The Digital Health Act was passed by the Kenyan Parliament on 8 September 2023, following its initial introduction on 20 July 2023. The Act represents a major initiative to regulate the use of digital technologies in the health sector. It is undoubtedly the first comprehensive regulatory framework to optimise the integration of information and communication technologies (ICTs) into healthcare. The objective of the present work is to build on this text with a view to stimulating discussions and collaborative actions to fully exploit the potential of digital health in Africa, thereby driving a positive transformation of the health sector on the continent. However, before presenting the salient aspects of this Kenyan law and its lessons in terms of opportunities and challenges for the African continent, it seems necessary to attempt a clarification of the terms around the concept of “digital health”.
A brief overview of the concept of “digital health”
Over the decades, terms such as medical informatics, e-health and m-health have emerged to describe the use of information and communication technologies (ICTs) in the field of health. Digital health, introduced by Seth Frank in the early 2000s (Frank, 2000), has now come to the fore, encompassing its competitors. At the same time, it has expanded to include various fields such as omics (e.g. genomics, metabolomics), Artificial Intelligence (AI), data science, embedded devices, mobile applications and telemedicine. This expansion qualifies digital health beyond the simple use of digital technologies in the field of health, positioning it, for the World Health Organisation (WHO), as “the domain of knowledge and practices associated with any aspect of the adoption of digital technologies to improve health, from their conception to their implementation”. This definition is aligned with WHO resolution EB142/20 of 2017 and makes it clear that digital health encompasses e-health, the use of which still confuses it with digital health (Safon, 2021).
The transition from e-health to digital health emphasises the importance of digital consumers, with the increased use of smart devices, connected equipment, and other emerging concepts such as the Internet of Things (IoT), AI, big data and data science. This perspective connects digital health to practical applications and measurable outcomes, emphasising that digital technologies are means to an end, namely improving health. In our analysis, we adopt the definition of Kairo et al (2022) to dispel any ambiguity. According to its authors, digital health encompasses health management and disease prevention, health promotion, risk prediction, and the development of tools for healthcare professionals. This goes beyond specific medical care, which comes under the heading of digital medicine, a particular modality of digital health.
Kenya’s “Digital Health Act”, 2023
The Kenyan law proposed clear and differentiated definitions of digital health and e-health. In this text, digital health is conceived as “the field of knowledge and practices associated with the development and use of digital technologies to improve health”, while e-health would mean “the combined use of electronic communication and information technologies in the health sector, including telemedicine”. Beyond conceptual clarifications, the “Digital Health Bill 2023” establishes the Digital Health Agency, charged with operationalizing the directives and provisions of the law, including in the provision of a framework for the delivery of digital health services; the establishment of an integrated information system; and the protection of personal health data. The law also emphasizes patient empowerment, innovation, interoperability and privacy, and is designed to support Kenya’s goal of achieving universal health coverage by 2030 through the use of digital technology in health . By covering such broad and varied areas, the Act establishes a comprehensive regulatory framework for the country.
The “Digital Health Act” offers numerous benefits for the Kenyan healthcare sector, with a potential impact beyond national borders. In particular, these benefits include opportunities related to: i) Improving access to healthcare: The implementation of digital technologies offers opportunities to improve healthcare accessibility by reducing costs, increasing the availability of services, and decreasing geographical distances between patients and providers. For example, the “e-Kamoyo” telemedicine program in Kenya has significantly improved healthcare accessibility for rural residents; ii) increasing the quality of care: Digital technologies have the potential to improve the quality of care in a number of ways, including facilitating communication between healthcare professionals, strengthening clinical decision-making, and optimizing patient monitoring. The “mTrac” patient monitoring program in Kenya is an example of how these advances are contributing to better quality of care, particularly for people with chronic diseases; and iii) increasing the efficiency of the healthcare system: The benefits of digital health also extend to healthcare system efficiency, with applications such as automating administrative tasks, collecting and analyzing health data, and improving care coordination. The “eHealth Kenya” program is a concrete example of how these technologies can improve care coordination by enabling the efficient sharing of medical records between healthcare providers.
Potential challenges of digital health in Kenya and sub-Saharan Africa
The implementation of digital health raises crucial concerns about data confidentiality. The collection and use of health data via information technology requires adequate safeguards. The law proposes provisions to address this, such as the creation of a register of authorized bodies, the obligation to implement security measures, and compliance with data protection laws. Kenya, like a growing number of African countries, has had legislation since 2019, the “Data Protection Act” aimed at protecting personal data. The “Digital Health Act” should also be able to build on the previous legislation. At the end of the day, these technical and material issues, and equity in the distribution of digital health services, are neither specific to Kenya nor to Africa. On the contrary, African countries can turn the virtual non-existence of health information systems into a unique opportunity to anticipate issues of standardization, interoperability and the scaling up of resilient and efficient information systems, by drawing the best lessons from initiatives already operational at international level.
On the other hand, the “Digital Health Act” clearly fails to give public health the place it deserves in its provisions; the emphasis having once again been placed on healthcare services (noted “health services”) in a mode that has become conventional and unbalanced. When one realizes the importance of non-transmissible chronic diseases (involved in over 2/3 of global deaths) and the double public health burden suffered by African countries, including Kenya, it is urgent to have a public health vision and to include it systematically within contemporary technological developments. It would be inappropriate for African countries to have to limit efforts to digital medicine, which should be included in a digital health strategy that cannot be reduced to its medical dimension alone.
Even more important are the non-normative questions that would be raised by the implementation of digital health solutions in Kenya in particular, and in sub-Saharan Africa in general. At a time when pan-Africanism is being reactivated, including in French-speaking Africa, to propose a vision drawn from experience, other than the one Africa has had to adopt to date, it’s a safe bet that technological and/or technico-material infrastructures will no longer be sufficient to satisfy the demands of endogenous development. These demands are being fuelled by Africa’s increasingly educated youth. In essence, in this drive to reclaim and reappropriate ancestral knowledge and practices, including through the gradual recognition of traditional African medicines and the inclusion of local pharmacopoeias, it is urgent that technological developments in the field of digital health should also be based not only on local skills and players, but also on principles and a certain metaphysics that are authentically African.
In the case of digital health solutions, it appears that the development and implementation of such solutions must be informed by an ethic rooted in African representations. In concrete terms, Western ethics, whether Kantian or utilitarian in inspiration, place the individual above nature and the community. Even if the metaphysics at work in sub-Saharan Africa are not recorded in texts, morals and ethical principles are expressed and recounted in oral tradition, through tales and proverbs: classically, mutuality takes precedence over individuality.
However, given the historical penetration of European and Eastern cultures and values into Africa, it becomes essential to consider the complexity of cohabitation and the different expression of moral values and ethical principles that everyone has come to regard as “universal”. In sub-Saharan Africa, for example, “Cogito ergo sum” (“I think, therefore I am”) coexists with, and sometimes even gives way to, “Sumus ergo sum” (Cullivan, 1997), similar to the South African principle of “Ubuntu” (i.e. “I am because we are”). What’s more, not only does “Sumus ergo sum” not have a single modality of expression throughout sub-Saharan Africa, but the composition or functioning of the couple {“Cogito ergo sum”; “Sumus ergo sum”} proceeds from a very different dosage from one person to another, even within the same nuclear family.
This is why sub-Saharan Africa is more plural, more complex and richer in its diversity than has been thought of or described to date. The acceptance of imported principles and values rarely constitutes a rejection of the self or an erasure of ancestral African values. Without understanding these subtleties and taking them into account, it would be another missed opportunity to attempt to bring together two strong and profound mutations: one social and societal in an Africa that wants to redefine itself; the other technological, for the benefit of the health of African populations and the development of the continent.
The repercussions of an Ubuntu-style ethic of mutuality, in which the benefits of the community prevail over those of the individual, are very concrete in digital health: As Dr. Corrigan pointed out, “If a community can use a health application for collective benefit, then the individual should consent to the use of his or her data.” (Manhart, 2023). This is hardly a call for various and sundry abuses vis-à-vis a particular individual, whose protection should in fact be ensured by the entire social body.
Consequently, it is important that decision-makers in health policy towards Africa, for Africa and in Africa include this ethical corpus in their thinking and strategy, all the more so as they were built and still function largely on the basis of political-administrative organizations, at the very least modelled on the Western model, if not inherited from the colonial period. If they are unaware of it, this ethic should henceforth feature in the major chapters of their training programs and/or preparation for the exercise of the functions of health policy decision-makers. Such a level of responsibility implies full awareness of the need for prior and sincere community consultation, including at the lowest granular level.
Finally, given the issues raised by climate change and the energy costs associated with infrastructures such as data centers, or those linked to the exploitation of massive healthcare data for algorithmic developments, digital healthcare solutions for Africa will need to take these global challenges into account, based on forward-looking analysis and assessment of the benefits of alternative solutions. For this to happen, the commitment of local players is essential, and turnkey solutions will have to undergo the most rigorous testing before they can be adopted and implemented on the continent.
Recommendations for Africa :
- Strengthening data protection
o Institute regular assessments to ensure that data protection measures are robust and consistently effective.
o Encourage collaboration between African nations to develop common standards and a framework for ethical reflection on health data protection. - Promoting inclusion and equity
o Develop telemedicine programs tailored to the specific needs of rural areas and low-income communities.
o Implement targeted initiatives to ensure that the benefits of digital health reach all populations, particularly those in rural and low-income areas. - Ensuring effective implementation
o Facilitate the sharing of best practices between African countries.
o Establish monitoring and evaluation mechanisms to adjust strategies in line with local realities. - Capacity building
o Invest in the training of healthcare professionals to maximize the benefits of digital technologies.
o Invest in the cultivation of digital literacy for the benefit of the population, including its inclusion in school curricula and other popular training courses.
o Encourage research into the effectiveness and impact of digital solutions in a variety of contexts.
Ultimately, Kenya’s Digital Health Act 2023, while ambitious, requires careful implementation and oversight to maximize its benefits while mitigating potential drawbacks. The lessons learned from this initiative can serve as a guide for other African nations, paving the way for an era of accessible, quality, efficient digital healthcare on the continent, particularly in sub-Saharan Africa. Beyond the technological challenges, sustainability and ethical aspects are of paramount importance, possibly even more so than in Europe or the USA. A separate analysis should be made for Northern Africa.
By Prof. Benjamin GUINHOUYA, Epidemiologist, Programme leader of Health Data Science.