This series offers a glimpse into healthcare in the most populous country Nigeria with 200 million people, South Africa with 59 million people, Tanzania with 58 million people, and Rwanda with 12 million people.

Africa has 54 countries, that differ a lot in terms of their quality of health care, political situation, and innovation.

F056 Digital health in Africa 1/4: Spreading health information in Tanzania (Mariatheresa Samson Kadushi)

According to WHO, only half of the population (54%) in Tanzania has access to improved drinking water, while only 24% has access to improved sanitation facilities. As such, maternal mortality, child mortality, HIV/AIDs, pneumonia, and malaria, are major issues that the health system faces, with malaria being the most common.

Pharmacies in Tanzania can be found attached to hospitals in large cities, but are harder to find in more rural areas. Pharmacies across the country are prone to running out of stock, Tanzania has one of the highest incidences of HIV/AIDS in the world.

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Mariatheresa Samson Kadushi is a Tanzanian innovator working to disrupt the public health sector in East Africa, leveraging her background in ICT and entrepreneurship with rich experience running a tech company while participating in country-level initiatives reforming communities; and also assisting small businesses, corporate companies and investors flourish. At the moment, Mariatheresa is fully engaged in building Mobile Afya, a company working to increase access of accurate health and medical information in Africa.

As she says, healthcare in the country is improving with digitization, which among other things includes, enabling instant connections between local doctors and doctors outside the country.

The birth of her work with Mobile afya came to life after a long study and research using human centered design methodologies whereby she initiated a social enterprise “Kids of Africa” to transform the lives of underprivileged children in Tanzania by assisting homeless children (street kids) develop their business and creativity skills to become self sufficient. After learning about challenges in accessing sexual and reproductive health education, teen pregnancies, poor knowledge about contraception and safe sexual engagement during her study and baseline research, Mariatheresa decided to shift her energy to awareness and education to help people and women make informed decisions regarding their health.

“Many beliefs about boys and girls are based on myths and misconceptions, but rooted in culture,” says Mariatheresa. For example, many people still believe women should be avoided during their menstrual cycles because they are naturally dirty and their body needs cleansing.  

Mobile Afya, which means mobile health in English, is a the USSD application using internet-free mobile technology to provide basic health information in local and native languages starting with Swahili in Tanzania (East Africa). As illustrated by Mariatheresa, communicable diseases like cholera are easy to prevent but still has high mortality because of lack of information and late diagnosis.

One of the focuses of Mobile afya is maternal health, as the platform focuses on access of information they have to be mindful of very specific concerns such as privacy. “Women worry that their husbands would see what information they are looking for. For example, if a married woman is looking to learn about STDs,  to their partners it might hint extramarital affairs which will cause problems in their families. In Europe the privacy concerns and debates are around who gets your data, in Africa, women wonder how they can keep their personal information private from those close to them.” With this challenge in mind Mobile afya provides information through mobile texts, where messages can be deleted without a trace right after reading. 

Some questions addressed:

1. How would you characterize Tanzania compared to other African countries in terms of healthcare?

2. Can you illustrate the environment you’re working in, what does every day look like, where do people get their information?

3. The Bill & Melinda Gates Foundation is involved in the development of these goals. Together with the global health nonprofit PATH digitizing and connecting Tanzania’s healthcare system, linking a fragmented array of databases and information sources.  How do you see the roles of donators and western investors in digital health development in Africa?

4. You had a social enterprise Kids of Africa to help underprivileged children in Tanzania. Your idea was to make street kids self-sufficient by assisting them in developing their business and creativity skills. How did that go?

5. I couldn’t help but notice that the Mobile afya team is women only. Is that intentional?

6. What is it like to be a woman entrepreneur in Africa, where women in many rural communities are being denied the right to own or inherit land and properties, gender pay gaps where women with the same qualifications and in same positions earn less money than men, in fact, only 22% of women against 78% of men are represented in senior levels. Furthermore, legalization of child marriage in some African countries has led to massive educational gaps due to early marriage and early motherhood and many - many more issues that need advocacy and gender-focused education to advance from.

F057 Digital health in Africa 2/4: Telemedicine can’t save healthcare in Nigeria (Ocoche Ubenyi)

As of 2016, Nigeria was Africa’s largest economy and most populous nation. By 2050, Nigeria is expected to be one of the ten largest economies in the world. Healthcare wise, the country is in dire need of reform and reinforcement in medical forces.

According to the World bank there are 0.4 doctors per 1000 people and 1.5 nurses and midwives per 1000 people. Many people seek medical care abroad. There are three systems of health care delivery in Nigeria: orthodox, alternative, and traditional - which refers to traditional healers.

PwC reports are highly critical towards healthcare in Nigeria: “Regulation of clinical practice is very modest and there are currently no accreditation standards or minimum quality requirements to run a health care facility enforced creating an environment where very poor clinical practice can be conducted largely unchecked.”

Ocoche Ubenyi is one of the country’s doctors eager to improve the situation in healthcare. As he says, many doctors wish to seek professional opportunities outside of the country, and there is a sharp contract between the country’s rising population and the decreasing number of doctors. As in many other African countries, many Nigerians still believe in spiritual powers, partially because of the difficulty i accessing healthcare. According to official statistics, between 6 and 9 percent of people have health insurance, but Ocoche disputes the number is even lower- between 2 and 3 %.

Ocoche is a medical doctor and the founder of Nimedix Ecosysyem - a blockchain project aiming to improve healthcare in Nigeria through technology and online solutions, enabling patients to own their healthcare data and share it to whom they wish in the healthcare sector.

Nigeria is supportive of blockchain and cryptocurrencies, at least according to Cointelegraph, which reported that: “Bitcoin is legal in Nigeria, but the Nigerian SEC, or Securities and Exchange Commission, warned citizens about cryptocurrency investments being risky and sometimes even fraudulent. However, the Nigeria Deposit Insurance Corporation and the Central Bank of Nigeria have plans to adopt cryptocurrency technology and have several sub-committees working on implementing blockchain into governmental insurance and financial services.”

According to TechCabal - a future-focused publication that speaks to African innovation and technology in-depth, there are between 50 – 100 health tech startups operating in Nigeria providing solutions such as digital health records, quicker access to health supplies like blood and oxygen, increasing access to health insurance for the mass market, among others. “Unfortunately, none of these startups have been able to achieve massive scale due to barriers like market access, very slow adoption (which is a consequence of Nigeria’s huge information gap), a very prominent income gap, little to no healthcare insurance options (HMOs are still out of the reach of the average Nigerian). Funding for the health tech sector is sparse and grants are the most popular type of capital. Low health expenditure and the poor implementation of the national health insurance scheme limits the ability of entrepreneurs to scale their businesses,” writes TechCabal.  

Ocoche believes telemedicine can have a very limited effect in Nigeria for two reasons: to a large extent, people often suffer from diseases and injuries requiring in person medical health. Secondly, people want to have personal contact with doctors. This is why the government is mostly investing in interventions focused on outbreaks of diseases. Additional problem preventing faster improvement is corruption. Transparency enabled by blockchain technology is what drives many entrepreneurs to develop solutions in fin-tech and healthcare.

Some questions addressed:

• For starters: You are an MD, an intern with the Benue state University Teaching hospital. What do you do in your clinical practice, how does your environment look like if you compared it to the western modern hospitals? 

• How would you describe Nigerian healthcare? Is it true that only 6–9% of the population covered by health insurance, that late spending often becomes catastrophic or impoverishing. The largely out-of-pocket spending is unorganized, inefficient and skewed towards expensive care, and people if they can, seek medical care abroad? 

• How many efforts are there to improve healthcare and what role does digital health play in this story? 

• Africa has been a black hole for developmental resources. How would DLT and blockchain help?  

• What do you see as the biggest challenge in digital health development in Nigeria? 

• You work for Nimedix and the main page of the company states that “healthcare is in the stone age”. Yet, you're applying top technologies that are in early stages (AI and blockchain) to it, seem like a very sharp contrast to me. How does that go together?  Do you work with any healthcare institutions already? 

• What is the current state of blockchain development in Nigeria?

F058 Digital health in Africa 3/4: Bringing Babylon to Rwanda (Patrick Singa Muhoza)

In 2016, the UK based company Babylon Health, radically transforming access to primary care in the NHS in the UK, opened a subsidiary in Rwanda. The Rwandan version ob Babylon is called Babyl, and has by today attracted over 2 out of 12 million people in Rwanda. Out of 2 million people, 700.000 consulted Babyls healthcare workers, says Patrick Singa Muhoza, Medical Director at Babylon health Rwanda.

Rwanda has 12 million people and a severely understaffed healthcare system. According to the Rwanda Medical and Dental Council (RMDC) data, the newly deployed doctors add on the existing list of 1,176 general practitioners and 495 specialists. According to some locals, the problem is not only a lack of doctors but also poor knowledge, which can cause extreme differences in second opinions, among other things.

As in many other African countries, the lack of IT infrastructure poses a challenge for faster implementation of EHRs. Some healthcare centers already use a version of and EHR, mostly for HIV patients. The inconvenience of paper records that can get lost, and the complexity of maintaining an archive, has been recognized by the government, says Patrick Singa Muhoza. This is also why the government is working towards national EHR that could be used country-wide. 

Asked if Rwanda could leapfrog development by using portable devices such as tablets and smartphones to achieve faster data gathering on the ground, especially in the communities in rural areas, where healthcare workers spend a lot of time in the field, Mr. Singa Muhoza explains that due to inconveniences of portable devices (can get lost, stolen), some basic infrastructure in the form of desktop computers or laptops still needs to exists. Luckily, new local manufacturers of computer hardware are entering the market. 

"Rwanda has universal health coverage, and more than 90% of people are insured," says Mr. Singa Muhoza. The healthcare system has a pyramid scheme consisting of community workers taking care of local community issues such as maternal health and pregnancies; health centers employ nurses that can give patients basic medical advice. Doctors work in district and referral hospitals. Because of difficult access to conventional medical care, many patients still consult traditional healers about their problems.  

Babyl currently employs 100 doctors and 120 nurses part-time. Unlike in the UK, where doctors consult patients from home, in Rwanda the healthcare workers work in a call center, says Patrick Singa Muhoza.

When Babyl first started operating in Rwanda, the mobile phone penetration was between 50 and 60 % and smartphone penetration between 6-7%, estimates Mr. Singa Muhoza. This is why, unlike in the UK, Canada, or the US, Babylon is not primarily a smartphone app but operates as a telehealth center at the moment. Patients in Rwanda register through their mobile phones with a USSD code (communications protocol used by GSM cellular telephones). 

 At the moment, between 2500 to 3000, consultations are done daily, and patients on average don't wait more than 15 minutes for a discussion with a healthcare expert in the call center.  

Some questions addressed:

• Rwanda has 12 million people, there is 0.1 doctor per 1000 people. It’s hard to imagine how a healthcare system like that functions at all. Can you describe your point of view?

• You were a Chief Medical Officer for the Rwanda National Police, deployed for two peacekeeping missions first in South Sudan than in Mali. Can you describe that situation a bit: What kind of healthcare problems were you faced within your primary setting and what kind in the conflict zones? (How does the work environment differ, patients, diseases, etc.) 

• You were a Chief Medical Officer for two years, before becoming the Director General of Kabaya Hospital. How did you work in the conflict zone impact your thinking and decision making in the director general role? 

• Given that you are a doctor and were a director - can you share a little bit about the perception of healthcare from the provider (doctor) role and then later on from the decision maker (director) role? What kind of challenges were you faced with? What was the hardest? 

• What are the most common problems Kabaya or other Hospitals in Rwanda?

• In Africa, the lack of IT infrastructure is usually a problem preventing faster progress in healthcare. What is the situation like in Rwanda, what kind of medical records or other IT systems or apps are used? 

• Babylon’s technology was launched in Rwanda in 2016. After three years, what are the impacts that you have been observing? 

F059 Digital health in Africa 4/4: Doctor’s appointments made easy in South Africa (Sheraan Amod)

South Africa is a restless country with race and ethnicity still causing a lot of tension in society. On the healthcare side there are only 0.9 doctors per 1000 people in the country. Out of 59 million people, 9 million people use private healthcare; the rest seek help in the public system. Soon, however, the system might change with the introduction of National Health Insurance.

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Sheraan Amod is the CEO and founder of South Africa’s largest and fastest-growing online healthcare booking platform RecoMed. Over 100,000 patients and 1,500 providers connect with each other every month via RecoMed. Sheraan is a serial entrepreneur who, in the past, founded Personara - the first company in the world to join social media content (Facebook) with personalized publishing. The company became a photo software reseller partner of Xerox Corporation and was sold in 2014. RecoMed is his third company.

Asked about his reflection of starting a business in healthcare compared to other industries, he observes that healthcare is slower and more complex due to various reasons. First of all, it has many moving parts making it inherently complex. “In general, executives are often doctors, prioritizing clinical excellence rather than business excellence, making changes slow. I would say health tech takes 3-5 times longer to get the traction and achieve milestones.”

While he does not have am medical or healthcare background himself, he comes from a family of doctors. His mother is a haematologist, and his father was a GP.

Healthcare in South Africa

South Africa has around 59 million people. Around nine million people access healthcare through private providers, and those can access doctors relatively quickly, says Amod. Patients in public systems can be less lucky. “It’s not that doctors in the public sector are bad or not as good experts as those in the private sector, it’s simply a matter of lack of resources. The government is trying to improve care in various ways. The current big reform predicts a restructuring of the healthcare system with universal health insurance where everyone would contribute to the public healthcare fund,” he mentions.

South Africa has a plan to introduce National Health Insurance until 2026. 84% of the nation’s 58.8 million people have no medical insurance and rely on a public health system with too few doctors and dilapidated facilities, resulting in delayed or inadequate treatment.

Because of these plans, there is a great deal of interest in technology that can lower costs - from booking, telemedicine, and other solutions to increase efficiency. RecoMed RecoMed is South Africa’s largest and fastest growing online healthcare booking platform. The mobile-friendly platform helps patients quickly find and make appointments with quality healthcare providers, 24/7, without any phone calls or paperwork.

RecoMed is currently present in South Africa but could spread to other countries in Africa as well. Sheraan Amod: “Healthcare is a local business and always has leading regional players. Unlike the very global hospitality industry, healthcare is quite local. However, we learned how to do our business properly in the African environment. For example, we have several options for booking an appointment: either through our online platform or with the help of a call centre that does the booking and follow-up with patients. 80% of our appointments are made in real-time, 20% of requests are left with the provider that gets back to the patient. Doctors can either integrate RecoMed in their management system or use an online calendar.”

Results and future of RecoMed

Patients can leave positive recommendations but not negative reviews on the platform. “ We found that if patients could leave open reviews, doctors would get worried. We allow positive recommendations. If the feedback is bad, we send it to the doctor privately,” explains Sheraan Amod, adding an important point about different perceptions of a good doctor:

“For the patient, a good doctor might be someone that gave them the prescription they wanted. For the doctor’s association, a good doctor might be a doctor with the best clinical outcomes. The insurance company’s definition of a good doctor is an individual operating inside the pricing guideline without overcharging. These are completely different criteria, which is why we have to be very careful about how we rate doctors,” says Sheraan Amod.

Some of the interesting observations coming out of the company’s statistics are that the most searched for specialists are gynaecologists, paediatrician and dermatologists. Winter has higher spikes in doctor visits compared to summer; women look for female doctors.

Looking at trends in Africa in general, Sheraan observes a wave of telemedicine applications - from video telemedicine, EHRs, practice management systems, and the doctor to doctor safe communication platforms. There is a range of services focusing on making access and delivery of medicine easier, either by last mile deliveries or ATMs for medications. In Sheraan’s observation, Africa is a future market with volumes and revenues much lower than elsewhere. However, interests from investments are coming to the continent from other countries such as Japan and China, alongside the European Pharma industry.

Tune in the discussion, where Sheraan Amod talks about his transition into healthcare, shares his views on the development of healthcare in the country and plans for RecoMed, which allows patients to leave positive recommendations about providers on the platform. Negative reviews are sent to providers privately.

Some questions addressed:

1. South Africa has been in the media a lot because of violence against women - every three hours a woman is murdered, according to police statistics, reports CNBC, violence against immigrants. Xenophobic attacks against immigrant, with the justification of stealing jobs. Crime statistics released by the government show there were more than 20,000 murders in 2017, a 7% increase over the previous year. The minister highlighted that this was 57 murders every day. What’s it like to live in a country with such high levels of xenophobia? 

2. Africa is a continent with 54 very diverse countries. Healthcare wise, common problems are communicable diseases, much more serious than in the West, serious workforce shortages - as a comparison: The average number of doctors per 1000 people in Europe is between 3-4, African countries have much less than 1 - South Africa 0.9, Kenya and Ghana 0.2, Nigeria 0.4, etc. What are the other most striking differences in your view, how would you describe South Africa?

3. What is your observation of changes in healthcare?

4. How will the planned healthcare reform influence RecoMed?

5. Prices of solutions need to be much lower in Africa than in the west. How does this influence digital health development? 

6. How much interest to be present on the South African market is there from the outside players (US, European, Asian companies) to enter Africa?