Second only to AI, local ownership is the buzzword we hear at every digital health conference and in every op-ed. And yet in many countries, we don’t see it fully realized in practice. Community health workers still use apps they didn’t co-design. Health systems don’t fully control the digital health infrastructure they depend on. And these systems often run on foreign investment that is short-lived.
Local ownership is a goal that almost no one disagrees with. So how have we as a sector collectively fallen short?
At Medic, fifteen years of building open-source tools for frontline health systems across Africa and Asia have taught us what real ownership demands, and why it’s so hard to get right:
1. Localization is not the same as local ownership.
Part of the problem is that we all use similar-sounding terms interchangeably. Localization, local ownership. Locally-led. Country-owned. It gives a false impression that they all mean the same thing, when in reality they each reflect something different.
Localization is adaptation: a tool or system built externally but adapted, managed, and run in the context of the communities it serves. It often manifests in local teams, with growing technical capacity, to keep the wheels turning day to day. But running a digital health system isn’t the same as having agency over it. The people and some of the knowledge may be local, but the consequential decisions are not. When a workflow needs to change, or a bug needs to be fixed, the decision still routes back to an external team. When a donor’s funding cycle ends, the question of whether the system will survive rests with someone abroad. The result is often unintentional layers of dependency that look like local operations but perpetuate external control.
Local ownership is something else. It’s local institutions holding real decision-making authority and governance over what the system does, who sees its data, and what it’s allowed to become. This is a shift of power and accountability, from running a system to driving its future.
In its fullest expression, ownership is generative. Where local actors not only govern the system, but extend and shape it, solve new problems with it and contribute these solutions back to the shared code. Local ownership that not only maintains, but also creates. This is when we see local breakthroughs that eventually become global innovations. This is, truthfully, where we all have the most to collectively learn.
2. Local ownership is not the last step. It’s the first.
If the first problem is what we mean by local ownership, the second is when we think it happens. In digital health, ‘ownership’ is often treated as a box that gets checked when local capacity strengthening is complete. Essentially, something that happens at the end of a project, after all of the ‘hard work’ is done.
But ownership transferred at the end cannot undo decisions made at the beginning. By the time handover comes, the system is already too complex, externally dependent, or underfunded, and behavioral patterns are already set in stone. The handoff may happen on paper, but the dependency remains. It also positions governments as recipients, rather than creators, of their systems and reinforces the very power imbalances that local ownership is meant to fix.
This is one of our biggest mistakes as a sector. Local ownership cannot be a closing act. It’s the very first design decision, and it means asking difficult questions from the outset. Who controls the data? Who can adapt the workflows? Who holds the institutional knowledge to make a configuration change without filing a support ticket with a vendor in another time zone? The answers need to be locked in early on, to shape the technical choices, partnerships, and the very ethos that will sustain the system for years to come.
For Medic, local ownership is not just a value statement but core infrastructure; it has to be intentionally invested in and built from the ground up. And, like any framework, its strength is determined when it’s tested under pressure.
Consider what happens when a national system goes down. One moment the application is live. The workflows function. The next moment, a dependency fails—maybe a local data center goes down, or a hosting layer run by a third party fails. It happens more often than the sector likes to admit.
When local ownership has been built in from the start, this is the moment it pays off. A government isn’t waiting for external support, it’s the one directing the response, deciding what gets restored first, and holding the authority to act because the system was always theirs to act on.
That is what real local ownership means: not immunity from failure, but the agency to meet it from a position of leadership rather than dependence.
3. There are no shortcuts.
Local ownership is hard. It is non-linear, messy, slow, and almost always costs more than we’d like to believe.
It requires continuous collaboration over time, between stakeholders with different incentives, who nevertheless commit to working towards a shared goal, even in the face of challenges like funding shocks and changing political will.
It means funding the long and unglamorous work, and investing in local capacity and infrastructure as a core program cost, not an afterthought. It means solving local problems with local solutions, instead of importing them or deepening reliance on outsiders. And it means pushing towards generative local ownership, even when that’s the harder route to take.
At Medic, we’ve asked these questions of ourselves, too. The same ones we navigate within our community of practice: who controls the Community Health Toolkit (CHT) roadmap, who can adapt it, who decides what it becomes.
Medic began as a small team building open-source tools alongside partners and the community health workers (CHWs) using them. Over time, we established local and regional teams, colocated with the CHWs we supported. It was our ‘localization 101’. As CHT deployments grew, it was clear this set-up wouldn’t sustainably scale because no single organization alone can meet all needs. More importantly, it didn’t live up to our own conviction: that the people closest to the problem should be driving the solution, not just delivering it.
So we went a step further. Through hands-on training, open documentation and communication channels, and the CHT Academy, we worked to embed technical capacity in-country so that local partners and software developers could build, adapt, and run CHT-powered tools themselves. With our co-development model, members of the CHT Community now collaboratively drive new features and functionality.
And our most recent step towards local ownership is perhaps the most important one. Over the past year, we’ve been preparing for a strategic shift: launching our Africa programs and team not as a regional office, but as Medic Afya—an independent, locally governed Kenyan entity with its own board, leadership, and authority to chart its own direction. Medic Afya is a digital partner to governments and organizations across Africa, as well as a collaborative peer of the CHT. That means local experts are driving sovereign health systems, while actively shaping global technology.
This is Medic’s values around openness and ownership put into practice: taking the more difficult route, shifting power and agency to local experts who will ensure that digital systems become durable public infrastructure that local institutions can own, evolve, and sustain over the long term.