Hadijah Namyalo-Ganafa, Lawyer and PhD Student, School for Cross-faculty Studies, University of Warwick

Digital health governance is pivotal in ensuring that developers, innovators and implementers of Digital Health Technologies (DHTs) in healthcare provision utilise them in an ethical and efficient manner and that patients’ needs and rights are not displaced by profit driven motives. Countries in the Global North prioritise digital clinical safety and they have laws, regulations and standards governing the piloting and implementation of DHTs. This has redirected the piloting of innovations to low- and middle-income countries. Such piloting enables corporations with links to the Global North operate outside the preview of regulation, build their apps and consequently “market” the apps to East African states as capable to solving existing problems. In the process, these corporations can create markets for their apps and generate profits while the East African apps struggle.

This blog uses three East African countries, Kenya, Tanzania, and Uganda to illustrate how DHT pilots evolve into fully fledged apps in some countries as others fail to take off as expected. Uganda, experienced pilotitis because of the fragmented digital health innovations which resulted in the wastage of scarce resources. Kenya, on the other hand, enjoyed global recognition as a hub of innovation, and it was dubbed the Silicon Savannah for having one of the fastest growing technology and innovation ecosystems. Tanzania has not experienced the same level of piloting tests nor growth.

These pilots attracted organisations from the Global North to study the local problems and propose digital solutions. One of the existing problems identified was the significant maternal and newborn morbidity and mortality, which arises from the high out of pocket expenses associated with accessing healthcare. This coupled with the absence of universal health coverage made East Africa receptive of DHTs in the form of applications (apps) which integrate microinsurance and ‘health wallets’. This blog post uses MomCare, an app that has been described as a digital revolution for quality maternal health care to illustrate how organisations can utilise DHTs to control the healthcare provision sector outside the purview and regulation of governments leaving the latter with no choice but to come on board.

MomCare MomCare is the world’s second-biggest value- based care initiative which has won awards for improving maternal health outcomes. The app is used in the provision of DHTs services in Kenya and Tanzania to allow expectant mothers and healthcare providers to agree on a predetermined maternal care journey and payment is subject to the provision of quality care. The app guides expectant mothers during their pregnancy journey and enables them to get healthcare access from over 40 healthcare facilities and studies have praised this app for improving service delivery and enabling continuity of care during Covid-19.

The foreign ownership of this app and the associated problems have been ignored and this blog seeks to discuss these issues. MomCare is owned by PharmAccess Foundation, a Dutch-based innovative organisation and NGO funded by the Dutch government.

MomCare dominates DHTs in Kenya because of a two-tier approach to platformisation, incorporating maternal healthcare access using two payment options, cash (accumulated through savings) and insurance (from existing insurance schemes). The platform hosts accredited providers, some of whom financially rely on PharmAccess, as will be explained in this blog post. MomCare’s payment is effected with a mobile health wallet system locally called “M-TIBA” which is a product from PharmAccess’ lucrative partnership with Kenya’s Safaricom. M-TIBA was launched in 2017 as a platform enabling Kenyans on low-incomes to save for healthcare. With time, the service extended to insurance holders following PharmAccess’ partnership with Kenya’s National Hospital Insurance Fund (NHIF) which permitted households that qualify for benefits on the NHIF to enrol onto the M-TIBA platform. As of 2023, M-TIBA had gained traction in Kenya’s health sector with over 4.7 million registered users, 4,552 connected healthcare facilities, and half a million medical treatments administered to Kenyans.

The accredited providers on the MomCare app undergo a certification process using SafeCare which is a distinctive standards-based approach that was developed by PharmAccess (Netherlands), the Joint Commission International (U.S.A) and COHSASA (South Africa) to measure and improve the quality of healthcare services in resource-restricted settings. SafeCare operates in Kenya, Tanzania and Uganda. PharmAccess uses SafeCare to determine if the health facility satisfies the International Society for Quality in Health Care External Evaluation Association (IEEA) standards. In cases where the facility is below the IEEA standards, PharmAccess can provide a loan to make the necessary improvements. The loans are provided from PharmAccess Foundation’s Medical Credit Fund which was launched in 2009 to support Small and Medium Enterprises in the health sector that are struggling with working capital shortages. In Kenya, these loans can be accessed through M-Tiba’s simplified digital solution, Cash Advance. As of 2023, more than 600 healthcare providers had accessed these loans in Kenya.

The rate at which PharmAccess is expanding to the different sectors that affect healthcare provision and access confirms its utilisation of co-creators who have deep knowledge of the local context. Together, they have revolutionized healthcare systems in African countries which spend more on servicing debt than providing public services to their people. This strategically positions PharmAccess as an experienced provider that can be trusted by international organisations to bypass the existing national bureaucracies. This can be illustrated by PharmAccess’ receipt of funding from the Global Fund to conduct pilots in some African countries for purposes of testing the utilisation of digital technology in the provision of universal health coverage. The above pilot resulted into the inclusion of PharmAccess’ MomCare app in Tanzania’s Improved Community Health Fund (iCHF), which is an insurance program that caters for a user and up to five dependents. The pilot of iCHF was supported by donors to prepare Tanzania for the introduction of Universal Health Insurance (UHI) but the processes leading to its adoption have been criticised for flouting the key steps in policy formulation because beneficiaries and providers were not consulted as required. PharmAccess is lobbying Tanzania’s Ministry of Health to adopt the MomCare app nationally. PharmAccess Foundation’s diverse approach favourably positions it to maximise profits and lobby its partners for funds to sustain its domination of the innovation ecosystem as East African home-grown solutions grapple with accessibility to funds. MomCare has not been introduced in Uganda due to the absence of a national public insurance programme, an aspect which falls within PharmAcess’ holistic approach. However, a similar health app, SafeCare was launched in 2016 as part of a USAID-funded program and a loan product like Cash Advance was launched in Tanzania and Uganda in partnership with Philips Foundation and other donors.

The apps discussed in this blog post are supported by corporations based in the Global North and granting them global recognition positions them as trendsetters who are capable of generating best practices that must be adhered to by other players, something that adversely affects organisations based in the Global South.

Conclusion This blog post has illustrated how Global North based organisations utilise their transcending commercial knowledge of everyday life to seek for new markets. East Africa has been a test-bed for new DHTs innovations that are largely funded by private-public partnerships, philanthropic capital, and corporate investments. The absence or delayed regulation and governance coupled with fragmented information systems, the presence of willing trial subjects who are spurred by poverty and a poor healthcare system makes pilots like MomCare and SafeCare successful. The developers of these apps reconfigure the social terrain after digitally collecting data. For example, PharmAccess is utilising its evidence base to advocate for proven, successful healthcare models and interventions. The creation of an evidence base by foreign organisations disintegrates the power of governments in the Global South because such organisations already have enough data to be collected through privately funded means, thereby bypassing government initiatives and making the data a private rather than public good. As a result, governments situated in the Global South are weakened and their priorities, which lack financial returns, are disrupted by organisations and corporations from the Global North. Such organisations and corporations replace governments in regulating the health sector thereby reinforcing the colonial relations of dependence and dominance.

There is a need for a power shift to the governments in the Global South so that they can regulate the provision of DHTs in their countries. This will enable them to control datafication in healthcare provision and curtail the emergence of a vicious circle that concentrates power and knowledge in the hands of foreign corporations and organisations. Otherwise, East African home-grown individuals, organisations and companies will be driven out of the digital health provision space leaving foreign corporations to remain in charge of health outcomes. Government must regulate the DHT space to prevent monopolization by corporations from the Global North and offer some support to the home-grown DHTs.

Part of the SLSA Blog Series, Exploring the Intersections of Technology, Health, and Law, guest edited by Prof. Sharifah Sekalala and Yureshya Perera. Written as part of the project There is No App for This! Regulating the Migration of Health Data in Africa, funded by the Wellcome Trust (grant number: 224856/Z/21/Z).