African digital health strategic plans analysis: key weaknesses in contextualization, intervention focus, and technological foresight

Abstract

Digital health strategies are increasingly being adopted in Africa, but their consistency with best practice planning is poorly documented. 54 countries were screened; 48 had a plan in the Global Digital Health Monitor, and 11 recent plans met the inclusion criteria. Using the “Ready, Extract, Analyze, Distill” methodology and a customized grid merging the Walt-Gilson policy triangle with WHO/ITU standards, we compared four dimensions: context, content, priority actions, and emerging technologies. Only one strategy reported complete socio-economic and health data; more than half of the strategies did not provide the challenges facing health systems; and there were recurring gaps in the pillars relating to workforce, legal frameworks, financing, and interoperability. Most visions cited universal health coverage (8/11) and quality of care (7/11), but objectives followed three distinct approaches to achieving them. Of 148 planned digital health interventions, 45% target providers, and just 7% clients; linkages between interventions and stated health system challenges are often weak. None of the plans explicitly provides for the integration of emerging technologies or locally adapted innovations. These findings have highlighted weaknesses in contextualization, challenge-based planning, and innovation in strategies, set priorities for the next review of these plans, and aim to increase the expected outcome.

Introduction

The term “Digital health” is defined by the World Health Organization (WHO) as the use of information and communication technologies (ICT) in health¹. It is considered as a strategic lever to transform health systems, particularly in African countries. Through integrated information systems, health data collection tools, and standardized interoperability mechanisms, ensuring good data governance². The production of evidence-based data for clinical and policy decision-making is a necessary factor in progressing towards universal health coverage³. For example, telemedicine can expand access to specialized care and reduce treatment delays in underserved areas, while electronic health records improve continuity of care and reduce medication errors; surveillance platforms and dashboards enable rapid detection of outbreaks and evidence based planning³. These changes brought about by digitization can have an impact on multiple areas of the health system, including prevention, diagnosis, treatment, monitoring, and health system management⁴.

Across the world, major digital health projects have emerged over the last two decades to transform local health systems. The innovation in the personal patient record (PPR) in 2006 in the USA through the Health Design project enabled the implementation of practical technological solutions and lessons on the acceptability of health management tools by users⁵. In 2018, in the United Kingdom, the National Health Service (NHS) and the General Medical Council (GMC) began with a digital health service provider, the General Practitioner (GP) at Hand project, a teleconsultation application integrating artificial intelligence, allowing patients to quickly consult general practitioners via video calls or in person, with a simplified appointment booking system⁶. In Africa, digital solutions have expanded in the health field with the advent of the COVID-19 pandemic^7,8. This outbreak accelerated the use of digital tools and highlighted the urgency for governments to invest in digital strategies to strengthen the resilience of health systems. Consequently, large-scale solutions such as mPharma are used in several African countries to guide patients and health professionals in prescribing and procuring pharmaceutical products⁹. However, this rapid proliferation of digital solutions has both highlighted and exacerbated pre-existing weaknesses in coordination. This has led to the fragmentation of health information, namely the duplication of autonomous and not interoperable digital platforms, as well as inefficient allocation of resources, which undermines the overall effectiveness of digital health interventions¹⁰. This fragmentation contributes to widening gaps in the quality and accessibility of care across the continent¹¹.

These issues of coordination and scalability of digital health projects prompted the WHO to adopt a global digital health strategy in 2020 for the period 2021-2025, providing normative guidance and strategic orientations to support countries to develop their strategic plans (SP)¹². At the same time, a practical guide for developing digital health SP co-developed by WHO and the International Telecommunication Union (ITU) has been made available to the member countries of these organizations¹³. These guidelines provide specific standards and recommendations for aligning local digital transformation with global best practices and technical requirements. Many years after the implementation of these strategies, significant shortcomings in digital health persist in African countries, including the fragmentation of health information systems linked to poor coordination of digital health interventions; insufficient funding due to the dependence on external donors, combined with low intrinsic budget allocation; and underdeveloped informatics (IT) infrastructure, namely poor internet coverage, unstable electricity supply, lack of informatics equipment, and insufficient national storage and backup capacity. The following studies highlighted these shortcomings: a 2022 review by H.C. Karamagi et al.¹⁰ counted 738 digital tools used to strengthen health systems in sub-Saharan Africa during the last decade, revealing overlapping solutions and a lack of scalability¹⁰; a study on the policy insights for scaling up and sustaining digital health projects showed the persistent failures of donor funded pilot projects and recommends transitioning to sustainable national programs¹⁴.; and several studies documented the infrastructural limitations hindering the deployment of robust digital health systems^15,16. This raises the question: Could the persistence of these shortcomings therefore be linked to the quality of national digital health SP? Although many African countries have developed digital health SPs, we found no studies in the literature assessing whether these plans comply with standards and recommendations proposed by WHO and ITU guidelines. In this study, we address this gap by evaluating whether the digital health SP developed in Africa are truly aligned with these international standards and recommendations. To do so, we applied a customized evaluation framework combining Walt and Gilson’s political triangle model, enriched by international guidelines, while respecting the READ methodology. This approach, rather than applying generic benchmarks, leverages a comprehensive analytical grid built from two complementary tools (the Walt and Gilson triangle framework and the WHO/ITU toolkit) to conduct a detailed and context-sensitive evaluation. This allows for a more precise comparison between countries and helps identify common gaps and good practices. Ultimately, this comparative analysis aims to identify concrete gaps and levels of alignment between national digital health strategic plans and WHO/ITU guidance, in order to help African countries integrate this guidance into the development of their strategic plans and thereby strengthen the relevance, feasibility, and sustainability of digital health initiatives and their expected impact on health systems.

Results

General characteristics

As of December 31, 2023, forty-eight (48) of the fifty-four (54) African countries studied had reported digital health information on the Global Digital Health Monitor (GHDM) platform. The search through our sources did not allow us to find the SP of the 6 remaining countries, and they were classified in the not found category. Of the 48 countries where information was available, 18 reported that they did not have any SP. Of the 30 countries with a SP, 12 had SP that have expired before 2020, 7 had SP that were up to date but had been elaborated before 2020, and only 11 had strategic digital health plans that met our inclusion criteria. As shown in Fig. 1, these plans cover different African regions, with a varied geographical distribution: West Africa, Central Africa, Northern Africa, Southern and Eastern Africa. The detailed characteristics of each plan are presented in Supplementary Data.

Fig. 1.

Situation of African countries according to the status of their digital health strategic plans.

Context analysis

The analysis of the context of the SP selected focused on the importance given to the description of the national context, the assessment of the enabling environment for digital health, and the explicit identification of the challenges facing health systems.

Firstly, the contextual analysis of the SP reveals significant disparities between the countries in terms of the presence or absence of contextual information identified. As shown by the data presented in Supplementary Table 1. (i) Only the Guinea SP provided all these data; (ii) Cameroon, Malawi, Botswana, Namibia, and Zambia provided data on at least 3 of the 6 defined contextual indicators; (iii) DRC and Tunisia provide only one contextual data; (iv) Ethiopia, Ghana, and Burundi do not provide contextual data.

Secondly, the analysis shows variability in the way countries have addressed the seven pillars of the enabling environment for digital health defined by the WHO. We found 3 ways of assessing: use of the Stages of Continuous Improvement (SOCI) tool, SWOT analysis (Strengths, Weaknesses, Opportunities, Threats), and narrative diagnosis. Ethiopia and Cameroon publish a maturity score, both based on the SOCI tool. SOCI is a tool developed by Measure Evaluation for assessing the health information system maturity. It comprises 5 dimensions (leadership and governance, workforce, infrastructure, standards and interoperability, data quality and use), which only cover 4 WHO/ITU pillars. A single score ranging from 1 to 5 is assigned to each dimension. Score 1 means low maturity, while score 5 means optimized maturity. Ethiopia’s pillar scores are between 2 and 4. Leadership 2.47; Workforce 3.37; Infrastructure 2.29; Standards & Interoperability 2.38; Data Quality & Usage 2.99. Cameroon, without giving the values obtained from the evaluation, ranked all the components at level 2 (Developing). Namibia and Ghana have effectively adopted the seven WHO-ITU pillars through a SWOT analysis per pillar, coupled with a narrative diagnosis. Unlike the SOCI tool, the SWOT does not assign a score but highlights the shortcomings associated with each pillar. Namibia highlights serious gaps in interoperability and uneven connectivity of rural centers, while Ghana acknowledges the existence of robust but ageing infrastructure and a fragmented legal framework. Malawi, Zambia, Burundi, DRC, Guinea, and Tunisia carried out general SWOT analyses of all the pillars. However, recurring issues include a shortage of ICT personnel, a weak legal framework, and a lack of interoperability standards. In contrast to all these SP, Botswana did not focus its assessment on the WHO enabling environment pillars. Still, it mentioned a list of successes, challenges, and opportunities with elements linked to the pillars. Among these challenges, there is a lack of governance structure at all levels, inadequate policies, standard operating procedures (SOPs), and guidelines for the effective implementation of the eHealth strategy. Additionally, there is duplication of effort, with EMR and District Health Information Software (DHIS) data, and data from the same source. Furthermore, some software is not real-time.

Thirdly, only five countries (Cameroon, DRC, Burundi, Botswana, and Namibia) explicitly identified the priority challenges for their health system (HSC) that digital health should help to resolve. Seven main types of challenge were identified, including reducing mortality and morbidity, improving the quality of care, strengthening institutional capacity, optimizing resource management, improving access to care, improving health information management, and developing technological infrastructures. Table 1 shows the distribution of HSCs by country. It should also be noted that some countries that did not specify the HSCs mentioned them in general terms without going into detail, while others focused on the technical challenges specific to the implementation of digital health, without linking them to the overall problems of their healthcare system.

Table 1.

The Health system challenges of the countries

Challenges	Cameroon	DRC	Burundi	Botswana	Namibia
Reduction of mortality and morbidity	✓	✓	-	-	✓
Improving the quality of care	✓	-	✓	✓	-
Institutional capacity building	✓	-	-	✓	✓
Optimised management of resources	-	-	✓	✓	✓
Improving access to care	✓	-	✓	-	✓
Health information management	-	-	-	✓	-
Development of technological infrastructures	-	-	-	✓	✓

Content analysis

Beyond the context, the content of SP, in particular the formulation of the vision, axes, and objectives, determines the direction and scope of national ambitions in terms of digital health.

In strategic planning, the vision is the long-term aspiration of any organization¹⁷. All eleven SPs in our study have outlined a vision for digital health, formulated rhetorically in one sentence, as shown in Table 2. The analysis of these visions has identified four main themes that structure them: (i) digital health for UHC, (ii) digital health focused on quality and clinical outcomes, (iii) data-driven governance and management, and (iv) interoperability and ecosystem security. Eight countries have the ambition to make digital health an accelerator of UHC. Ethiopia, Cameroon, Namibia, Zambia, Ghana, Tunisia, Malawi, and Guinea explicitly place access “for all” at the heart of their vision. For example, Ethiopia envisions “affordable, equitable, and technologically supported services,” Cameroon aims to make UHC effective through “reliable, robust, and interoperable” systems, and Zambia aims for a sustainable and innovative ecosystem aimed at “better health outcomes for the entire population.” Seven SP (Guinea, Ethiopia, Botswana, Ghana, Namibia, Malawi, Zambia) highlight the ability of digital solutions to improve the quality, performance, and clinical impact of care. For example, Ghana promises “timely, quality, and comprehensive” care through ICT, and Malawi aims for a harmonized system enabling “efficient service at all levels.” For data-driven governance and management, four SP, Cameroon, the DRC, Tunisia, and Namibia, emphasize the use of digital platforms for informed decision-making and increased transparency. Tunisia wants “enlightened governance” supported by secure systems, Cameroon aims for “informed decision-making” through reliable systems, the DRC wants “a complete, reliable, and accessible source of information for steering health policy.” At the same time, Namibia makes “real-time” information the foundation of its care model. On the technical level, four visions (Tunisia, Cameroon, DRC, and Zambia) emphasize interoperability and ecosystem security: Tunisia and Cameroon emphasize “interoperable, robust, secure, and sustainable” platforms, while Zambia and the DRC focus on “interoperability and security”. Concerning the temporal projection of the visions, a fundamental element 8/11 PS did not integrate this temporal dimension. Cameroon, Guinea and Ethiopia have defined specific timeframes, ranging from a short timeframe for Cameroon (2024) to a longer timeframe for Ethiopia and Guinea (2030).

Table 2.

Overview of digital health SP visions

Country	Vision
Guinea	By 2030, digital health must be used at all levels of the healthcare system to guarantee universal access to quality healthcare for the entire Guinean population.
Cameroon	By 2024, digital health will contribute effectively to Universal Health Coverage (UHC), thanks to informed decision-making at all levels of the health pyramid, through reliable, robust, secure and interoperable systems.
DRC	The strategic vision for digital health is the creation of an integrated health information system, fed by primary collection digital tools centred on the patient and on the jobs of health professionals, offering a complete, reliable and accessible source of information in good time for steering a health policy geared towards universal health coverage.
Tunisia	Improving the health of Tunisians and achieving Universal Health Coverage for all citizens through enlightened governance at all levels of the health pyramid, and through reliable, robust, secure and interoperable digital systems.
Malawi	To achieve a sustainable and harmonised digital health system, led by the country, covering all service areas and enabling efficient delivery of health services to beneficiaries at all levels of the health system.
Burundi	The vision of the PNDIS is to put in place a coherent set of effective instruments that will enable optimal management of health information in line with the implementation of the PNS and PNDS.
Botswana	A healthy and productive nation benefiting from high-quality digital health services
Ethiopia	Providing quality, affordable, equitable and technologically appropriate health services by 2030
Ghana	All communities in Ghana have access to timely, quality and comprehensive healthcare through the use of information and communication technologies.
Namibia	A healthy nation with a high standard of living and quality health and social services is enabled by digital health.
Zambia	Improved health outcomes for all Zambians through a sustainable, secure and innovative digital health ecosystem that operates transparently.

To achieve the vision, strategic axes are defined, outlining the broad courses of action to be followed. These general directions are then translated into strategic objectives, which are measurable milestones that enable progress towards the vision to be monitored¹⁷. Each objective must be directly linked to one or more strategic axes. Our study shows 2 types of structuring in the SP. The first is vision/axes/objectives structure (Cameroon, Guinea, DRC, Tunisia, Burundi, Malawi, Ethiopia), where the document defines priority areas (axes, pillars or blocks) and then objectives for each; second structure is vision/objectives strategics (Zambia, Namibia, Ghana, Botswana), where priorities take the form of a limited set of strategic objectives with no additional hierarchy. All strategic objectives explicitly contribute to an identified axis or theme of the vision. As shown in Supplementary Table 2, an analysis of the content of the axes and objectives reveals several common priorities, which converge towards three distinct conceptual approaches:

1. Focus on the enabling institutional environment (Cameroon, Namibia, Tunisia and Botswana): these strategies aim to start systematically with the institutional axes (governance, the legal framework, the mobilisation of resources, and the strong workforce) before setting up the technical platforms. The logic behind these strategies is to ‘prepare the ground’, by creating steering committees for multi-sectoral coordination, by seeking the sustainability of financing the digital ecosystem, and by developing the necessary skills before deploying electronic platforms.

2. Focus on the deployment of digital health interventions (DHI), interoperability, and data (Guinea, Burundi, DRC, and Malawi): application offerings, infrastructure, and standards for improving healthcare services and data production are the priority for these countries. The institutional environment is either not taken into account (DRC) or takes a back seat as levers of support rather than pre-requisites (Guinea, Malawi, and Burundi).

3. Hybrid approach (Ghana, Ethiopia, and Zambia): a combination of institutional actions and the deployment of digital solutions characterizes these plans. Botswana, for example, plans from the beginning to put in place dedicated leadership and governance structures at all levels and to secure sustainable funding for the implementation of the strategy, as well as to set up an ‘eHealth platform’ comprising the creation of an integration of all electronic applications into a data warehouse via an interoperability service.

Priority actions

A distribution of the number of interventions according to the 4 groups of the WHO classification of digital health interventions (DHI) showed some inequalities. Among the eleven countries, DHI aimed at healthcare providers dominate (45%), followed by those aimed at data services (25%), and at system managers (24%), while client-oriented functionalities remain poorly represented (7%). Ethiopia (20 DHI) and the DRC (19 DHI) have the most comprehensive digital portfolios, covering all four classification groups. In contrast, Namibia (2 DHI) and Botswana (4 DHI) rely almost exclusively on a few electronic patient records and other data collection tools. Only five countries (Cameroon, DRC, Tunisia, Ethiopia, and Malawi) include at least one intervention from each group. Figure 2 illustrates this distribution.

Fig. 2.

Distribution of digital health interventions within the SPs.

Among the five countries listed explicitly HSC, alignment with planned DHI is heterogeneous. Cameroon and the DRC show the most consistent alignment: each priority challenge in Cameroon and the only mortality reduction challenge in the DRC is accompanied by at least one DHI. Burundi achieves intermediate consistency: its DHI targets quality of care, access, and optimization of resources, but the lack of client-focused tools limits direct benefits for patients. Conversely, Botswana and Namibia show the biggest gaps: their plans, focused on electronic medical records and data collection, neglect critical challenges in their health systems, such as logistics, financing, and infrastructure. Supplementary Table 3 summarizes the alignment between HSC, DHI.

Innovation and adaptation

The ability of health systems to integrate recent technological advances is an indicator of their potential to adapt and improve in the face of contemporary health challenges. This section assesses the extent to which emerging technologies have been taken into account in the strategic digital health plans analyzed. According to the WHO, these technologies offer measurable public health benefits, reduce costs, strengthen resilience in the face of crises, and limit inequalities¹⁸. None of the analyzed SPs incorporate or plan to use artificial intelligence (AI), the Internet of Medical Things (IoMT), blockchain, drones or other approaches adapted to low-resource areas in their DHI.

Discussion

Our results indicate that a substantial proportion of African countries (43 out of 54) did not have an updated and developed post-2020 digital health SP by 31 December 2023. Only 11 countries met these inclusion criteria. This highlights that, despite growing recognition of the potential of digital health, translating it into formal, up-to-date strategic planning remains a major challenge on the continent. Analysis of these 11 SPs shows that they indicate a desire to improve African health systems, but there are several shortcomings in their content.

The study reveals significant disparities in the integration of basic socio-economic and health contextual data in the SP. We noted the almost total absence of these data in some plans (Ethiopia, Ghana, Burundi) and their partial presence in others (DR Congo, Tunisia), which contrasts with the exhaustiveness of the Guinean plan. As a reminder, planning is a methodical process of forecasting a set of resources and activities through the efficient and appropriate use of information available now and in the future, the implementation of which will make it possible to achieve a well-defined objective¹⁹. The absence of health and socio-economic indicators of countries in the analysis of the overall context makes it difficult to assess the appropriateness of the proposed interventions and to measure the real impact of the strategy over time. For example, these limitations reduce the ability of DHI to effectively meet the needs of populations, particularly in contexts where factors such as a low level of digital literacy, limited access to digital infrastructure, or a disadvantaged socio-economic context complicate their adoption^20–24.

As regards the assessment of the enabling environment (the 7 WHO/ITU pillars), the diversity of approaches (SOCI, SWOT, narrative diagnosis) and their variable application reflect a lack of standardisation or perhaps a pragmatic adaptation to local capacities. The use of the SOCI tool by Ethiopia and Cameroon provides a quantifiable measure of maturity, albeit limited to the 5 pillars of this tool, omitting crucial aspects such as legislation or investment, which are also identified as weak in several SWOT analyses. The common point is that investment strategy, standards, interoperability, and human resources pillars are often missing. A. Mamuye et al. drew similar conclusions from a systematic review of 32 digital health strategies and health information systems documents in Africa, which found that the ‘standards & interoperability’ and ‘human resources’ pillars were the least addressed by the countries²⁵. The impact of this lack of contextualization depends on the pillar concerned and risks leading to strategies that do not effectively target the most critical bottlenecks. For example, without clear governance and legal frameworks, projects proliferate without coordination, leading to fragmentation and duplication of effort; this is the ‘pilotitis’ phenomenon described in some African countries^15,26.

In our study, more than 50% of the SPs did not explicitly describe the challenges facing the healthcare system in their respective contexts, limiting themselves to the ‘technical’ issues of digital health instead of linking these to the problems of the healthcare system. This ‘contextual gap’ leads to misaligned, costly, and unsustainable DHI. A review has shown that the lack of an explicit link between health system challenges and digital solutions is one of the reasons why DHI don’t scale among low and middle income countries²⁷.

The 11 analyzed plans comply with the recommendations by setting a vision and strategic objectives. The recurring themes of the visions (UHC, quality/performance, data governance, interoperability/security) are broadly aligned with global health priorities and the expected capabilities of digital health¹⁸. Indeed, technologies deliver measurable gains when the stated visions clearly link them to clinical outcomes and access to care²⁸. The focus on UHC by eight countries is particularly notable and consistent with the Sustainable Development Goals. However, the often rhetorical formulation of these visions requires translation into concrete objectives and actions to truly bring about change.

The structuring in the formulation of strategic objectives in the PS is variable (Vision/Axes/Objectives and Vision/Strategic Objectives). The first structure follows the recommendations of the WHO and ITU, and the second is also described in the literature. The analysis of conceptual approaches to strategic axes and objectives noted three types of convergence. Four countries prioritize the enabling institutional environment, which appears prudent and aims for sustainability, but could delay the achievement of tangible benefits for users and professionals²⁹. Four others prioritize the deployment of interventions, interoperability, and data, which can bring visible results more quickly but risk creating pilot projects without any real scaling-up²⁵. The other 3 adopted a Hybrid approach, which seems the most balanced, seeking to simultaneously develop institutional capacities and technical solutions. It is potentially more complex to implement, but could offer the best compromise between speed and sustainability.

The WHO Global Digital Health Strategy recommends that each digital solution should be linked to a clearly stated system need. The distribution of planned DHI, according to the WHO classification, reveals a clear predominance of tools intended for healthcare providers (45%), followed by those for data services (25%) and system managers (24%). Interventions directly targeting clients (patients/citizens) are significantly underrepresented (7%). This distribution replicates the initial trends in digital health in low-income countries described by Labrique et al.³⁰ (2013). The authors highlighted that DHI choices prioritized direct support to clinicians rather than patient empowerment or reform of management functions³⁰. However, this imbalance represents a missed opportunity. Patient-centred tools have the potential to improve accessibility, equity, patient engagement, and self-care, contributing directly to the vision of the UHC outlined by many countries³¹.

The analysis of the adequacy of the principle of HSC-DHI coupling defined by the WHO for the 6 countries that had explicitly stated the HSC shows that only Cameroon and, to a lesser extent, the DRC systematically translate each of their health challenges into concrete numerical interventions. The lack of alignment between these two couples could lead to a proliferation of uncoordinated digital solutions, which have been documented in several African countries and are associated with a waste of scarce resources³².

The total absence of any explicit mention of emerging technologies such as AI, IoMT, blockchain or drones in the 11 SPs analyzed is striking and a major gap. At a time when the WHO and others are highlighting the transformative potential of these technologies to address health challenges, particularly in low-resource settings^33,34. This may be explained by the lack of control over all aspects, including ethics, data security, and the mistrust of decision-makers with regard to these innovations. There is also a lack of infrastructure, basic interoperability, skills, and data quality in these countries. However, these risks rendering strategies rapidly obsolete and depriving African healthcare systems of opportunities for technological leapfrogging to improve access, efficiency, and quality of care. Nevertheless, the development of SPs dedicated solely to AI by certain African countries could also justify their exclusion from digital health SPs³⁵.

The study highlighted specific gaps and opportunities for improvement, but it is important to recognize its limitations. The study is based on the strategic documents available publicly or via specific sources at 31 December 2023, and may not reflect all the activities or informal strategies existing on the ground. The assessment focuses on the content of the plans and not on their actual implementation or impact. In addition, the rapid evolution of the field means that the situation may have changed since the data was collected or the SP was elaborated. Finally, the analysis is based primarily on WHO/ITU frameworks, although other perspectives may exist.

Future studies should assess the impact of DHI implemented in these African countries to better understand their effectiveness and limitations. It would also be useful to explore the governance and financing mechanisms that influence the development and implementation of SP. Also useful to compare the state of digital health strategic planning in Africa with other developing regions. Finally, research on models for the integration and interoperability of disruptive technologies, such as AI and IoMT, could provide practical guidance for optimizing digital health in Africa.

The results highlight systematic gaps that may limit the relevance and impact of digital health investments in Africa. The lack of comprehensive contextualization in most SP, namely a lack of systematic analysis of socioeconomic and health indicators, the frequent omission of priority challenges facing the health system, and recurring shortcomings in some key pillars of the enabling environment (human resources, legal frameworks, sustainable financing, and interoperability). The portfolio of priority actions is unbalanced, with only 7% targeting users, and the links between interventions and the identified HSC often remain weak. Finally, the absence of an explicit strategy for integrating emerging technologies or innovations adapted to the local context reveals a lack of technological foresight.

To remedy these shortcomings, we recommend that the development of plans require (i) a minimum set of contextual indicators, a better assess of digital health environment and the explicit formalization of HSCs; (ii) the obligation to align each digital intervention with a measurable priority challenge; (iii) the integration of requirements relating to interoperability standards and sustainable financing models; and (iv) the development of a technology foresight component including ethical and safety assessment criteria for the adoption of innovations. Further empirical work will be necessary to determine the extent to which enhancing the quality of SP content leads to more integrated, scalable deployments that have a positive impact on health outcomes.

Methods

Study design

To determine whether African digital health SP are aligned with international standards and recommendations, this study used a documentary and comparative analysis approach. To structure this approach, we applied the READ tool (Ready, Extract, Analyze, Distill), a systematic strategy for document review and interpretation.

Overview of frameworks used

The study employed a customized evaluation grid based on the Walt and Gilson framework, enriched by the WHO and ITU toolkit guidelines. This grid facilitated the thematic extraction of the required information for a comparative analysis of the data drawn from the documents.

The Walt and Gilson triangle framework is a widely used analytical tool to understand and analyze public policies, particularly in the health field, comprising four dimensions: the context, the content, the process, and the actors. The context includes health, political, socio-economic, and demographic aspects. The content focuses on specific policy elements, such as the objectives, strategies, and measures envisaged. The process indicates the methodology used to develop the new strategy. The dimension actors identify and study the stakeholders involved, their roles, interactions, and influences.

The global digital health strategy and the practical guide to elaborate digital health strategic plans are guidelines proposed by the WHO and ITU to help countries draw up their strategic plans. These documents recommend 4 stages in the development of a high-quality digital health SP:

• Defining the strategic context: identify the health system specific to the country and analyse the national digital health enabling environment.

• Involve stakeholders and develop an elaborate the initial strategy: ensure the participation of all stakeholders. Describe the digital health vision, the strategic orientations, and ensure to link the vision to the strategic objectives.

• Identify priority components and actions, and explore disruptive innovation solutions: make sure you cover the 4 function areas of DHI of WHO classifications, and ensure the integration of actions with the HSC.

Establish a multi-year action plan, and a measure, improve, and iterate plan.

Ready and document selection

Document research was performed to identify and collect relevant strategic plans. The study targeted all 54 African countries with a valid digital health SP. To retrieve the documents, we first checked the existence of a SP for each country on the Global Digital Health Monitor (GDHM)³⁶. GHDM is an interactive digital resource that reports on the maturity of digital transformation in healthcare around the world. It was set up by Health Enabled, a non-profit, non-governmental organization based in South Africa. Then we retrieved the documents from the WHO’s Global Repository on National Digital Health Strategies (GRNDHS)³⁷ and the official websites of national Ministries of Health of the countries, targeting the search on the countries that had declared that they had a SP on GDHM. Furthermore, for countries where we were unable to find the SP on the GRNDHS and the official websites, direct engagement with resource persons played a crucial role in acquiring additional SP documents and clarifying missing information. These engagements involved interactions with persons working for Ministries of Health or key organizations such as WHO and ITU, which play a key role in the development of the global digital health strategy.

To ensure a targeted and relevant selection of documents for analysis, specific inclusion criteria were applied. SP were included if they were national digital health strategies officially recognized by African countries and valid until 31 December 2023. In addition, only plans developed after the launch of the WHO Global Strategy for Digital Health in 2020 were considered to ensure alignment with current international standards.

Extract (document collection and sampling)

To ensure that the new grid can be used to extract the relevant information for analyzing the content of the plans to check that they comply with planning standards, the following changes and improvements have been made:

• The ‘process’ and ‘actors’ dimensions from the Walt and Gilson framework have been removed. Because the evaluation focused on the content of the SP, and not on the development process and the stakeholders involved. The same applies to ‘the involvement of stakeholders’ from the WHO/ITU recommendations.

• Two additional dimensions with their subdimensions taken from the WHO/ITU recommendations, namely ‘priority actions’ and ‘Innovation’, have been included to replace the two dimensions that have been removed.

• The ‘context’ dimension from Walt et Gilson triangle framework was maintained with 2 sub-dimensions (socio-economic and health indicators). It has been enriched by 2 sub-dimensions from the strategic context formulated by the WHO/ITU (evaluate the seven pillars of enabling environment and identify the health system challenge (HSC). We identified 2 indicators to verify socio-economic context (total population, GDP/capita) and 4 indicators for health system indicators (life expectancy at birth, infant mortality rate, maternal mortality rate, number of doctors/inhabitant).

• The ‘content’ dimension of the Walt and Gilson framework have been enriched as sub-dimensions by the recommendations on the content of the SP formulated by the WHO/ITU, namely ‘describe the vision of digital health’, ‘the strategic orientations or objectives, and ensure that ‘the vision and the strategic objectives are aligned’.

The various changes made to the primary tools to obtain our custom grid are shown in Supplementary Fig. 1.

Analyze (comparative and thematic analysis)

The data extracted was subjected to an in-depth analysis. This analysis consisted of verifying the existence of the elements of each dimension of our customized framework. We also compared countries according to the information available. The following Table 3 describes the analysis process according to a defined rating.

Table 3.

Rating according to our customised tool

Dimensions	Sub-dimensions	Scoring
Context	Define socio economic indicators Define Health indicator Define the pillars of enabling environment Define HSC	Yes/No Yes/No Yes/No Yes/No
Content	Define the DH vision Define the strategic objectives Verify the Link between the vision and each strategic objective	Yes/No Yes/No Yes/No.
Priority action	Define the DHI covering the 4 function areas of WHO classification Verify the alignment of DHI with the HSC	Yes / No High (if DHI meet 100% or over of HSC); Moderate (At least 50% of HSC); Low (less than 50%).
Innovation	Include the innovation solutions	Yes/No

Distill (synthesis and interpretation of findings)

The synthesis of results was used to assess compliance with international planning standards. This methodology enabled a comprehensive, structured, and comparative analysis of African countries’ digital health SP, highlighting best practices, gaps, and areas for improvement in the formulation and implementation of digital health policies. Figure 3 illustrates the design of our study.

Fig. 3.

Conceptual framework of the study.

Author contributions

B.S. and A.P.S. designed the research project. B.S. and A.P.S. conducted data compilation and analysis. A.P.S. and B.S. drafted the first version of the manuscript. N.M., G.D., and L.G.B.S. validated the methodological approach. N.M., G.D., J.N.N., and L.G.B.S. improved the manuscript. All authors participated in the final revision of the manuscript, corrected it, and approved it for submission.

Data availability

The personalized grid extraction grid, full-text PDFs of the eleven national digital health strategies plan, and the coding spreadsheets used in this analysis are deposited into a Google Drive repository at [here]. No custom software was developed; analysis was performed with Microsoft Excel and manual qualitative coding.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s41746-025-02121-z.