Debating Ideas is a new section that aims to reflect the values and editorial ethos of the African Arguments book series, publishing engaged, often radical, scholarship, original and activist writing from within the African continent and beyond. It will offer debates and engagements, contexts and controversies, and reviews and responses flowing from the African Arguments books.
The Covid-19 pandemic reminded African countries that population health is the foundation on which success in social, economic and development progress is built. Most countries have poor health infrastructure and weak health systems that are unable to provide quality care to patients. Covid-19 has further worsened the already fragile foundation of Africa’s health services and caused sharp decline in the provision of key life-saving essential health services. Across the region, patients have struggled to access essential services including maternal and child care services, chronic care for diabetes and HIV/AIDS, treatment of confirmed malaria cases and childhood vaccination programmes. Some 14 countries evaluated by WHO have recorded a 50% decline in services within 3 months compared to the same period in 2019.
Inadequate physical infrastructure limits physical access to healthcare services, a big challenge for rural communities. Power supply is often unstable and internet connectivity expensive. Health information is not always delivered in a manner that is linguistically and culturally accessible which limits its effective adoption by communities. Fears of going to health facilities and risking catching Covid-19 and restricted access to health services to maintain health facility capacity for Covid-19 patients have widened these gaps further.
The necessary improvements require billions of dollars in investments to expand physical infrastructure like clinics and roads. Countries must prioritize investing in strengthening health infrastructure in order to improve pandemic preparedness and the resilience of health systems by having widely accessible primary healthcare services, an adequately skilled workforce and quality health products needed for effective disease management provided at a cost that people can afford. Without resilient health systems with adequate health infrastructure, any economic progress African countries make is extremely fragile and unsustainable. Ten months of the Covid-19 pandemic have wiped away an entire decade of economic development resulting in 50 million Africans who will fall below the poverty line of living on $1.5 a day.
With countries not having the billions of dollars needed in investment, a critical question, given the resource constraints, is: how can African countries bridge the infrastructure gap to improve the resilience of health systems against similar future shocks? Use of digital health solutions in Africa’s public health institutions could bring significant improvement to the delivery of essential health services by bringing services closer to communities in a more cost-effective way. It could also potentially lower the cost of investment needed to improve infrastructure and enhance progress towards universal health coverage. Digital health solutions could be more feasible in situations where countries can plan these most optimally prioritized based on their ability to create value in their national context of limited resources and acute burden of disease. These solutions would need to be designed and executed in a way that enhances service delivery whilst at the same time complementing gaps in physical infrastructure.
The benefits of digital health solutions
Digital health refers to the use of information communication. Some of the most common digital health solutions on the African continent include mobile telephony (mHealth), telehealth and eLearning. Social media platforms have also been extensively used by the WHO and Ministries of Health to disseminate accurate health information during the Covid-19 pandemic. This includes the internet of things (IoT) which can enhance supply chain planning, organization and service delivery to ensure quality products can be delivered at a cost that is not a barrier to access by patients. The benefits of digital health solutions are best realized when national health priorities align with health development goals and real health needs of citizens. They deliver the greatest value and impact when they are designed to be cost-effective, at scale and in a way that is suited to the relevant context. They can drive improvements in healthcare service delivery to the last mile where there is limited physical infrastructure like roads and clinics and an inadequate health workforce, all major constraints in access to care.
Digital health solutions can be used to provide preventive and curative health services including for the management of acute and chronic diseases including cancers, diabetes, childhood immunization and HIV/AIDS management. Deployment of solutions like digital medical devices needed to create digital clinics and digital patients would bring services closer to communities. In 2016, Ghana rolled out telemedicine to allow remote diagnosis and treatment of patients thereby expanding healthcare delivery especially to women and children. Clinics can be staffed by adequately trained health workers who are equipped with medical devices to support remote diagnostic processes and procedures and reduce the burden on services including shortages of health professionals. For example, Kenya and Tanzania have piloted the use of digital ultrasound delivered using mHealth and telemedicine whilst Kenya has used rapid diagnostic tests (RDTs) integrated into cloud-based mHealth.
Ghana’s Ashanti region established tele-consultation centers (TCCs) that were managed by qualified nurses who advise community health workers in remote communities through mobile phones. The nurses provide advice on reported illness and interface with the doctors when dealing with more complex medical cases. Uganda and Malawi have used smartphone-powered portable electrocardiograph (ECG).
Digital health solutions could be used to manage health knowledge and access to health information by health workers and communities (eLearning). When managing highly contagious infectious disease outbreaks like Ebola, it is important to have capacity to rapidly transmit public health information in real time to support timely decision making. Digital health solutions provide a highly effective conduit for providing timely, easily accessible, culturally and linguistically appropriate health information and improve engagement by users and providers of health services. They also facilitate rapid detection of sociocultural, physical, and financial barriers to service access which allows quick adaptation to improve the efficiency and responsiveness of public health services. There is great potential to expand access to affordable health services and capture feedback on the quality of care to raise efficiency gains in service delivery, which could be leveraged to improve the quality of care and patient safety.
Does Africa have adequate mobile telephony and mobile internet coverage?
Whilst the application of digital health solutions has been shown to have great potential in pilot studies, countries cannot effectively leverage them to improve service provision to the masses without adequate mobile internet connectivity. An estimated 95% of the global population currently lives in areas that are served by mobile networks. It is thus technically possible to reach 95% of the global population with services provided through mobile telephony.
People can access mobile phones and data services. In Africa, mobile phone penetration is relatively high at an estimated 74%, whilst internet coverage at 21.8% is much lower than in other regions. Amongst African populations, projected regional population coverage with internet connectivity in 2020 is 38%. Mobile economy estimates that there are 942 million sim connections and 535 million unique subscriptions in Africa in 2020. Mobile internet connectivity is estimated at 38% of Africa’s population.
Investment in wider population access to data and wifi would create the opportunity to increase population connectivity through mobile internet. In order to increase the resilience of Africa’s health systems during health emergencies, governments would need to invest in expanding wifi and internet coverage as an enabler for better service delivery in health, education and other sectors of the digital economy. Governments could provide public wifi facilities serving communities where they could go to access critical digital health services.
The most critical elements to the successful adoption of Africa digital health solutions
Countries would need to articulate their eHealth strategy and develop standard guidelines. The WHO and the International Telecommunication Union (ITU) eHealth toolkit which articulates standards, legislation, appropriate technical and service delivery solutions provides a good guide. The strategy should aim to close gaps in knowledge, services and human resources responsible for managing and maintaining digital health infrastructure. It should also include a communications strategy for engaging, mobilizing and informing digital health end-users of their benefits. Most importantly, it should adopt lessons from the successful initiatives from similar resource-limited settings, for instance, how to address internet connectivity challenges in rural communities. Guidance documents from other regions with similar contexts could help inform Africa’s strategies towards effective use of digital health to complement physical infrastructure. Countries would also need to design a national digital health strategy supported by appropriate national governance structures, regulatory mechanisms, policies, strategies and guidelines.
Countries would also need an adequate legal framework with capacity to address ethical issues like who owns digital health data, what constitutes informed consent to use data and what are considered adequate measures for data security. Initiatives would need to be piloted to capture lessons that can guide the development of evidence-based national strategies, regulatory and legal frameworks needed for effective application of these solutions and to build the capacity of health facilities and institutions. Ghana piloted its Telemedicine initiative in the Ashanti region before expanding it nationally.
In order to have greater impact, projects need to be scalable, but few initiatives have gone beyond short-term pilots to demonstrate public health benefits and impact in the long term. The number of pilots would need to be kept manageable in order to avoid poorly coordinated initiatives that result in duplication, over-stretched capacity, or result in systems that are not interoperable and therefore redundant, which leads to a waste of resources. Sustainable financing of these initiatives, primarily through local government and local private sector funding, will be critical and should be informed by collaboration between Ministries of Health and ICT.
The Ebola outbreak showed that public health campaigns cannot succeed in the absence of community adoption and ownership. To successfully deploy digital health solutions, countries would need to inform communities how these solutions could improve service delivery and mobilize communities to accept and adopt them. A critical mass of appropriately trained health workers who are adequately trained to promote uptake, manage digital health solutions and manage the increase in health service uptake resulting from such messaging campaigns in countries will be an essential element.
At a minimum, adopted digital solutions should make it easy to transmit health promotion and education information rapidly and in a timely way that communities can accept and which encourages wider participation. The public health messages would need to be well-designed by health communication experts who possess a nuanced understanding of cultural norms to enhance their acceptance by communities. In turn, communities must be well connected digitally. African public health learning institutions will have a critical role to play in designing messages and providing training to generate awareness and promote understanding of how digital health services help to bridge and complement the infrastructure gap amongst politicians, decision makers, health workers and communities.
Going forward, African countries should consider digital health solutions as a critical component of national strategies for improving the resilience of health systems. They should initiate a national conversation by bringing together relevant stakeholders in public health and ICT to lead discussions about which gaps in infrastructure can be solved through digital solutions and criteria for deciding what should be a national priority based on population health needs. These evaluations should take into consideration the feasibility and cost-effectiveness of proposed digital solutions in the specific national context and the sources of sustainable domestic financing to support implementation. Digital health solutions can provide a practical path to improving service delivery. However, their success will depend on political will. Leaders need to go beyond political rhetoric and put resources towards the integration of digital health solutions into national health service provision. Resilient health systems of the future will be those that are able to harness the power of well selected digital health solutions and strategic development of physical health infrastructure to meet the needs of populations at an affordable cost.