Yinka Oyerinde

Felix Bankole
email: bankofo@unisa.ac.za

Investigating the Efficiency of ICT Infrastructure Utilization: A Data Envelopment Analysis Approach

Keywords: ICT4D, Data Envelopment Analysis, ICT Infrastructure, Educational Attainment/Adult Literacy Rates, Human Development Index, Learning Analytics

A lot of research has been done in the field of Information and Communication Technology for Development (ICT4D) investigating and measuring the impact of Information and Communication Technology (ICT) investments on Human Development. Education is a major component of the Human Development Index (HDI) which affects the core of Human Development. This research investigates the relative efficiency of ICT infrastructure utilization with respect to the educational component of the Human Development Index (HDI). A Novel conceptual model is proposed, and the Data Envelopment Analysis (DEA) methodology used to measure the relative efficiency of the components of ICT infrastructure (Inputs) and the components of education (Outputs). Results show a strong impact of ICT infrastructure on educational attainment and adult literacy rates, a strong correlation between this infrastructure and literacy rates as well as provide a theoretical support for the argument of increasing ICT infrastructure to provide an increase in human development especially within the educational context.

Introduction

The field of Data Analytics in Education, otherwise known as Learning Analytics (LA) and Educational Data Mining (EDM) is fast gaining grounds in term of research interests and advancement in technology [START_REF] Oyerinde | Predicting students' academic performances-A learning analytics approach using multiple linear regression[END_REF]. The ever-demanding need for knowledge and knowledge management drives the thirst for technological advancements in the aid of learning delivery [START_REF] Romero | Educational data mining: A survey from 1995 to 2005[END_REF]. With the overwhelming successes gained in Data Analytics in the Business Industry, it is little wonder that Data Analytics has found its way into the Education Sector especially in ICT4D research. Considering that the amount of data produced inside and outside higher education institutions is growing exponentially, more and more educational institutions, seem to be exploring the potentials of Data Analytics [START_REF] Moreira | Learning Analytics as a Core Component for Higher Education Disruption: Governance Stakeholder[END_REF]. As new findings and outcomes of research crop up daily, it is evident that successes in Data Analytics in Education can have overwhelmingly positive impacts on learning management and delivery. With Educational Attainment being one of the core indices for measuring Development with respect to the Human Development Index [START_REF] Bankole | Investigating the impact of ICT investments on human development[END_REF][START_REF] Bankole | ICT Infrastructure and It's Impact on National Development: A Research Direction for Africa[END_REF][START_REF]The Millennium Development Goals[END_REF], there is no doubting the viability of any Data Analytics in Education research.

Recently, researchers and developers in the education community began to explore the potentials in adopting analogous techniques for gaining insight into learning management and delivery. Two major areas currently under development and which are oriented towards the inclusion and exploration of big data capabilities in the educational environment are Educational Data Mining (EDM) and Learning Analytics (LA) [START_REF] Papamitsiou | Learning Analytics and Educational Data Mining in Practice: A Systematic Literature Review of Empirical Evidence[END_REF]. Romero and Ventura [START_REF] Romero | Educational data mining: A survey from 1995 to 2005[END_REF], postulated that although prior researches have focused more on the implementation of data mining techniques and models to discover educational data, EDM is however an emerging discipline for developing methods to explore unique types of data from within the educational context. In fact, according to Zorrilla et al., [START_REF] Zorrilla | A decision support system to improve e-learning environments[END_REF], EDM is an application of data mining techniques implemented in education for better comprehension on students' learning processes and acknowledging the ways they participate in it with the sole aim of improving the quality of the educational system.

With regards to ICT4D, national development encapsulates the notion of human development as the means of enlarging people's choices to acquire knowledge, amongst others, in order to have access to the resources needed for a decent standard of living [START_REF] Bankole | ICT Infrastructure and It's Impact on National Development: A Research Direction for Africa[END_REF][START_REF]The Millennium Development Goals[END_REF]. Over the last three decades, the lexicon of national development has been expanded to certain intervening variables and social factors such as education and some other aspects of human welfare. [START_REF] Anand | Human Development in Poor Countries: On the Role of Private Incomes and Public Services[END_REF][START_REF] Bankole | ICT Infrastructure and It's Impact on National Development: A Research Direction for Africa[END_REF][START_REF] Desai | Human development[END_REF]. In line with this, countries have defined policies that show an emphasis on creating support mechanisms for the use of ICT, including for example, technical and pedagogical support, and putting special attention on the use of ICT in teaching and learning [START_REF] Hinostroza | New Challenges for ICT in Education Policies in Developing Countries: The Need to Account for the Widespread Use of ICT for Teaching and Learning Outside the School[END_REF]. However, in providing and defining these policies, a crucial question all policy makers must answer is if increased investments in ICT infrastructure provides any improvement in human development especially for Africa [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF].

In this paper, we aim to investigate the efficiency of ICT Infrastructure utilization on Education as a component of National Development vis a vis adult literacy rates and educational attainment for post-secondary and tertiary education levels. We also employ the same education index employed by Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] introduced by Orbicom [START_REF] Orbicom | From The Digital Divide To Digital Opportunities: Measuring Infostates for Development[END_REF] and ITU to emphasize the impact of higher education on ICT development. With most of the research in Learning Analytics focusing on the teaching and learning activities, this research aims to show how LA can be implemented for policy and decision making within the general context of ICT4D research and thus show it is not limited to enhancing class room interactions. The rest of the article is organized as follows: Section two provides the overview of literature, section three discusses the theoretical framework, section four provides the research methodology, section fives provides the DEA analysis, section six provides discussion of findings, section seven limitations and section eight conclusion and future work.

Overview of Literature

The need to understand the relevance of education in Human Development cannot be over-emphasized. A lot of research postulates that increase in ICT investments and penetration on the continent will bring about a corresponding increase in Human Development [START_REF] Akpan | Africa and the New ICTs: Implications for Development[END_REF][START_REF] Neumayer | The human development index and sustainability-a constructive proposal[END_REF]. Ganju et al., [START_REF] Ganju | Does information and communication technology lead to the well-being of nations? A country-level empirical investigation 20[END_REF] believe that the use of ICT enables the transfer of information to communities that may not have access to education. However, in Africa, three quarters of the population is illiterate and live in rural areas that lack basic facilities [START_REF] Ngwenyama | Is There a Relationship Between ICT, Health, Education and Development? An Empirical Analysis of Five West African Countries from 1997-2003[END_REF] and lack of these facilities, which include infrastructure, on which ICT development requires to run, limit the effectiveness of ICT interventions and penetrations especially in education [START_REF] Oyerinde | A review of challenges militating against successful e-learning and mlearning implementations in developing countries[END_REF]. Even though the last decade has seen an explosion in the use of ICTs in developing countries [START_REF] Walsham | ICT4D research: reflections on history and future agenda[END_REF], it is important to consider the unequal distribution of access to the affordances of ICT in Africa [START_REF] Prinsloo | Context Matters: An African Perspective on Institutionalizing Learning Analytics. Include us All! Directions for Adoption of Learning Analytics in the Global South[END_REF].

Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] showed that any empirical investigation with regards to education for ICT4D research, needs to consider higher education as one of the main parameters. The empirical study carried out by Kiiski [29] found that tertiary education has a positive and statistically significant impact on ICT development. Briede [START_REF] Briede | Usage of the Goals for Sustainable Development in Formation of Learning Outcomes in Higher Education[END_REF] believes this is so because those who have attained levels of higher education usually are the leading persons and have an important impact on public events and its development. Many Higher Education institutions in the Developing Economies have invested heavily in the use of ICT for teaching and learning i.e. use of mobile and/or home-based ICT infrastructure as tools to extend teaching and learning possibilities [START_REF] Hinostroza | New Challenges for ICT in Education Policies in Developing Countries: The Need to Account for the Widespread Use of ICT for Teaching and Learning Outside the School[END_REF] however, its impact has been minimal [36], despite the differences in the level of ICT development across countries [START_REF] Hinostroza | New Challenges for ICT in Education Policies in Developing Countries: The Need to Account for the Widespread Use of ICT for Teaching and Learning Outside the School[END_REF].

Recent studies also believe that Higher Education quality and attainment are necessary to bridge the "digital divide" defined by [20,[START_REF] Molina | The digital divide: the need for a global e-inclusion movement[END_REF][START_REF] Norris | Deployment of Information and Communication Technology in Higher Education Learning Environment of Emerging Nigerian Economy[END_REF]. An example of such is India's National Mission on Education through Information and Communication Technology (NMEICT) which seeks to bridge the digital divide by formulating an educational policy which, amongst others, aims at enhancing the use of computing devices for the purpose of teaching and learning among urban and rural teachers/learners in the Higher Education domain [START_REF] Sahu | Role of ICT in Enhancement of Quality Learning and Teaching in Higher Education 45[END_REF]. Also, the Plan Ceibal initiative in Uruguay [START_REF] Hinostroza | Chapter 6: Case study: Uruguay[END_REF], seeks to bridge this digital divide by being both a social and an educational policy that, amongst others, has the purpose of establishing the conditions for equal access to ICT; facilitate the construction of new learning environments adequate to demands of the information and knowledge-based society; and making available to students and teachers new tools that can widen their learning, increase their knowledge, and develop their awareness of lifelong learning [START_REF] Hinostroza | New Challenges for ICT in Education Policies in Developing Countries: The Need to Account for the Widespread Use of ICT for Teaching and Learning Outside the School[END_REF]. ICT facilitates and improves students' knowledge and promotes positive attitude to learning. Therefore, if students in developing economies are to compete with their counterparts in the developed world, effort must be made to develop their ICT abilities [36].

Moving to ICT and its effects on educational technologies, a New Media Consortium (NMC) Horizon report in 2013 identified, amongst other things, emerging technologies that would have significant impacts on education within a 5-year window. One of such technologies identified was Learning Analytics which would impact education by customizing the learning experience and/or measuring performance through analysis of massive amounts of student learning data [START_REF] Kadam | Impact of Technology in Higher Education[END_REF]. In the context of higher education, Big Data and Learning Analytics promises increased efficiency and cost-effectiveness [START_REF] Hargreaves | Data-driven improvement and accountability[END_REF][START_REF] Papamitsiou | Learning Analytics and Educational Data Mining in Practice: A Systematic Literature Review of Empirical Evidence[END_REF][START_REF] Siemens | Learning analytics: a foundation for informed change in higher education[END_REF][START_REF] Siemens | Penetrating the fog: Analytics in learning and education[END_REF][START_REF] Siemens | Learning analytics: envisioning a research discipline and a domain of practice[END_REF]. With the potential of educational technologies to positively improve educational quality and attainment, there is great optimism that ICT in education can greatly increase both average literacy rates and educational attainment levels in developing economies. However, despite these promises being included in education policies that are related towards achieving a positive impact of ICTs on students' achievements, there is no conclusive evidence to support this, especially in developing countries [START_REF] Hinostroza | Information and communications technologies for improving learning opportunities and outcomes in developing countries[END_REF]. This situation has posed new questions to the research community and policy makers, who are now looking for much more precise definitions of the role of ICT in teaching and learning [START_REF] Hinostroza | New Challenges for ICT in Education Policies in Developing Countries: The Need to Account for the Widespread Use of ICT for Teaching and Learning Outside the School[END_REF]. It is in search for these precise definitions that we carry out this study to investigate the efficiency of ICT infrastructure utilization on education with respect to human development.

Theoretical Framework

This research falls within the progressive perspective of ICT-enabled development as postulated and defined by Avgerou [START_REF] Avgerou | Discourses on ICT and development[END_REF]. The theory behind this perspective is that it considers ICT as an enabler of transformations in multiple domains of human activities. ICT-enabled developmental transformations are assumed to be achieved within the existing international and local social order [START_REF] Avgerou | Discourses on ICT and development[END_REF]. Central in this theoretical perspective is the view that investment in ICT and effective use do matter for the economic development of a country [START_REF] Mann | Information technologies and international development: Conceptual clarity in the search for commonality and diversity[END_REF]. It is however acknowledged that ICT needs to be accompanied by organizational or national restructuring to deliver productivity gains [START_REF] Dedrick | Information technology and economic performance: A critical review of the empirical evidence[END_REF][START_REF] Draca | Productivity and ICTs: A review of the evidence[END_REF].

This research proposes a novel conceptual model for measuring efficiency of ICT Infrastructure on Education and is derived from Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] model for measuring impact on education within the Human Development Index. In this model, we make use of ICT infrastructure available for utilization from 2010-2016 and obtained from ITU and not ICT investments as was done by Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF]. We also focused on educational attainment and not enrolment as we are measuring impact of a utilized infrastructure within the educational context and not its potential utilization which will be valid for enrolment. Finally, this research does not consider the interaction of the facets of ICT investments as was done by Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] because it is not considering investments anymore but the infrastructure available for utilization.

The model for this study is:

The impact on Education (Adult Literacy rates / Attainments) = f[Internet Infrastructure (II) + Computer Infrastructure (CI) + Mobile Phone Infrastructure (MPI)].

Research Methodology

The research methodology employed in this study is the Data Envelopment Analysis (DEA) model. DEA is a well-known non-parametric linear programming method for measuring the relative efficiency [START_REF] Bankole | ICT infrastructure utilization in Africa: Data envelopment analysis based exploration[END_REF][START_REF] Thanassoulis | Costs and efficiency of higher education institutions in England: a DEA analysis[END_REF] and has also been used for understanding the impacts of IT investments on performance and productivity [START_REF] Hatami-Marbini | An ideal-seeking fuzzy data envelopment analysis framework[END_REF]. DEA is a dataoriented method for evaluating the performance (efficiency) of entities known as Decision Making Units (DMUs) [START_REF] Bankole | ICT infrastructure utilization in Africa: Data envelopment analysis based exploration[END_REF] which uses input-output data to compute an efficient production frontier produced by the most efficient DMU's. DEA, unlike a parametric method, is context specific with respect to the interpretations of the results of the analysis, which are restricted to the sample and should not be generalized beyond the sample [45]. DEA, therefore, can then be viewed as a multiple-criteria evaluation methodology where DMUs are alternatives, and DEA inputs and outputs are two sets of performance criteria where one set (inputs) is to be minimized and the other (outputs) is to be maximized [START_REF] Cook | Data envelopment analysis: Prior to choosing a model[END_REF]. In DEA, these multiple criteria are generally modelled as in a ratio form, e.g., the CCR ratio model [13,[START_REF] Cook | Data envelopment analysis: Prior to choosing a model[END_REF] which is expressed as:

Maximise:

Subject to:

Where:

where xij and yrj represents DEA inputs and outputs of the jth DMU, and ur ,vi 0 are unknown variable weights to be determined by the solution of the problem [START_REF] Charnes | Measuring the efficiency of decision-making units[END_REF]. Although xij and yrj can be referred to in different terms, rather than "inputs" and "outputs", for this research, ICT infrastructure serve as the Inputs and Educational Attainment/Adult Literacy Rates serve as the Outputs.

There have been some studies that have used DEA to measure efficiency in education. Gupta & Verhoeven [START_REF] Gupta | The efficiency of government expenditure: experiences from Africa[END_REF] measured the efficiency of education in Africa and Clements [START_REF] Clements | How efficient is education spending in Europe? European Review of Economics and Finance[END_REF] measured efficiency of education in Europe. St. Aubyn [START_REF] St. Aubyn | Evaluating efficiency in the Portuguese health and education sectors[END_REF] and Afonso and St. Aubyn [START_REF] Afonso | Non-parametric approaches to education and health efficiency in OECD countries[END_REF][START_REF] Afonso | Cross-country efficiency of secondary education provision: a semiparametric analysis with non-discretionary inputs[END_REF][START_REF] Afonso | Relative efficiency of health provision: a DEA approach with nondiscretionary inputs[END_REF] measured with respect to OECD countries. However, only Tondeur et al., [START_REF] Tondeur | Towards a typology of computer use in primary education[END_REF] and Gülbahar, [START_REF] Gülbahar | ICT usage in higher education: a case study on preservice teachers and instructors[END_REF] have examined the efficiency of countries in utilising their ICT resources for educational outputs and the Impact of ICT on eduction. Recently, Aristovnik, [START_REF] Aristovnik | The impact of ICT on Educational Performance and its efficiency in selected EU and OECD countries: a non-parametric analysis[END_REF] did a study on the impact of ICT on educational performance and its efficiency in select EU and OECD countries using DEA.

Based on Bankole et al., [START_REF] Bankole | The Impact of ICT Infrastructure on Human Development: An Analysis of ICT-Use in SADC Countries[END_REF] investigation of the impact of ICT investment on human development, this research goes a step further to measure ICT infrastructure available for utilization and no longer investments in ICT which are available for potential utilization. Hence the variables used will be individuals with access to computers, internet and mobile phones. Since the focus of this paper is to investigate with respect to education only as an aspect of human development, the education component will include educational attainment from post-secondary level through to bachelors' level and adult literacy rates. An Input-Oriented Basic Radial Model (BRM) with Constant Returns to Scale (CRS) DEA approach is used for this research. This is based on the theoretical assumption that the ICT infrastructure (Input) are controllable and increase or decrease in the levels of these inputs is expected to bring about a corresponding increase or decrease in the levels of Educational Attainments and Literacy Rates (Output) respectively.

For this study, time series data from UNESCO; educational attainments; World bank; literacy rates and ITU; individuals with computers, internet and mobile phones were obtained. Available data was collected for all countries in Sub-Saharan Africa, Northern Africa, and select countries in Europe and Northern America. These were compared with world values to measure relative efficiency. Data for the past 7 years, 2010-2016 was collected and the average was calculated and used for the values representing each DMU.

DEA Analysis

The analysis was done using the Data Envelopment Analysis Online Software (D.E.A.O.S.) available online at https://deaos.com . An Input oriented BRM model using the Constant Returns to Scale method was used for calculating the relative efficiency of the DMU's. Table 1 shows the data collected computed as ratios to population as well as the indices and their respective parameters. Tables 2 and3 show the outcomes of the analysis carried out while table 4 gives an overview of the data statistics.

Discussion of Findings

From the analysis, we can see from table 5 that Northern Africa is 97.2% relatively efficient in its utilization of ICT Infrastructure for the educational component of National Development while Sub-Saharan Africa, Europe and North America and the World are optimally relatively efficient. Interesting to note, however is that even though Sub-Saharan Africa has the average lowest percentage of ICT infrastructure utilization, educational attainments and adult literacy rates, it is optimally using its current ICT infrastructure with respect to Education in the Human Development Index. This may be as an outcome of a well-known bias of Data Envelopment Analysis where the DMU with the lowest input is more likely to have a high efficiency rating, however, this supports the notion that should there be an increase in ICT Infrastructure, there will be a somewhat corresponding increase in educational attainment and Adult Literacy rates which will inevitably bring about an increase in the Human Development Index. As expected, Europe and North America have the highest average values for ICT Infrastructure utilization, educational attainments and literacy rates and are optimally relatively efficient in this regard. Although Northern Africa have higher average values than Sub-Saharan Africa across most of the indices, the fact that there was no data available for Educational Attainment (Bachelors) may be a mitigating factor against their relative efficiency frontier thus reducing the efficiency value. This is not to say however that Northern Africa is not efficient, but rather has the lowest relative efficiency in this grouping and within the context of the model used.

Another interesting finding from the analysis of the data, as presented in table 6, is the correlation between the input indices and the output indices. Individuals with computers has the strongest correlation with educational attainment and adult literacy rates while individuals with mobile phones has the weakest correlation. This may also be a strong indication of the outcome of pedagogical changes in teaching and learning which now include higher usage of computers. This could be a result of the introduction of online learning and blended learning environments into education. It would be interesting to see, as m-learning initiatives pick up, whether the correlation between mobile phones and educational attainments and literacy rates will become stronger.

Limitations

The main limitation of this study is the availability of the data for the dataset. The data was collected from the United Nations Educational, Scientific and Cultural Organization (UNESCO) -educational attainments; World bank -literacy rates and the International Telecommunication Union (ITU) -individuals with computers, internet and mobile phones. Considering that the years being investigated are the most recent and the sources of the data are credible and well cited sources for scientific data collection, some countries within each region did not have data available for one or more years being investigated. This may have positive or negative effects on the regional averages calculated as the data collected is represented as a percentage of the population of the countries. Also, the limitation in availability of data make it difficult to carry out intra-regional comparative analysis in order to see how individual countries within each region fare amongst themselves.

Conclusion and Future Work

This research has been able to show that ICT infrastructure available is currently making an impact on human development with respect to educational attainment and adult literacy rates. This is evidenced by the fact that the data collected was data of ICT infrastructure currently available for utilization by the regions within the specified time and not investments made during this time. This is a direct response to Bankole et al., [START_REF] Bankole | ICT infrastructure utilization in Africa: Data envelopment analysis based exploration[END_REF] which asked the question if increased investments in ICT infrastructure provide any improvement in human development in Africa. The research further shows that regions with significantly lower educational attainment and literacy rates are relatively efficiently utilizing their significantly lower ICT infrastructure and therefore provides an albeit assumptive basis for justifying increased spending in ICT infrastructure. Using the CRS model for the DEA analysis, the research has been able to show that while controlling the inputs (ICT Infrastructure) an increase in the input has a tendency to result in a corresponding increase in the output (Educational Attainment / Adult Literacy Rates) and vice-versa, therefore impacting positively the educational component of the Human Development Index.

The research has also been able to show that there is a strong correlation between ICT Infrastructure and Educational Attainment / Adult Literacy rates. The correlation is strongest on the individuals with computers index of the ICT Infrastructure. This shows that increased spending in computer hardware and availability of these resources to individuals may have a strong impact on education. The correlation not only justifies the spending on ICT infrastructure for education, but also justifies the notion that its increased utilization brings about increase in educational attainment and not just enrolment thereby increasing literacy rates. It is important to note that the strongest correlation occurs between the individuals with computers and educational attainment post-secondary indices. This also justifies the increased investments being made in ICT in secondary education and not just tertiary education. While acknowledging that DEA as a methodology in itself is context specific and by its very nature of being non-parametric does not allow for generalization beyond the context [45], the research has been able to prove that within the sample itself and within the context of educational attainment / adult literacy rates, there is a strong impact of ICT on Human Development albeit within the Educational index. The research has also been able to show how Learning Analytics can be applied for decision making outside the teaching and learning environment and for policy directions. An area of future research would be to expand this context by showing how ICT impacts on each of the components of the Human Development Index within the specified DMU's and determine the correlations, if any between them. Another area of future research also would be to explore the other DEA models available and determine if there are any other significant correlations or findings, which can have strong impacts on ICT infrastructure investments, on the individual Human Development Indices, as well as measure the productivity over time of the ICT infrastructure utilization. Future research can also be carried out to investigate further the impact, if any, of the strong correlations between ICT infrastructure and educational attainment/adult literacy rates and what this may mean in the broader ICT4D context.

Fig. 1 .

 1 Fig. 1. Correlation between Individuals with Computers and Adult Literacy Rates

Fig. 2 .

 2 Fig. 2. Correlation between Individuals with Computers and Educational Attainment Post-Secondary

  model for measuring Impact on Human development. From this study Human Development is expressed as: For this research we focus solely on the Education component of Human Development and propose a model which takes on a linear equation derived from Bankole et al.,

HDI = f[Standard of living (GDP per capita), Education (Literacy rates / Enrolments) and Health (life expectancy)]

Table 1 .

 1 Data Envelopment Analysis Values

	Regions	Individuals	Individuals	Individuals	Educational	Educational	Educational	Adult
		using	using	using Mobile	Attainment	Attainment	Attainment	Literacy
		Computers	Internet	Phones	(Post-	(Short Cycle	(Bachelors)	Rate
					Secondary)	Tertiary)
		INPUT	INPUT	INPUT	OUTPUT	OUTPUT	OUTPUT OUTPUT
	Sub-Saharan Africa	0.24	0.1399	0.7495	0.1086	0.056	0.0288	0.6287
	Northern Africa	0.4257	0.3004	0.8827	0.1235	0.1327	N/A	0.7236
	Europe & North America	0.7631	0.7074	0.9134	0.2962	0.2539	0.2168	0.9915
	World	0.61	0.4343	0.8772	0.2695	0.2167	0.1507	0.8559

Table 2 .

 2 Basic Radial Models (Envelopment Forms) Weights

	Regions	Individuals	Individuals	Individuals	Educational	Educational	Educational	Adult
		with	with	with Mobile	Attainment	Attainment	Attainment	Literacy
		Computers	Internet	Phones	(Post-	(short cycle	(Bachelors)	Rates
					Secondary)	tertiary)
	Sub-Saharan Africa	3.984	0	0.058	9.208	0	0	0
	Northern Africa	2.349	0	0	0	4.737	0	0.475
	Europe & North America	1.31	0	0	1.073	0	2.159	0.216
	World	1.605	0	0.024	3.711	0	0	0

Table 3 .

 3 DEA Analysis Summary for the Regions

	DMU	DEA	Individuals	Individuals	Individuals	Educational	Educational	Educational	Adult
		Parameters	with	with	with Mobile	Attainment (Post-	Attainment (short	Attainmnet	Literacy
			Computers	Internet	Phones	Secondary)	cycle tertiary)	(Bachelors)	Rates
	Sub-Saharan Africa	Slacks Weights Values Targets	0 3.984 0.24 0.24	0 0 0.14 0.14	0 0.058 0.75 0.75	0 9.208 0.109 0.109	0 0 0.056 0.056	0 0 0.029 0.029	0 0 0.629 0.629
		Slacks	0	0.013	0.065	0.061	0	0.087	0
	Northern	Weights	2.349	0	0	0	4.737	0	0.475
	Africa	Values	0.426	0.3	0.883	0.124	0.133	0	0.724
		Targets	0.414	0.279	0.793	0.184	0.133	0.087	0.724
	Europe & North America	Slacks Weights Values Targets	0 1.31 0.763 0.763	0 0 0.707 0.707	0 0 0.913 0.913	0 1.073 0.296 0.296	0 0 0.254 0.254	0 2.159 0.217 0.217	0 0.216 0.992 0.992
		Slacks	0	0	0	0	0	0	0
	World	Weights Values	1.605 0.61	0 0.434	0.024 0.877	3.711 0.27	0 0.217	0 0.151	0 0.856
		Targets	0.61	0.434	0.877	0.27	0.217	0.151	0.856

Table 4 .

 4 Data Statistics

	Index	Minimum Maximum Mean Standard Deviation
	Individuals with Computers	0.24	0.7631	0.51	0.1963
	Individuals with Internet	0.1399	0.7074	0.396	0.2081
	Individuals with Mobile Phones	0.7495	0.9134	0.856	0.0628
	Educational Attainment Post-Secondary	0.1086	0.2962	0.2	0.0841
	Educational Attainment Short-cylce Tertiary	0.056	0.2539	0.165	0.0766
	Educational Attainment Bachelors	0	0.2168	0.099	0.0884
	Adult Literacy Rates	0.6287	0.9915	0.8	0.1369

Table 5 .

 5 Efficiency Summary

	DMU	Efficiency
	Sub-Saharan Africa	100%
	Northern Africa	97.20%
	Europe and North America	100%
	World	100%

Table 6 .

 6 Correlation between Input and Output Indices

Index Individuals with Computers Individuals with Internet Individuals with Mobile Phones

	Educational Attainment (Post-Secondary)	0.9456	0.905	0.6947
	Educational Attainment (Short Cycle	0.9942	0.951	0.8794
	Tertiary)
	Educational Attainment (Bachelors)	0.8972	0.8982	0.5709
	Adult Literacy Rates	0.9932	0.9913	0.8246
	AVERAGE	0.9576	0.9364	0.7424


Trymore Chawurura

Ronald Manhibi

Janneke Van Dijk

Gertjan Van Stam
email: gertjan@vanstam

eHealth in Zimbabwe, a case of techno-social development

Keywords: eHealth, development, Africa 1 eHealth

This paper presents a transdisciplinary eHealth narrative as it appears to health professionals, information and communication technology experts, and health practitioners in Zimbabwe. Harvesting from rich experiences and focus group discussions, the embedded authors present how various traditions position eHealth. Reflecting upon the genesis of the multiple perspectives -anthropological, computer science, medical, among others -this paper presents a practice of eHealth in Zimbabwe. The paper serves as a rationale for aligning eHealth with people, processes, systems and categorisations that consider the local cultures, the local way of meaning-making, and value local systems.

forms of health care, but as an integral part of such a care. eHealth does not necessarily replace the 'older systems' of health care provisioning. Instead, it gives scalability and ability to additional forms of health care and, thus, overlays and coexists with it. Advanced information technology and the integration of information systems through telecommunication networks and services, including Internet applications, are used to increase operational efficiency, efficiencies in decisionmaking processes, and management effectiveness [START_REF] Southard | Information Technology in the Health Care Industry: A Primer[END_REF]. Therefore, eHealth is a horizontal contemporary to the current means of health management and supports health and health care provisioning, operating in the same space. eHealth, however, changes the space as it questions of the spatiality (the reach) of local practices in health. Therefore, eHealth thrives on inputs from social, cultural, health, and information systems. It opens up both exciting opportunities and real threats to the central features of contemporary health management in Africa. eHealth challenges the spatialisation of the (local) health institute and the encompassing role of national health governance. ICTs, through their global nature, alter or bridge spatial imaginaries [START_REF] Smart | Connecting the world from the sky": Spatial discourses around Internet access in the developing world[END_REF]. Due to new communication possibilities, improved information flows breach long-established spatial and scalar ways of health management and healthcare provisioning. Therefore, eHealth represents opportunities and challenges for the established practices in both public and private health management and healthcare systems.

New manifestations of health provisioning, 'the trans-nationalisation of the local' through the employing ICTs, raise political and epistemically issues as to their cultural and moral fit. Also, services emerge that compete with those provided for at the local health institute. In many parts of Africa, these kinds of developments are in their early conceptualisations and review. As in Africa less than a quarter of the population is using facilities provided for through Internet, eHealth is still to go beyond the stage of sensitisation, testing, amending and small-scale implementation, into ubiquitous availability and operation. Evidence as to how eHealth can enhance the wellbeing of the disenfranchised, or potentially brings harm by changing the health management and care landscape, is still meagre in most parts of Africa. However, the growing precariousness of the position of current actors in the contemporary manifestation of changes in health care systems within institutions, in social systems, and in societies need academic scrutiny, regulatory oversight, professionally executed programmes, case-building and the development of African models. Unfortunately, scientific models sensitive to the African contexts and cultures are scarce. Therefore, with this paper, we seek to introduce eHealth from an African context.

Methodology

The object of this paper is an introduction to perceptions of eHealth in Zimbabwe, setting the context for the development of African models and theories to be wrestled from a non-African hegemony. Our research utilised living research [START_REF] Van Stam | Method of Research in a We-Paradigm, lessons on Living Research in Africa[END_REF]. We reflected upon our experiences of implementing and reviewing eHealth and related activities in Zimbabwe and Zambia over the last 15 years. Our experience encompasses research in development studies, computer science, medicine, and culture studies respectively. During 2017 and 2018, the co-authors presented the outcomes of their experiences and reflections during focus group discussions at Technical Working Group meetings at Zimbabwe's Ministry of Health and Child Care (MoHCC) and at national and international meetings, upon their requests. The intersection of the lived experiences, and a quest with, in, and for theory allows participation while observing [START_REF] Burawoy | The Extended Case Method[END_REF].

eHealth as a Multi-episteme in Africa

eHealth is multi-faceted and can be approached from various methodological and conceptual angles. Trans-disciplinarity gives a pertinent voice to practitioners involved in the actual field of implementation and use of eHealth. Our area of review is the whole of Zimbabwe, while we review cases in Masvingo Province. Geopolitically, eHealth seems to be firmly established in a foreign narrative of the 4 th industrial revolution, where anticipated internet of services and internet of things are expected to fuel further industrialisation and economic growth, as well as human capacity development [START_REF] Hermann | Design principles for industrie 4.0 scenarios[END_REF]. The data revolution that is instrumental for eHealth, ushers forth predictive healthcare, where international -often North-America basedplatforms and institutions aim to predict health challenges upon aggregated data [START_REF] Boerma | Monitoring country progress and achievements by making global predictions: is the tail wagging the dog?[END_REF]. Such development, potentially, reduces Africans (again) as hunters and gatherers of raw data, as native informants who collect and provide empirical data from their areas for external processing in West [START_REF] Mamdani | The importance of research in a university[END_REF].

In general, the realisation of the promises of eHealth appears to be a distant reality in Africa in 2019, both in temporal and spatial practices. Some islands of activities do exist, mainly in urban conglomerates and countries with relatively high penetration of mobile networks and tools, like Kenya, South Africa, Ghana and Rwanda. However, in other countries, like Zimbabwe, eHealth remains disunited, with fragmented and distant pockets of activities in society and socio-technical systems.

eHealth came as an autonomic arousal process in the wake of international nongovernmental organisations (INGO) operating in the African space. Oxfam's report on digital development [START_REF] Haikin | Digital Development: What Is the Role for International NGOs? Oxfam[END_REF] shows that a significant majority of development specialists see the development sector (including health) 'going digital'. However, they regard INGOs being unengaged with the advances in ICT. This verdict is troubling as, in the health sectors in Africa, INGOs are crucial resource partners in national health programs. Therefore, there appears a unhingedness of contemporary approaches and the resource challenges that affect the use of ICT in many African government ministries. As a result, the most disenfranchised populace in African places, like those in rural areas, risk being left out of eHealth opportunities.

The Emerging Materialisation of eHealth in Zimbabwe

The Zimbabwe ICT Policy Framework for MoHCC, states that "ICT has the potential to impact upon almost every aspect of the health sector. In public health, health information management and communication processes are pivotal and are facilitated or limited by the available information and communication technology". The National Health Strategy (2016-2020) states that "The hospital information systems need to be harmonised and fully computerised with all departments, equipment and patient flow properly linked electronically." [START_REF]MoHCC: The National Health Strategy for Zimbabwe, 2016-2020. Equity and Quality in Health: Leaving No One Behind[END_REF] An eHealth strategy has been in the making for several years, guided through technical support by the WHO eHealth strategy development toolkit supported by the International Telecommunications Union (ITU).

In the MoHCC, a variety of initiatives could be gathered under the denominator 'eHealth' or 'digital health'. As these are nationwide initiatives, most of them are at the platform level. In Zimbabwe, like many other African countries, the MoHCC is heavily reliant on funding from external partners, mostly sourcing from outside the country. As a result, the architecture and functionalities of eHealth platforms are influenced by organisations from the outside, often through the method of technical assistance.

The MoHCC operates three nation-wide main electronic health information platforms and some specific care related platforms. The main ones are the electronic Patient Management System (ePMS) for HIV related patient-level care and the Zimbabwe health information system (a national rendering of the District Health Information System (DHIS2)) reporting aggregated information. The third one is an eGovernment initiative, connecting all government ministries to the Ministry of Finance and Economic Development, called the Public Finance Management System (PFMS). Example of a specific care related platform is the Laboratory Information Management System (LIMS/LIS) for viral load testing. All platforms reside upon computer systems located within the premises of the government of Zimbabwe. They feature stringent data security and access measures to secure the integrity of the data.

Additionally, the MoHCC is involved in various experiments and projects, like the development and piloting of an Electronic Health Record (EHR) system. Further developments include an application for e-partograph, the piloting of telehealth in Manicaland province, the notification of maternal deaths, the implementation of blended learning and the monitoring of clinical mentoring, among others. Each of these developments is undertaken with a variety of partners (e.g. Global Fund, CDC, SolidarMed, and the World Bank). INGOs in health in Zimbabwe mostly focus on HIV/AIDS and maternal, neonatal and child-health plus the adolescents (MNCH+A). These organisations run a variety of national and international platforms, using different setups. A few organisations use dedicated computers and software located in Zimbabwe. Many organisations, however, appear to utilise platforms residing in other countries, outside of the control of the Government of Zimbabwe. In general, most ICT activities take place without the active involvement of eHealth experts from government ministries, and, therefore, without local capacity building or transfer of data, knowledge, and skills.

Due to the many possible angles with which eHealth can be approached, in practice, multiple players and local, regional and international powers strive to take control of tools, platforms, and, most importantly, the data that these platforms contain. Struggles on 'where to manage eHealth' are particularly rampant in spheres where colonial and 'old era' organisational structures have remained. From these long-term embedded structures, the multiverse of eHealth varies from different angles, as will be shown below.

eHealth as the backbone of health systems

eHealth as the (future) backbone of the health system sees technology as a tool for prevention and management of disease with the aim of epidemiological control [START_REF]WHO/ITU: National eHealth Strategy Toolkit[END_REF][START_REF] Shields | SmartCare. Electronic Health Record System. Continuity of Care… the long view…[END_REF]. The National Health Strategy (NHS) of Zimbabwe gives ample evidence for the adoption of this view when it states "Significant investments in health system strengthening are necessary for the health facilities and other service delivery and coordination platforms to function optimally" [START_REF]MoHCC: The National Health Strategy for Zimbabwe, 2016-2020. Equity and Quality in Health: Leaving No One Behind[END_REF]. Further, the NHS states an objective to drive the production of key health indicators by using ICT platforms.

eHealth as a measurement and evaluation of health service delivery

In this perspective, eHealth is seen as a necessary and instrumental part of the statistical and administrative enterprise, for the respective, real-time and prospective monitoring and evaluation of health developments, to inform health programs and their (potential) outcomes [START_REF] Rajkomar | Scalable and accurate deep learning for electronic health records[END_REF].

eHealth as a network of tools, platforms, and applications

In this view, eHealth is regarded as a network of technologies, requiring attention from technology inclined departments, or from technologically dedicated ministries (e.g., the Ministry of ICT). In a narrative leaning towards technology determination, eLearning and the dissemination of guidelines using Information and Communication Technologies is positioned as to take the health industry by storm.

eHealth in the private sector

In Zimbabwe, the most prominent component of health care is provided through the MoHCC. Private business and clinics serve the remaining populace, focusing mainly on the well-to-do and urban people. Private health providers do have obligations to report to the government. In practice, they rely on information systems sourced from private industries that do not necessarily interface with the information systems in the MoHCC. A variety of commercial initiatives are available, with mobile operators, hardware (like IBM), and software (like SAP) providers yielding significant influence. For instance, mobile operators provide health messages and operate systems for mobile money transfer and the facilitation of remittances from the diaspora [START_REF] Fulgencio | mMoney Remittances: Contributing to the Quality of Rural Health Care[END_REF].

eHealth and ICT in Zimbabwe

When exploring the role of information and communication technologies (ICTs) in eHealth and considering the definition of eHealth by the WHO as cited at the start of this paper, we have tried to narrow the field down by categorising ICTs in tools and platforms. In this view, mobile phones and other devices are seen as tools like a multipurpose equivalent to a Swiss knife, being separated from the transfer, storage and processing of the data in third-party service platforms.

We analysed the documents and presentations offered during continuous education meetings and conferences organised by medical associations, monthly UNICEF's brown bag meetings, and presentations on eHealth at the Computer Society of Zimbabwe, over the last two years. From these, we deduced the main subjects discussed under the banner eHealth. These are: applications in eLearning (focussing on health professionals), electronic health records, big data analysis, and telemedicine. To a lesser extent, aspirational narratives feature the potential of artificial intelligence, the internet of things, and robotics with little to show in daily Zimbabwean practice yet.

An Anthropological Perspective

eHealth can be approached as to how underserved individuals and communities engage with its existence in the form of tools and platforms. From practices in eHealth within Masvingo Province, Zimbabwe [START_REF] Bishi | Community Engagement for eHealth in Masvingo, Zimbabwe[END_REF] involves sharing of resources and opportunities as well as giving equal opportunities to both women and men. These non-exhaustive prerequisites are a focus in the private sector, which, naturally, is inclined to align with local realities. However, possibly due to the dominant guidance from players from outside Zimbabwe, these prerequisites seem less guiding in the daily practice within the MoHCC.

A Computer Science Perspective

In the natural sciences, technological development is related to the creation of a 'modern society', aligned with ideological constructs from outside Africa [START_REF] Ndlovu-Gatsheni | The Entrapment of Africa within the Global Colonial Matrices of Power[END_REF].

Computer scientists and engineers are the builders of infrastructure, industrial and mechanised production, modern transportation systems, and technological innovations such as mass media, computers and communication systems. Often, in a onedimensional view, technological interventions are positioned as determining essential outcomes [START_REF] Van Stam | Unveiling Orientalism in Foreign Narratives for Engineering for Development that Target Africa[END_REF][START_REF] Toyama | Geek Heresy: Rescuing Social Change from the Cult of Technology[END_REF]. Gomez and Pather [START_REF] Gomez | ICT Evaluation: Are We Asking The Right Questions?[END_REF] show how such a view of technology determination are in need of a critique of its paradigmatic foundation. This view coincides with Dourish and Mainwaring [START_REF] Dourish | Ubicomp's Colonial Impulse[END_REF] observation of the colonial bias in ubiquitous computing. In Zimbabwe, testing of blended learning solutions includes social interactions and computer-aided provisioning of study materials. These are signs of the possibility of contextualised bridging of socio-technical divides [START_REF] Apollo | eHealth approaches for training of Zimbabwe's health workforce in the national response to HIV/AIDS and TB _ introducing Blended Learning in Integrated HIV Prevention, Treatment, Care and Support[END_REF].

A Medical Science Perspective

In this perspective, 'quality of care' involves issues of workload and contextual practicalities in the contact between the health client and the health practitioner [START_REF] Eysenbach | What is e-health?[END_REF].

In its assessment of the diffusion of eHealth at a global scale, the WHO [START_REF]Global diffusion of eHealth: making universal health coverage achievable[END_REF] states that universal health coverage cannot be achieved without the support of eHealth. Further, the WHO research indicates that eHealth supports interoperability of peoplecentred health services, moving practices from disease-silos to resilient health systems.

A Data Science Perspective

eHealth is the rendering of data from mission-critical medical operations to garner evidence that focuses attention and resources in a particular direction. This perspective is primarily concerned with harvesting and processing of data, regarding it a resource comparable to other precious resources like oil. Data Science propels eHealth into the non-African concept of the 4 th industrial revolution where everything hinges around harvesting and processing of data from a universal interconnectedness. An important and contentious area of development is the generation and use of big data to provide health predictions [START_REF] Boerma | Monitoring country progress and achievements by making global predictions: is the tail wagging the dog?[END_REF]. The onslaught of data leakage and political influencing, enabled by the borderless exchange of information, is putting African governments in difficulties. The scientific basis set in a negotiation of subalternised local and dominant international experiences and epistemes is not yet balanced.

Countries are scrambling to react, doing so differently. For instance, Tanzania has put severe restrictions on the transfer of information from its state [START_REF] Dahir | Tanzania's government is casting itself as the nation's sole custodian of data[END_REF], Zambia has adopted its own home-grown EHR (SmartCare), and Zimbabwe implemented a Ministry of Cyber Security.

A Political Science Perspective

Zimbabwe's government implements its projects in the geopolitical realities of INGOs and international policies. An example is the blueprint for Zimbabwe's economy, Zimasset [START_REF]Government of Republic of Zimbabwe: Zimbabwe Agenda for Sustainable Socio-Economic Transformation (ZimAsset) "Towards an Empowered Society and a Growing Economy[END_REF], in which the government painted a moral imperative: the focus of the development of the country according to its terms. However, the direction of (monetary) benefits of the global information society remains one-sided as the architecture of the internet maps disturbingly well with the global information society that was created (by shipping) in the 16 th and 17 th century [START_REF] Williams | Digital Imperialism[END_REF]. The big question is how African governments and health institutions can benefit from its national data resources. Beneficiation of resources (among which is the healthcare data), is needed to be done 'in country' to ensure the creation of embodied knowledge in all aspects of eHealth [START_REF] Lindström | Getting Past the Hype & Practical with New Technologies[END_REF]. Through the central management of its data platforms, the MoHCC controls which data can be accessed by whom. In political manoeuvring, stringent access rules are being used as an excuse by some INGOs to launch their parallel eHealth setups which collect data in parallel to the government systems, directly from health facilities in acts of defiance.

An Economic Perspective

eHealth helps to lessen the workload in health care through the elimination of costly paper registers that are difficult to procure and maintain. Although there are apparent benefits of using paper registers in resource-limited settings -and their phase-out is not yet eminent -they do not allow for easy linkage of data [START_REF] Sahay | Grand challenges of public health: How can health information systems support facing them?[END_REF]. Through eHealth, hybrid formats of national data can be managed and be readily available and accessed by authorised (partner) organisations. However, local communities do not have the resource to purchase nor maintain capital-intensive equipment and, therefore, are subject to the whims of the (foreign) financiers and their perspectives. Thus, the implementation of eHealth can result in local exposure to geopolitical meddling of, for instance, the aid-industry. Foreign notions of eHealth are not embedded aligned with Africa's relatio-economy, with its precepts of sharing and giving. The beneficiation of local data gives rise to regional markets of constructive engagement, for instance by coupling healthcare processes with remittances [START_REF] Fulgencio | mMoney Remittances: Contributing to the Quality of Rural Health Care[END_REF].

A Practitioners Perspectives

Trans-disciplinarity includes the various practitioners involved in the actual implementation and use of eHealth. These practitioners include health experts, computer scientists, ICT engineers and others. Johnson et al. [START_REF] Johnson | Constraints for Information and Communications Technologies implementation in rural Zambia[END_REF] have argued that ICT practitioners are facing environmental, skills and cultural challenges. They often handle technologies that are unaligned with local contexts [START_REF] Johnson | The Shortcomings of Globalised Internet Technology in Southern Africa[END_REF]. Due to the geography of African countries like Zimbabwe and the challenges of travelling, the focus of developmental attention is often limited to urban areas. Therefore, deep-rural areas lack attention. Rural realities remain less understood, with interventions being managed 'from the centre' creating barriers for local capacity building. In the meantime, computer literacy remains a challenge, with health staff having little exposure to, and experience with, ICTs [START_REF] Braat | Evaluation of the utilization of an online perinatal training program[END_REF]. Lastly, the discordance of local means of gaining embodied knowledge and the top-down manner of introduction of eHealth interventions disempower practitioners in fully engaging the community.

Discussion

Literature and narratives on eHealth appear to be originating from a well-resourced, western, individualistic epistemology [START_REF] Van Stam | Unveiling Orientalism in Foreign Narratives for Engineering for Development that Target Africa[END_REF][START_REF] Mawere | Research in Africa for Africa? Probing the Effect and Credibility of Research Done by Foreigners for Africa[END_REF]. To ensure access to eHealth, to both contextually sound platforms and tools, the MoHCC recognised the continuous processes of community engagement (focused on reaching collective potential), workforce development (to inspire local talent), and thought leadership (to ensure respectful representation). In the development of eHealth in rural areas, the Masvingo based INGO SolidarMed operates an iterative, inclusive eHealth development process through a monthly Hackathon and daily eHealth lab activities [START_REF] Bishi | Community Engagement for eHealth in Masvingo, Zimbabwe[END_REF][START_REF] Hobbins | eHealth: Connecting communities for health, selected cases in Zimbabwe[END_REF]. In a hackathon process, every month ICT professionals and health experts mingle in a transdisciplinary and voluntary design event. During the events, computer programmers and vocational experts involved in software development, together with health subject-matter-experts, collaborate voluntarily and intensively on projects. Their collective goal is to create usable technologies, applications and services. This engagement aligns with the renderings of the communal values of ubuntu (providing moral grounds in communal love), oratio (communicating embodied knowledge), relatio (relational resource allocation), animatio (continuous present moment), and dominio (striving for maturity) [START_REF] Van Stam | Reflections: a narrative on displacement of technology and meaning in an African place[END_REF]. eHealth developments are context sensitive and must take into account the practices of paradigm switching (between the I, we, and it-paradigms), and the presence and subconscious agency of the Terrible Three, being orientalism, imperialism, and colonialism [START_REF] Van Stam | Reflections: a narrative on displacement of technology and meaning in an African place[END_REF]. Further, eHealth in African settings should be sensitive to the technical realities that influence technical performances due to latency, congestion, and the vast variety of technologies, tools, platforms, and applications. Although ICTs appear enthralling, they harbour real difficulties and fuel inequalities [START_REF]Digital Economies at Global Margins[END_REF]. Among them is the capabilities and disempowerment of 'the haves and the haves not'. Those with equipment 'have', those without 'not'. Those with electricity 'have', those without 'not', and those with 'good' connectivity 'have', those without 'not'. Connectivity and ICTs, and thus eHealth, are unequally distributed. The issues hampering access to communication networks are highly complex while mobile networks are not necessarily reliable in rural areas. Geopolitics and platforms from the West are playing a predominant role [START_REF]UNCTAD: Trade and Development Report 2018. Power, Platforms and the Free Trade Delusion[END_REF]. In this hegemony, the development and maintaining of national, African data platforms are being crowded out. In the meantime, equipment is varied and might not be patched in time and thus have security issues [START_REF] Furnell | The price of patching[END_REF].

New technologies can lead to new dependencies. These dependencies include having to align with people, processes, systems and categorisations that not necessarily respectful or considerate to local cultures and the local way of meaningmaking [START_REF] Van Stam | Unveiling Orientalism in Foreign Narratives for Engineering for Development that Target Africa[END_REF]. Further, foreign involvement involves foreign payments depleting foreign currency reserves. In settings with imported technologies, training is mostly done off location, involving disproportional travel and logistical expenses. Of course, development partners are bound to pursue their agenda, for their organisations and themselves, rather than for the people that they claim to serve [START_REF] Ndlovu-Gatsheni | The Entrapment of Africa within the Global Colonial Matrices of Power[END_REF][START_REF] Alesina | Who gives foreign aid to whom and why?[END_REF]. Therefore, the support of technical assistants in eHealth is not necessarily aligned with the needs of the country. This misalignment, again, can lead to dependencies on foreign organisations and persons. In the meantime, national research and development remain underfunded and uninvolved. As shown, the attention for data security is mounting, however, through data breaches that circumvent sovereignties, foreign researchers can assess information and deduce knowledge out of context [START_REF] Mawere | Research in Africa for Africa? Probing the Effect and Credibility of Research Done by Foreigners for Africa[END_REF].

Instantiations of eHealth seem connected to coloniality that places peoples and knowledge in systems of thought that strengthen Eurocentric meaning making [START_REF] Van Stam | Method of Research in a We-Paradigm, lessons on Living Research in Africa[END_REF]. However, there is a need for epistemic diversity to envision social life, knowledge and technology in Africa, providing for cognitive justice of African experience [START_REF] Mawere | African Engineering and the Quest for Sustainable Development: Levelling the Ground for all Players[END_REF]. From our experience, there is much room for the deconstructing of to which knowledge and power structures eHealth are linked and a reconstruction of knowledge that acknowledges the agency of African people and groups. Therefore, there might well be contrapuntal developments in eHealth, with different paths in a globalised society that show differentiated pathways to the aim of quality health provisioning.

Conclusion

In this paper, we show that eHealth is part of a digital infrastructure that is increasingly becoming all-pervasive in the global society and human life. Though our work on eHealth is situated in Zimbabwe, the deductions offered could resonate with other African settings where eHealth projects are being deployed, providing a platform that can be further built upon by more vertical research. We argue for the primacy of the local episteme in eHealth. eHealth is connected to a dramatic expansion in the production and use of large amounts of data with a potential of bypassing local and even national policies. eHealth development, therefore, needs careful, contextual guidance as for how to ensure data integrity and that information management and knowledge generate local benefits and empower local communities of practice.