Comment

Sub-Saharan Africa—the new breeding ground for global

digital health
Sub-Saharan Africa has become an emerging arena for estimated 66% in 2025. The mobile money market of
digital health innovations directed at strengthening sub-Saharan Africa has become an epicentre, accounting
health care, in terms of both patient management and for almost half of all mobile money registered accounts
disease surveillance and prevention. Across the region globally.9 Despite these promising figures, many people
with the world’s largest burden of disease and the most in the region today deal with several real-life barriers
severe shortage of health-care workers, we see increased to the access of digital health (see figure, red square),
use of digital health solutions and interventions for especially the urban–rural and gender divide, low digital
clients, health-care providers, health-system managers, literacy, and shortage of connectivity and electricity.
and data services. As the traditional health-care systems As digital health implementations depend on the
are typically ill-equipped, understaffed, or not accessible surrounding context, populations need tailored digital
at all, sub-Saharan Africa is booming with digital health. content in their own language, not only to guide access
Digital health technologies come in many forms and to health-care systems but also for disease prevention.
shapes. Mobile phones have been used to get maternal Health information and digital health solutions and
health support in South Africa,1 detect fake drugs in interventions should always be co-designed with local
Ghana2 or access a digital health-financing platform in communities in order to ensure uptake. The Non-
Kenya.3 We find various telemedicine collaborations and Discriminating Access for Digital Inclusion consortium,
use of social media tools for health promotion throughout of which the authors are part, has co-designed together
the region. Emerging technologies such as the Internet with the communities, digital health messages for
of Things-related system development,4 wearables, and disease management and prevention for HIV/AIDS,
sensors have opened possibilities for new, small, and tuberculosis, and zoonotic diseases on the basis of
compact diagnostic tools and for easier tracking and multistakeholder inputs and endorsement by the
monitoring of individuals’ health in a hospital setting, or Ministry of Health. The intervention also considers the
underserved and remote areas. The use of big data and local context in terms of connectivity and access to
artificial intelligence has proven an excellent applicability mobile devices.
for both outbreak control and preparedness,5 and might
be applied to a range of diseases in sub-Saharan Africa. Barriers to access of digital
health solutions and
Improved visibility of logistics data, from the primary interventions:
• Urban–rural and gender divide
health-care level and upwards, has resulted in improved in connectivity and access to
decision making in supply chain management and mobile devices
• Limited content in local
in fewer stock-outs (eg, in Uganda).6 Drones are language
• Low digital (and functional)
increasingly used to transport blood and medical supplies Enabling environment for
literacy
Effect of digital health
digital health solutions and solutions and interventions
from one clinic to another and this activity has led to interventions:
• Shared phone use
related to health outcomes:
• Low quality phones
• Innovations (smartphones and
a new academy in Malawi,7 educating students in the devices)
• High costs for internet access
• Effectiveness, efficiency, and
quality in health facilities
• Limited access to electricity
understanding of drones and data. Community health • Young people • Aggregation of health data for
• Infrastructure policy makers
workers across sub-Saharan Africa can now register • Leadership and governance • Disease management and
• Strategy and investment Digital health solutions and prevention
vital events with various apps that feed into national • Public–private partnerships interventions for: • Patient tracking and safety
vital registration systems. District Health Information • Policy, legislation, regulations, • Clients • Universal health coverage
and compliance • Health-care providers • Health system performance
Software 28 is changing the digital ecosystems for • Skilled workforce • Health system managers • Acceleration of the sustainable
• Standards and interoperability • Data services for health care development goal agenda
monitoring and analysing disease patterns, populations,
and outbreaks, by gathering data collected routinely in Figure: Enablers and barriers for digital health solutions and interventions, their target populations and
health-care facilities and communities. effect on health outcomes
The figure is inspired by the WHO–ITU National eHealth Strategy Toolkit 2012, the WHO Classification of digital
Also, smartphones have definitely arrived in the health interventions v1.0 2018, and the WHO Guideline: recommendations on digital interventions for health
region, with 39% of all SIM connections in 2018, and an system strengthening 2019.

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 Comment
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.10 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
e161 www.thelancet.com/digital-health Vol 2 April 2020
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.
Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY-NC-ND 4.0 license.
*Christine Holst, Felix Sukums, Danica Radovanovic,
Bernard Ngowi, Josef Noll, Andrea Sylvia Winkler
christine.holst@medisin.uio.no
Centre for Global Health , Institute of Health and Society (CH, ASW), Department
of Technology Systems (JN), University of Oslo, 0318 Oslo, Norway; Muhimbili
University of Health and Allied Sciences, Dar es Salaam, Tanzania (FS); Basic
Internet Foundation, Kjeller, Norway (DR); National Institute for Medical
Research, Dar es Salaam and University of Dar es Salaam College of Health and
Allied Sciences, Tanzania (BN); Basic Internet Foundation, Kjeller, Norway (JN);
Center for Global Health, Department of Neurology, Technical University of
Munich, Germany (ASW)
1 South African National Department of Health. MomConnect. http://www.
health.gov.za/index.php/mom-connect (accessed Jan 30, 2020).
2 mPedigree. https://mpedigree.com/ (accessed Jan 30, 2020).
3 M-TIBA. https://m-tiba.com/ (accessed Jan 30, 2020).
4 Al 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: 1–9.

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model and multi-source data in Chongqing, China. EBioMedicine 2019;
47: 284–92.
6 Ministry of Health, Uganda. mTrac. http://www.mtrac.ug/ (accessed
Jan 30, 2020).
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unicef.org/malawi/african-drone-and-data-academy-malawi (accessed
Jan 30, 2020)
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Comment
8 District Health Information Software 2 (DHIS2). https://www.dhis2.org/
(accessed Jan 30, 2020).
9 GSMA. State 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.pdf
(accessed Jan 30, 2020).
10 World Bank. Population ages 0–14 (% of total population). https://data.
worldbank.org/indicator/SP.POP.0014.TO.ZS (accessed Jan 30, 2020)