Opinion: Rebooting digital health in Africa

Over the past few years, hundreds of millions of dollars have poured into digital health projects in sub-Saharan Africa . While there have been successes — such as digitally enabled community health workers and the provision of telehealth in the hardest-to-reach areas — evidence of broader impact is sparse. Very few digital interventions have scaled with wide adoption and even fewer have translated into measurable population health outcomes.

Much has been written about the lack of accountability in international aid. Yet, as funding for digital health continues to grow, the nuances that accompany software development require special attention. In previous Devex articles and interviews, we have described several technical barriers — digital tool fragmentation, lack of clear interoperability standards, poor digital infrastructure, and an overindexing on a narrow set of digital public goods — that have limited the impact of digital health solutions. While these challenges persist, we have also observed obstacles to digital health adoption that have more to do with a structural misalignment between donor-driven projects and local community needs.

We see four key drivers of this misalignment, especially relating to digital health: time-bound project delivery, high administrative burden, lack of proximity to communities being served, and a focus on data collection instead of health system transformation. With so much momentum behind digital health, it’s the right moment for a shift. We have an opportunity to reboot digital health with African governments and organizations, shaping an affirmative vision for digital health on the continent and beyond.

For sustainability, focus on acquiring capabilities, not just tools

Traditionally, much of international development has revolved around time-bound projects that deliver a set of agreed-upon activities. Donors define a project and time frame, identify an implementer to build and deploy a digital solution, and then expect the solution to live on. Yet, few digital tools are sustained.

Building and maintaining software is fundamentally different from delivering malaria bed nets, training doctors, or building hospitals. Technology becomes outdated quickly, which can lead to consequences such as security breaches and malfunction as technical debt builds. For example, in our work, it is not uncommon to see deployments of DHIS2 — a widely used open-source reporting tool — that are 10 years old. Software development also requires a range of competencies, including product managers, designers, and engineers to continue to iterate and manage products over time. Too often, we see digital health tools die off due to a lack of capacity to iterate or maintain the product. We are not arguing that all software should be delivered in-house by government health systems. This is unrealistic, given the difficulty in attracting and retaining talent in the public sector. Ideally, we’d have a mix of skilled public sector technologists alongside a strong local health technology ecosystem with local firms equipped to deliver software services.

There is nothing wrong with acquiring tools per se. But, instead of delivering discrete projects, we need to define the total cost of owning digital health solutions and ensure that the financing is in place to both build the capability of the health system and maintain the software over time. Before embarking on new digital health initiatives, we should ask: Will the public health system acquire a software tool alone, or will they acquire the capability to own and manage software for the long term?

Build competency in product, not contracting  

Shifting from time-bound donor-driven projects also means reducing the high administrative burden that accompanies traditional development contracts. While there is a burgeoning number of African-led digital health initiatives, large donors remain fundamental to digital health on the continent. Despite reform efforts, the administrative burden required to secure and manage “big aid” contracts de facto disqualifies most organizations from securing funding.

Recent Devex reporting found that, in spite of localization efforts, about 50% of total USAID funding in 2022 — around $2.9 billion — went to a few large U.S.-based firms such as Chemonics and Deloitte. Unfortunately, competency in contracting does not translate into expertise in software or product management. In fact, the focus on administrative oversight and “checking the boxes” crowds out organizations that might be better placed to deliver an impactful solution that adds value to health systems.

Instead of relying on standard aid-based contracts, we need to establish a road map for digital health sovereignty, enabling country governments to make decisions on how to procure and manage their digital health initiatives. We’ve already seen examples of strong country ownership in digital health yielding results. Following Estonia’s footprint, countries such as Rwanda and Tunisia have put in place procurement frameworks for digital innovation that make a clear distinction between digital innovation and standard procurement for commodities like bed nets. Both countries have also established policies to support a burgeoning health tech sector with local firms augmenting government capacity. With fit-for-purpose procurement and country leadership, it’s possible to unlock innovation in health tech.

Breaking silos by putting users at the center

Even if we fix the nature of projects and contracting, we still face a stakeholder management problem. Too often, multilateral institutions, donors, health systems, digital innovators, and the communities they serve operate in silos. For example, the World Health Organization may be interested in disease surveillance while other stakeholders may be interested in delivering digital infrastructure or in tech-enabled maternal health. Without understanding what communities want and need, many digital health efforts fail at implementation. We’ve found that, ultimately, proximity to patients, communities, or users of the health system is the most important factor in building digital health solutions that work.

The key shift needed is to center health systems around patients rather than institutions. This means putting the patient at the center of care, with features such as a unified health record to address interoperability issues and data ownership demands. A person-centric digital health model gives users access and control of their health data. Designing with and for communities is the only path to success. To do this, community members, patients, software developers, designers, implementers, policymakers, and donors must have a seat at the table from the beginning.

Transformation, not data collection

With the right people around the table, we need a common definition of what delivers value to health systems. Most governments agree that the end goal is to improve health outcomes for their populations. Yet, most digital health projects simply collect data for reporting purposes or digitize existing paper-based services without improving them. Digital health’s potential lies in using data to transform health services. Digital health tools should deliver value to health systems and patients through measurable improvements in population health outcomes. If we aren’t improving population health, then what is the point of digitization?

An Africa-led digital health future

To realize the vision for digital health, we need to respect the mandate and capacity of African governments and established institutions to define their own digital health agendas. We’ve seen that when countries come together, health security is stronger for everyone. For example, with a broad set of investments from multilateral institutions and member states, the Africa Centres for Disease Control and Prevention played a preeminent role in the fight against COVID-19. The power of this pan-African approach is growing, including in digital health. The Africa CDC Digital Transformation Strategy forms the scaffolds of an affirmative vision for digital health in Africa: a future that centers around principles of sustainability, sovereignty, interoperability, and a strong pan-African technology ecosystem.

To move the needle, however, we will also need to address historical and structural misalignments. With a renewed focus on building health systems’ capabilities, rewarding competency in product, designing with and for communities, and measuring the value of digital solutions based on population health outcomes, Africa can become the world’s leader in digital health.