DEPM 622 Marinucci Francesco Assignment #4

Expanding professional development of laboratory professionals in Kenya through distance education: A business idea Francesco Marinucci University of Maryland University College, MD, USA

Expanding professional development of laboratory professionals in Kenya through distance education: A business idea

Marinucci, Francesco University of Maryland University College, MD, USA

The way towards distance learning Background - The Kenya Medical Laboratory Technicians and Technology Board (KMLTTB) is the Regulatory Body responsible for certifying laboratory workers and approving training institutions in the country. The Chairman of the Board, Mr. Odhiambo, and Dr. Marinucci worked together with the Global Laboratory Program of the University of Maryland in Kenya for the past four years. During this period, huge amount of resources were invested in training laboratory workers, either through training sessions held in central locations or directly on-site (Marinucci, Medina-Moreno, Paterniti, Wattleworth, Redfield, 2011a). For the purpose of program sustainability and reduction of training costs, the option of introducing Distance Education (DE) has been extensively debate and explored but with no success due to the lack of resources at that time. In December 2012, Dr. Marinucci presented Mr. Odhiambo the opportunity of offering Continuous Professional Development courses through distance education to KMLTTB members for renewing their professional license. Mr. Odhiambos positive reaction echoes the decision of the African Society for Laboratory Medicine (ASLM) of promoting laboratory workforce development across the Africa continent. In 2012 ASLM

granted its sponsorship for piloting refresher course for laboratory professionals in Ethiopia through DE. Dr. Marinucci served as Director for this course and he designed the structure that was delivered online from September to October 2012 through Mayo Clinic eduonline portal. Nowadays, ASLM is planning to expand its training offer but due to few staff and the lack of expertise on distance education the decision on the way forward is still pending. KMLTTB chairman welcomed Dr. Marinuccis proposal in piloting innovative training offer online as way to promote ASLM in country and to prove the efficacy of DE approach within the Kenya context. Mr. Odhiambo believes that DE will help Kenya to fill the gaps of current pre-service laboratory training offers that leave new graduates in need of intensive in-service or on-the-job training (World Bank, 2009). Distance learning as the way forward Dr. Marinuccis vast experience in East Africa region and his expertise in laboratory medicine support plans to launch a start-up company specializing in laboratory training designed to meet the certification requirements of laboratory professionals in Kenya. With this goal in mind, Dr. Marinucci enrolled in the Master of Distance Education program at University of Maryland University College with the objective of entering into DE business. SWOT Analysis Strengths of online learning the offer of self-paced training modules accessible online eliminate transport and accommodation costs without disrupting daily operations

of medical laboratory services. This approach will be very helpful to reach laboratory professionals even in remote areas while keeping knowledge and skills up-to-date (Wamalwa, 2012). Central trainings are no longer sustainable because of the high costs associated, the low retention of knowledge and the very limited development of practical skills through lecture-based training only (Marinucci, Medina-Moreno, Wattleworth, Paterniti, Redfield, 2011b). Weaknesses of online learning both infrastructure and computer literacy among distant learners are two major challenges for effectively implementing DE program countrywide (Beaudoin, 2007). While learners knowledge assessment can occur online, the evaluation of technical skills can only take place in face-to-face mode. This means that both online and blended delivery modes should be taken into consideration when developing an adequate DE laboratory training infrastructure at regional level. Opportunities of online learning due to the fact that the majority of laboratory equipment is interfaced with a PC, the idea of using the existing IT technology in the laboratory for providing online education on-site is promising. Addition paper-based material would be used to reach all those laboratories with poor or non-existing IT capacity (Leary & Berge, 2007). Threats of online learning a serious threat would be the innovation represented by offering continuous professional development delivered at distance. In this regard, crucial to starting a pilot DE business under both the ASLM and KMLTTB umbrellas would be their support in promoting in-service DE. Pilot 4

To better understand the real challenges of delivering professional courses through distance education in Kenya such as infrastructure, pedagogy, learning styles, and delivery mode, four courses will be piloted at the beginning of year 1. Initially, the courses will be delivered within Nairobi province where IT infrastructure is more reliable, but also because the proximity with stakeholders will facilitate regular communication and meetings. The topics covered in the pilot will be selected to have two courses delivered entirely online, while the other two will be offered in blended learning mode. In the latter, the use of local instructors for the hands-on portion of the training will be also evaluated. In this regard, the partner to whom asks to provide laboratory facility and staff time as in-kind contribution will be the Kenya Medical Technical College (KMTC). All participants to the pilot will be different cadres of certified laboratory professionals selected among laboratory fraternity in Kenya. In the future, Dr. Marinucci and KMLTTB will evaluate to introduce same DE approach for laboratory professionals seeking first-time professional certification. For the online part of the pilot, one course will have up to 20 while the other up to 40 learners enrolled. Despite the highly automated grading and reporting system, this differentiation will allow Dr. Marinucci to better understand the manageability of online courses through learning management system in Kenya (Unwin et al., 2010). To assess this aspect, Dr. Marinucci will develop together with KMLTTB customer satisfaction survey able to identify all the potential obstacles for scaling up this delivery mode in the future. Also the blended component of the pilot will be offered in two different modalities. Each course will be attended by up to 20 participants, but only to the participants of one 5

course will be asked to present a presentation at the face-to-face part of the training. The hands-on part will take place at KMTC premise in Nairobi. Also in this case, Dr. Marinucci will work closely with KMLTTB to develop the final exam to assess the technical skills at the end of the course. More details on this business are available in Table 1 below. Table 1 Business overview
TOPIC Registration STATUS Paper work to register the business as start-up in Italy is under development. Registration in Kenya will follow soon since it is a prerequisite to have KMLTTB approval as professional training provider in Kenya. To improve competitiveness in the international market as DE provider, Dr. Marinucci is exploring the possibility of certification (e.g. with ISO 29990:2010) All courses will be offered in English Kenya official language. This business initiative will be financially supported by both GoK and KMLTTB and it will be offered free of charge to Kenyan laboratorians renewing their professional license Both blended and full online modes will be available depending on the topic The area covered by this business at its full capacity will comprise all eight Kenyan provinces The initial pilot will conducted within Nairobi province where IT infrastructure is more reliable The following four topics will be offered during the pilot phase: 1. CD4 T-cell count for HIV monitoring 2. Malaria microscopy 3. ISO 15189:2007 4. Development of Standard Operating Procedures Topics 1. and 2. will be offered in blended mode, while topics 3. and 4. fully online

Quality Course language Financial support Delivery mode Area covered Area of the pilot

Topics of the pilot

Delivery mode

Topic 1 KMLTTB made this topic a top priority due to the massive transfer of technology for HIV monitoring and the high lab staff turnover in Kenya. This test is crucial for assessing the immune status of HIV patients, containing HIV epidemic and avoiding the spread of HIV drug-resistance. Rationale behind the topics of pilot Topic 2 Malaria is still the major cause of death nationwide and malaria microscopy-based test is available at any level of the laboratory network. Topic 3 Due to the lab accreditation competition promoted by ASLM in Africa, KMLTTB aims at accrediting as many laboratories as possible. The topic ISO 15189 will help laboratories to achieve and maintain ASLM accreditation. Topic 4 KMLTTB identified the lack of Standard Operating Procedures as the major threat for low quality laboratory testing in Kenya. Awarding policy Learners will be awarded with pass/fail certificate needed for renewing their professional license with KMLLTB.

Target Market Analysis Background Dr. Marinucci has carried the following target market analysis out with two major focuses. First, the identification of the customer base; and, second, the assessment of current distance learning market in Kenya by narrowing down the research to the clinical laboratory training area. This was achieved both through consultation with stakeholders and extensive research on the WWW. The latter activity brought Dr. Marinucci to deepen the ongoing development of the so-called E-health Strategy in Kenya promoted by both the Ministry of Medical Services and the Ministry of Public Health and Sanitation (Ministry of Medical Services, 2011). Among the stakeholders interviewed are: Mr. Abel Onyambo, chairman of Kenya Medical Laboratory Technician and Technology Board (KMLTTB); Mr. Shadrack Were, Research Specialist at the University of Maryland School of Medicine (UMSOM) and former country laboratory lead of UMSOM in

Kenya; Dr. Paula Fernandes, Founder and Chief Executive Officer of Global Scientific Solutions for Health, subcontractor of the African Society for Laboratory Medicine. Market Analysis Customer base Medical Laboratory Sciences (MLS) students in Kenya have two steps to take before getting their Bachelor Degree. First, they have to study to become Laboratory Technician following three-year diploma program; second, they have to follow an additional course for getting the Higher National Diploma in MLS; last, they have access to degree programs to become Medical Laboratory Scientists at several universities in Kenya. Based on World Health Organization Global Atlas of Health Workforce (2007) data, there were a total of 6,000 laboratory scientists in Kenya in 2004, while no data are available for laboratory technicians. According to Africa Health Workforce Observatory (AHWO, 2010), in 2009 the total density of laboratory technicians in Kenya per 1000 population was 0.03, with a percentage of female laboratory workers of about 40%. In AHWO report, laboratory workers are Biochemist, Lab Technologist/Technician, and Medical Laboratory Technologist/Technician; while designations like Chemist, Chemist/Analyst, and Medical Parasitologist are categorized as other health workers by World Health Organization aggregated categories. The same report presents data on the distribution of laboratory workers by age group. Table 2 Numbers of Laboratory Workers by Age Group
Age Group <30 Laboratory Workers 81 31-40 599 41-50 953 >51 197

The distribution of laboratory workers ranges from 1.10% in the Northern Province to 12.94% found in the Rift Valley province; while the urban/rural distribution of laboratory workers is 41.80%, 7.98%, and 50.22% in urban, least urban, and mixed settings respectively. As observed by Chankova, Muchiri, and Kombe (2009), two major causes of attrition among laboratory staff in Kenya were retirement and death. Even if the respective proportions varied between health centers and district hospitals, it is likely that new, younger laboratory staff has been deployed to health facilities across Kenya. The fact that diploma level technologists account for 79% of new technologists entering the laboratory workforce annually, while degree level technologists account for the remaining 21%, should be seen as positive factor in laboratory workforce rejuvenation in Kenya (Kenya Health Work Force Project, 2010). Competitor analysis - Before the diffusion of computers, WWW, and mobile technologies, both government and non-governmental organizations have implemented education programs at a distance through interactive radio instruction as documented by Eilers, Layne, Rhoad, and Robins (1982). While printed materials still plays a predominant role, the growing infrastructure and communication technology sector has opened new opportunities to the expansion of DE using new technologies (Abbott & Coenen, 2008; Laaser, 2006). In 1997 the World Bank started funding the African Virtual University, which consists of a network of 55 learning centers in 27 African countries. Since then, the majority of public and private higher education institutions in country have moved towards open and distance learning. Very little has been achieved in regard to professional development and continuous education through distance learning, even if

the private sector has just started offering professional courses in distance learning mode (African eDevelopment, 2013). The African Medical and Research Foundation (AMREF) started pioneering distance-learning courses in Kenya for different cadres of health workers such as doctors, clinical officers, community health workers, nurses, midwives, and laboratory workers since 1973. AMREF has adopted Abbotts (2007) view about the role of Information and Communication Technologies (ICT) as a global game-changer in health by adding to its training offer courses delivered using different technologies (AMREF, 2013a). Among the laboratory courses offered by AMREF, the Medical Laboratory Practices and Management Course is offered in blended learning mode divided into three phases. Phase one consists of pre-training period that lasts for two months where learners receive training course tasks and exercises in a CD-ROM. Phase two consists of two weeks of face-to-face training period; while phase three comprises a three month work-based training at their working site. The fee to be paid to AMREF for this blended course is about USD 2,500 comprising tuition, books, course materials, field trips, stationery, photocopies, accommodation, food, and local travel (AMREF, 2013b). Besides AMREF laboratory courses, the inception of the Presidential Emergency Plan For AIDS Relief (PEPFAR)1 in 2004 has undoubtedly put the spotlight on clinical laboratory services. Through the Medical and Nursing Education Partnership Initiatives, numerous United States-based organizations have started playing a role in addressing health workforce skills and knowledge in sub-Saharan Africa, including many laboratory
PEPFAR is the United States contribution to the fight against HIV and AIDS that has significantly strengthened health systems and laboratory networks in 13 African countries.
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topics (PEPFAR, 2013). The American Society for Clinical Pathology (ASCP) has developed an international certification exam for non-US-trained laboratory to prove their knowledge and skills in specific thematic areas (www.ascp.org, 2013). For ASCP and other US-based organizations such as the American Society for Microbiology, the American Association for Clinical Chemistry, the American Society for Clinical Laboratory Science, the Association of Public Health Laboratories, have been easy to reach Kenya market because of their already existing professional training offer through online courses. Also private entities have started gaining some space within the PEPFAR program as laboratory training providers. In 2007 US Government (USG) funded the public-private partnership between Becton Dickinson and PEPFAR (CDC, 2010) with the aim of expanding laboratory trainings within the countries supported by the grant. In 2012, PEPFAR has recently announced similar initiative to improve the capacity of laboratory workers through a partnership with Roche Diagnostics with the goal of introducing certification programs for laboratory professionals so to improve the quality of diagnostic services (Roche, 2013). Current needs Distance education in Kenya is not new phenomenon. The advent of new ICT technologies and the well-rooted practice of distance education in country has pushed eLearning forward on the Government of Kenya (GoK) agenda. In 2011 GoK launched socalled E-health Strategy, which aims at building capacity among health staff through technology transfer and training at minimal cost. A major challenge of Kenya health system is the shortage of skilled health care professionals, laboratory staff included; and for this reason e-Learning is one of the five strategic areas of intervention forming the 11

pillars of the E-Health Strategy. One of the numerous reforms of the health sector driven by this strategy consists in the reorientation and retraining of health manpower. While many of the tasks and challenges facing decision makers in Kenya as highlighted by Juma (2008) still persist, this institutional commitment should be seen as positive step forward in the adoption and scaling up of e-learning in country. In the interviews Dr. Marinuccis asked one open question about the challenges and opportunities offered by E-Health Strategy for in-service laboratory trainings. Based on Dr. Marinuccis view as well as on the three stakeholders opinion, the attitude towards technology-enhanced learning is still a major barrier to fully understand and adopt of ICT-based distance education in Kenya (Unwin et al., 2010). To scale up successful e-learning programs it is therefore crucial to have learners changing the common mindset by accepting that quality education can be delivered through information technology (Juma, 2008, p.25). It is still Dr. Marinuccis belief that this mindset has enormously limited the access of Kenyan laboratorians to the huge offer of the canned distance learning laboratory courses offered by the international providers listed above. It is likely that the institutional commitment through the e-Health Strategy will fix the most common problems such as costs and slow Internet connectivity (Beaudoin, 2007). However, a real push of e-learning into the current in-service laboratory training scenario in Kenya can come only if it is promoted as continuous professional development by the laboratory sector regulatory body, KMLTTB. The buyin from KMLTTB top management, as confirmed by the chairman of the board interviewed by Dr. Marinucci, is willing to endorse e-learning as official tool to achieve the required professional standards among laboratory workers in Kenya. As highlighted

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by Mr. Were during his interview, the best approach would be to involve together with KMLTTB chairman also the Chief Medical Laboratory Technologist who sits in the same board. Following their buy-in and engagement, Dr. Marinucci can call for broader meeting with other stakeholders where to present the initiative for further discussion and ratification. Added value To achieve these professionals standards, and hence for KMLLTB to successfully promote e-learning, it is of crucial importance that the content of the courses will reflect the current clinical laboratory scenario in country. As expressed in unison by all three interviewees, to really motivate learners, and effectively transfer knowledge and develop skills, course content must reflect the current medical laboratory vocabulary in country and take into account national standard operating procedures. Similarly, course structure and teaching pedagogy should be tailored to in-country existing standards to avoid loosing people when passing from content-centered to learner-centered learning. Table 3 Current needs of primary and secondary customers

Primary Customers Laboratory workers Easy-to-access Self-paced Affordable Credits available

Secondary Customers KMLTTB National course content Defined educational objectives Credits available

Needs

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In this scenario, the major added value of Dr. Marinuccis business idea to differentiate his training offer is to align course-content and educational objectives with KMLTTB certification requirements. The specific course content and the different delivery modes will be likely to improve current KMLTTB training offer by increasing the amount of registered laboratory workers and the quality of their professional skills. The business model Rationale of professional training model in Kenya Continuing Professional Development (CPD) of health care workers in Kenya is mainly delivered through private organizations. The government of Kenya plays a central role by involving different partners in the delivery and scale up of trainings, including bilateral agencies (ABT Associates, 2006), which offer in-service trainings to specific cadres of health workers. Recently, Clinton Global Initiative has funded a new e-learning program designed to improve management skills of pharmaceutical technologists and technicians (IntraHealth, 2013). Unfortunately, in-service training solutions for laboratory professionals are rarely funded; however, in the efforts of strengthening its organizational capacity and business processes, the Kenya Medical Laboratory Technician and Technology Board (KMLTTB), has started exploring distance learning to provide CPD opportunities to its members. Online laboratory training business model in Kenya Due to the scenario described above, online laboratory training accessible upon direct payment of fees will not be accepted. This would mean that among all cadres of health workers in Kenya only laboratory professionals would have to pay for CPD. The

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subscription model is likely to fail too, mainly because paying upfront fees by the learners will not fit in the country-specific training scenario. Therefore, the business model proposed will not have laboratory professionals as direct buyers but only as customers. The business model comprises a direct product-buyer relationship where Dr. Marinuccis business (hereinafter KSA-Lab) develops and sells the final product to the national accreditation body in the laboratory sector. KSA-Lab will partner with KMLTTB and it will have, as primary buyers, the Ministry of Medical Services, the Ministry of Public Health and Sanitation, and the Ministry of Education, Science, and Technology. The partnership with KMLTTB is key for Dr. Marinuccis business model primarily to promote the training approach within the government. The source of funding is the government of Kenya to whom KSA-Lab will present the business idea, and its key elements illustrated in figure 1 below, to address in-service training gaps of laboratory professionals in Kenya.

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Figure 1. Key elements of learning product of KSA-Lab direct product-buyer relationship Value chain To better present the role of KSA-Lab and the supportive function of KMLTTB, the business has been divided into three general activities and sub-activities (Standing Stones Consulting Ltd., 2000). As shown in Figure 2, KSA-Lab plays a key role in course design and program development by sharing with KMLTTB the delivery of the blended portion of the courses only.

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Figure 2. KSA-Lab business general activities and sub-activities In this case, the trainers selected by KMLTTB will provide hands-on training at laboratories located within KMTC premises. The fact that KMTC laboratories are evenly distributed nationwide will ensure full coverage of courses offered in blended mode. The business case aims at piloting the two delivery modes of the comprehensive training package KSA-Lab will offer to KMLTTB for continuing professional development of its members. A competitive advantage of the KSA-Lab business model is to complement the governmental efforts of Kenya in achieving professional development training of laboratory professionals by providing all the primary activities necessary to create and deliver the final training product. At the same time, national players such as KMLTTB

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and KMTC will contribute by providing the support activities specific to the mission of each single organization such as regulatory and pre-service training. Primary activities - According to Elloumi (2007) it is rare for an organization to undertake all primary and support activities (p. 73), and KSA-Lab will not be an exception. Table 4 below illustrates the primary activities divided by implementer that are covered by KSA-Lab business. Table 4 Primary activities in KSA-Lab business
PRIMARY ACTIVITIES Inbound logistics Learning specific hardware (i.e. client/server) Learning Management Systems Learning Content Management Systems Knowledge Management Hiring of authors Authoring tools Operations Course instructional design Content (learning objects, units, etc.) Courseware, study guide, and student manual development Writing Formatting Capture and edit Multimedia creation Graphic design Printing Outbound logistics Online registration Integrated portal Packaging and storage of courses Learner access to course (Web access or mail delivery) Integrated channel management (process control) Automated learner specific account Delivery and marketing Online course delivery Hands-on course delivery Threaded discussion Audio/video over IP Real time access to student information, calendar, fees, course availability Real-time learner feedback through Web surveys and promotion Branding Service Online support of learners Coaching, mentoring Assessment and testing Technical and support services Tutor support Academic experts/marking Counseling Awarding prizes

KSA-Lab

Others

Secondary activities Despite the few support activities, they play a crucial role for successive funding and effective functioning of the KSA-Lab training product. Table 5 Support activities in KSA-Lab business

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SUPPORT ACTIVITIES Organizational infrastructure CPDs dedicated office Learner relations for enrollment, requirements, and license renewal Human resource management Dissemination of info related to license renewal process Definition of requisites for enrollment in CPDs Technology development Establishment of web-based learning centers at KMTCs Procurement Purchase and inventory of IT KSA-Lab Others

Financial Plan Key costs The key costs of the financial plan are divided into three categories: structural, procedural, and operational (Elloumi, 2007), and all primary and support activities identified above are assigned to the pertinent category. Table 6 Key cost categories of KSA-Lab business
Structural Course production facility Hands-on training labs CPDs dedicated office KEY COSTS Procedural Enrollment License renewal process Awarding prizes KSA-Lab Others Operational Course production Delivery Assessment

The key costs under the structural category covered by KSA-Lab comprise only the renting of the office space located in Nairobi and the initial equipment such as computers and server. The resources to be included in the KSA-Lab financial plan cover both indirect costs and direct costs; the latter are then divided into development and presentation costs.

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Table 7 Direct and indirect costs of KSA-Lab business

INDIRECT COSTS Renting and operating office Computers and server IT support and maintenance Operational category DIRECT COSTS Human Material resources* development DE manager Authorship of training material Secretarial Editing and design support Copyright clearance Development of assessments

Maintenance & updating Authorship of training material Editing and design Development of assessments

* Human resources involved in both course development and delivery are located either in Kenya or elsewhere. Monitoring and evaluation Evaluating the outcomes of the business model by measuring its impact is critical to ensure long-term sustainability. In order to streamline or improve the status quo, Balanced Score Card (BSC) will be used regularly. As pointed out by Lauridsen (2011) the sage advice about what is measured can become improved applies to education as well (p.103). KMLTTB, as beneficiary of the service developed and offered by KSALab, will be involved in the process of developing the evaluation framework that will rotate around KMLTTB vision and strategy. The evaluation activity will be central to KSA-Lab to satisfy both customers and stakeholders by adapting and changing the business process accordingly over time. It will also be of crucial importance to monitor expenditures and reinvest revenues in order to achieve financial sustainability in the long run. It is reasonable to plan the use of BSC on a yearly basis since a twelve-month span is the timeframe for renewing the professional license in Kenya. By using the model described by Tatikonda (2007), laboratory workers would demonstrate upgraded 20

knowledge and skills as a result of participation in a twelve-month program of in-service laboratory training in Kenya (t12). The raw material is the current knowledge and skills laboratory workers have at the time of enrollment (t0). The work-in-process is represented by the different steps laboratory workers take quarterly (t3, t6, t9, t12) by moving along a series of four online and/or blended courses to fulfill the credit requirements over the established timeframe of one year. The BSCs are used at the time of the fourth step (t12) by involving both primary users and different customers.

Figure 3. KSA-Lab business process over one-year period Financial statement and forecasting To better present the financial plan associated with the business case, the estimated total budget has been divided in the following three categories: 1) investment capital and start-up contributions, 2) revenues, and 3) expenses. Investment capital and start-up contributions A synergic effort from different players within Kenyan institutions will be needed to initially fund the project. In particular, KMLTTB will negotiate with the Ministry of Medical Services and the Ministry of Public Health & Sanitation to provide the initial capital necessary to start the e-learning component of Kenya National E-Health Strategy for the laboratory sector.

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Therefore, the World Bank Group, as founder of Kenya National E-Health Strategy through its Health in Africa Initiative, will provide the initial monetary resources for KSA-Lab business. At the same time, KSA-Lab will explore potential investors in the private sector, especially among the major technology players in Africa both in the information technology and communication sectors. KMLTTB will provide in-kind contributions such as office facilities, computers, staff time, office furniture, printing, and marketing; while KMTC in-kind contributions will comprise laboratory facilities and staff time. Revenues Increasing KMLTTB membership fees will generate the primary source of revenue. The new subscription will comprise the renewal of professional license and comprehensive online professional development offer in line with the KMLTTB professional accreditation requirements. At present the annual fees are equivalent to 110USD, and it is realistic to improve them up in the range 200-250 USD. The resulting increase will be allocated to the CPDs business as students fees. The enrollment process will be gradual in line with the approach of piloting four courses in year 1. The total target for five-year period is to enroll 27,500 laboratory professionals with an average of 5,500 learners per year. Expenses - The costs of production per course have been estimated to be in the range of 20,000USD inclusive of content development, syllabi, assessments, editing and design, and copyright; while using the online delivery mode and assessment will set to zero the total variable costs per student as part of the annual presentation costs. This will allow maintaining the total costs equal to the fixed costs so to increase the revenues with the increasing of enrollments. Two staff will provide the needed help for students to

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navigate the course-content and understand the course structure. They will be hired on a full-time basis to perform these duties at an average annual gross cost of about 18,000USD. Other expenses to be included in human resources management will include face-to-face instructors allowances for hands-on laboratory sessions. Also IT equipment, software, all the accounting and legal/tax services, and other outsourced inbound logistics are part of the general expenses. The remaining activities of marketing and advertising will be part of in-kind contributions from KMLTTB. All estimated expenses of KSA-lab are detailed in Table 8 below. Table 8 Expenses of KSA-Lab business
ITEM Human resources (Support specialists, f2f allowances) Facilities (Office renting) IT (Computers, server, software, maintenance) Course development Course maintenance/updating Accounting and legal/tax services Travel Outsourced inbound logistic Marketing and advertising ESTIMATED COST 38,000/year 21,000/year 3,200/year 20,000/course 4,000/course 6,000/year 3,000/year 16,000/year KMLTTB in-kind contribution

Conclusion Assessing the viability of Dr. Marinuccis business case at this stage might result difficult for a series of pending questions, in particular regarding the funding sources. It is noteworthy that while the funding mechanism for programs like the Kenya National EHealth Strategy are gradual; it is very likely that they will open numerous opportunities within the same sector in the future. Therefore, some of the open questions might find the

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right answer in the near future, for instance as the e-learning activities of the national strategy will start taking off. Following the initial presentation to the stakeholders, Dr. Marinucci will refine his proposal especially based on the quantitative and qualitative support offered by KMLTTB. Also both inbound and outbound logistics are two areas where the variability is very high and depending on the involvement of KMLTTB and its in-kind contribution. However, while the needs of KSA-Lab customers, its competitors strategies, and the primary and secondary markets might change, other factors must be taken into consideration for successful DE business in this setting. The strong network Dr. Marinucci has built in the past ten years in Kenya and his working experience in the laboratory sector in the same area are two key elements that will play crucial role for adjusting the business case to the ever-changing scenario.

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