Sub-Saharan Africa—the new breeding ground for global digital health
Authors: Christine Holst, Felix Sukums, Danica Radovanovic, Bernard Ngowi, Josef Noll, Andrea Sylvia Winkler
Journal: The Lancet Digital Health (2020)

Sub-Saharan Africa has become an emerging arena for digital health innovations directed at strengthening health care, in terms of both patient management and disease surveillance and prevention. Across the region with the world's largest burden of disease and the most severe shortage of health-care workers, we see increased use of digital health solutions and interventions for clients, health-care providers, health-system managers, and data services. As the traditional health-care systems are typically ill-equipped, understaffed, or not accessible at all, sub-Saharan Africa is booming with digital health. Digital health technologies come in many forms and shapes. Mobile phones have been used to get maternal health support in South Africa,1South African National Department of HealthMomConnect.http://www.health.gov.za/index.php/mom-connectDate accessed: January 30, 2020Google Scholar detect fake drugs in Ghana2mPedigreehttps://mpedigree.com/Date accessed: January 30, 2020Google Scholar or access a digital health-financing platform in Kenya.3M-TIBAhttps://m-tiba.com/Date accessed: January 30, 2020Google Scholar We find various telemedicine collaborations and use of social media tools for health promotion throughout the region. Emerging technologies such as the Internet of Things-related system development,4Al Isma'ili S Li M Shen J He Q Alghazi A African societal challenges transformation through IoT. 21st Pacific Asia conference on information systems, PACIS 2017.AIS Electronic Library. 2017; : 1-9Google Scholar wearables, and sensors have opened possibilities for new, small, and compact diagnostic tools and for easier tracking and monitoring of individuals’ health in a hospital setting, or underserved and remote areas. The use of big data and artificial intelligence has proven an excellent applicability for both outbreak control and preparedness,5Su K Xu L Li G et al.Forecasting influenza activity using self-adaptive AI model and multi-source data in Chongqing, China.EBioMedicine. 2019; 47: 284-292Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar and might be applied to a range of diseases in sub-Saharan Africa. Improved visibility of logistics data, from the primary health-care level and upwards, has resulted in improved decision making in supply chain management and in fewer stock-outs (eg, in Uganda).6Ministry of Health, UgandamTrac.http://www.mtrac.ug/Date accessed: January 30, 2020Google Scholar Drones are increasingly used to transport blood and medical supplies from one clinic to another and this activity has led to a new academy in Malawi,7UNICEFThe African Drone and Data Academy in Malawi.https://www.unicef.org/malawi/african-drone-and-data-academy-malawiDate accessed: January 30, 2020Google Scholar educating students in the understanding of drones and data. Community health workers across sub-Saharan Africa can now register vital events with various apps that feed into national vital registration systems. District Health Information Software 28District Health Information Software 2 (DHIS2)https://www.dhis2.org/Date accessed: January 30, 2020Google Scholar is changing the digital ecosystems for monitoring and analysing disease patterns, populations, and outbreaks, by gathering data collected routinely in health-care facilities and communities. Also, smartphones have definitely arrived in the region, with 39% of all SIM connections in 2018, and an estimated 66% in 2025. The mobile money market of sub-Saharan Africa has become an epicentre, accounting for almost half of all mobile money registered accounts globally.9GSMAState of the mobile money industry in sub-Saharan Africa 2018.https://www.gsma.com/mobilefordevelopment/wp-content/uploads/2019/07/GSMA-Sub-Saharan-Africa-SOTIR-presentation.pdfDate accessed: January 30, 2020Google Scholar Despite these promising figures, many people in the region today deal with several real-life barriers to the access of digital health (see figure, red square), especially the urban–rural and gender divide, low digital literacy, and shortage of connectivity and electricity. As digital health implementations depend on the surrounding context, populations need tailored digital content in their own language, not only to guide access to health-care systems but also for disease prevention. Health information and digital health solutions and interventions should always be co-designed with local communities in order to ensure uptake. The Non-Discriminating Access for Digital Inclusion consortium, of which the authors are part, has co-designed together with the communities, digital health messages for disease management and prevention for HIV/AIDS, tuberculosis, and zoonotic diseases on the basis of multistakeholder inputs and endorsement by the Ministry of Health. The intervention also considers the local context in terms of connectivity and access to mobile devices. In sub-Saharan Africa, users and potential users of digital health solutions and interventions have unique characteristics. For instance, people between the age of 0 and 14 years account for 43% of the total population.10World BankPopulation ages 0–14 (% of total population).https://data.worldbank.org/indicator/SP.POP.0014.TO.ZSDate accessed: January 30, 2020Google Scholar We see a young generation ready to move from traditional communication in health towards (smart) phone-based communication. As the young absorb digital knowledge at a faster pace than their parents, it is reasonable to believe that their health might improve when quality digital health solutions and interventions are implemented on a large scale. However, to show the effect of digital health solutions and interventions in low-income and middle-income countries, population-level studies of digital health tools are much needed. eHealth strategies are being developed and implemented at impressive speed. 41 of 54 African countries have national digital health strategies and architectures. Digital health strategies (eg, in Tanzania) show that countries, at a national level, see the opportunities within digital health. With increased governmental emphasis on challenges such as reliable infrastructure and policy, as well as regulations related to successful implementation and use of digital health solutions and interventions, the enabling environment for digital health in general is strengthened (see figure, yellow square). The figure emphasises further the need to create an enabling environment for digital health solutions and interventions that are data driven with user-centric design. Factors such as technical innovations, strong digital health leadership and governance, good coordination of investments and public–private partnerships, and policies for transferring the digital health initiatives into national health systems and regulatory frameworks play important roles in access and adaptation of digital health solutions and innovations for clients, health-care providers, health system managers, and data services. Obvious threats to the health of the African population are the shortage of well-trained health-care workers and good quality medicines, climate change, and poor infrastructure. Here digital health does not represent a one size fits all solution, but if tailored might be able to alleviate some of the challenges. However, even if highly innovative it can never be a good replacement for the human support that patients get from health-care workers, although digital health solutions and interventions can affect some of the health outcomes (see figure, green square; eg, releasing time from health-care workers, increasing patient safety, and thus improving quality, effectiveness, and efficiency in the health-care facilities). In that context, digital health might also have the potential to strengthen universal health coverage and, through the support of health-care systems in most countries, advance the Sustainable Development Goals. In summary, our commentary shows the breadth of digital health solutions and interventions in sub-Saharan Africa and the opportunities that lie within the African context, accelerated by the large proportion of young people who are eager users of smartphones. To make digital health flourish within sub-Saharan Africa, enabling environments need to be created that are firmly anchored within the local context, driven by African needs, endorsed by decision makers such as national governments and supported by global key players such as the United Nations and WHO. Individual barriers such as low digital literacy skills and the shortage of connectivity are important to address when boosting the digital health activity in the region. Regardless of this, sub-Saharan Africa has become an attractive partner when it comes to cooperation within the development of digital innovation and the experiences gained in sub-Saharan Africa could be interesting for partners in the global north, who more and more harness opportunities for reverse innovation. We declare no competing interests; however, JN has a Basic Internet patent pending.