Table 2.

Interoperability domain maturity scores

Leadership and governance
Subdomain	Level	Comment
Governance structure for HIS	(3+) established	Kenya’s Ministry of Health has an established governance structure for the management of HIS activities. There are technical working groups (TWGs) that meet regularly, namely the HIS TWG, eHealth TWG, Monitoring and Evaluation TWG and the Central Registration of Vital Statistics TWG. Their activities are coordinated through a ministry-led, interagency coordinating committee. These working groups comprise of stakeholders from both the public and private sectors. However, a routine HIS curriculum focused on building an environment that enables policy, building a resource pipeline and creating champions does not exist.
Interoperability guidance documents	(4) institutionalised	The National Government has developed and launched guidance documents to support different aspects of digital health implementation. The Kenya eHIS interoperability standards document is specific to interoperability in the health sector and is based on and supported by other guidance documents in place: the Kenya National eHealth Policy, the Kenya National eHealth Strategy (2011–2017), the Kenya HIS Policy, the Kenya Standards and Guidelines for mHealth systems and the Kenya Health Enterprise Architecture.15–17 21 22 In general, these documents are intended to guide implementation of HIS interoperability. Plans are underway to review the interoperability document.
Compliance with data exchange standards	(1) nascent	The Kenya eHIS interoperability standards document outlines the data exchange standards that are recommended for system interoperability.21 Despite its existence, there are no structures, processes or procedures in place to guide or enforce compliance with the data exchange, messaging and data security standards as envisaged in the guidelines.
Data ethics	(2) emerging	This subdomain addresses the moral dimensions of data management, including the policing of adherence to ethical principles throughout data generation, recording, curation, processing, dissemination, sharing and use. No enacted general or healthcare-specific data protection laws, regulatory frameworks or ethics provisions exist to guide data ethics around security, privacy and confidentiality. While the 2018 Data Protection Bill is a good start (currently under review before parliament), it may not adequately address the unique and specific nuances of healthcare data.
HIS interoperability monitoring and evaluation	(1) nascent	This subdomain refers to the use of indicators/attributes from the maturity model to facilitate the tracking of inputs, processes and outputs against desired results of HIS interoperability implementation, and the use of these data to make decisions. The Ministry of Health has a monitoring and evaluation framework that focuses on the improvement of information systems at all levels and a stewardship goal of establishing common data architecture to ease the sharing of data.
Business continuity	(1) nascent	The interoperability maturity tool defines business continuity as the capability of an organisation to continue the delivery of products or services at acceptable predefined levels following a disruptive incident. It entails devising plans and strategies that enable an organisation to continue operations and to recover quickly from any type of disruption. There is currently no government-approved business continuity plan in place for both the national and county levels of HIS.
Financial management	(2+) emerging	Financial management includes the legal and administrative systems, and procedures that permit a government ministry, its agencies and organisations to conduct activities that adhere to procedural and appropriate use of public funds. Resource mobilisation includes the activities involved in securing new and additional financial resources for HIS management. The government has budgeted for digital health including interoperability activities. Furthermore, it was found that a significant proportion of financial resources for HIS strengthening including HIS interoperability were donor driven.
Financial resource mobilisation	(2) emerging
Domain total	(1) nascent
Human resources
Human resources policy	(2) emerging	The maturity assessment did not identify the presence of a human resources policy that recognises HIS-related cadres. A national needs assessment has been completed showing the number of staff and types of skills needed to support HIS including digital HIS and interoperability. However, there is an absence of a long-term plan to grow and sustain staff with the skills needed to sustain HIS and digital HIS and interoperability. Further, HIS-related cadre roles such as health records and information officers (HRIOs) at county level are mapped to the government’s workforce and schemes of work.
Human resources capacity (skills and numbers)	(2) emerging	The country does not have enough staff dedicated to maintaining digital HIS and interoperability. The HRIOs are involved in all aspects of health records and information, but not necessarily digital HIS. Furthermore, it was found that the country depends on technical assistance from external stakeholders to support the national and county digital HIS.
Human resources capacity development	(2+) emerging	Tertiary education institutions such as Moi University and Kenyatta University have started programmes to build capacity for digital health roles. However, there is no plan for or ongoing in-service training for HIS staff to build their skills around digital HIS and interoperability. Furthermore, the country does not have the capacity to train enough staff to support digital HIS and interoperability through in-country, preservice and in-service training institutions or partnerships with other training institutions.
Domain total	(2) emerging
Technology
National HIS enterprise architecture	(3+) established	A national enterprise architecture for an HIS defines how HIS subsystems interact and exchange data and shows necessary services for data exchange. Kenya has a validated national HIS enterprise architecture that defines technology requirements and exchange formats for interoperability.16 There are also foundational tools and rules for HIS interoperability including health information management systems for routine and surveillance data and core authoritative registries (facility registry and health worker registry). These tools are owned and implemented by the National Government.
Technical standards	(3+) established	The technical standards provide a common language and set of expectations that enable interoperability among systems and/or devices. They include standards for data exchange, transmission, messaging, security, privacy and hardware. The National Government, through the Ministry of Health, has published and disseminated standards for data exchange. There are plans to develop a certification mechanism for new HIS subsystems to be integrated into a national HIS using the specified standards. Additionally, an interoperability laboratory, Digital Health Applied Research Centre, has been set up by a collaboration between the Jomo Kenyatta University of Agriculture and Technology and a development partner to test technical standards and new digital HIS. 23
Data management	(1) nascent	There was no national document for data management procedures for the Kenya HIS.
HIS subsystems	(3) established	Although the standards and guidelines for digital health system interoperability are published, most digital HIS in the country consist of standalone program-specific subsystems working in silos addressing only the basic needs such as routine HIS, surveillance systems and human resource management systems. The government requires that all HIS subsystems comply with the country’s interoperability plan, but this has not been effectively enforced.
Operations and maintenance	(2+) emerging	This refers to a set of procedures to ensure a high uptime for computer hardware, software and network resources. Kenya has strong in-country capacity for computer technology maintenance, but the maintenance for network and hardware is a mix of reactive and evolving preventive procedures.
Communication network: LAN and WAN	(4) institutionalised	Through the National Fiber Optic Backbone network, the government has begun implementing a technical solution to ensure permanent connectivity to HIS services. 24 All national offices of the Ministry of Health have a strong and reliable network connection to access the various HIS network services.
Hardware	(2) emerging	These are the physical parts of a system of computers including desktop computers, laptop computers and servers that provide services to a user in the HIS. The country has inadequate hardware (eg, servers, computers, printers and supportive accessories) to support a national HIS.
Domain total	(1) nascent

HIS, health information systems; LAN, local area network; WAN, wide area network.