# The State of Health Information Systems Research in Africa: A Scoping Review

Josue Kuika Watat, Ebenezer Agbozo

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Josue Kuika Watat, Ebenezer Agbozo. The State of Health Information Systems Research in Africa: A Scoping Review. International Working Conference on Transfer and Diffusion of IT (TDIT), Jun 2022, Maynooth, Ireland. pp.249-258, 10.1007/978-3-031-17968-6_19. hal-04666773

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# The State of Health Information Systems Research in Africa: A Scoping Review

Josue Kuika Watat<fnref n="1" />[0000-0003-4673-3800] and Ebenezer Agbozo<fnref n="2" />[0000-0002-2413-3815]

**Abstract.** Research on health information systems is gaining momentum, given the importance of the topic in curbing various healthcare issues which are challenging the African health system. The relevance of the topic is reflected in the exponential growth of technological innovations for health and scientific research that assesses their impact. This plethora of research avenues poses a situation of missing evidence on the state of the art of the topic in its diversity. In this research, we report on an overview of research on health information systems across Africa, outlining key insights such as current trends and institutions addressing the topic. We examined 353 articles collected in the Scopus database, and screened them using the biblioshiny. Based on the findings, we ascertained the intricacy of the topic and pinpointed key areas for future research. The outcomes of our research provide information for practitioners engaged in understanding the advancement and state of the art of technology for healthcare in Africa, and research analysis for scholars and researchers on health technologies in Africa.

**Keywords:** Health Information Systems, Healthcare, Africa, Bibliometrics

## 1 Introduction

Since the onset of recent healthcare crises and pandemics such as Ebola and Covid19, it has become more challenging to envision a safe and effective health environment without the use of Information and Communication Technologies. The health fabric of many states is now based on critical data and information for health needs analysis and quality service delivery [1]. The African context represents a significant window of opportunity regarding the sheer volume of information produced but not aggregated due to their states, which makes its use difficult and unstructured [2]. The advent of technological tools has significantly reshaped the health landscape, its data and information, and working practices. For clinicians, the ever-growing demand for health services ought to be at the core of innovations that pertain to the health care system, and they should be key performers in monitoring the evolution of needs by disease, and any resulting technological changes [3].

<footnote n="1">¹ HISP Centre and Department of Informatics, University of Oslo, Ole-Johan Dahls Hus Gaustadalleèn 23B, 0373 Oslo, Norway
josuekw@ifi.uio.no</footnote>

<footnote n="2">² Ural Federal University, Mira 32, 620078, Yekaterinburg, Russia
eagbozo@urfu.ru</footnote>
The use of health information systems in Africa has been presented as a solution to address shortcomings related to cost-effectiveness, quality of health care delivery, data security and process efficiency [4]. Thus, policymakers and government decision-makers emphasized the necessity for the health sector to emulate the examples set by other industries, where the use of technology has been instrumental in expanding access to critical data for decision making, automating formerly resource-intensive processes and tasks, and minimizing human error [5-7].

A number of previous investigations have employed bibliometric analysis to con-
strue the research evidence on health information systems, the role of technology in
health within Africa, and the relevance of cutting-edge technologies in the fight against
epidemics. To our knowledge, no research has documented the emerging literature on
mapping health information systems research in Africa, explicitly through the use of
bibliometric analysis. Pertaining to our topic, a systematic review is a relevant source
of the progress and state of the art which will provide statistics, information on affilia-
tions, origin of studies, as well as the thematic overview of the topic. Thus, a major
contribution of this research for practitioners and scholars lies in the documentation of
the state of the art of the current literature on health information systems in Africa. In
addition, one of the contributing components of our research is the prioritization of
themes that drive research on this topic in Africa, along with the compilation of lacunae
and promiscuous avenues of research that serve as a foundation for future research and
a forum for practitioners to engage in dialogue.

This research underscores the complex nature of discussions around health infor-
mation systems in Africa, especially the technological, social and economic endeavors
that need to be made. Also, it demonstrates the relevance of such an innovation in trans-
forming the African health landscape, which has a significant impact on the One Health
vision [8, 9]. The research enables a variety of institutions to engage in prioritized,
results-oriented thinking with efficient resource allocation. The remainder of this paper
focuses on the methodology identified and applied to this research, the associated find-
ings, and the implications.

## 2 Methodology

The study is based on a systematic literature review methodology, which is built upon
the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
paradigm. Systematic reviews have been applied by researchers in providing insights
on how empirical studies employed co-design strategies in mobile health (mHealth)
systems development [10]. The PRISMA statement guidelines undergirds this study by
adopting the four (4) steps - identification, screening, eligibility and inclusion criteria
[11-13]. A systematic literature review acts as an instrumental source of summarize
evidence relating to efficacy of any domain of discourse accurately and reliably [14].
The PRISMA guidelines have been adopted by studies focused on information systems
in Africa, as such it was deemed as an efficient backing for this study [15, 16].
**2.1 Setting the Academic Scope and Study Background**

The academic field engaged in this study is health information systems, and the back-
ground to the study is Africa. Recognizing that health information systems contribute
to improving the health system throughout all levels of performance (strategic, social),
health information systems research in Africa has the substantial promise of providing
transformational proof to issues surrounding the use of technology in health, in a weak-
ened environment, and amidst uncertainty.

**2.2 Identification and Curation of Relevant Publications on the Subject**

We compiled bibliometric records from the Scopus database due to its completeness, inclusivity, ease of use, comprehensiveness, and credibility with regards to research sources [17, 18]. Studies have recommended Scopus as enough for systematic reviews because it is an effective search engine and contains majority of the credible research publications [19, 20]. Fig.1 illustrates the research methodology by visually depicting keyword combinations. The results of our keyword combination yielded a sample size of N = 572 articles published and indexed until March 2022. By applying the PRISMA guidelines, we furthermore derived a subset of the final list of articles to N=353, by excluding non-English articles, undefined authors, articles in press (due to the fact that articles in press are likely to be withdrawn since they are not yet officially published), and limiting sources to scientific journals only.
<figure><img src="image_3.png" /><figcaption>Fig. 1. Research Design</figcaption></figure>

## 2.3 Bibliometric Assessment

In order to obtain the relevant results for the study, we adopted the bibliometrix package - an open-source scientometrics and bibliometrics research tool - in R and used the biblioshiny tool as our knowledge extraction tool [21]. The tool has a proven track record of performing elaborate analysis of a large set of compiled data, generating reliable outputs with an easily readable and understandable layout [22, 23]. In the next section, we present the results of our knowledge extraction and data analysis.

## 3 Findings

In this section, we uncover our research findings. The bibliometric analysis generated essential insights that highlighted the scientific production and cited sources, most relevant affiliations of authors, topic trends based on keywords, and a co-occurrence map network with respect to healthcare information systems research in Africa. From our data source, Scopus, the earliest research papers on information systems and healthcare with respect to Africa were published as early as 1995. Out of 353 articles, the average citations per document was 10.73, with 1973 authors and 5.59 authors per document.
<figure><img src="image_4.png" /><figcaption>**Fig. 2.** Most Local Cited Sources.</figcaption></figure>

Figure 2 highlights the most cited sources with the number of local clusters on the x-axis and the cited sources on the y-axis. Lancet topped the number of cited sources for research on healthcare and information systems research in Africa.
<figure><img src="image_5.png" /><figcaption>**Fig. 3.** Most Relevant Affiliations</figcaption></figure>

Another relevant statistic is the affiliation of authors (as highlighted in Figure 3) with the London School of Hygiene and Tropical Medicine (UK), University of Kwazulu Natal (South Africa), Ministry of Health (which is as a result of affiliation name dis-ambiguation), and the University of Cape Town (South Africa) being the topmost in-stitutions. The presence of Ministry of Health research, indicates the immense contri-bution by scientists and academics associated with government institutions as a means of improving healthcare delivery within the various countries in Africa. Also, corre-sponding authors and their countries of affiliation by publication count are South Africa (53), USA (48), United Kingdom (34), Ghana (15), Nigeria (14), Ethiopia (13), Kenya (10), Canada (7), Netherlands (6), and Australia (5) respectively. This is indicative of the fact that researchers within the sub-Saharan region are putting in the effort to tell the story of the state of healthcare and information systems within their region and contribute towards its development.
<figure><img src="image_6.png" /><figcaption>**Fig. 4.** Trend Topics (Author Keywords)</figcaption></figure>

Figure 4 illustrates topical trends with respect to research on information systems and healthcare in Africa. By observation, one can infer that topics such as public health, data quality, and primary healthcare will be the focus of future studies with regards to information systems in African healthcare studies. Themes such as malaria and health systems continue to be studied. One can also observe the sudden decline in certain topics right after 2019, and this could most probably be linked to the covid-19 pandemic and a shift of research focus. Studies confirm this observation (publication boom) by indicating the fact that there was an urgency to disseminate new research findings, with Nigeria ranking second (2nd) in research productivity with respect to covid-19 studies [24-26]
<figure><img src="image_7.png" /><figcaption>**Fig. 5.** Co-occurrence Network Map (based on Authors' Keywords)</figcaption></figure>

Fig. 5 illustrates the co-occurrence network map of health care and information systems research in Africa, drawn from the authors' keywords. A co-occurrence network is a graph *G(V, E, W)*, where *V* is the vertex set (representative of entities - keywords in this case), *E* is indicative of the set of edges that connect vertices, and *W* is a set of weights associated with the edges (it is indicative of the strength of the relationship) [27]. The network parameters include: (a) the Louvain clustering algorithm which is used to cluster words, after which each word is scored based on the sum of several scoring approaches such as word score based on dependency relations, and term frequency score of each word [28] (b) graph normalization by association, the number of nodes (50) and the minimum number of edges (2). The graph is composed of seven (7) clusters. The red cluster shines a light on geographic information systems (GIS) linked to public health, maternal health, accessibility, healthcare policy, covid-19 and the country of Mozambique. From these nodes, one can conclude that one of the key components of IS and healthcare research in Africa is targeted at providing accessible services to maternal healthcare as well as the utilization of GIS for healthcare provision especially with respect to contact tracing during the COVID-19 pandemic in 2020.

The blue cluster links maternal health (from the red cluster) to Nigeria (the central node) which is linked to health information systems and primary healthcare. It can be deduced that healthcare and information systems research focused on Nigeria has been narrowed down to the need for quality primary healthcare delivery via IS within the rural and public health scope.

The green cluster is an isolated cluster with three (3) nodes: Ghana, antenatal care and GIS. This cluster buttresses the points made in studies that highlight the use of GIS in evaluating the impact of community-based health initiatives in rural Ghana[29]. Studies have also focused on the application of GIS (road network analysis) to analyze
the distance from the homes of women living in Bo, Sierra Leone to the nearest healthcare providers and to their preferred acute care providers[30].

The orange cluster has the keywords HIV, information systems, primary healthcare, tuberculosis, South Africa, Sub-Saharan Africa, Malawi, and healthcare workers. Studies have revealed the positive strides South Africa has taken in curbing the HIV crisis and tuberculosis related issues via formidable policies and health information systems[31]. Such initiatives have eased the burden on health workers and optimized the process of delivering quality healthcare.

The pink cluster which is healthcare information systems, healthcare, Africa, data quality, mobile phones, integration, and health. In recent years, studies on data quality interventions (i.e. effective management) have been a priority of healthcare research in Africa[32]. One study highlighted the improvement in data quality with respect to reports submitted to health authorities in South Africa [33]. Studies continue to focus on assessing and improving data quality in electronic healthcare records for optimal service delivery[34].

The brown cluster comprises the following keywords: health system, maternal, newborn, quality of care, and mortality. Previous studies have revealed the huge rate of infant and maternal mortality within African countries [35, 36]. Conversely, research has also focused on countering child and maternal mortality [37].

Finally, the purple cluster which constitutes the tokens mhealth, ehealth, and telemedicine reveal the adoption of technology within Africa's healthcare sector. Digital healthcare initiatives have been integrated in the African healthcare experience for healthcare education, disease prevention initiatives, medical appointments and drug adherence programs[38]. They were adopted as a form of sustainable technology capable of protecting patients, medical practitioners during the covid-19 pandemic to reduce patients' social mobility (so as to decrease viral spread) [39]. It is evident that technological integration within healthcare in Africa has come a long way and will continue to make progressive strides.

## 4 Conclusion & Research Avenues

In this research, we report on a systematic overview of the nascent literature on health information systems in Africa. The methodology applied revealed how complex the topic is, considering the major interests at stake, and the importance of Africa's health system in the global health agenda as spurred on by the World Health Organization (WHO). Various research priorities such as health data quality, primary health care and telemedicine emerged as key factors that warrant further investigation by researchers. The fight against diseases such as tuberculosis and HIV/AIDS is still a major issue for the African continent [31, 40, 41]. In our research, we note some limitations. One practical implication of our study includes validating the efficacy of data-driven methodologies as tools for furthering knowledge discovery research in order to provide factual insights to researchers and knowledge workers. Another implication is in the adoption, utilization and management of digital transformation tools as decision support systems for quality healthcare delivery. Theoretical implications of the study include the necessity of developing and integrating data-driven mobile-based frameworks in healthcare
delivery for the sub-region owing to the fact that mobile usage in Africa is at an all-
time high.

Our research derives its entire analytical focus and implication from articles indexed in Scopus only. This restriction would indicate a level of bias at a scale, as well as an underestimation of the state of the art. We therefore advocate for further research to extend our reflections to other databases and publication sources.

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