A Review of Digital Health Strategies in 10 Countries With Young Populations: Do They Serve the Health and Wellbeing of Children and Youth in a Digital Age?

Abstract

Children and youth merit special attention from digital health policymakers and practitioners because of the great potential for digital transformations to both enhance and undermine their health and wellbeing. However, an analysis of digital health strategies from 10 African countries with young populations suggest that national approaches to digital health are overlooking young people's specific health needs and unique risks in relation to digital technologies and data. To better serve the needs of children and youth in a digital age, future digital health strategies—and the global guidance that many strategies are based upon—should consider the ways in which digital transformations can positively or negatively impact the health and wellbeing of different populations, and the forms of cross-sectoral and multi-stakeholder collaboration required to amplify or mitigate them. Future strategies should be developed through inclusive processes that support young people's right to participate in decision-making that affects their lives.

Introduction

In October 2021, a Lancet and Financial Times Commission titled Governing health futures 2030: Growing up in a digital world¹ published a report with recommendations for a value-based approach to governance of digital transformations that maximizes health and wellbeing, particularly for current and future generations of children and youth (1). Children and youth are a group that merits attention from digital health policymakers and practitioners because of the potential that digital transformations offer for countries to improve newborn, child, adolescent, and youth health. Furthermore, in many countries, young people are the most digitally connected and literate group and as such have greatest exposure to the potential opportunities and risks in relation to the use of digital technologies. Considering children and youth in the governance of digital health—which includes not only the application of digital technologies for health but the broader ways in which digital transformations can affect health—is therefore essential to optimize the health benefits of digital transformations for current and future generations.

In this review, we analyze national digital health strategies from 10 African countries with large and growing populations of children and youth. National digital health strategies are seen as essential tools for governments to set out their priorities and align governance aims for digital transformations in health (2). We begin by analyzing to what extent children and youth are represented in the strategies and then analyze the inclusion of universal health coverage (UHC) and core principles that we argue should be prioritized within digital health governance in order for young people to flourish in a digital age.

To understand barriers to implementation of these digital health strategies we conducted interviews with digital health experts from the 10 countries. Together, our analysis and interview findings suggest that digital health strategies do not sufficiently serve the needs of children and youth in a digital age. We propose ways for policymakers to strengthen the content and implementation of national digital health strategies so that they can better serve young people's health and wellbeing. Specifically, our recommendations focus on including children and youth in the development of national digital health strategies, and for strategies to consider the wider effects of digital transformations on health more thoroughly.

Background: National Digital Health Strategies, Children and Youth, and Governance

“Digital health” is an umbrella topic as exemplified by the WHO's Global Strategy on Digital Health: “Digital health expands the concept of eHealth to include digital consumers, with a wider range of smart and connected devices. It also encompasses other uses of digital technologies for health such as the Internet of Things, advanced computing, big data analytics, artificial intelligence including machine learning, and robotics” (2). Therefore, the governance of digital health includes both the governance of digital technologies for health as well as the governance of the ways in which the broader digital transformations influence health outcomes.

While digital health appears promising for accelerating progress toward UHC and other health goals, it comes with both opportunities and challenges. Opportunities include increased access to health care, better health outcomes, and increased efficiency of health systems. Risks include further widening health inequities due to the digital divide and biases within AI-powered health solutions, the proliferation of unregulated digital health tools, increased exposure to health misinformation, and threats to health information privacy and security (3).

Children and Youth Online

Children and youth are amongst the groups most affected by digital transformations. First, global estimates of internet users by age groups across geographies show that young people use the internet more than the overall population: While nearly 70% of people aged 15–24 are online, the average in the total population is just 48% (4). Although connected, children and youth often lack digital literacy and skills to protect themselves from online harms, predatory marketing and data extraction practices, infringements on consent, and other rights violations (5, 6). Data on young people's disproportionately high use of digital technologies often hides the fact that many children's and youth's online access is irregular and of poor quality, and many still remain totally unconnected. According to UNICEF and ITU, two out of three children globally have no broadband internet connection at home (7). Children and youth that are digitally disconnected are at increased risk from material and social deprivations resulting from reduced access to education, job opportunities, healthcare, and social environments for mental wellbeing.

Challenges to Implementing Digital Health Governance for Children and Youth

A focus on children and youth within digital health governance has begun to emerge in other recent initiatives. For example, the WHO recently published guidelines on Youth-Centered Digital Health Interventions (8). As such, attention has increased on the way that digital transformations influence young people's health and wellbeing, and the need for governance structures that aim to enhance children's and youth' health and rights (9).

However, digital health governance poses novel challenges because of the ways that digital transformations intersect across traditional domains of governance. For example, digital platforms and their content may be supportive or damaging to health, but their governance does not fall within the remit of health ministries. While a social determinant of health such as education may be addressed within a Ministry of Education, digital determinants of health such as connectivity and access to quality online health information often requires inter-ministerial coordination.

Further complicating digital health governance is the need for governments to establish meaningful and ongoing child and youth engagement to understand the perspectives of young people. While some government departments may be able to report particular examples of youth engagement on digital health, continuing engagement of children and youth in the governance of digital transformations and health is rare or even non-existent (8, 10). Because of the novel and evolving nature of digital transformations, governments are often underprepared to govern, resulting in judicially Reactive governance in cases of human rights and child rights violations vs. legislatively proactive governance (11).

To establish more proactive governance that maximizes the opportunities of (digital) health, the WHO and ITU have encouraged all countries to develop national digital health strategies and have provided a toolkit to assist countries in constructing these strategies (12). WHO encourages countries to actively use digital health strategies to accelerate progress toward UHC and other health-related targets of the Sustainable Development Goals, and to develop these strategies through an inclusive multi-stakeholder approach (2). Existing global guidance does not specifically recommend that countries design and implement national digital health strategies that fully reflect the needs and voices of children and youth. A review of national digital health strategies was therefore undertaken to understand the extent to which these strategies reflect young people's specific health needs and support their right to participate in decision-making that affects their lives.

A Review of National Digital Health Strategies in Ten African Countries With Large Youth Populations

We collated and reviewed national digital health strategies from around the world in order to better understand countries' priorities and activities for strengthening digitally-enabled health systems, barriers to implementation, and the extent to which the needs and views of young people—who stand to inherit the health systems that are being digitally-transformed today—have factored in these efforts.

This article focuses on a deeper analysis of digital health strategies from African countries where young people under 25 make up a substantial proportion of the population. There were three reasons to focus on African digital health strategies: Firstly, Africa is home to the countries with the highest proportions of young people, and it is estimated that by 2030 almost one-third of the world's children will live in Africa (13). Secondly, both disease burden and levels of mortality are high among children and youth in Africa (14). Finally, whilst the percentage of young people under 25 with internet access at home is currently low-−5% in West and Central Africa; 13% in East and Southern Africa—the number of African children and youth coming online will increase rapidly over the coming decade (7).

Search Strategy and Selection Criteria

Ten countries with large child and youth populations were selected for the purposes of the study. This included: Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Liberia, Malawi, Mali, Niger, Nigeria, Tanzania, and Uganda (see Figure 1; Table 1). These countries were also found to be of interest because they have significantly higher uptake of digital technologies among young people; for example, 39.6% of 15–24-year-olds were using the internet vs. 28.6% in the overall population of Africa (15).

Figure 1

The WHO's Directory of eHealth Policies² was our starting point for searching national digital health strategies for the 10 focus countries of this review. We then used internet searches to identify more current strategies. The WHO Regional Office for Africa and key informants interviewed for this study also provided copies of digital health strategies that were not available online.

Overview of National Digital Health Strategies

To analyze the strengths and limitations of national digital health strategies and their implications for children and youth, we collected information on six domains. This included (i) the period of validity of the strategy and which government ministry it was created by; (ii) the focus and goals defined within the strategy; (iii) how children and youth are considered within the strategy, if at all; (iv) the alignment of strategies to UHC goals; and (v) other core values or principles represented in the strategies. The former three domains were meant to provide descriptive information for the purposes of this study, while the latter two domains aimed to understand the normative basis for the strategies.

The Current Status of National Digital Health Strategies

All 10 countries have published a strategy to guide the digital transformation of their health system as shown in Table 2. In most cases, these strategies were developed to support the implementation of a national health strategy and as part of a broader digital transformation agenda. Nine out of the ten countries had current strategies at the time the research was conducted in the third quarter of 2020. During the research period, consultations were underway in Malawi and Mali to develop a new digital health strategy, but drafts were not available to review.

The titles of the 10 strategies reflect changing terminology. More recently published strategies, such as ones from Cameroon and Tanzania, are called “digital health” strategies. Whereas, Mali, Niger and Uganda have “eHealth” strategies and the remaining are health “information/informatics” or “ICT” strategies.³

The Focus and Goals of Digital Health Strategies

As seen in Table 3, all 10 strategies reflect their respective government's aspiration to use digital technologies and data to improve the performance of health systems and achieve better health outcomes for the population. The situation analysis within each strategy describes both significant health challenges and relatively low levels of digital maturity. Therefore, all strategies place strong emphasis on building the necessary foundations for digital transformations in health. With the exception of Mali, all strategies draw heavily on the WHO-ITU's National eHealth Strategy Toolkit and many strategies are structured according to the Toolkit's seven building blocks.

Each strategy has a strong emphasis on strengthening integrated health information systems (HIS) to improve data collection and use for decision-making. In the cases of Ethiopia, Liberia and Malawi, HIS is the primary focus of the strategy. In all countries, increasing the availability of high-quality data, and the capacity of the health workforce to use that data, are recognized as essential for optimizing the efficiency and effectiveness of health services.

In addition to strengthening HIS, all strategies outline plans to use telemedicine, mHealth and/or eHealth tools to improve quality and increase service coverage, especially for underserved populations. Tanzania is unique in having a strategy that includes a reference and commitment to explore and research emerging technologies such as artificial intelligence.

How Children and Youth Are Considered in Digital Health Strategies

While the national health strategies of all 10 countries prioritize newborn, child, and adolescent health, none of the digital health strategies reviewed included any specific consideration of children and youth in the development and application of digital technologies, the management of health data, or the development or monitoring of the strategy. The context sections of several strategies did reinforce that improved child and adolescent health are intended outcomes of digital health (see Table 4). Ethiopia's strategy identified “youth-focused” as a guiding principle for the health sector but did not elaborate on how this principle would be applied in relation to digital health. Several strategies noted their country's young population and opportunities presented by large numbers of young people entering the workforce to support the digital transformation agenda. However, none of the documents reviewed indicated that children and youth had been involved in the development of the strategy, and none referred to the potential health benefits or concerns arising from broader digital transformations that may impact children and youth.

Alignment of National Digital Health Strategies to UHC and Its Foundational Values

Improving the health of children, youth, and other left behind communities as part of a primary healthcare approach is recognized to be the cornerstone of UHC (16). Our analysis therefore included an assessment of the extent to which digital strategies look to support the achievement of UHC as represented in Table 5.

Nine out of 10 strategies are explicitly aligned to the Sustainable Development Goals (SDGs) and the realization of UHC. The exception is Mali's strategy which predates the adoption of the SDGs and high-level political commitments to UHC.

The UHC and SDG agendas are built upon a number of core values including equity, ethics, and human rights (17). Table 6 provides an overview of whether these values are explicitly referenced in a country's digital health strategy, if there are elements of the strategy that support a value or principle and thus indirectly referencing, or if there is no reference to the value.

Eight out of 10 strategies explicitly reference equity as a core principle and the remaining two (Cameroon and DRC) indirectly reference equity by stating that digital health will be used to reduce health disparities through its alignment with an equity-focused national health strategy.

Five strategies explicitly talk about the need for an ethical approach to digital health; one references the need for users of HIS to be trained in ethics (Liberia); and the remaining four do not mention ethics. Only two strategies (Malawi and Uganda) outline a human-rights based approach. Two strategies (Mali and Niger) note that the right to health is enshrined in the country's constitution and one (Nigeria) references the right to privacy. Three strategies (Ethiopia, Liberia and Tanzania) do not use rights-based language but indirectly talk about the need to protect individual privacy and confidentiality. None of the strategies make any specific reference to children's rights.

Inclusive Processes to Strategy Development

The inclusion and the enfranchisement of affected communities are widely recognized to be effective strategies for addressing global health challenges and strengthening health governance. In line with the Principles for Digital Development, approaches to digital health should be designed with the user⁴. This means that intended users or beneficiaries should be partners in the design and application of digital health solutions, and as such the principle of inclusion should be promoted within digital health strategies. Further, the Principles indicate that communities—including children and youth—should be enfranchised to contribute to digital health policy and to use digital health tools to support their own health.

As summarized in Table 7, six strategies make no reference to the inclusion of communities. Two (Ethiopia and Uganda) are explicit about the importance of involving communities in planning, implementation, and monitoring. Niger commits to civil society involvement in creating a legal framework. Tanzania refers to the Principles for Digital Development but doesn't reference activities to include communities.

Four strategies (Ethiopia, Mali, Niger and Uganda) explicitly plan to use digital tools to enfranchise and empower communities. Two strategies (Nigeria and Tanzania) plan to use digital tools to empower health workers and the remaining four strategies make no reference to enfranchisement.

Discussion: Is an Insufficient Focus on Children And Youth in Digital Health Strategies a Barrier to Their Implementation?

All 10 countries in this study have a digital health strategy but the realization of these strategies is not progressing at the anticipated pace. To better understand the reasons for this, we conducted interviews with digital health experts from the study countries. Through these interviews, we were also able to consult experts on the advantages and disadvantages of focusing on children and youth in national digital health strategies.

Interview Methodology

Between August and October 2020, we contacted more than 50 digital health experts working in 1 or more of the 10 focus countries via email or social media and invited them to participate in an interview. To identify potential interviewees from different sectors—including government; academia; civil society; international organizations; private sector; and donor agencies)—we drew upon known experts in digital health and snowball sampled through these contacts.

Authors' host institutions do not have an ethical approval committee or institutional review board. An interview protocol was developed and shared with participants in advance of their participation in the study. This protocol outlined the purpose of the study and how participant data would be used. The protocol confirmed that interview data would be anonymized and participant privacy would be protected. Oral consent was sought for a second time before recording interviews.

A semi-structured, open-ended questionnaire was shared with respondents in advance and used as an interview guide. Questions focused on implementation progress and bottlenecks in four areas: digital infrastructure; digital health; growing up in a digital world; and governance of data in health (see Box 1). The same questions were offered as written questionnaire in English and French for respondents unable to attend an interview.

In total, 18 individuals agreed to participate in an interview and 11 semi-structured interviews were successfully held in English using Zoom or Skype. A further two respondents provided written responses to the interview questions in French (see Table 8 for respondents' profiles). Interviews were conducted under Chatham House rules so that respondents felt able to speak freely and in their personal capacities. Interviews were recorded and transcribed. Interview and questionnaire data was extracted and compiled in a database. Data was manually coded using the rounded theory method.

Despite regular outreach and follow-up, it was not possible to secure interviews with the desired number and diversity group of experts from each of the 10 countries. Locating suitable interviewees and conducting interviews during the COVID-19 pandemic proved challenging. Whilst the findings from such a small sample size cannot claim to be representative of the 10 countries, we felt the data to be sufficient to identify common barriers to implementation of digital health strategies and to capture different perspectives on the utility of focusing on children and youth in future national digital health strategies.

Barriers to Implementing National Digital Health Strategies

Major barriers to implementation described by interviewees fell into four broad categories: weak leadership and coordination; underinvestment in basic infrastructure; weak “infostructure” (18) (i.e., weak health information systems to support data sharing and interoperability); and insufficient engagement of stakeholders. Addressing all of these bottlenecks is necessary for countries to realize the goals of their national digital health strategies and to accelerate progress toward UHC and greater health equity.

Lack of involvement of diverse stakeholders in the development of digital health strategies was perceived by interviewees as contributing to their slow implementation in many countries (see Table 9). Outside of a small group of stakeholders already working closely with governments on digital health, interviewees indicated that few people are aware that such strategies exist, let alone what their aspirations are. Interviewees who were involved in the development of digital health strategies confirmed that children and youth had not been consulted as part of the strategy development process. The evidence gap about young people's behaviors and experiences in relation to digital health was acknowledged to be a reason for the lack of focus on children and youth within the strategies.

The failure to engage diverse population groups, including children and youth, in the development of digital health strategies has resulted in a lack of ownership among the wider health community and contributes to ongoing fragmentation. Private sector stakeholders, for example, despite being major players in digital health, make very little contributions to the development of these strategies and have very little incentives for adoption. Limited engagement of civil society in the strategy development process weakens the potential for independent monitoring and accountability efforts that could accelerate progress toward implementation.

Focusing on Children and Youth in Future Health Strategies

Most interviewees noted that whilst young people are not specifically considered in digital health strategies, child and adolescent health are clearly articulated priorities within broader health strategies and policies. Several interviewees also noted the demographic distribution in Africa to be a strong indicator for the future growth and adoption of digital health technologies. Young people, namely those in urban areas, were seen to more easily adopt digital technology and prioritize the need for broadband access, mobile phones, and the electricity required to power them. Young people are also helping to educate older family members about digital health. Some of the interviewees shared examples of their own work with young people who are training in digital health and involved in the development of digital health solutions.

When asked whether future digital health strategies should have a stronger focus on children and youth, responses fell into two camps (see Table 10). One group felt that strategies should maintain a whole population approach and that looking at different population groups may lead to unnecessary complexity and even further fragmentation. Other interviewees felt that future digital health strategies should pay greater attention to the specific needs of children, adolescents, and youth, and involve them in the strategy development process. Interviewees noted that young people are both the main users of digital technologies and have particular health and developmental needs that can be positively and negatively impacted by digital transformations. Some argued that future strategies should recognize the risks that young people are exposed to through digital means and also their need for stronger protections in relation to their health data.

Whilst interviewees were divided on the benefits of including a stronger focus on children and youth within the content of digital health strategies, there was general agreement that the involvement of children and youth would add value to future policymaking. More inclusive processes would result in digital health approaches and interventions that better meet the needs of children, youth, and other underserved groups, as well as to increasing individuals' knowledge of their digital rights and digital health opportunities. Interviewees expressed an interest, yet lack of capacity, to more meaningfully include civil society, communities, and young people in the development of future strategies.

Developing Digital Health Strategies that Better Serve the Health Needs of Children and Youth in a Digital Age: Recommendations for Policymakers

Digital health governance incorporates both the governance of digital technologies and data for health and the governance of the ways in which broader digital transformations influence health outcomes. Our review of 10 digital health strategies suggests that policymakers in countries with large populations of young people are prioritizing the former whereas the role of digital transformations as determinants of health for children, youth, and other groups are underexplored.

Digital transformations offer new ways for countries to accelerate progress toward UHC and goals related to newborn, child, adolescent, and youth health. We recommend that digital health strategies should identify the ways in which digital transformations can positively or negatively impact the health and wellbeing of different populations, and the forms of cross-sectoral and multi-stakeholder collaboration required to amplify or mitigate them. Even in countries with lower levels of digital maturity, anticipatory governance is important to maximize the health benefits and decrease future risks associated with digital transformations. By taking a broad and more holistic approach to digital health governance, a stronger focus on children and youth would likely emerge in countries with both large and smaller populations of young people since this group is entitled to additional protection from digital harms and also stands to gain so much from the benefits of digital health.

To ensure effective digital health governance, it is essential to design and implement national digital health strategies that fully reflect the needs and voices of children and youth. We therefore recommend that future digital health strategies are developed through a more inclusive process that involves children, youth, and other marginalized groups. As enshrined in human rights instruments such as the UN Convention on the Rights of the Child and African Charter on the Rights and Welfare of the Child, young people have a right to be involved in decision-making that affects their lives. Given the health risks presented to young people by digital transformations, and the implications of digital health approaches on other aspects of their lives, it is important to involve children and youth in the development of future digital health strategies so that the strategies steer a course toward more equitable health futures. More inclusive approaches to policy development would not only produce digital health strategies that more accurately reflect the health needs and priorities of children, youth, and other vulnerable groups, they would also foster greater ownership and accountability.

Finally, we recommend that policymakers and their partners invest in mechanisms for ongoing engagement of children and youth in digital health governance that avoid tokenism. This will require building capacity and skills within relevant government departments to effectively work with children and youth from diverse backgrounds, as well as creating channels for young people's voices to inform and monitor policymaking. As recommended by the WHO in its guidance on Youth-centered digital health interventions, crafting meaningful health interventions for youth requires meaningfully engaging youth (8). This is particularly relevant for the governance of digital transformations because policymakers may not comprehend the unique and novel ways in which the social worlds of youth interact with digital technologies and their infrastructures. When reflecting on barriers to implementation, interviewees for this study referenced the need for greater youth engagement, but often within traditional models of governance such as maternal, newborn, child, and adolescent health programs. They indicated that a more open space, both in consultation and governance, needs to be ideologically and financially fostered to create long-term, meaningful child and youth engagement in digital health.

This review poses several questions that merit further exploration. Additional research is needed to test whether the hypotheses arising from this study—namely that broadening the scope of digital health strategies and more inclusive policy development processes—will produce strategies that more explicitly prioritize the needs and views of children and youth. Longer-term analysis of digital health strategy implementation should also be undertaken to better understand the barriers faced by countries in translating their digital health ambitions into reality, and the effectiveness of different approaches to digital health in realizing UHC and health equity for current and future generations of children and youth.

Funding

The Lancet and Financial Times Commission on Governing Health Futures 2030 was funded by Children's Investment Fund Foundation, Foundation Botnar, GIZ, SDC, UNICEF (in-kind), and Wellcome Trust. There was no involvement by the funding sources in the conceptualization, writing, or submission of the manuscript.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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