The Tanzanian digital health agenda
Authors: Geoff Watts
Journal: The Lancet Digital Health (2020)

“Digital technologies play a potential fundamental role in facilitating timely availability of quality health information for provision of better-quality health care services.” A sentence from the typically dry prose of a government policy statement. What makes it notable is not the content—virtually self-evident in the digital age—but its source: a strategy document recently compiled not in the health ministry of a wealthy, industrialised country, but that of Tanzania. As measured by GDP per capita, Tanzania is among the world's poorest nations. But with imagination, careful planning, and relatively modest investment, digital health technology is already making an impact. Poverty, it seems, need not be an insurmountable stumbling block to its successful introduction. The country first applied digital technology to health care in the 1990s, with a scheme for digitising the country's health management system under which data collected from local health facilities were used for planning at the district level. Hospitals performing research and clinical trials, especially on HIV, then began to go digital. As such, the spread of digital health technology in Tanzania would seem to be following a course that is similar to its dissemination in high-income countries. But there is a marked difference: the mobile phone. In less developed countries this has been a game changer. A 2018 estimate was that around 42% of the population of Tanzania was subscribing to a mobile service, and that mobile internet penetration since 2010 had nearly quadrupled. From the outset, health workers have recognised the value of this new tool in communicating health messages. Professor Val Curtis of the London School of Hygiene & Tropical Medicine works on sanitation and hygiene in Tanzania. The campaigns she runs promoting the installation of better toilets rely heavily on social media. Modernisation is a recurring theme in many spheres of African life and, as Curtis points out, “One of the drivers of modernisation has been the spread of communications technology.” She estimates that about half the mobile phones owned by people she works with are now smartphones: themselves products of modernisation, but also a stimulus to still more change. As elsewhere, what began with a capacity for simple messaging soon became more sophisticated. One scheme aiming to exploit the expansion of digital communications technology for health in Tanzania is Afya-Tek. Funded by the Swiss-based charity Fondation Botnar, it is underpinned by a consortium of five organisations that are trying to improve the decision making and quality of care at the community level in the country's Kibaha health district near Dar es Salaam. Afya-Tek will offer a digital link between patients, government health facilities, community health workers, and the private sector drug dispensers known as Accredited Drug Dispensing Outlets. All staff will have access to appropriate information about their patients' health, including following referrals from one practitioner to another. Central to the scheme is, needless to say, an app that can run on a smartphone or a tablet. As well as acting as a customised channel for the back and forth flow of health information, the system will also provide health workers with decision-making tools. As Nandini Sarkar of the Institute of Tropical Medicine in Antwerp explained, the app “will guide decision making, but not necessarily make the decision”. The Institute of Tropical Medicine's role in Afya-Tek is to help develop the initial pilot scheme, and then evaluate its success. The two trial areas are a township and a more rural, less densely populated district. “The programme probably won't be implemented until some time next year,” says Sarkar, “and then we'll be following it for a whole year.” If successful, the scheme could be a model not only for the rest of Tanzania, but also for neighbouring countries. Another tangible example is the Tanzanian Government's Better Immunisation Data (BID) scheme. Launched in 2013 with support from the Bill & Melinda Gates Foundation, it is led by PATH, a non-profit organisation that collaborates with public institutions, businesses, grassroots groups, and investors to tackle global health challenges. BID's core feature is an electronic immunisation registry. “When a child is born or comes to a health facility for the first time they're registered”, Henry Mwanyika, PATH's regional director based in Dar es Salaam, told The Lancet Digital Health. “Any immunisation they're given at that time will be documented, and that data will be available at any other health facility they visit.” The immediate benefits of BID are the most obvious: staff can identify infants who miss clinic visits. The system also simplifies the maintenance of vaccine stocks, and their timely reordering. “So far [the system] is in ten out of 22 regions and covering 3000 facilities out of 6000”, says Mwanyika. In the medium term, BID could be expanded into other areas, such as nutrition or maternal and newborn health. But its greatest value may lie in what it offers for the long term and wider development of health care in Tanzania: the goal of universal health coverage (UHC). UHC can only be achieved by expanding primary health care, and this in turn relies on governments knowing of the existence and whereabouts of their people. In poor countries, such records are often far from complete. Health interventions are one of the best ways by which governments can make initial contact with people, and immunisation is particularly well suited. 40 years ago, only one in 20 of the world's children underwent routine immunisation; the figure is now more than four out of five. Children immunised under the BID scheme in Tanzania automatically receive a digital identity that will stay with them for the rest of their lives. As the country develops new medical facilities and programmes of health intervention, the information in the electronic immunisation register will form the basis of a complete electronic medical record. Therefore, this modest electronic immunisation registry could be the first step in attaining UHC. Tanzania's first formal policy statement on the role and importance of digital technolgy, the National eHealth Strategy, appeared in 2013. The document was a plan “to guide the use of ICT in supporting health sector transformation”. Mwanyika knows how important it is to be realistic about government plans. “Sometimes you have a document that is a nice shiny object, but nothing is done,” he comments. Happily, this one does appear to have made an impact. Reported improvements over the 5 years following its publication range from the quality of planning and decision making through to the better organisation of health service delivery. Particularly important was that the strategy led to the development of Tanzania's Digital Health Investment Road Map. Mwanyika describes this as a costed implementation plan. “It took the strategy, and identified key investment areas,” he explains. “It's understandable and digestible.” A first-of-its-kind achievement in the digital health field, the plan helps government, commercial operators, and aid donors to prioritise need and make appropriate digital investment decisions. The cost of implementing all the recommendations of the Road Map would add up to US$74 million, but not all this will be borne by the Tanzanian Government. The Gates Foundation, for example, has given $15 million to fund seven of the highest priority projects. A newly released policy document covers the period from 2019 to 2024. This National Digital Health Strategy deals with some of the challenges unresolved by its predecessor, such as inadequate numbers of trained personnel, limited eHealth skills among users and decision makers, and the user-unfriendliness of some digital solutions. “Its focus is on health impact and on patient experience,” Mwanyika comments. “It's talking not to the digital experts but to the health experts.” Whereas the emphasis of the first policy document was on the technology needed to bring Tanzania into the digital age, its successor focuses on the best way to use and, if necessary, modify that technology to maximise its benefits in patient care. One difficulty identified by the new strategy document is coordination. “Currently, there are over 160 digital health or health-related systems [in Tanzania],” it reports. “However, some of the systems have national coverage while others are institution-based. Some of them are at piloting phase while others are operational but with limited interoperability.” Laurie Werner, director of the digital and data programme at PATH, is well aware of the problems created by poor coordination between government agencies, NGOs, and commercial enterprises. “This has happened a lot,” she says. In response, the strategy document recognises the need to take control: “The Government will build on ongoing efforts to ensure that digital health systems are implemented in a well-coordinated and interoperable manner.” Things should improve, Werner thinks. “The Tanzanian Road Map is a fabulous tool for the Government to bring implementing partners like PATH and the donors around the table to talk about where they want to go [with a project].” Although an appetite for digital technology is growing in many countries, it seems to be particularly strong among Tanzanians. As Werner comments, “They are exceptionally keen.” The publication of the country's new policy document demonstrates that, even in the poorer regions of the globe, digital approaches to health planning and provision are no longer a complete novelty. Equally encouraging is that Tanzania is now eager to adapt and deploy these technologies in the way that best suits them. Digital health is firmly on the country's agenda. For more on Fondation Botnar and Afya-Tek see https://www.fondationbotnar.orgFor more on the BID scheme see https://bidinitiative.orgFor more on the Tanzania National eHealth Strategy (2013–18) see http://www.tzdpg.or.tz/fileadmin/documents/dpg_internal/dpg_working_groups_clusters/cluster_2/health/Key_Sector_Documents/Tanzania_Key_Health_Documents/Tz_eHealth_Strategy_Final.pdfFor more on the Tanzania Digital Health Investment Road Map see http://moh.go.tz/images/eHealth_Initiatives/TZ_Investment_Recommendations_Roadmap.pdfFor more on PATH in Tanzania see https://www.path.org/where-we-work/tanzania For more on Fondation Botnar and Afya-Tek see https://www.fondationbotnar.org For more on the BID scheme see https://bidinitiative.org For more on the Tanzania National eHealth Strategy (2013–18) see http://www.tzdpg.or.tz/fileadmin/documents/dpg_internal/dpg_working_groups_clusters/cluster_2/health/Key_Sector_Documents/Tanzania_Key_Health_Documents/Tz_eHealth_Strategy_Final.pdf For more on the Tanzania Digital Health Investment Road Map see http://moh.go.tz/images/eHealth_Initiatives/TZ_Investment_Recommendations_Roadmap.pdf For more on PATH in Tanzania see https://www.path.org/where-we-work/tanzania