Ohia C, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 1 | 11 Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare providers Chinenyenwa Ohia1, Pierre Ongolo-Zogo2, Olufunmilayo Ibitola Fawole3 1 Department of Environmental Health Sciences, University of Ibadan, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria; 2 Agrégé des Facultés de Médecine - FMSB, Université de Yaoundé 1, Cameroon; 3 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Med- icine, University of Ibadan, Nigeria; Corresponding author: Ohia Chinenyenwa M.D.; Address: Department of Environmental Health Sciences, Faculty of Public Health, College of Medicine, University of Ibadan; Email: ohiacmd@gmail.com; Phone: +234 703 831 8289 REVIEW ARTICLE mailto:ohiacmd@gmail.com Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 2 | 11 Abstract In tandem with the current drive to achieve the SDG 2030 goals, the Universal Health Coverage (UHC) is been projected as a strong propelling strategy with key indicators, all aimed at achiev- ing universal access to health services without having to endure financial difficulties in individ- ual countries. Currently, Africa is lagging in meeting the targets of the UHC with between 5% - 25% coverage across countries. Adoption of new innovations are critical for the actualization of Universal Health Coverage in Africa. Digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the Universal Health Coverage targets. It has been suggested that digital health provides an opportunity to overcome the longstanding prob- lems of inefficiency of health information gathering, sharing, and access. In addition, literature is already replete with various factors that can aid countries to achieve UHC and one of such fac- tors is the urgency of generating valid and quality evidence to inform decision-making. Although the Primary Health Care remains at the core of the achievement of Universal Health Coverage, the utilization of digital health technologies remains very poor at the grassroots in Af- rica and this poses a huge barrier to effectiveness and quality of healthcare delivery. Given the foregoing, it is obvious that there is an urgent need to understand the landscapes, issues and bar- riers to utilization of digital health at the Primary Health Care levels. However, there remains a paucity of data to support evidence-based decision making about full implementation of digital health services across the continent while also taking into cognisance the peculiarities of individ- ual countries. Hence, there is a critical need to determine the current levels of knowledge, skills, attitude, prac- tice and readiness to adopt digital health in service delivery by healthcare workers at the Primary Health Care levels across the continent. The generation of such data from major stakeholders such as health workers and health managers, providers among others will provide important evi- dence needed for attaining optimal utilization of digital health in the context of health for all. Summarily, a clear understanding of the contextual and implementation bottlenecks highlighted from such assessment(s), especially as it relates to individual African countries, will go a long way to guide decisions to address the low utilization of digital health technologies in health ser- vices delivery in Africa. Keywords: Digital health technologies, willingness to adopt, Primary Healthcare providers, Universal Health Coverage, Africa. Source of funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgement The authors acknowledge the support of the Department of Environmental Health Sciences, Uni- versity of Ibadan and contributions of Prof. G.R.E. E Ana, Prof. M.K.C. Sridhar, Dr. E.C. Uwalaka, Dr. O.T. Okareh and Dr. O.M. Morakinyo, in the writing of this paper. We also thank the World Health Organisation (WHO) for the technical support and the publishing of this manuscript. Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 3 | 11 CO is supported by Consortium for Advanced Research Training in Africa (CARTA) which is funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100029), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). Conflict of interest statement The authors declare that they have no known competing financial interests or personal relation- ships that could have influenced the writing of this paper. Author contributions CO: Conceptualization; CO, PO and OF: Writing- Original draft preparation, CO, PO and OF: Writing- Reviewing and Editing. Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 4 | 11 Introduction The Universal health coverage (UHC) target is a strategic ambition with an overarching goal that all individuals and communities re- ceive universal access to good quality health services without having to endure pain and fi- nancial difficulties [1-3]. In tandem with the SDG-2030 goals these ‘coverage’ refers to an array of services encompassing promotion, prevention, treatment, rehabilitation and pal- liation, particularly the health-related goals of the SDGs [3]. UHC is widely recognised as a priority track to aid and accelerate the achievement of the SDG-2030 goals and consequently three key indicators for the achievement of UHC have been defined: (1) equity in access to health ser- vices (those who need health services irrespective of whether they can or cannot af- ford them should receive them); (2) quality of healthcare services (health services should be good enough to improve the health status of those receiv- ing them); and (3) financial risk protection (the guarantee that health service costs do not expose people to financial problems) [4,5]. Several factors can help countries to move to- wards the achievement of the UHC goal and literature is already replete with suggestions of possible factors that can propel countries towards achieving UHC. One of such factors is the urgency of generating valid and quality evidence to inform decision-making. All these factors are important for all stages of the UHC process including the exploration, development and sustenance of interven- tions- including novel strategies such as utili- zation of Digital Health information technol- ogy- at the Primary Healthcare level. The aim of this paper is to enumerate and de- scribe barriers identified from available liter- ature as limiting the adoption of Digital Health information technology among Pri- mary Healthcare providers and proffer the way forward to enhance adoption in order to ultimately propel the African continent to- wards the actualization of the UHC targets. Method A preliminary search of literature was con- ducted to determine the need for the study. This was important and helped to refine the initial broad concept of digital health and gave clarity and objectivity to the choice of topic. Then literature searches of electronic databases (PubMed, Medline and Google scholar) were carried out from May through November, 2020. In addition, the snowball- ing technique of literature search was em- ployed and this involved searches through the references of relevant published articles that were retrieved from the electronic databases. Keywords used in the search included ‘Digi- tal health technologies’ or ‘mobile health’ and ‘willingness to adopt’ and ‘barriers to adoption’, ‘Primary Healthcare’ and ‘Univer- sal Health Coverage’. The inclusion criterion was that published articles should be pub- lished in English. Furthermore, articles not related to the aim of the study topic were ex- cluded. Figure 1further describes the stages of the literature search process that was un- dertaken during this review. Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 5 | 11 Figure 1: Stages of the literature search process Discussion Factors limiting the actualization of Uni- versal Health coverage (UHC) targets in Africa Currently, Africa is lagging in meeting the targets of the UHC with between 5% -25% coverage across countries. Several barriers limit the actualization of the targets of the UHC in Africa. These barriers are far reach- ing and include high operational and finan- cial costs required for the expansion of health service access to areas or communities cur- rently lacking access [6]; paucity of data due to lack of appropriate researches [5]; exten- sively weak health systems; poor infrastruc- ture; inefficient transport; inadequate physi- cal access to several communities due to in- accessible, difficult topography, insecurity; and sociocultural barriers [7]. These barriers limit the potential of current approaches to health service delivery and may in the long run hinder the achievement of the UHC tar- gets given the realities on ground. This is worrisome especially in the face of dwindling economic capabilities of these African na- tions and the prevailing political and social environments. It is imperative to begin to consider new paradigm shifts and innova- tions in the achievement of the UHC targets in Africa for the ultimate actualization of the Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 6 | 11 SDGs goals. Hence, adoption of new innova- tions is key for the actualization of Universal Health Coverage in Africa. Digital health technology: a novel ap- proach to delivering quality healthcare services and achieving the UHC targets in Africa Digital health technology offers one of such novel approaches to providing quality healthcare services and can help countries achieve the Universal Health Coverage tar- gets [7]. It has been suggested that digital health provides an opportunity to overcome the longstanding problems of inefficiency of health information gathering, sharing, and ac- cess [5]. Digital Health information technol- ogy is a term synonymous to mobile health (mHealth) or eHealth. This refers to a broad range of information and communication technologies that are used to gather, collate, transmit, display and store patient data [8- 10]. The World Health Organisation (WHO) defines digital health as the use of mobile tel- ecommunications and multimedia technolo- gies to address health-associated issues within health service delivery and public health systems [11]. This concept encom- passes a range of technologies, products and services comprising but not limited to medi- cal devices, tele-monitoring instruments and devices, remote mobile health technologies, cloud-based services in addition to assistant and sensor technologies [12]. Digital Health information technology has the potential to enhance the quality, efficiency of health ser- vice delivery for improved results, client safety and may possibly reduce healthcare delivery costs in resource poor settings as prevalent in Africa. [13,14]. Digital Health approach finds application in several spheres of health service delivery including patient data management (e-health records), health information and services provision via mo- bile technology (mHealth), remote services (telemedicine/telehealth), health knowledge learning and management [7]. Application of Digital Health information technology ensures the prompt deployment of health information and thereby enhances accessibility of health services by all stake- holders including patients, health service pro- viders and relevant agencies of government. Also, it can reduce medical mistakes, costs, and paperwork associated with medical ser- vice delivery. This subsequently increases ef- ficiency, quality of health service delivery while enhancing the empowerment of pa- tients and healthcare providers including cli- nicians [15]. The various applications of dig- ital health have shown its potential for use in promoting individual health and public health at large. Furthermore, these technologies can improve efficiency of health care services; reduce cost of health services delivery [16]; enhance the dynamism and timeliness of de- cision making by expediting speedy trans- mission of real time public health infor- mation; and enhance the monitoring and evaluation capacity of the health system in general. This provides ample opportunity for enhanced planning, organization, and man- agement of health services at all levels in- cluding the Primary Health care level. How- ever, in spite of the potential benefits of the Digital Health information technology, adop- tion is a huge challenge especially in low and middle income countries including Africa. This has greatly limited the utilization of the technology in health care service delivery. It is therefore imperative to identify the obsta- cles to the adoption of Digital Health infor- mation technology among relevant stake- holders across levels in the health care ser- vice delivery network especially at the pri- mary healthcare level. Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 7 | 11 Barriers to adoption of Digital Health in- formation technology among Primary Healthcare providers. A key impediment to adoption of Digital Health information technology in resource low communities is low level of technology knowledge and limited accessibility to tech- nological devices. A study conducted in Iran found that the level of technology literacy was poor; utilization of these technologies among health care personnel was limited [17]. In addition, computer possession and use among health care professionals and stu- dents were low [17]. This may be due lack of structured trainings and limited access to technological devices such as computer in these settings [17]. Despite the fact that ma- jority of the respondents owned a computer, only a few number of them had acceptable skills and practice habits. Another study in Nigeria reported that just 18.9% of health personnel and medical students had good knowledge of computer while 58.8% had av- erage knowledge and 22.3% revealed poor knowledge [18]. Similarly, Mohammed et al. [19] reported that only 33.7% of health work- ers had sufficient knowledge of computer or other digital devices. In more developed countries the case is different, as 57.91% of health personnel were well-informed about digital information technologies including use of computers in India [20]. And majority (82%) of health workers in countries like Po- land were knowledgeable about the concept of telemedicine [21]. Studies have shown that digital knowledge and experience of healthcare personnel have considerable im- pact on their readiness, perception, attitude, and probability of adopting and utilizing these health technology applications in prac- tice [22,23]. Healthcare professionals with sufficient and requisite information technol- ogy knowledge and experience are likely to have better and positive disposition towards the utilization of new innovations like digital health technology applications. Thus the need to focus on developing context-specific training on digital health in order to fill the knowledge gap. Another barrier to adoption is the low level of acceptance of the innova- tion in most of low and middle income coun- tries [14]. These maybe due to the fact that very few healthcare workers know and un- derstand the enormous benefits of digital health information technology [24] in provid- ing prompt and efficient services at any level of the healthcare system. Resistance to the use of digital health technologies from healthcare professionals may be due to low level of digital literacy and limited skill in the use of digital health technology applications [25]. In addition, absence of motivation, poor organizational and management level poli- cies also pose very formidable barriers to the adoption and utilization of these technologies [26]. Poor technology infrastructure in rela- tion to hardware, software, and networking facilities is also a main obstacle to healthcare personnel’s decision to embrace e-health technology applications [25- 29]. This is due to the fact that most digital infrastructure pro- jects in countries have previously been run as pilot projects resulting in duplication of ef- forts and technologies with little or no focus on sustainability [7, 26]. Another salient lim- itation to adoption in low and middle income countries (LMICs) is monetary barriers espe- cially with respect to budgeting and funding [26,30-32]. Although the level of funding varies across countries, however most devel- oping countries allocate very little funding for the health sector which are mostly lower than the World Health Organization (WHO) benchmark, that requires countries to appor- tion at least 13 percent of their annual budg- etary spending to the health sector. This makes funding of such investments such as digital health grossly inadequate in develop- ing countries when compared to more devel- oped countries. Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 8 | 11 Administrative issues including political will and bureaucracy related to organizational and management policies go a long way to deter- mine the level of adoption of these technolo- gies [33]. These could pose very formidable barriers to the efficiency of the implementa- tion of these technologies at all levels of health service delivery. Security barriers re- lated to privacy and trust arise both among healthcare workers and patients [26]. This could be due to prevalent myths and socio- cultural beliefs especially in African coun- tries with the potential to negatively impact decisions when contemplating the adoption and utilization of digital health technology. Although evident in most of the barriers dis- cussed, it is important to consider human re- source barriers distinctly in addressing the is- sue of technology adoption. This is important especially in relation to individual attitude, readiness and belief of the overarching goal and benefits of digital health technologies. This has significant influence on the individ- ual’s intention to adopt and use available dig- ital health technology applications. Table 1 provides a summary of barriers identified from available literature in the field. Table 1: Identified barriers to adoption and utilization of digital health information tech- nology applications in most of low and middle income countries. S/N Identified barriers to adoption References 1. Low level of technology knowledge and limited accessibility to technological devices. 17-21 2. Low level of acceptance of the innovation in most of low and middle income countries 14, 24.25 3. Low level of digital literacy and limited skills in the utilization of digital health infor- mation technology applications in most of low and middle income countries 21-23, 25 4. Poor technology infrastructure in relation to hardware, software, and networking faci- lities 7, 25-29 5. Absence of motivation, poor organisational and management level policies to drive adoption of novel interventions at the Primary healthcare level 26 6. Monetary barriers especially with respect to budgeting and funding 26, 30-32 7. Administrative issues including political will and bureaucracy related to organizatio- nal and management policies 33 8. Security barriers related to privacy and trust arise both among healthcare workers and patients 26 9. Human resource barriers distinctly in addressing the issue of technology adoption 17-21, 25,26 Way forward to enhance adoption of Digi- tal Health information technology among Primary Healthcare providers. There is an urgent and critical need to deter- mine the current levels of knowledge, atti- tude, practice and readiness to adopt digital health in service delivery by healthcare work- ers especially at the Primary Health Care lev- els across the continent. A mixed study approach including a longitu- dinal study is recommended to enable the col- lection of quality information. The genera- tion of such data from major stakeholders such as health workers and health managers, providers among others will provide im- portant evidence needed for attaining optimal utilization of digital health in the context of health for all. In addition, the deployment of Ohia Ch, Ongolo-Zogo P, Fawole OI. Digital health information technology utilization for enhanced health services delivery in Africa: Unravelling barriers to adoption among Primary healthcare pro- viders (Review article). SEEJPH 2021, posted: 26 April 2021. DOI: 10.11576/seejph-4381 P a g e 9 | 11 context-specific digital health information technologies is essential in African countries, if the full potentials of the strategy are to be realized. It is also important to evaluate the outcomes, effect and cost effectiveness of proposed models of digital health alongside the development of clear sustainable funding models with contextual relevance to target countries. The need for community and stakeholder engagement, mobilization and education cannot be over-emphasised as ena- blers and drivers of dynamic participation in Digital Health initiatives and activities at the primary care level in African countries. Hence, policy and public health interventions such as creation of awareness and promotion of use of digital health will go a long way to enhance its integration into the mainstream healthcare system in countries. Conclusion The Primary Health Care remains at the cen- tre of the actualization of Universal Health Coverage and digital health technologies have huge potential to enhance service deliv- ery and access to health with minimal finan- cial burden to both individuals, communities and nations. However, the utilization of digi- tal health technologies remains very meagre at the grassroots in Africa and this poses im- mense impediments to the efficiency and quality of healthcare delivery. In addition, there remains a paucity of data to support ev- idence-based decision making about full im- plementation of digital health services across the continent; aside from the reality of the in- herent peculiarities of individual countries. This paper has identified some of the barriers to adoption of digital health approach in LMICs especially in Africa and posits that there is an urgent need to understand the con- textual and political landscapes, issues and barriers to the utilization of digital health at the Primary Health Care levels. In addition, some recommendations have been proffered as the way forward is sought to improve adoption level of digital health in Africa. Summarily, a clear understanding of the con- textual and implementation bottlenecks high- lighted from such assessment(s), especially as it relates to individual African countries, will go a long way to guide decisions to ad- dress the low utilization of digital health tech- nologies in health services delivery in Africa. References 1. O’Connell T, Rasanathan K, Chopra M. What does universal health cover- age mean? Lancet 2014; 383:277–9. doi: 10.1016/S0140-6736(13)60955- 1 2. What is Universal Health Coverage? 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A Narrative Literature Review on the Impact of Organiza- tional Context Perspective on Innova- tive Health Technology Adoption. Journal of Soft Computing and Deci- sion Support Systems 2018; 5:(4): 1- 12. © 2021 Ohia et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0) Chinenyenwa Ohia1, Pierre Ongolo-Zogo2, Olufunmilayo Ibitola Fawole3 Source of funding Acknowledgement Introduction Method Figure 1: Stages of the literature search process Factors limiting the actualization of Uni- versal Health coverage (UHC) targets in Africa Digital health technology: a novel ap- proach to delivering quality healthcare services and achieving the UHC targets in Africa Barriers to adoption of Digital Health in- formation technology among Primary Healthcare providers. Table 1: Identified barriers to adoption and utilization of digital health information tech- nology applications in most of low and middle income countries. Conclusion References