Digital Health in the African Region Should be Integral to the Health System’s Strengthening

Digital Health in the African Region

Weak health systems contribute to mortality and other poor health outcomes across low-income and middle-income countries.^1,2 Countries in the World Health Organization (WHO) African region experience common and cross-cutting issues of health care including but not limited to the availability of human resources for health,³ a high burden of disease (malaria, tuberculosis, HIV/AIDS, and non-communicable diseases), poor health system organization and referrals, lack of essential medicines and supplies, access to health facilities and associated factors such as long waiting for times,⁴ lack of and poor diagnostics,⁵ high costs, loss to follow-up, poor training on technologies, and lack of medical equipment. Digital health, interchangeably described as eHealth, could contribute to better patient outcomes by harnessing and using health resources, information, and technologies for healthcare analysis, delivery, management, and planning.^6,7 Investment in eHealth could strengthen the health systems, extend services in hard-to-reach areas, and reduce wastage of health resources.

eHealth encompasses but is not limited to mhealth or telemedicine, and includes technologies such as the internet of things (IoT), advanced computing, big data analytics, Geographic Information Systems (GIS), artificial intelligence (AI) including machine learning (Figure 1).⁶ However, their implementation in the public sector in African settings is still sub-optimal. This includes innovative use of data, information and communication technologies, and human capacity. The emergence of eHealth strategies in Africa (Table) has been aided by several important developments. Firstly, the evolution in technologies since the turn of the century, such as mobile technologies, GIS, computation, and big data analytics, has led to a growth in the availability of tools for mobile applications. GIS technologies for example have expanded in public health surveillance since the mid-2000s.⁸ Secondly, countries in the African region recognize the importance of eHealth by guidance and resolutions of World Health Assemblies (WHA), and the 71st Regional Committee (RC) on digital health, in 2021, encouraging countries to develop a national policy on eHealth. Thirdly, there is now a recognition of the importance of using data for action in health and the emergence of DHIS2 for national Health Management Information Systems (HMIS) with dashboards to improve health outcomes at all levels of healthcare delivery.

Figure 1.

Components of e-health framework.

Table.

Country Level eHealth Strategies and Goals in 47 WHO Africa Region Countries^a

WHO Africa Region Country	Has developed a National eHealth Policy or strategy	eHealth Strategy Year	eHealth Titlea	Summary of eHealth Strategy
Algeria	No	-	-	-
Angola	Yes	2011	Relatório de avaliação nacional do sistema de informação sanitária (sis)
Benin	Yes	2017-2018	Stratégie Nationale de Cybersanté	Strengthening health sector governance; development of human resource (HR) for health. Improvement of the health information systems
Botswana	Yes	2020-2024	The eHealth strategy for Botswana	To strengthen health service delivery through utilisation of digital solutions that address needs of health system.
Burkina Faso	Yes	2016-2020	Cyberstratégie sectorielle eSanté	Contribute to improving the health of populations by building the capacity of the health system in the use of Information and Communication Technologies (ICTs)
Burundi	Yes	2015	Plan national de développement de l'Informatique de la Santé	Plan the creation of an overall management of all health information subsystems based on common databases
Cameroon	Yes	2020-2024	The 2020-2024 national digital health strategic plan	By 2024, improve the performance of the health system through optimal
Cape Verde	Yes			Use of effective digital technologies at all levels of the health pyramid.
Central African Republic	No	-	-	-
Chad	No	-	-	-
Comoros	Yes	2017 - 2021	Stratégie Nationale de CyberSanté	Strengthen the HR capacities of health professionals; Produce the most complete and up-to-date health and medical information to improve care in health structures; contribute to the prevention and fight against diseases; use telemedicine to improve patient care, particularly in isolated areas, and reduce disparities; improve information and communication between service providers and beneficiaries and strengthen health education actions with communities; and improve managerial information and management of the health system to strengthen sector governance
Congo	No	-	-	-
Côte d'Ivoire	Yes	2012	Plan stretegique de cybersante	This plan has aims to ensure the digital management of the health system in order to guarantee access for populations to quality, effective, safe, and cost-effective health care
Democratic Republic of the Congo	Yes	2014	Plan National de Développement de l'Informatique de la Santé (PNDIS)	The e-health enterprise architecture should contribute to the rationalization of investments in the
Equatorial Guinea	No	-	-	-
Eritrea	No	-	-	-
Eswatini	Yes	2016-2020	Kingdom of Eswatini eHealth Strategy 2016 - 2020	Laying the foundation for eHealth; eHealth solutions that are practical, relevant, and sustainable; sustainability (change management and governance)
Ethiopia	Yes	2018-2025	Information Revolution Strategic Plan	The information revolution aims to transform the culture of data use to positively impact population health and health-system performance
Gabon	Yes	2017-2022	Schéma Directeur Stratégiquedu Système d’Information de Santé du Gabon
Gambia	Yes	2021-2030	National eHealth ICT policy	-
Ghana	Yes	2010	National eHealth Strategy	To systematically deploy information and communication technology to improve the health status of people living in Ghana
Guinea	No	-	-	-
Guinea-Bissau	No	-	-	-
Kenya	Yes	2016-2030	Kenya national eHealth policy 2016-2030	The goal of eHealth policy is to improve the availability and quality of healthcare services through the use of ICTs
Lesotho	No	-	-	-
Liberia	Yes	2016-2021	Liberia Health Information System & ICT Strategic Plan (2016-2021)	-
Madagascar	Yes	2018-2022	Plan strategique de reinforcement du systeme d'information sanitaire	Strengthen the availability of comprehensive and quality data, increase access to health information for all users, improve the technical platform and capacities of the institutions in charge of data management, build the capacity of staff in data management institutions to collect, verify, analyze and generate quality data, and to use health information in decision-making and action.
Malawi	Yes	2020-2025	National Digital Health Strategy 2020-2025	Establish a reliable ICT infrastructure that enables utilization of digital health systems; build the capacity of clients, communities, health care workers, and information technology personnel to participate in and benefit from digital health interventions; leverage technology to increase access to and quality of service delivery; improve security of information and ICT Systems; promote interoperability of digital health solutions to enable information sharing for continuity of care; and strengthen the sharing and accessibility of data across systems to enable use.
Mali	Yes	2013	Politique Nationale Cybersanté au Mali	Contribute to the improvement of the health system through the inclusive use of information and communication technologies
Mauritania	Yes	2005	Renforcement et consolidation du projet national de tele medecine.	To allow the extension and strengthening of the telemedicine in Mauritania by contributing significantly to the improvement of the system
Mauritius	Yes	2015	He@lth 2015 Seamless Continuity of Care	To make the Mauritian Ministry of Health & Quality of Life (MoHQL) a single integrated source of information and focal point of reference on matters on health in Mauritius
Mozambique	No	-	-	-
Namibia	Yes	2021-2025	National eHealth strategy 2021-2025	The primary goal of the strategy is to strengthen health and social welfare service delivery through the utilization of electronic solutions that address the needs of the people of Namibia
Niger	No	-	-	-
Nigeria	Yes	2015-2020	National health ICT strategic framework	With a focus on primary health care, and innovations including the use of Health ICT to improve service delivery, access and coverage
Rwanda	Yes	2018-2023	The national digital health strategic plan	The overarching goal of the digital health strategic plan is to improve health service delivery and accessibility through digital health
Sao Tome and Principe	No	-	-	-
Senegal	Yes	2018-2023	Plan strategique sante digitale 2018-2023	By 2023, the digital health strategy will enable Senegal to sustainably improve the universal health coverage of populations and ensure decision-making by actors based on quality and secure information
Seychelles	No	-	-	-
Sierra Leone	Yes	2018-2023	National Digital Health Strategy	By 2023 an effective and efficient ICT enabled system supports delivery of quality, accessible, affordable, equitable, and timely healthcare services and move Sierra Leone closer to achieving universal health coverage
South Africa	Yes	2019-2024	National Digital Health Strategy for South Africa	Complete health electronic record, which will improve patient management, the digitisation of health systems business processes. That will include digitisation of various health systems to improve efficiency and quality at an institutional level for human resource, and medicine access; establishing an integrated platform and architecture for the health sector information system, which will ensure interoperability and linkage of existing patient-based information systems; to scale up high impact mHealth for community-based interventions. Within the context of the National Health Insurance (NHI), it will expand health promotion coverage to vulnerable groups such as children, the elderly, women and others who are prioritised; the development of digital health knowledge workers for successful digital health as well as economic development
South Sudan	No	-	-	-
Togo	Yes	2013-2015	Plan strategique de developpement de la cybersante au Togo	To ensure the entire population the highest possible level of health by making every effort to develop an efficient health system based on public and private initiatives, individual and collective, accessible, and equitable, capable of satisfying the right to health for all especially the most vulnerable
Uganda	Yes	2017-2021	Uganda national eHealth strategy	To harness and create an enabling environment for the development and utilization of sustainable, ethically sound, and harmonized ICT at all levels to promote health and improve health services delivery in Uganda
United Republic of Tanzania	Yes	2019-2024	The national digital health strategy	Strengthened digital health governance and leadership; improved client experience through efficient provision of high-quality health services; empowered health care providers and managers to take evidence-based actions; sustained availability of health resources; standardised information exchange
Zambia	Yes	2017-2022	eHealth strategy	The strategy is designed to guide and mainstream the use of ICTs in health and other related sectors; hence it is designed to fit within the socio-economic development agenda of the country rather than a stand-alone technology framework permitting exploitation of existing structures and use of an incremental approach
Zimbabwe	Yes	2013-2017	Zimbabwe’s E-Health Strategy	To improve and aid health practitioners Continuous Personal Development (CPD) through availing E-learning facilities and clinical case studies in facilities; assist in improving private-public sector collaborations and standardisation so that both these sectors will be able to interact seamlessly, this will also allow all health actors to be able to interconnect and create linkages; provide ease of reach of health services to the greater populace; assist in allowing greater resource utilization, collaboration and removal of duplicate activities between health funders, WHO, UN agencies and the government; provide a standard patient identification template to all health actors

CPD, Continuous Personal Development; HR, Human Resources; ICT, Information and Communication Technology; MOHQL, Mauritian Ministry of Health & Quality of Life; NHI, National Health Insurance; PNDIS, Plan National de Développement de l'Informatique de la Santé; sis, Sistema de Informação Sanitária; UN, United Nations; WHO, World Health Organization.

^aNational strategies downloaded from https://www.ictworks.org/african-national-ehealth-strategy-policy/

Although disease burden is highest in many countries in Africa, they also face the highest challenges in the implementation of eHealth strategies (Table). The strengthening of the link between eHealth strategies and health systems lies in 4 important components of an enabling environment (strategy and development); an investment in capacity building, legal or regulation frameworks and governance; infrastructural or enabling technologies; and finance. The Table shows a commitment from most countries in the region to invest in eHealth as a component of their overall health sector strategic plans. Although this commitment is commendable, most show a lack of broad development along the key pillars of digital health and an in-depth implementation at the country level to realize its full benefits. Infrastructural, regulatory, and technological development remain undocumented.⁹ In many settings, there is no comprehensive assessment of readiness for digital technologies as a whole or digital societies owing to literacy at subnational contexts, operationalization, and evaluation.¹⁰

Components of eHealth Frameworks

The Development of eHealth Strategies

eHealth interventions are important for general strengthening and building resilient health systems that can respond to crises and shocks, in addition to impacting the Sustainable Development Goals (SDGs) on health.^11,12 Thirty-three countries have formulated eHealth strategies that are generally aligned with national health goals and entrenched in national-level policy documents (Table). Across these countries, the overarching objective is to strengthen service delivery through the implementation and use of digital solutions that address health system needs. These include, for example, the implementation of DHIS2 in all these countries (including those without eHealth policies) and varied mhealth applications. The Table also shows gaps in the scale-up health data informatics and eLearning frameworks.

Capacity Building and Governance

There exist localized eLearning initiatives in different countries (eg, South Africa ¹³ and the Réseau Afrique Francophone de Télémédecine (RAFT) project in West Africa)¹⁴. However, most countries are yet to incorporate digital health in schools as part of the education curriculum. Investing in the future digital society would contribute to a future health workforce with the knowledge and capacity in implementing eHealth. The technical working groups are often created during the eHealth strategy development process, and it will be beneficial for these groups to function as national digital health steering committees. More importantly, training the current health workforce is important for service delivery at all levels, along with implementing regulations and guidelines for eHealth. The gaps include regulation for data governance, electronic data management in patient-centred systems and public health information through the use of social media.

Technological Development

The adoption of electronic and web-based DHIS2 in over 40 countries in Africa replaced the manual and paper-based health information management. This platform incorporates adaptable dashboards that capture data, from the public and private health sectors. However, almost all eHealth strategies state a lack of interoperability with existing electronic data systems, such as the electronic Laboratory Information Systems (eLIS), including electronic government systems. COVID-19 triggered a demand for digital solutions across the globe stemming particularly in the areas of disease case management, contact tracing, and digital certification of vaccination.¹⁵ The use of these technologies in Africa suggests that different health crises can be better managed through an effective and more efficient integration of digital technologies and processes.¹⁶

Finance and Country Economies

The COVID-19 pandemic continues to affect the national economies,¹⁷ and governments face challenges in mobilizing resources for health investment in different areas of eHealth. In terms of digitalization of health programs, digital health financing has the potential to increase efficiency in the health sector’s financial transactions, including health program level expenditure. However, this is only likely to improve with improvement in other sectors, such as banking, or for example the maturing mobile money systems Figure 1.

Discussion and Conclusion

The Development of eHealth Frameworks for Digital Technologies in the African Region

Figure 2 shows steps in the development of an ehealth framework. These steps address 2 areas of problem identification and problem-solving. The first component starts with desktop reviews and ends with the prioritization of challenging issues of delivery. This process indeed is common to many disease-related strategic documents. The second component of problem-solving includes both the identification of optimal solutions in priority areas and the identification of appropriately tailored, culturally sensitive, and financially feasible solutions. An additional step is conducting a secondary evaluation and a repetition of the outlined 2 processes. There remains a gap in many countries in the implementation of existing ehealth strategies that adhere to these broad theoretical frameworks.

Figure 2.

Steps in eHealth strategy development.

There are other challenges of implementation including growth of digital societies in African settings, the availability of affordable and reliable internet connections in rural populations and at peripheral health facilities (or community health care workers or primary health care), and increasing literacy in most vulnerable population, such as women. Although recent population-based surveys suggest an increasing use of the internet predominantly through mobile devices, the literacy level remains very low (see Supplementary Information Table, available online at https://www.mcpdigitalhealth.org/). The link between education and health outcomes at the household level has already been illustrated in previous studies.¹⁸ Transforming population health by taking advantage of digital technologies will equally require growth in digital societies and a recognition that there is an important interface between education and health outcomes.¹⁹

The Proposed Way Forward on ehealth Strategies and Technologies in the African Region

The following could be considered as possible areas of investment in either the development or implementation of comprehensive ehealth strategies.

• •Audit existing ehealth strategies within African countries, including alignment with the overall goals of the country’s health strategy.
• •Conducting robust country readiness or optimal implementation assessments under different scenarios of implementation and along the 3 pillars of eHealth framework at sub-national levels. This will promote a decentralized system of implementation sensitive to infrastructural, cultural, and financial feasibility.
• •Address existing infrastructural issues such as the interoperability of digital tools and systems. During the pandemic, the interoperability of different digital technologies emerged as a barrier across different settings or countries.
• •Initiate a well-designed and decentralized change management enterprise along with establishing e-learning platforms at subnational levels.
• •Conduct post-operational and post-implementation assessments under different settings to foster further learning and improve effectiveness.

Potential Competing Interests

All authors declare no competing interests.