Ecosystems also sanction the use of
innovation principles to mitigate the challenges and
restrictions which may arise as a result of sharing information
in a digital health ecosystem. Iyawa et al. [10] also suggest
that a Digital Health Innovation Ecosystem has the potential
to help developing countries meet the Millennium
Development Goals, and as a result, important to the
Namibian context.
Implementing a Digital Health Innovation Ecosystem for
the Namibian context represents a complex problem as the
concept of digital health is still emerging within the Namibian
context. Design Science Research (DSR) is known for
addressing wicked problems [30] therefore, the
implementation of a Digital Health Innovation Ecosystem for
the Namibian context would first require critically examining
the existing healthcare infrastructure within the Namibian
context to provide a framework for establishing a Digital
Health Innovation Ecosystem in Namibia. A Digital Health
Innovation Ecosystem is a complex and extensive ecosystem,
and, as a result, this paper aimed at developing a
contextualised Digital Health Innovation Ecosystem
framework for the Namibian context using Design Science as
a strategy.
This paper contributes to the emerging body of literature
on Digital Health Innovation Ecosystems. The study further
contributes to how Design Science Research (DSR), as a
strategy, can be used to develop meaningful solutions to
problems by refining an artefact to meet the need of the
context for which it is needed.
This paper is structured as follows: Section 2 discusses
Design Science Research as a strategy and how it was applied
in this study, Section 3 presents the results and discussion of
the findings. Section 4 presents the contextualised Digital
Health Innovation Ecosystem framework for the Namibian
context. Section 5 concludes the study.
II. RESEARCH METHOD
A. Design Science Research (DSR)
The research design and methodology adopted for this
paper is DSR, which focuses on the creation of new
knowledge, as the purpose of design science is “to change
existing situations into preferred ones” [31]. Design Research
is research “into or about design, whereas DSR mainly
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involves research which uses design as a research method or
technique” [32]. DSR is a research procedure which facilitates
the creation of innovative constructions intended to solve
problems faced in the real world and so contribute to the
theory of the discipline in which it is applied [33].
DSR addresses wicked problems in information systems
(IS) [34] and is often used as a “problem-solving” technique
[30]. According to Hevner and Chatterjee [30], wicked
problems relate to “ill-defined environmental contexts as well
as the creativity and teamwork needed to produce effective
solutions.” “Messy” problems are also investigated using DSR
[30] which are often denoted by “a large degree of uncertainty
as to how the problem should be approached and how to
establish and evaluate the set of alternative solutions” [35].
This description is applicable to the development of the
Namibian Digital Health Innovation Ecosystem framework,
since there are many possible ways to develop such an
ecosystem. It should thus be evaluated and validated in its
own, and global, contexts for specific purposes.
The researchers acknowledge the existence of other
research methodologies such as grounded theory, action
research, case study research and ethnography, but posits that
DSR is the best choice of methodology for this study as it
provides practical solutions in a complex context.
Design science is a strategy that “creates and evaluates IT
artefacts intended to solve identified organisational problems”
[36]. The artefacts are refined until the final solution is
presented [37]. There are four types of artefacts identified in
literature are: constructs, models, methods and instantiations
[38]. However, the artefact in this study is labelled as
framework. Baskerville et al. [39] explain that an artefact
contributes to knowledge when it is ‘novel or useful.’ The
final framework consists of the relevant components that
make up a Digital Health Innovation Ecosystem for the
Namibian context, such as digital health, innovation and
digital ecosystems. The framework is useful and can be
applied within the Namibia context.
Design science has been applied in different fields
including architecture [40] and Information Systems [41].
Hevner [42] postulates that that which makes design science
unique is “relevance cycle and rigor cycle” which enhances
the process of creating innovative solutions. Hevner [42]
further highlights three cycles relevant to design science
namely: the rigour cycle (informs the research based on
alignment of the already known facts), relevance cycle (the
applicability of the artefact within its desired context) and
design cycle (the process of developing and improving the
artefact). Recently, a fourth cycle was added by Drechsler and
Hevner [43] namely the change and impact cycle (relates to
the overall impact of the artefact on a larger context).
B. DSR methodology guidelines
Phase 1 focused on the literature study which led to the
development of the initial framework. Phase 2 focused on the
development and evaluation of the initial framework by
Digital Health, Innovation and Digital Ecosystems local
experts within the Namibian context and the development of
the intermediate framework. Phase 3 focused on the
development and validation of the intermediate framework by
global experts and the development of the final framework.
The guidelines for carrying out design science research are
explained in the next section. Hevner et al. [36] provide
guidelines for carrying out DSR. Table 1. lists each guideline, method and descriptive statistics) data collection techniques
its description and how it was applied in the study. were applied. Different authors have identified the different
data collection techniques that can be applied in research [45]
TABLE I. GUIDELINES FOR CARRYING OUT DESIGN [46].
SCIENCE RESEARCH [36]
Guideline Description Application to this III. RESULTS AND DISCUSSION
Study
Guideline Design-science research The study identified the
A. Phase 1 (Literature study and initial framework)
1: must result in the creation components that The literature study was an important part of this study as
Design as of a practical artefact in the constitute Digital Health it provided an insight on existing research in the area of Digital
an Artefact form of constructs, models, Innovation Ecosystems Health Innovation Ecosystem. The first phase of the study
methods or instantiations. which led to the
development of the entailed a literature study, towards identifying the components
contextualised Digital of the concepts: Digital Health, Innovation and Digital
Health Innovation Ecosystems through a systematic literature search [27], Iyawa
Ecosystem framework et al. [28] and a scoping review of Digital Health Innovation
Guideline Design science research The problem identified in Ecosystems in developed and developing countries [10]. The
2: aims at building up this study refers to the
Problem technology-based solutions
components of Digital Health Innovation Ecosystems were
lack of information
Relevance to inherent and relevant compiled to present the initial Namibian Digital Health
sharing among healthcare
business problems. practitioners, healthcare Innovation Ecosystems framework as presented by Iyawa et
institutions and patients al. [27]. The literature review is an important part of the
in the Namibian context application of DSR as it helped identify what is necessary for
because of organisational a Digital Health Innovation Ecosystem to be developed. Two
policies and competitions different types of literature reviews were conducted, namely,
among healthcare systematic literature review and scoping literature review.
practitioners and health This provided an in-depth analysis of what is already covered
institutions in Namibia. in the literature in terms of Digital Health Innovation
Guideline The design artefact must be The framework was
3: thoroughly evaluated refined in three different
Ecosystems. This set the path for establishing what is required
Design through well-executed phases. in the development of a Namibian Digital Health Ecosystem.
Evaluation methods to yield utility, The initial framework developed in phase 1 was evaluated in
quality and usefulness. phase 2.
Guideline Design science research The framework is
4: needs to offer new and expected to provide B. Phase 2 (Intermediate framework)
Research acceptable contributions in useful insights for the The components, identified in phase 1, were evaluated by
Contributio the fields of design artefact, implementation of a
ns design foundations and/or Digital Health Innovation 22 local experts in Namibia, as presented by Iyawa et al. [11].
design methodologies Ecosystem within the The method of evaluation, employed by local experts in
Namibian context. Namibia, involved ranking the different components of
Guideline Design science research To maintain rigour, Digital Health, Innovation and Digital Ecosystems through the
5: employs rigorous methods different approaches application of the quantitative Delphi method [11]. The results
Research in the construction and were applied in the study.
Rigor evaluation of the design From the literature [10]
are presented through using descriptive statistics and
artefact to ensure coherence [27], the components of interviews, also conducted with local stakeholders in
and consistency. Digital Health, Namibia. These adopted a qualitative approach towards
Innovation and Digital investigating: the perceived value of Digital Health,
Ecosystems which were Innovation and Digital Ecosystems for the Namibian context,
validated in different the potential stakeholders of Digital Health Innovation
phases by both local [11]
and global [12] experts. Ecosystems within the Namibian context and strategies
Guideline The creation of an effective Literature reviews were needed for the establishment of Digital Health within the
6: artefact requires used to identify relevant Namibian context [47]. The components of Digital Health
Design as a consideration of the components of Digital Innovation Ecosystems were compiled to present the
Search problem environment and Health, Innovation and intermediate Namibian Digital Health Innovation Ecosystems
Process mechanisms that can find Digital Ecosystems.
an effective solution.
Framework [11]. The evaluation of the framework by local
Guideline Design-science research Some of the findings of stakeholders was necessary to understand from a local
7: must be communicated the study have been perspective, what is required in a Namibian Digital Health
Communic effectively, both to published in the form of Innovation Ecosystem. The intermediate framework
ation of technology-oriented as well conference paper [10], developed in phase 2 was evaluated in phase 3.
Research as management-oriented book chapter [28] and
audiences. journal articles [27] [11] C. Phase 3 (Final framework)
[12] [47].
Phase 3 presents expert reviews used to gather data from
C. Qualitative and quantitative data ollection techniques global experts. In order to validate the feedback provided by
Qualitative research is used to explore and understand a local experts, the intermediate framework was presented to
social, or human, problem from the individual’s perspective. global experts which included experts in digital health,
The research process includes: the combining of processes and innovation and digital ecosystems from developed and
questions, inductive analysis, building from facts to more developing countries (Portugal, Germany, Finland, Ireland,
general themes and interpreting of data [44]. Nigeria, Italy, Taiwan, Australia and the United Kingdom).
The questionnaires, administered to the global experts,
In this study both qualitative (semi-structured interviews, contained open-ended questions which sought to investigate:
expert reviews, literature reviews) and quantitative (Delphi the perceived value of Digital Health, Innovation, and Digital

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Ecosystems for the Namibian context, the potential
stakeholders of Digital Health Innovation Ecosystems within
the Namibian context and strategies needed for Digital Health
to be established within the Namibian context [47]. The
questionnaire issued to global experts adopted a qualitative
approach.
The final framework, incorporating the findings from the
global experts, is presented in Figure. 1.
Evaluation is an integral part of the Design Science
Research Process model [37]. It should “observe and measure
how well an artefact supports a solution to the problem and
involves comparing the solution to actual observed results
from use of the artefact in the demonstration” [37]. However,
it has been stated that little guidance exists in the literature
with respect to the evaluation of artefacts [48] [49], and that
methods and objectives of evaluation are fragmented and
unclear [49]. Authors such as Prat et al. [49] and Venable et
al. [50] have proposed evaluation design frameworks to
address this gap in the DSR literature.
In general, a method of evaluation needs to suit the nature
of the item that is being evaluated. Furthermore, it needs to
“provide feedback for further development, and… [assure] the
rigour of the research” [50]. The why, as well as the how, what
and when to evaluate become central to the evaluation method
[49] [50].
For the purpose of this research, both of the frameworks
of Prat et al. [49] and Venable et al. [50] were applied to
describe the nature of the artefact’s (a Namibian Digital
Health Innovation Ecosystem) evaluation: FEDS (a
Framework for Evaluation in Design Science) was used to
determine the functional purpose of the artefact (to inform the
Namibian health department to consider implementing it in
Namibia) and to evaluate the artefact by both experts from
Namibia, as well as from a global perspective. This addressed
the relevance and utility of the artefact.
IV. CONTEXTUALISED DIGITAL HEALTH INNOVATION
ECOSYSTEM FRAMEWORK FOR THE NAMIBIAN CONTEXT
The final Namibian Digital Health Innovation Ecosystem
Framework consists of the components Digital Health,
Innovation and Digital Ecosystems which have been
evaluated by local experts and validated by global experts in
Digital Health, Innovation and Digital Ecosystems. The
framework not only contains components of Digital Health,
Innovation and Digital Ecosystems relevant to the Namibian
context, but it also provides useful insights to be taken into
consideration for the implementation of Digital Health in
Namibia.
Ecosystem-oriented architecture was identified by both
Namibian and global contexts as an architecture which should
be deployed in a Namibian digital health innovation
ecosystem. As described by Ion et al. [51] this architecture
supports the interoperability and the integration of the
different processes that characterize a digital ecosystem. The
final Digital Health Innovation Ecosystem should thus adopt
an ecosystem-oriented architecture which suits both the
Namibian and global context. The stakeholders (biological
and economic species) in the final Digital Health Innovation
Ecosystem framework consist of different health, and non-
health professionals, as well as health institutions.
Stakeholders were identified by both local experts, and global
experts, as an important component in a Digital Health
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Innovation Ecosystem. However, stakeholders will not work
alone but collaborate with international experts and/or
stakeholders.
There is a network of global health experts which can
assist local professionals within the Namibian context, as
indicated by the innovation expert. This assistance could
include interaction in response to specific needs, thus
improving the quality of care provided to patients within the
Namibian context. However, collaborations between local and
international stakeholders, as well as the network of global
health experts, will be guided by context specific policies on
innovation relevant to their own countries (based on the
innovation components described in [27] [28]). The ideas and
knowledge shared by stakeholders, and global health experts
in the Digital Health Innovation Ecosystem, will be guided by
intellectual property rights and thus influence the free flow of
information among stakeholders. The parties concerned, both
locally and internationally, will be motivated to work as
collaborators, rather than competitors.
The final Namibian Digital Health Innovation Ecosystem
Framework is presented in Figure 1 after the intermediate
framework was evaluated by global experts.
Fig. 1. Final Namibian Digital Health Innovation Ecosystem framework
The final framework is a visual representation of the
concepts, their components and their interrelated links, as
explored in this study.
Sharing of information between stakeholders in a Digital
Health Innovation Ecosystem can be facilitated when cloud
computing is deployed. As indicated by a Namibian
innovation local expert, research and development is relevant
to a Namibian Digital Health Innovation Ecosystem as it
facilitates innovation and development. Research and
development can be a collaborative activity between local and
global professionals.
As indicated in the framework, informed by both
Namibian local experts and global experts, the infrastructural
support (both physical and technical) needed to create and
sustain the Digital Health Innovation Ecosystem, will be
provided by Namibian stakeholders and external sources.
As indicated by both Namibian local experts and global
experts, implementing a Digital Health Innovation Ecosystem
in a developing country, like Namibia, will be challenging.
However, relevant policies and adequate planning should go a
long way in addressing potential challenges in a timeous
manner. Global stakeholders can assist Namibian role-players
with human and/or capital resources as well as infrastructural
and/or knowledge-based support.
Privacy and security are components which both
Namibian local experts, and global experts, deem important to
the Namibian Digital Health Innovation Ecosystem. Privacy
and security concerns affect both the Namibian and global
health experts participating in activities within the Digital
Health Innovation Ecosystem. Information shared and
applications deployed in the Digital Health Innovation
Ecosystem need to be protected. If not properly addressed,
privacy and security issues may deter stakeholders, and global
health experts, from freely taking part in the Digital Health
Innovation Ecosystem. Policies regarding the enforcing of
security measures within the Digital Health Innovation
Ecosystem should be put into place and strictly implemented.
Such policies include the incorporation of the Health
Insurance Portability and Accountability Act (HIPAA)
security rule to protect patient health information [52]
As indicated, by both Namibian local experts and global
experts, a strategy for training patients regarding the use of
digital health technologies is paramount.
Technologies, which will be used by medical practitioners
and patients, form a relevant part of the expert evaluated
Digital Health Innovation Ecosystem. These systems need to
be managed by IT professionals. The digital health
technologies, as used in the Digital Health Innovation
Ecosystem, can also be used by global health practitioners to
provide support to the Namibian medical practitioners.
Technological support can also be provided by global
professionals. Within the Namibian context, healthcare
practitioners and patients in the Digital Health Innovation
Ecosystem platform can agree on mechanisms to share
information guided by innovation principles such as open
innovation and intellectual property rights [27], hence,
addressing the complexities of information sharing within the
Namibia health sector.
User Experience (UX) and patient-centredness, as pointed
out by a global digital health expert, is to be incorporated into
those systems which will be used by patients. The
implementation of these components will facilitate patients’
learning and adoption process.
V. CONCLUSION
In conclusion, it is evident that the mere transfer of
existing solutions, methodologies and models to the Namibian
context is not feasible. The experience and knowledge of co-
creating with users and of industry identifying the
beneficiaries of digital health systems, or the adaptation of the
cost structure of solutions, would probably be the traditional
focus areas when considering the value of European examples
for Africa. Failure to appreciate the local context and/or user
needs is a mistake typically made when solutions are designed
for local contexts. Learning from other countries’ experiences,
at system level, requires stakeholders to pay attention to how
the emerging Namibian digital health system has adapted to,
integrated and coordinated with the Namibian National
Innovation System.
This study is relevant as it can provide a Digital Health
Innovation Ecosystem Framework, based on the requirements
and needs of the Namibian context. Components of the
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framework, known as Digital Health, Innovation and Digital
Ecosystems, contribute both theoretically and practically
through their exploration, evaluation and validation within the
Namibian context.
The final framework will provide decision makers in the
Namibian healthcare sector with useful information regarding
which important components to consider when implementing
a Digital Health Innovation Ecosystem. The findings of the
study also provide valuable insights into strategies needed for
Digital Health to be established within the Namibian context.
The guidelines, with approaches for implementing a Digital
Health Innovation Ecosystem as provided in the study, can be
adopted by other countries with a similar context.
This study is limited to identifying the components of
Digital Health Innovation Ecosystems relevant to only the
Namibian context. Although guidelines with approaches for
implementing a Digital Health Innovation Ecosystem in
developing countries and for the Namibian context
specifically were proposed [10], the guidelines for
implementing the individual components of the final Digital
Health Innovation Ecosystem in Namibia was not provided.
Possible future research could include how best to
implement the Digital Health Innovation Ecosystem
framework within the Namibian context and the provision of
guidelines on how individual components of the Digital
Health Innovation Ecosystem Framework could be
implemented.
ACKNOWLEDGEMENT
The authors acknowledge that this paper is based on
research conducted at the University of South Africa for a PhD
(Information Systems) degree [53].
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