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The COVID-19 pandemic rocked the foundation of healthcare systems around the world with how fast and how wide it spread. It easily exposed the gaps that exist in healthcare systems around the world. This was no surprise considering sub-Saharan Africa is home to many existing fragile healthcare systems and a legion of diseases like malaria, Ebola, HIV/AIDS, Sickle Cell among others. The healthcare system was already battling with various diseases coupled with infrastructural and budgetary issues that could be resolved by the government taking an interest in the health of its people and allocating adequate funding to curb the infrastructural nuances that plaque the system. The occurrence of the epidemic certainly sent shock waves down the spine of government as it showed how far behind the healthcare system is in the adaptation of health tech.
The pandemic brought along with it a number of solutions that was able to mitigate the crisis of the spread of the disease. Practically overnight, the entire system had to rethink its approach to healthcare since traditional health management was no longer viable. Digital health through contact tracing, data generation and patient care, Artificial Intelligence (AI) and much more were able to mitigate the negative impact COVID had on the health system. The pressure that came along with this epidemic has been seen as an opportunity not only for the governments to acknowledge that the healthcare systems are in a bad condition but also for innovators, developers and local organisation to partner and provide essential healthcare services that are reliable, affordable and tailored to local needs.
This paper will comment on the impact the COVID-19 pandemic had on African countries healthcare system, the challenges it has faced in the race of digitisation of the healthcare system and possible recommendations that can improve the digital healthcare system in Africa.
Healthcare systems in Africa suffer from neglect and underfunding leading to severe challenges across the six World Health Organisation (WHO) pillars of healthcare delivery. Healthcare systems in Africa have, over the years, suffered from man-made issues which cut across institutional, human resources, financial, technical and political developments.[1] The World Health Organization (WHO) in 2007 proposed a framework that describes healthcare systems in terms of six core components or ‘building blocks’ i) service delivery; ii) healthcare workforce; iii) healthcare information systems; iv) medicines and technologies; v) financing; and vi) leadership/governance.[2] The majority of African countries are unable to meet the basic requirement for good healthcare systems. Poor governance and human resource challenges are linked to ineffective integration of services in resource-limited nations.[3]
Africa has the world’s worst health record.[4] Developing countries continue to face poor healthcare funding, which affects access, quality, cost and key health outcomes. About 400 million people do not have access to essential healthcare services in Africa.[5] The shortage of health professionals and facilities is significant. The number of professionals, for example, is below the World Health Organization (WHO) recommendation in many countries. Seven of the 10 most populous low- and middle-income countries have maternal mortality rates above the Sustainable Development Goal (SDG) target– India, Indonesia, Pakistan, Nigeria, Bangladesh, Philippines and Ethiopia.[6] Current health infrastructure makes achievement of the target challenging. The birth continent of humans bears one quarter of the global diseases burden yet it spends 1% of the worldwide health expenditure and has only 3 percent of the world’s health workers. According to the WHO, the regions, where there is more than one physician for less than 1,000 patients are rare.[7]
There are even extremities that are incomprehensible to anyone living in a luckier part of the world. For example, one of the poorest countries in the world, Mozambique, has just 548 doctors for a population of more than 22 million.[8] One of Africa’s most populous nations, Ethiopia is extremely short of doctors, with fewer than one doctor for every 36,407 people. Niger has just 288 doctors for a population of 14 million and one of the worst health crises in the world. These ratios are not strange for other parts of the continent either.[9]
In Nigeria, according to the Nigerian Medical Association, there are about 25 consultant oncologists to a population of approximately 200 million.[10] More so, many countries in the region lacks the infrastructure to provide even basic health care to many of its people.[11] There are hardly any doctors or nurses, only a handful of good hospitals and appropriate hospital beds; there is a lack of medical devices. Even the aspect of specialization is rarely seen.
The African Healthcare start-up scene is one of the few that has witnessed positive impact due to the COVID-19 pandemic. The sector has become one of the highest performing sectors in 2020.[12] In a 2020 report concluded by Disrupt Africa, a website for news on African tech start-ups, the year 2020 was a record-breaking one for African tech start-ups, with 397 companies securing US$701.5 million worth of investment.[13] For example, the Nigerian start-up funding report 2020 states that the Nigerian healthcare start-up has received an increased funding which can be greatly attributed to the pandemic.[14] While before COVID-19, the health tech sector did attract funding but it cannot be compared to that of 2020. In 2020 alone, digital healthcare start-ups have raised over $90M in disclosed venture funding across 39 deals, which is 87.5% more funding than what they raised in 2019 ($48M, 58 deals). However, in comparison to the other sectors, Healthcare is still wanting and ranks lower compared to Financial Services ($191M).[15]
The general attitude of the government towards digital healthcare has also improved greatly. Before the pandemic hit, the World Health Organization (WHO) in 2005 made member countries sign a resolution to ensure the implementation of digital health in order to foster adequate healthcare delivery.[16] Although, the countries signed the resolution, digital health in Africa was still received with ‘side eye’ as many governments had a lot of reasons why it should not be implemented. To be fair, Africa has been dealing and still dealing with a lot of menaces that rids the officials the ability to invest in digital health ranging from violent extremities to food shortages.[17] Asides that, there is a lingering economic disparity in the purchasing power of the masses. In Africa, the poor are extremely poor, then the middle class that struggles not to fall below the poverty margin which is nearly impossible sometimes because of the economy and then the extremely wealthy. There are very few individuals that have access to digital technology as having technology is not top of their priority. Access to internet is seen as a luxury that only the affluent can possess. The high rate of illiteracy and unavailability of content in local languages only widens the already existing gap in digital divide.
The pandemic was a wakeup call for the African healthcare system. The already fragile healthcare system was a major cause for concern but, Africa’s digital health start-ups are proving that they can fill the gaps in service delivery and contribute to the fight against Covid-19. A number developers came together to create solutions that will help out the healthcare system and provide affordable services to its population.[18] According to Salient Advisory a healthcare consulting firm, more than 60 new and existing private firms are now distributing health products to consumers and hospitals via technology across Nigeria, Ghana, Kenya and Uganda.[19] Disrupt Africa, a website on African start-ups profiled 397 start-ups from across Africa detailing the sector, funding, location and the approximate amount raised.[20]
In the study of a 1000 new or modifications of existing technologies that have been developed worldwide to target different areas of the Covid-19 response finds that Africa accounts for 12.8% of the innovations.[21] The response areas include surveillance, contact tracing, community engagement, treatment, laboratory systems and infection, prevention and control. With the pandemic at large, developers had to prioritize what was important and could be handled with technology which will reduce the workload on the traditional health workforce.
In Nigeria, through the help of Electronic Health (e-Health), the government has set up a system that alerts patients that test for the virus an automated text message that shows the result of the test.[22] It has used the platform for contact tracing.[23] Many applications based on geographic information technologies are used to track and monitor the pandemic. Many African start-ups developed contact tracing applications to reduce the stress on the healthcare system.[24] In Kenya, an innovation hub developed an application called Msafari[25] which can track people on public transport. In Morocco, a Covid tracking application was launched called Wiqaytna. The application is downloaded onto mobile phones and uses GPS and Bluetooth technology. Once a case is found, the application crosschecks the person’s movements over the last 14 days. Users who have been in contact with someone who has tested positive are notified with a text message.[26]
Websites were also launched to slow the spread of the virus by sharing virus prevention advice. In Cameroon, the start-up Teachmepad, launched a website in local languages that provides prevention information. This initiative is being offered to other African countries.[27] Self-assessment was also widely used during the outbreak of the pandemic. People were told to monitor themselves, note down any changes in their health and match symptoms with the Covid-19 symptoms in order to reduce the pressure on the healthcare workers. Developers thus invented self-diagnosing applications. Wellvis, a healthcare application, is offering a tool that helps people diagnose themselves and contact medical emergency workers in 15 African countries.[28] Such services are particularly useful in countries with a weak healthcare system that cannot serve large numbers of patients at a time. In Sierra Leone, the government partnered with local start-ups and launched a self-assessment based technology.[29]
The use of drone technology and robots was an invention that was desperately needed given that there are populations in the low income countries that are unable to access the hospital due to distance and transportation. In April, as the corona virus was spreading in Ghana, an American start up, Zipline[30] started using drones to collect test samples from health facilities in rural areas, and deliver them to medical laboratories in the country’s two largest cities, Accra and Kumasi.[31] Rwanda, in partnership with the United Nations Development Programme (UNDP), uses four humanoid robots in coronavirus treatment centres to minimise physical contact. These robots can screen 50 to 150 people per minute.[32] The robots can deliver food and medication to patient rooms and monitor patient status. These robots protect health workers’ lives by minimising physical contact and can speed up service delivery.
In the race for the digitisation of the healthcare systems in Africa, the Health Management Information Systems and other data collection systems exist for multiple purposes such as staffing, routine health facility data, disease outbreaks, population estimates etc.[33] In the case of a pandemic, it proved most effective as it highlighted the importance of health data exchange and interoperability. Several healthcare software developers have adapted their offers during the pandemic, focusing on COVID-19 monitoring.[34] The mHERO18 solution – initially developed in 2014 for the fight against Ebola and used in Uganda, Guinea, Liberia, Mali and Sierra Leone – has enabled many countries that have adopted it to continue their fight against pandemic situations.[35] mHERO is a two-way mobile phone-based communication system that connects ministries of health and health workers. Communication can reach the healthcare workforce in rural areas with no internet coverage by using simple talk-and-text phones. While the platform is built on free technologies, countries are only responsible for the cost of sending texts through mobile network operator and employees’ time for using and maintaining the system.[36]
Healthcare software developers developed applications to enable countries track the supply of medical equipment in real time.[37] Djibouti is currently relying on BI Dashboards to monitor stocks of medical supplies and critical imports.[38] The number of start-ups that are active in the digital health sector on the continent has grown by 56.5% over the last three years, with 180 ventures in operation currently.[39] Clearly, Africa’s digital health start-ups are rising to the COVID-19 challenge, and are actually gaining customers and getting funding while at it.
Although, a number of different solutions has been established in order to keep the healthcare system afloat in the midst of a pandemic, there are a number of challenges that still pose a problem to these health tech start-ups.
There are several challenges that exist in mainstreaming digital health in Africa. From the existing digital divide in rural areas to the lack of strategized policies and framework that govern ethical issues arising from the use of digital technology. The Covid-19 crisis is a typical example of the impossibility of establishing single global technological solution to a given problem.[40] Before the pandemic, a good number countries in Africa were reluctant to integrate the innovations into the healthcare system. This made social distancing rules and other infection prevention control protocols in Africa difficult to implement.[41]
A number of the digital health solutions developed are invasive and erode individual’s freedom example the contact tracing applications (Msafari etc.). Although, these applications may impact the spread of the virus, they also raise privacy and data protection concerns. Digital measures used for the pandemic must comply with data protection and privacy legislation or be in line with locally approved practices.[42] In a country like Nigeria, where there is no single framework for the regulation of health tech and the guidelines available are more focused on the traditional healthcare system rather than the digital, it is fair to say that the government holds the upper hand. Digital health start-ups could be shut down at any time and for any reason since there is no concise regulation advocating for them.[43]
Due to the lack of infrastructure, communication is always a challenge in Africa especially in the poor and isolated communities. Although, governments of several nations have made efforts in setting up structured communication campaigns like the use of websites, television, radio, and social networks[44] there are still a good number of people that live in abject poverty and are unable to gain access to any of these means. As important as internet connectivity is to the global world, there is still an obvious digital divide that exist in Africa making the access to these digital health solutions impossible for many, an estimated number of 900 million people in Africa lack the means of internet connectivity.[45]
There is also the obvious challenge of the lack of financial incentives and priorities, inadequate electricity supply and lack of well-trained workforce were the main obstacles to implementing digital health during the pandemic.[46] There is the common saying that ‘you cannot teach an old horse, new tricks’, the healthcare workforce applies to this saying. It becomes difficult to implement digital health solutions when the workforce itself is not adequately trained to use the solutions that are presented.
African countries have faced many obstacles in the past especially health related emergencies such as the Ebola Virus. The Covid-19 virus could hurt positive trends which the African economies have achieved so far.[47] Practically overnight, the healthcare industry had to rethink how it drove access to, delivery and the overall management of healthcare.[48] There had to be some sort of ‘digital leap’ in order to reduce the impact the virus had on the economy. Different start-up aimed at alleviating one form of emergency or the other was developed. This shows that in an emergency, Africa has the ability to launch impactful digital projects.[49]
However, despite the impact digital projects has had on the healthcare system, most governments have reached their limits in terms of financing and lack the ability to go that extra mile in the digital transformation required to fight COVID-19 and future crises.[50] Beyond government investment, there is need for venture capital funding in the form of Public Private Partnerships (PPP). The government cannot do it alone. The changing healthcare sector has prompted a greater need for innovation and the private sector is a key player.[51]
Africa has become a hub of digital health inventions. It is therefore important that policies and legislations are put in place overseeing issues that may arise from using these inventions. In Africa, not all 54 countries have digital/eHealth policies/strategies. Of the 54 countries on the continent, only 42 African countries have digital health strategies.[52] Though, these policies have been implemented, it is fair to say that there are existing gaps that exist in them; some not paying attention to the existing issues that may arise with digital health solutions or even the use of Artificial Intelligence (AI) or big data. With the increased use of telemedicine products, it is imperative that there are policies and guidelines that guide the ethical and legal implications of using these products and protects its various users. It is therefore imperative to recommend that there be the adoption of the regulatory sandbox model.
A regulatory sandbox is a controlled environment that allows entrepreneurs and regulators, and other players in the fintech industry to test out new financial products or services without being too constrained by inappropriate regulations.[53] One can say that it is allowing the testing of new inventions with the regulators’ oversight. As earlier mentioned, in a country like Nigeria where there is no single regulatory framework, the government holds an upper hand as it can shut down any innovation for whatever reason it deems fit. With the use of the regulatory sandbox model, innovations are encouraged without fear of cumbersome stifling regulations. It also gives the opportunity for the right stakeholders such as the legal fraternity, medical personnel, entrepreneurs, investors and even the consumer itself to have a say in impactful the innovation will be. Country like Rwanda has recently applied this approach and it is making waves in terms of digital health.[54]
In conclusion, it is unarguable that work still needs to be done in the aspect of strengthening the healthcare system with digital technology. But, due to the pandemic the continent is in a far better position than it was digitally before the pandemic hit.
In order for the innovations that has been made to continue progressing, the aforementioned recommendations must be taken into consideration. It is important that the improvement that has been made due to COVID is not lost for reasons that could be easily fixed with a working structure in place.
[1] Oleribe, Obinna O., et al. “<p>Identifying Key Challenges Facing Healthcare Systems in Africa and Potential Solutions</P>.” International Journal of General Medicine, 6 Nov. 2019, doi:10.2147/IJGM.S223882.
[2] WHO. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action. Geneva: World Health Organization; 2007. Available from: http://www.who.int/healthsystems/strategy/everybodys_business.pdf Accessed May 7, 2019.
[3] Petersen, Inge, et al. “Strengthening Mental Health System Governance in Six Low- and Middle-Income Countries in Africa and South Asia: Challenges, Needs and Potential Strategies.” Health Policy and Planning, vol. 32, no. 5, June 2017, pp. 699–709. DOI.org (Crossref), doi:10.1093/heapol/czx014.
[4] “Africa is a Hotspot for Digital Health.” The Medical Futurist, 5 June 2018, https://medicalfuturist.com/africa-hotspot-digital-health.
[5] https://www.gsma.com/mobilefordevelopment/wp-content/. Accessed 08 Apr. 2021.
[6] Ibid.
[7] Supra at Note 4
[8] Supra at Note 4
[9] Supra at Note 4
[10] Supra at Note 4
[11] “Africa Needs More Health Data to Improve Response to Health Crises.” The Africa Report.Com, 9 Apr. 2020, https://www.theafricareport.com/25951/lack-of-statistical-capacity-means-africa-risks-shooting-in-the-dark-on-coronavirus/. Accessed 11 July 2021.
[12] Mureithi, Carlos. “The Covid-19 Pandemic Has Created Africa’s next Big Investment Opportunity.” Quartz, https://qz.com/africa/1986528/the-covid-19-pandemic-has-boosted-african-health-tech-startups/. Accessed 11 July 2021.
[13] “Disrupt Africa African Tech Startups Funding Report 2020 & Full Startup List.” Gumroad, https://app.gumroad.com/l/njrzl. Accessed 11 July 2021.
[14] Webinar on ‘The Digital Health Ecosystem: Technologies, Policies and their Implications’ organized by Tech Hive Advisory, 6th May 2021, http://youtu.be/fkLYI77j-Jc Accessed 19 May, 2021.
[15] “Africa’s Digital Healthcare Sector Performance Pre and Post-COVID-19.” Digest Africa, https://digestafrica.com/digital-healthcare-sector-performance. Accessed 20 May 2021.
[16] https://www.assets.publishing.service.gov.uk/media/assessment_of_eHealth_Africa/. Accessed 08 Apr. 2021.
[17] https://www.eib.org/infocentre/ Accessed 20 May 2021.
[18] Supra at Note 12
[19] “Health tech Firms on Rise in Africa, spurred by Covid-19” https://www.bloomberg.com/news/articles/2021-05-18/healthcare-tech-firms-on-rise-in-africa-spurred-by-covid-19 Accessed 11 July, 2021
[20] Supra at Note 13.
[21] “COVID-19 Spurs Health Innovation in Africa.” WHO | Regional Office for Africa, https://www.afro.who.int/news/covid-19-spurs-health-innovation-africa. Accessed 20 May 2021.
[22] “Beyond Covid-19: The Future of e-Health in Africa.” The Africa Report.Com, 25 Mar. 2021, https://www.theafricareport.com/74874/beyond-covid-19-the-future-of-e-health-in-africa/.
[23] Ibid.
[24] Supra at Note 14.
[25] “We can get it done here”: Africa’s tech scene tackles virus”, Rosebank Killerney Gazette, by Fran Blandy and AFP Africa bureaus, Nairobi (AFP) | Accessed 19 May 2021.
[26] https://www.eib.org/attachments/country/africa_s_digital_solutions_to_tackle_covid_19_en.pdf. Accessed 20 May 2021.
[27] Ibid.
[28] COVID-19 Triaging App – Wellvis.Org. /. Accessed 20 May 2021.
[29] “Sierra Leone Goes Live with SMS and USSD COVID-19 Self-Assessment Mobile Services.” DSTI, 13 Apr. 2020, https://www.dsti.gov.sl/sierra-leone-goes-live-with-sms-and-ussd-covid-19-self-assessment-mobile-services/.
[30]Zipline – Vital, On-Demand Delivery for the World. https://flyzipline.com/covid-19/. Accessed 20 May 2021
[31]In Ghana, Drones Help Combat COVID-19 | Voice of America – English. https://www.voanews.com/covid-19-pandemic/ghana-drones-help-combat-covid-19. Accessed 20 May 2021.
[32]Ibid.
[33] Supra at Note 20
[34] Supra at Note 20
[35] https://www.mhero.org/sites/mhero/files/mherobrochureenglish2018.pdf Accessed 19 May 2021.
[36] “FAQ.” Intrahealth MHero, 30 Mar. 2017, https://www.mhero.org/faq. Accessed 19 May 2021
[37] Supra at Note 20
[38] Sign in | Microsoft Power BI. https://powerbi.microsoft.com/en-us/landing/signin/. Accessed 21 May 2021.
[39] “African Startups That Are Helpful in The Fight Against COVID-19.” Digest Africa, https://digestafrica.com/african-startups-helpful-against-covid-19. Accessed 21 May 2021.
[40] Fagherazzi, Guy, et al. “Digital Health Strategies to Fight COVID-19 Worldwide: Challenges, Recommendations, and a Call for Papers.” Journal of Medical Internet Research, vol. 22, no. 6, June 2020, p. e19284. www.jmir.org, doi:10.2196/19284.
[41] Adepoju, Paul. “Africa’s COVID-19 Health Technologies’ Watershed Moment.” The Lancet Digital Health, vol. 2, no. 7, July 2020, pp. e346–47. DOI.org (Crossref), doi:10.1016/S2589-7500(20)30146-1.
[42] Supra at Note 21.
[43] Supra at Note 11.
[44] Supra at Note 21.
[45] Supra at Note 21
[46] Supra at Note 35
[47] Supra at Note 21
[48] Mureithi, Carlos. “The Covid-19 Pandemic Has Created Africa’s next Big Investment Opportunity.” Quartz, https://qz.com/africa/1986528/the-covid-19-pandemic-has-boosted-african-health-tech-startups/. Accessed 21 May 2021.
[49] Supra at Note 21
[50] Supra at Note 21
[51] Supra at Note 17
[52] https://www.ictworks.org/african-national-ehealth-strategy-policy/Accessed 19 May 2021.
[53] “Regulatory Sandboxes in Africa.” Empower Africa, 29 Mar. 2021, https://www.empowerafrica.com/regulatory-sandboxes-in-africa/.
[54] Ibid.
