Analysis of digital health products in Africa
## INTRODUCTION The Covid-19 pandemic has brought on a rapid increase in vaccinations across the globe, including digital health solutions for tracking, monitoring, and evaluation. Countries within Africa, especially low to middle-income countries (LMICs), have challenges with efficiently tracking their Covid-19 vaccination management programs within their countries. Digital tools are especially critical in ensuring equitable distribution and ensuring that no one is left behind. World Health Organization (WHO) has developed a global repository to register digital health products, including those related to COVID19 vaccination management, called the Global Digital Health Atlas (DHA), which confirms WHO norms and standards on digital health described in the WHO digital health classification taxonomy. Establishing up-to-date global inventories of "implemented digital products" is key to understanding the current situation and allowing the Member States to strengthen their digital health strategies and plan possible synergies between tools already in place and scaled up. The visibility of digital health products implemented at the country and regional level has been a big challenge among countries. Such digital tools have sometimes been documented in nonstructured formats, including excel spreadsheets, PDF formats, word documents, etc. In some instances, the documentation of digital health products deployed does not exist or is fragmented. Countries have also not had the opportunity to share best practices with each other. Standards used in these systems are not always documented systematically. COVID-19 has significantly impacted countries, with multiple products being piloted at the country level. Alignment with existing national eHealth strategies remains a concern and alignment with interoperability standards. Within the context of digital health and the numerous health solutions being developed, it can be challenging to understand what solutions can be classified as digital health solutions. The World Health Organisation has developed a classification guide known as the "Classification of Digital Health Interventions" which can be easily described as "A shared language to describe the uses of digital technology for health". The Digital Health Atlas, in conjunction with the use of the guidelines set out in the Classification Guide of Digital Health Interventions, will provide a path to shaping this jungle of digital health solutions into a garden of cultivated, well-understood, and structured solutions. ## OBJECTIVES 1. Analysis report on digital health products inside the WHO digital health atlas and digital health products related to COVID-19, focusing on the 47 African countries. 2. Produce a recommendations report on the status of the Digital Health Atlas in the African region, utilising the data in the DHA as much as possible. These reports should, as much as possible, use the WHO classification of digital health interventions. ### Classification of Digital Health Interventions #### What is it? The classification of digital health interventions (DHIs) categorises the different ways digital and mobile technologies are used to support health system needs. Targeted primarily at public health audiences, this Classification Framework aims to promote an accessible and bridging language for health program planners to articulate functionalities of digital health implementations. Also referred to as a taxonomy, this classification scheme is anchored on the unit of a "DHI", representing a discrete digital technology functionality to achieve health sector objectives. ### How to use it? The DHIs are organised into the following overarching groupings based on the targeted primary user: - Interventions for clients: Clients are members of the public who are potential or current users of health services, including health promotion activities. Caregivers of clients receiving health services are also included in this group. - Interventions for healthcare providers: Healthcare providers are members of the health workforce who deliver health services. - Interventions for health systems or resource managers: Health systems and resource managers are involved in the administration and oversight of public health systems. Interventions within this category reflect managerial functions related to supply chain management, health financing, and human resource management. - Interventions for data services: This consists of cross-cutting functionality to support a wide range of activities related to data collection, management, use, and exchange. ### Why was it created? The diverse communities working in digital health - including government stakeholders, technologists, clinicians, implementers, network operators, researchers, and donors have lacked a mutually understandable language to assess and articulate functionality. A shared and standardised vocabulary was recognised as necessary to identify gaps and duplication, evaluate effectiveness, and facilitate alignment across different digital health implementations. In particular, four primary use cases prompted the development of this classification scheme: 1. synthesising evidence and research; 2. conducting national inventories and landscape analyses; 3. developing guidance resources to inform planning; 4. articulating required digital functionality based on identified health system challenges and needs. Although frameworks such as the Control Objectives for Information and Related Technologies (COBIT), Health Level Seven (HL7), and International Standards Organization (ISO) exist, these frameworks provide highly technical terms for use by computer scientists and software developers in health. This new classification scheme offers a simplified language to help support a dialogue between public health practitioners and technology-oriented audiences. ## ANALYSIS OVERVIEW The analysis conducted on the digital health atlas data export (13/01/2022) consisted primarily of the data within the Digital Health Atlas. The data export was extracted through the API provided by the DHA platform, then processed and analysed to understand what digital health solutions have been captured by the 47 African countries (Table 1 and figure 1) into the platform. The results of the data analysis can be seen below, which have been broken down into various categories to understand the level of detail of the solutions being used by the respective countries. Out of the 47 African countries in question, two countries, namely Seychelles and the Central African Republic (marked in red), have not made any inputs into the Digital Health Atlas. The classification framework references four domains, further broken down into respective categories and interventions. The digital health solutions captured by the countries into the DHA platform link to these domains, categories and interventions. ### Classification Framework The Classification Framework outlined in the WHO Classification of Digital Health Interventions is further explained below. It comprises four overarching groups or domains broken down into Categories and further Interventions. This classification of Digital Health Interventions (DHIs) should be used in tandem with the Health System Challenges (HSC) list to articulate how technology addresses identified health needs, such as lack of service utilisation. The classification of DHIs also highlights functionalities that fit within various System Categories, such as Logistics Management Information Systems (LMIS) or Electronic Medical Records (EMR). System Categories represent the types of ICT applications and information systems designed to deliver one or more digital health interventions. A digital health intervention such as "notify stock levels of health commodities" would fit into the System Category of LMIS. Linking digital health interventions to system categories is critical as these serve as the starting point for interoperability considerations. The diagram above represents one of the four overarching groups, or (1) **Domains** within The Classification Framework outlined in the WHO Classification of Digital Health Interventions. The Domains are broken down into (2) **Categories** focused on a specific aspect of the classification of digital health interventions. These categories are further broken down into actionable or measurable (3) **Interventions** that will help ensure that aspects within each domain can be achieved. ## RESULTS OF THE DATA ANALYSIS The results and interpretation of the data exported from the Digital Health Atlas have been broken down into eight (8) categories. This has been done to provide a comprehensive analysis and understanding of the products or solutions that have been captured within the DHA platform, as well as the different disaggregation that the data can be interpreted. This analytical representation and interpretation of the data provide a good understanding of the countries that have interacted with the platform and the level of knowledge they may possess regarding the information they are entering into the platform. The interpretation of the data also gives us a sense of the understanding or working knowledge that the countries (representatives) may possess about how their digital health solutions align with the Classification of the Digital Health Interventions (DHI) guide. ### Project by Country The graph (Figure 3) below represents the 45 African countries and the number of projects they have captured into the Digital Health Atlas platform. What we can deduct from the data is that there are several projects within these African countries that constitute digital health solutions. The number of projects varies from country to country. The grand total of projects within these 45 African countries is 469. There are 12 countries with ten (10) or more DHA projects (Figure 3), namely (Ethiopia, Kenya, Uganda, United Republic of Tanzania, Malawi, Nigeria, Sierra Leone, Zambia, Mozambique, Lesotho, South Africa, Ghana) respectively. ### Project by DHI The Heatmap below (Figure 4) represents the 45 African countries with DHI projects. The data used the Strategy Type (Domain) linked to projects and the number of Categories (Strategies) linked to projects. One project may be linked to more than just one Strategy Type (Domain) and thus have multiple Categories and subsequent Interventions. More DHI projects are found in the Eastern Region of Africa, dominated by the following countries (Uganda-268, Kenya- 258, Ethiopia-201, Malawi-115), whereas Nigeria has the more projects in the Western Region at 144. Moreover, these DHI projects are focused on providers (834). They are again topped by Uganda-138, Kenya-110, and Ethiopia-86 presenting with most Provider data (Table 2). ### Digital Health Intervention (DHI) by Country The graphs (Figures 6 & 7) below represent each country's total number of DHI Categories (Strategies). Countries with the most DHI categories are in the Eastern Region of Africa, with five (5) countries being more than 100 (i.e. Uganda-214, Ethiopia-184, Kenya-173, United Republic of Tanzania-130, Malawi-107). ### Covid-19 Project by Country The graphs (figures 8 & 9) below represent the number of Covid-19 Projects in effect in the respective countries. Of the 45 African countries, 34 reported Covid-19 digital health solutions on the Digital Health Atlas platform. Out of the 469 projects in these 45 African countries, 71 are Covid-19-related projects. ### Covid-19 DHI by Country The graphs (Figure 10 & 11) below represent 30 African countries, and the Strategy Type (Domain) each of the Covid-19 projects are linked to, as well as the number of Categories (Strategies) each project has. One project may be linked to more than just one Strategy Type (Domain) and thus have multiple Categories and subsequent Interventions. Out of 34 African countries that have reported Covid-19 Projects, only 30 African countries linked their Covid-19 projects to a Digital Health Intervention (Figure 10). Eight (8) countries are reporting with Covid-19 projects more than 10. Furthermore, strategy type (domain) focuses more on the provider (122) as compared to the domains. ### Project by Stages The table (Table 3) below represents the number of projects and the different stages of these projects in the Digital Health Atlas platform. Out of the 469 projects, 391 are not recorded at any stage. ### Covid-19 focus Project by Stages The table (Table 4) below is a representation of the number of Covid-19 projects and the different stages these projects are reflected within the Digital Health Atlas platform. Out of the 71 Covid-19 projects, 40 are not recorded at any stage. ### Covid-19 Projects by Interoperability Standards The graphs (Figure 12) below reflect 34 African countries that have reported Covid-19 Projects, and of those 34 countries, 13 countries have captured an Interoperability Standard linked to a project (highlighted in orange bar lines). ## CONCLUSION Findings from the analysis and interpretation of the data extracted from the Digital Health Atlas (DHA) reflect: - There is a use of the DHA platform by the respective African countries (45 out of 47 countries). - There is a limited understanding or knowledge of the WHO Classification of the Digital Health Interventions (DHI) guide. This can be seen from the fact that the projects captured within the DHA platform are not largely linked to DHIs. - Countries might be aware of the DHIs, but not knowledgeable on applicability. - Countries in the eastern region of Africa seem to be more knowledgeable of the DHIs. - DHI by countries and strategy type is more focused on providers - Only 34 out of the 45 African countries reported Covid-19 Projects. Of the 34, only 30 countries have linked their projects to a DHI. Whereas only 13 have linked their projects to Interoperability Standards. countries have linked their projects to a DHI. Whereas only 13 have linked their projects to Interoperability Standards. ## RECOMMENDATIONS - There is a need to create more awareness and understanding of the WHO Classification of the Digital Health Interventions (DHI) guide and the integrated use of the Digital Health Atlas (DHA). This will enable countries (representatives) to participate in the DHA platform. - The strategic development and training on the DHA will promote better utilisation and understanding of the platform. Moreover, encouraging participation will enable countries to comply with interoperability standards. - The benefits of extending the WHO Classification of the Digital Health Interventions (DHI) guide and the use of the Digital Health Atlas (DHA) on a global scale will add great value as it will promote “A shared language to describe the uses of digital technology for health”