Joy Malala, Assistant Professor, School of Law, University of Warwick

Introduction

Digitalisation helps solve health system problems, especially in Africa. Digital infrastructure and smartphone use can improve healthcare access and equity. Governments are investing in universal health coverage and digital health initiatives to enhance healthcare delivery and outcomes. Policies and strategies are evolving to enable and prioritise digital environments. 

The Covid-19 pandemic made digital health interventions mainstream, making the digitisation of many aspects of life both essential and political. Globally, nations tried to “flatten the curve” and limit infection rates to health system capacities. This flattening relied on identification, isolation, and contact tracing measures, alongside the rapid digital transformation of public health systems. These tactics redefined health and “thematized the depths of our relations with other humans, non-humans and artefacts, including technologies” .This period also revealed the complexities of implementing digital infrastructures for analogue health delivery, particularly in African countries, where unique challenges such as the need for better coordination among health agencies, the development of clear standards, and addressing structural and regulatory considerations are essential for successful outcomes. Despite the complexities, these environments have primed business opportunities in the digital delivery of health care. In this blog post, I consider some implications of the rise of apps, or the “appification” of health services in Kenya. I highlight how the increasing use and integration of mobile applications (apps) to manage, monitor, and enhance various aspects of health and wellness are transforming how individuals engage with and maintain their health. I focus on the apps that distribute prescription medications as these bring emergent regulatory concerns. 

‘Appification’ of Health Services 

App use in Kenya has been prevalent since the introduction of smart phones. Health apps provide personalised digital health services that focus on patients. They offer specific benefits, among them convenience, reduced costs, and ubiquity, allowing users to have access to their health information. Health apps are increasingly becoming a pervasive option to access healthcare and particularly access prescription medication both online and in-store. These apps and some services they offer are regulated through a combination of legal frameworks, including the Digital Health Act 2023, the Data Protection Act, 2019, which mandates explicit consent and data security for personal health information, and the Kenya Information and Communications Act (KICA), 1998 which governs electronic transactions and requires licensing by the Communications Authority of Kenya. The Health Laws (Amendment) Act, 2019 ensures that e-health and telemedicine services meet the same standards as traditional healthcare, while the Pharmacy and Poisons Board (PPB) regulates health apps classified as medical devices. Additionally, health apps must comply with consumer protection laws and the Kenya Medical Practitioners and Dentists Council’s (KMPDC) telemedicine guidelines, ensuring they provide safe, secure, and ethical services consistent with professional standards. However, some apps are purposely created with gamified, social media-like features to promote seamless user experiences that mirror how people interact online and in digital spaces. 

These apps take different forms, the most dominant apps are BYON8  and Zuri Health which provide health-related services while operating on a for-profit model and Maisha Meds operates based on funding from grants, donations, and collaborations with Kenya’s Ministry of Health often as development agents. These apps make claims about transforming healthcare in Africa, as seen on the copy of Maisha Meds’ website. This transformation is undergirded by techno-optimism, with promises and predictions of enabling individuals to better manage their ‘own’ health, including health risks to receive more personalised treatment and care. This appification of healthcare, which is the progressive transformation of healthcare services and processes into app-based solutions, transforms the medical encounter into an “appified” experience.

 This experience raises concerns regarding the commodification of user data, digital surveillance, and infringement on privacy, as well as behavioural exploitation, in a time when applications are a significant part of the digital landscape. These gimmicks may create consumer-like subjectivities as engagement increases because of their affordances leading to blurred lines between regulated and unregulated health services. Additionally, many apps are becoming superapps creating digital ecosystems that enable interactions, transactions, and services by connecting patients with pharmacies, doctors, and insurance providers resulting in health marketplaces. Appification is hence becoming a central tenet of most managed care in Kenya a partial consequence of privatisation. Consequently, the burden of addressing critical issues like the availability, quality, cost, and distribution of healthcare is increasingly being shifted away from the state and onto a competitive private digital marketplace. This shift highlights the state’s challenge in maintaining a universal healthcare system, leaving essential health services subject to market forces that prioritize profit over equitable access and quality care for all citizens.

Dispensing of Drugs and the Appification Problem 

The e-pharmacy industry has mainly been unregulated and has brought about considerable public health issues, such as the unauthorised sale of prescription-only medications and insufficient dissemination of information to patients. Furthermore, additional risks such as consumer fraud and inadequate protection of personal data privacy. Traditionally, drug administration relies on a variety of actors, including doctors who prescribe medications, pharmacists who store, handle, and prepare medications, and pharmacies where they are sold or delivered. In Kenya, medications are distributed through a variety of routes, including state hospitals, private pharmacies, and community health clinics. Public health agencies control and establish rules for drug dispensing, ensuring that safety criteria are met. Private pharmacies frequently fill gaps left by public institutions, while community health workers dispense medication in remote areas with restricted access to healthcare facilities. Apps therefore offer functionalities enabling patients to order medication online and have them delivered to their homes. Some apps also offer medication management and telemedicine, which includes consultations with healthcare providers and prescriptions for medications. These apps make affordances about improved adherence to medication regimens through reminders and alerts and increased accessibility and efficiency. As a result, health apps are rapidly being designed to resemble online stores. This appified ecosystem directs users to not only “buy” health services but also plan one’s life as if one were “consuming” health. For instance, one app, Zuri Health, reads, 

“Welcome to Health 360: Elevate your well-being with unlimited chats with a doctor, therapist, or nutritionist. Enjoy discounts on labs and medication, conveniently accessible on WhatsApp.”

Drug applications, especially those that complete prescription orders, raise legal issues. While privacy and data use from these apps are major concerns, prescription accuracy is vital in avoiding health issues. This involves validating patient and healthcare provider identities, and compliance with the Pharmacy and Poisons Act and other laws, essential for legitimate drug distribution. Inspections of drug quality, authenticity, and supply chain security are also necessary to guarantee pharmaceutical integrity. Apps like BYON8 introduce new market dynamics in the healthcare sector. They mediate between patients and providers, extracting value through transaction fees or data monetisation. This model shifts the traditional patient-healthcare provider relationship and introduces new layers of economic relations that can obscure the true cost of healthcare. This, in turn, ensures the cost efficiency of the human body for insurance providers . For instance, BYON8 uses referral marketing to benefit from network effects, which produces more value for itself. The appification of healthcare may result in a fragmented healthcare delivery system, with private actors ensuring that end users are buying health without being patients. This fragmentation frequently promises improved access at a slightly cheaper cost, with little impact on quality. 

Furthermore, drug apps in Kenya present several further concerns. They are often promoted as innovative solutions to healthcare delivery challenges, but frequently duplicate services already provided by the existing infrastructure, such as pharmacies and clinics. This raises questions about their true necessity and whether they address any real gaps in healthcare access. Additionally, these apps often collect sensitive health data, ostensibly to improve care, but with the underlying motive of commercialising this data by selling it to pharmaceutical companies and insurers. This practice not only raises serious ethical concerns but also contributes to the commodification of healthcare, shifting the focus from patient care to profit. Furthermore, these apps are typically accessible only to the upper-middle class, creating a digital divide that excludes those who may have greater health needs but lack the necessary resources or digital literacy. This limited accessibility risks deepening existing inequalities in healthcare access and quality leading to further exclusion and marginalisation. Moreover, these apps could undermine public trust in healthcare institutions and divert resources from more inclusive public health initiatives. The rapid growth of these apps also often outpaces regulatory oversight, leading to concerns about the safety and quality of the prescriptions they fulfil, potentially putting patients at risk. These concerns are pertinent as public institutions and supply chains for pharmaceutical products are increasingly outsourcing their entire mission to private corporations with minimal regulatory oversight. 

Conclusion

The digital solutions aggressively promoted by both industry power players and opportunistic start-ups embed into a well-established narrative about technology as a solution to exclusion and marginalisation, and we should rupture this illusion. Health apps are marking a significant transformation in healthcare delivery, offering numerous benefits in terms of efficiency and accessibility. However, the cultural shift towards app-based health consumption may create new subjectivities that reshape how individuals interact with and perceive their health. Effective regulation and a critical understanding of these dynamics are essential to harness the benefits of health apps while mitigating their risks. While apps may have indeed led to transformation in some aspects of healthcare, the broader and often socio-legal effects are yet to be explored. 
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).