LEVERAGING MATURING TECHNOLOGIES FOR HEALTH FINANCING NEEDS IN EAST AND SOUTHERN AFRICA 01/25 © 2024 International Bank for Reconstruction and Development / The World Bank Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 27 26 25 24 This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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ES Abr 1 2 3 4 5 6 7 Con Ref Anx LEVERAGING MATURING TECHNOLOGIES FOR HEALTH FINANCING NEEDS IN EAST AND SOUTHERN AFRICA 01/25 This interactive document has been optimised for use on a personal computer. Please follow the guide below for easy navigation. Access all sections Red button navigates to a larger version of the figure. Next page Back to contents Previous page ES Abr 1 2 3 4 5 6 7 Con Ref Anx Contents ii 14 Explore blockchain to Acknowledgements record transactions Make use of FinTech iii Abbreviations 16 innovations to send money to facilities Explore machine learning and iv Executive Summary 19 artificial intelligence for risk mitigations and efficiency gains Introduction and 01 motivation 23 Conclusion 02 26 Health financing challenges References and technology innovations i 08 30 Make use of identity Annex A: Key concepts management technology and features of blockchain Leverage availability of 12 mobile phones for service use verification Acknowledgements This report was led by Moritz Piatti-Fünfkirchen The report benefited from management (Senior Economist, HNP). The team of experts oversight by Ernest Massiah (Practice Manager, include (in alphabetical order) Mahesh HNP), and Stella Mocan (Manager, ITS). Chandrahas Karajgi (Senior IT Officer, ITS lab), Annie Liang (Health Specialist, HNP), Jinhee Park Generous financial support for the production of (IT Officer, Business Solutions), Christine Lao the report was provided by the Global Financing Pena (Senior Economist, HNP), Chenjerai Sisimayi Facility (GFF). (Senior Economist, HNP), and Mark Talary (Blockchain Expert, Independent Consultant). The report benefited from generous feedback and guidance from Matthew Hulse (Senior Health Specialist, HNP) and Olena Doroshenko (Senior Economist, HNP). Excellent editing was offered by Alexandra Michele Beith (Senior Consultant, HNP). The report was designed by David Lloyd. ii ES Abr 1 2 3 4 5 6 7 Con Ref Anx Abbreviations AfDB African Development Bank IoT Internet of Things AI Artificial Intelligence ML Machine Learning API Application Programming Interface MNO Mobile Network Operator Mobile Telecommunications Network AU African Union MTN (specific provider) Centers for Disease Control NGO Non-Governmental Organization CDC and Prevention CHW Community Health Worker P2P Peer-to-Peer (e.g., payments) DDCS Digital Drug Control System PHC Primary Health Care DLT RBF Results-Based Financing Distributed Ledger Technology iii DSCSA Drug Supply Chain Security Act SDGs Sustainable Development Goals FinTech Financial Technology UHC Universal Health Coverage GDP Gross Domestic Product UI/UX User Interface/User Experience Health Management Information UN United Nations HMIS System HNP Health, Nutrition, and Population WB World Bank Information and Communication WHO World Health Organization ICT Technology Executive Summary iv Maturing technologies hold immense and utilized, thereby supporting health potential to transform health financing systems that are better resourced, more systems, offering innovative solutions to efficient, inclusive and equitable. However, long-standing challenges. Tools such as despite growing evidence of how technologies mobile payment platforms, smartcards, have contributed to other domains, their biometric identification systems, and application to health financing remains limited blockchain have transformed sectors like and frequently underexplored. financial services and logistics, demonstrating their ability to streamline processes, reduce Emerging technology adoption in health inefficiencies, and enhance accountability. financing in East and Southern Africa has When applied to health financing, these been further slowed by structural, financial, technologies have the potential to improve how and operational challenges. Despite the financial resources are mobilized, allocated, widespread availability of digital tools like ES Abr 1 2 3 4 5 6 7 Con Ref Anx these. For example, a meaningful budget allocation to health care providers requires use of good service utilization data, yet these can scarce. The report notes that capturing and verifying utilization data can be done through a combination of identity management technology and mobile verification services, which are widely available in the region. Given that health providers often stand to benefit from overreporting, blockchain technology can be used to support the integrity and transparency of data, as well as to strengthen accountability. Making payments to providers can be challenging, especially in remote areas with limited access to banking services. Innovations in the FinTech space such as mobile money or smart cards can be used to resolve this as a mechanism to make a budget balance available to providers. This also has the potential to make processes more efficient and secure and can support improved accounting v and reporting. Finally, efficiency gains are possible through applying machine learning applications on expenditure reports. Context is critical and the report cautions against a solutions-driven engagement. Technology innovations hold tremendous potential. Yet, investments in this area need to mobile money platforms and biometric carefully balance anticipated reward with risks. identification systems in the region, their Effective engagement needs to be problem- application to address health financing driven, iterative, and integrate into the existing bottlenecks remains limited. Many countries infrastructure and legacy systems, even if still rely heavily on paper-based systems and these are slow and operate inefficiently. fragmented digital infrastructure, which makes Reforms that are solution- or technology- integrating new technologies complex and driven are less likely to yield success. The resource-intensive. report also acknowledges the importance of political economy challenges as the This report identifies a set of common introduction of new tools, software and regional health financing challenges in the systems is likely to be disruptive to some delivery of care and identifies opportunities constituencies. from maturing technologies to address Introduction and motivation ES Abr 1 2 3 4 5 6 7 Con Ref Anx Maturing technologies hold immense potential Exploring available and maturing technologies to transform health financing systems, in health financing is becoming increasingly offering innovative solutions to long-standing important in the face of fiscal pressures, challenges. Tools such as mobile payment health emergencies and the growing impacts platforms, smartcards, biometric identification of climate change.1 It is increasingly important systems, and blockchain have transformed sectors to leverage all tools available for government use like financial services and logistics, demonstrating to elicit an effective response: digital payment their ability to streamline processes, reduce systems and blockchain technology can facilitate inefficiencies, and enhance accountability. When real-time disbursement of funds, ensuring that applied to health financing, these technologies resources reach frontline providers and affected have the potential to improve how financial populations without delays or leakages. Similarly, resources are mobilized, allocated, and utilized, biometric systems can enable accurate thereby supporting health systems that are better beneficiary identification during crises, ensuring resourced, more efficient, inclusive and equitable. equitable distribution of services and financial However, despite growing evidence of how support. In such contexts, technologies like technologies have contributed in other domains, mobile money platforms can allow displaced their application within health financing remains populations to access resources even in the limited and frequently underexplored. absence of traditional banking infrastructure. These tools also improve the transparency and The adoption of emerging technologies in accountability of emergency funds, increasing health financing has been slow in East and trust among donors and governments. By Southern Africa due to structural, financial, and leveraging these technologies, health financing operational challenges. Despite the widespread systems can become more resilient, adaptable, availability of digital tools like mobile money and capable of responding to the complex and platforms and biometric identification systems in dynamic challenges posed by health 01 the region, their application within health financing emergencies and climate change. remains limited. Many countries still rely heavily on paper-based systems and fragmented digital This report explores the potential of maturing infrastructure, which makes integrating new technologies to address specific health technologies complex and resource-intensive. For financing challenges in East and Southern example, while Kenya’s M-Pesa has revolutionized Africa. To the extent possible, it draws on digital payments, its integration into health examples from countries in the region and shows insurance schemes like the National Hospital how some technologies have been used in other Insurance Fund (NHIF) has faced scalability sectors that could inform similar application to challenges, limiting its broader application in health health financing challenges. The report discusses financing (Nzioka, 2023). Similarly, Tanzania’s benefits, drawbacks, risks, and costs of the Community Health Fund (CHF) has struggled with various options and emphasizes that these need fully incorporating biometric systems into its to be balanced when exploring the introduction operations, partly due to high implementation of any such tools. costs and operational inefficiencies (WHO, 2022). 1 Climate change further amplifies the need for these technologies, as it intensifies health risks such as vector-borne diseases, food insecurity, and displacement due to extreme weather events. Health financing challenges and technology innovations 02 ES Abr 1 2 3 4 5 6 7 Con Ref Anx This section provides a brief overview of some interrelated health financing challenges in health care service provision, and then maps out how these could be addressed through maturing technological innovations. Systemic and governance issues further Challenge 1 complicate data capture efforts. Many HMIS frameworks in the region suffer from Recording what service, fragmentation, with multiple parallel systems and what service quantity operating without integration, resulting in data has been delivered duplication and inefficiencies. Inadequate to whom coordination between health ministries, donors, and implementing partners To take evidenced informed decisions on exacerbates this problem, as different how much should be allocated to providers, stakeholders often use proprietary systems it is necessary to understand what type of that are not interoperable. Data privacy and services and what volume of services were security concerns also limit the adoption of provided by health facilities. This feeds into advanced digital tools, especially in countries the estimation of the cost of provision at that lacking robust legal frameworks to protect level of care. Any output-adjusted budget health information. These challenges allocation decision would require it to be a collectively undermine the ability of HMIS to function of what and how much was delivered. provide timely, accurate, and actionable data For operation of capitation-based payment needed for decision-making and resource systems that incentivize coverage, the given allocation in health systems across East and 03 population must register with a facility, which Southern Africa (OECD, 2021; WHO, 2022). then becomes the basis of the payments. Operational challenges also impede However, capturing data in health effective data capture in HMIS. A shortage of management information systems (HMIS) in skilled health workers and data managers often East and Southern Africa is fraught with leads to incomplete or inaccurate data entry. challenges stemming from infrastructural, Health personnel, already overburdened with operational, and systemic issues. One of the service delivery, may lack the time or training primary barriers is the limited digital required to maintain high-quality data records. infrastructure, particularly in rural and Additionally, high staff turnover disrupts underserved areas, where unreliable internet continuity, while inconsistent training programs connectivity, frequent power outages, and fail to equip personnel with the necessary skills inadequate hardware - such as computers and to use HMIS effectively. Standardization of servers - hinder data collection and reporting. data collection tools and indicators is another Many health facilities still rely on paper-based issue, as variations between facilities or records, making data entry labor-intensive, regions create inconsistencies in how data is prone to errors, and difficult to digitize reported and interpreted (World Bank, 2022). consistently (WHO, 2022). Health financing challenges and technology innovations Registering the population for health Challenge 2 services in East and Southern Africa is challenging due to a combination of Ensuring data structural, logistical, and socio-economic quality and integrity factors. Many countries in the region face to whom limited access to infrastructure, particularly in rural and remote areas, where healthcare The main problem with facility-level data facilities and access to administration offices integrity of health service coverage in East are sparse. This is compounded by weak civil and Southern Africa lies in the inconsistency registration systems, with many people lacking and unreliability of data reporting and official identification documents, such as birth management systems. Health facilities often certificates or national IDs, which are often face significant challenges in accurately prerequisites for enrollment. Socio-economic recording, validating, and reporting service barriers, including low literacy levels and coverage data due to limited resources, limited awareness about the importance of inadequate training, and fragmented systems. registration, further hinder participation, Many facilities rely on manual or paper-based especially among marginalized populations. record-keeping, which is prone to errors, Additionally, logistical challenges such as poor omissions, and duplication. Even where digital road networks, unreliable internet connectivity, systems are in place, poor standardization of and power outages make it difficult to data collection tools and processes leads to 04 implement and maintain digital registration discrepancies, as different facilities may use systems. Cultural factors, including mistrust of varying methodologies or definitions for government initiatives or skepticism about the indicators such as patient visits or service benefits of formal health systems, also delivery outcomes (WHO, 2022). contribute to low registration rates. These issues are exacerbated by resource Moreover, data manipulation and service constraints, with organizations charged with coverage figure inflation can occur due to registration campaigns lacking the financial performance-based incentives tied to reported and human resources needed (WHO, 2022; metrics, as facilities may feel pressure to meet World Bank, 2022). targets set by governments or donors. This undermines data credibility and complicates efforts to allocate resources effectively. High staff turnover and insufficient data management training exacerbate these issues, as health workers may lack the skills to maintain accurate and consistent records. Furthermore, poor infrastructure, including unreliable internet connectivity and limited access to functional digital tools, hinders real-time data validation and aggregation at the facility-level, reducing overall health information system reliability (World Bank, 2022; OECD, 2021). ES Abr 1 2 3 4 5 6 7 Con Ref Anx contribute to these difficulties. Health facilities frequently lack the necessary financial Challenge Making payment to providers 3 record-keeping practices to account for and reconcile payments effectively. This is often compounded by fragmented health financing systems, where funds are channeled through multiple intermediaries, increasing delays and Making direct payments to health facilities reducing transparency in the payment process. in many African countries is challenging Additionally, complex bureaucratic processes due to a combination of infrastructural, and delays in disbursement from central or administrative, and systemic issues. regional governments further complicate Many health facilities, particularly in rural direct payments to facilities (OECD, 2021). and underserved areas, lack access to banking infrastructure, such as accounts in formal Corruption and mismanagement are financial institutions, which are necessary additional barriers, as funds intended for to receive and manage digital or electronic facilities are sometimes diverted at payments. Inadequate digital payment systems intermediary levels before reaching their further exacerbate this issue, as facilities intended recipients. A lack of standardized often operate in areas with limited internet financial frameworks and oversight connectivity and unreliable electricity, mechanisms across health systems in many hindering the use of digital transfer platforms countries creates opportunities for leakage 05 (World Bank, 2022). and inefficiency, making it harder to implement direct payment systems that are both reliable Administrative inefficiencies, including and secure (WHO, 2022). weak financial management systems, also Challenge facilities, leading to resource leakage or 4 mismanagement. Limited financial Accountability and management systems, especially in rural and transparency in remote areas, exacerbate this challenge, resource use making it difficult to ensure that funds reach their intended destinations and are used Key accountability and transparency appropriately (UNDP, 2023). problems in financing health facilities in East and Southern African countries stem from Inadequate reporting practices are another inefficiencies in fund tracking, reporting, critical challenge. Health facilities often struggle and oversight mechanisms. One significant with incomplete or inaccurate financial reporting issue is the inability to trace funds effectively due to insufficient training and lack of from central governments or donors to health standardization in data collection processes. Health financing challenges and technology innovations This results in discrepancies between allocated to be informed (at least somewhat) by what and utilized funds, which undermines confidence services facilities offer and to whom they were among stakeholders, including governments, provided. Lastly, accountability mechanisms donors, and local communities. Furthermore, need to be in place to ensure money is spent many facilities lack the tools or systems prudently and in line with rules and regulations. needed to track and report on expenditures consistently, creating gaps in accountability Process mapping helps understand how (AfDB, 2021). Inability to adequately track technology innovations can help remedy expenditures at the level of cost centers health financing shortcomings. The following and relating these to outputs leads to little process map (figure 1, page 08) shows how knowledge of the costs associated with the steps are interrelated, where pressure production of specific services. points can lie and how these could be addressed through maturing technology Weak oversight and limited public innovations. The steps in the process are transparency further hinder health as follows: A person is registered before financing integrity. Many countries lack receiving a service. robust auditing systems or enforcement mechanisms to monitor how funds are spent  The service is provided, and a record at the facility level. Corruption, favoritism in of the provided service is created in resource allocation, and insufficient access the management information system. 06 to public data on funding decisions reduce accountability and limit opportunities for  This data entry is verified to ensure external scrutiny. Without adequate checks integrity. Together they form a larger and balances, funds are often misallocated or database of the utilization of services. misused, impeding equitable resource distribution and effective healthcare service  The utilization data inform payment delivery (Transparency International, 2022). to the provider or future budget allocations.  A mechanism is in place to make 2.1 Mapping technology that payment to the facility. innovations to health financing processes  Resources at the facility can then be used following local financial management rules Health financing challenges are interrelated and regulations and funds are accounted and create a difficult environment for the for and duly reported on. effective delivery of services. Effective health financing is difficult to imagine without If the registration process is a challenge, a mechanism to finance facilities directly. identity management solutions can be How much they should be paid then needs draw upon.This is discussed in chapter 3. ES Abr 1 2 3 4 5 6 7 Con Ref Anx Once a service has been provided to a payment to facilities (or budget allocation registered patient, this record needs to decisions). Actual payment can be facilitated be stored in a database. This requires through innovations in the FinTech space such (i) verification that the service did indeed as Smart Cards or Mobile Money (chapter 6). take place; and (ii) that the database itself Lastly, there are options to ensure fund use is not tampered with. Mobile verification transparency, accountability and reporting can support the first aspect (chapter 4) and through the FinTech options or use of artificial innovations with blockchain can be explored intelligence (AI) or machine learning (ML) to support database integrity (chapter 5). technology applications (chapter 7). Suchy a database can then inform the Figure 1: Process mapping illustrating the role of technology innovations in addressing health financing needs To enlarge figure 1, click here Source: World Bank ITS Lab. Record that service 07 Capture patient Provide Service was perfomed Message to patient Inform budget allocation Service Provider ID and service from Benefit (type, time, date, to confirm details of (or payment for record on Package name, ID, phone service performed purchasing agency) blockchain number of patient App Distributed Ledger Mobile Messaging ID connector Identification of service Purchasing Agency Message to Record response Receive notification Perform manual Patient Administrator for (Y/N) and patient ID and add entry to verification Administration Follow-up on blockchain HMIS process Yes: Distributed Ledger Service Distributed Ledger performed Identification of person No: Service not performed Patient Digital Confirm identification Recieve N/A: Patient did NOT respond details of service (fingerprint, name, Service or has NO Phone provided phone number) Populate confidential medical records ID connector Mobile Messaging Distributed Ledger Make use of identity management technology 08 ES Abr 1 2 3 4 5 6 7 Con Ref Anx Identity management technologies offer a secure, as iris patterns are unique and stable range of solutions - each with unique over time. Its non-contact nature makes it strengths and challenges - to enhance suitable for healthcare environments, but high health financing systems. Fingerprint costs, infrastructure requirements, and user recognition is widely used due to its high discomfort can limit its implementation. Voice accuracy and cost-effectiveness. It is user- recognition, on the other hand, is accessible friendly and can operate offline, making it and operates on basic mobile phones, making it suitable for low-resource settings. However, particularly useful in remote areas. However, it is hygiene concerns arise in shared healthcare sensitive to background noise, environments, and poor-quality fingerprints caused by manual labor, aging, or injuries can health conditions that affect voice, and hinder enrollment and verification (Biometric privacy concerns. Multi-biometric systems, Update, 2023). Additionally, if fingerprint data which combine methods like fingerprint and is not securely stored, privacy concerns may facial recognition, enhance reliability and emerge, creating ethical and legal challenges inclusivity by offering redundancy. While (UNDP, 2023). effective, these systems are costly, complex to manage, and may cause delays in service Facial recognition provides a contactless and delivery. Selecting the appropriate technology convenient solution that leverages existing requires a careful balance of cost, scalability, camera technology for identification. Its inclusivity, and data privacy considerations to non-intrusive nature eliminates hygiene ensure long-term success in health financing 09 concerns, and its scalability allows integration systems (World Bank, 2022). with mobile devices for broader accessibility. However, accuracy can be affected by lighting, Several African countries are leveraging facial obstructions, or changes in appearance, identity management technologies to such as aging or illness. Facial recognition improve health financing systems, with systems also require robust computational promising results. For example, in Kenya, power, which can be a barrier in low-resource biometric fingerprint systems have been settings. Furthermore, certain algorithms may implemented to enhance the efficiency of the exhibit biases that affect individuals of specific National Hospital Insurance Fund (NHIF). These ethnicities or skin tones, raising concerns about systems ensure that beneficiaries are accurately equity in access. identified at the point of service, reducing fraud and ensuring that only registered members Other advanced biometric solutions, such as access benefits. The technology has also iris scanning and voice recognition, offer streamlined claims processing, minimizing unique advantages but also present distinct errors and enhancing trust between healthcare limitations. Iris scanning is highly accurate and providers and patients. Make use of identity management technology Box 1: Use of fingerprint technology in the Kenyan health system to combat fraud Biometric fingerprint systems are used in Kenya for combating fraud. These systems verify identities with unique fingerprints, making it very difficult to create fake patients (“ghost patients”) or impersonate others to receive undeserved benefits (Ayang, 2024). This technology also prevents individuals from registering multiple times to exploit the system (Integrated Biometrics, 2022). The system should also ensure that healthcare providers are held accountable for their actions, as each transaction is linked to their fingerprint, making it easier to track fraudulent claims (Eastleigh Voice, 2023). Overall, these reforms were noted to have: } Reduced fraudulent claims: This translates to financial savings and ensures resources are directed towards legitimate beneficiaries. } Improved patient identification: This enhances service delivery and allows for better tracking of individual health records. } Enhanced overall accountability: This fosters trust in the system and deters fraudulent activities by healthcare providers. Kenya’s National Hospital Insurance Fund (NHIF) initially faced challenges with 10 biometric implementation, as some providers misused the system. Misuse was reported during early implementation. For example, health facilities revived dormant insurance accounts, made up fictional medical insurance claims and used fraudulent methods and biometrics collected from elsewhere to secure undeserved payments (standardmedia.co.ke, 2024). However, remedial action has been taken through integrating the system with the national registration database in the transition to the SHIF, making it more secure (Ayang, 2024; Eastleigh Voice, 2023). While some implementation challenges remain, the Kenya example shows how the use of biometric identification systems have the potential to significantly reduce fraud and ensure that resources reach those in need. This ultimately leads to a more efficient and trustworthy healthcare system (Onyango et al., 2022). Facial recognition and other biometric tools data into health and social service programs. are also being used to extend health By linking individuals’ national identity numbers coverage to underserved populations. In (NINs) to health financing schemes, such as Nigeria, the National Identity Management health insurance and subsidy programs, the Commission (NIMC) is integrating biometric system ensures that benefits reach the ES Abr 1 2 3 4 5 6 7 Con Ref Anx 11 intended recipients. This integration reduces technology to enroll members and authenticate duplication and improves access to health beneficiaries during service delivery. Combined services, particularly for vulnerable populations with mobile payment platforms like M-Pesa, in rural areas. this approach has expanded coverage, enabling rural households to contribute to the Mobile-integrated biometric systems are fund and access essential healthcare services helping bridge gaps in healthcare access without the need for traditional banking across remote regions. In Tanzania, the infrastructure. These examples highlight the government has adopted a biometric transformative potential of identity registration system for its Community Health management technologies in improving the Fund (CHF), a voluntary health insurance efficiency, transparency, and inclusivity of scheme. This system uses fingerprint health financing systems across Africa. Leverage availability of mobile phones for service use verification 12 ES Abr 1 2 3 4 5 6 7 Con Ref Anx Mobile phones offer innovative and Mobile-based verification systems have efficient methods for verifying the receipt been successfully applied in various of healthcare services, enhancing African countries, improving the efficiency accountability and reducing fraud. One and transparency of healthcare delivery. common approach is the use of unique In Kenya, mobile payment platforms like verification codes or one-time PINs (OTPs) M-Pesa are integrated with health financing sent to a beneficiary’s registered mobile schemes to streamline service delivery and number after a service is rendered. The verification. For example, beneficiaries of the beneficiary inputs this code into a system or National Hospital Insurance Fund (NHIF) use shares it with the insurer to confirm the mobile phones to receive OTPs for service service. Biometric authentication, such as verification, ensuring that only registered fingerprint or facial recognition on mobile members access benefits. This system has phones, can also be used at the point of reduced fraud, expedited reimbursements for service to ensure secure and accurate healthcare providers, and enhanced trust in the identification. These methods are particularly insurance program (Nzioka, 2023). useful for streamlining processes and reducing the risk of impersonation or service duplication In other African nations, mobile and biometric (GSMA, 2023). technologies have been used to extend healthcare access and improve service Other mobile-based verification methods tracking. In Nigeria, mobile-based platforms are provide additional flexibility and accessibility, linked to biometric national identity systems to particularly in resource-limited settings. verify health service delivery under government Mobile apps are increasingly used to allow insurance schemes. Beneficiaries can confirm 13 beneficiaries to log in, approve transactions, or their identity and validate services via SMS or provide digital signatures to confirm services. mobile apps, creating a digital audit trail for For populations with limited smartphone accountability (NIMC, 2023). Similarly, in access, SMS-based systems remain effective, Tanzania, the Community Health Fund (CHF) enabling beneficiaries to confirm receipt with incorporates mobile verification with fingerprint simple replies (e.g., “YES”). QR codes and biometrics and mobile money platforms. This Near-Field Communication (NFC) technology integration allows rural populations to enroll in also add convenience by allowing patients to health insurance schemes, make payments, and scan or tap devices to log their service receipt confirm receipt of services using their phones, digitally. These solutions not only ensure that significantly expanding coverage and health services are delivered to the intended accessibility in underserved areas (WHO, 2022). recipients but also create a digital audit trail, These examples demonstrate how mobile improving transparency and fostering trust in verification technologies are driving progress in health financing systems (WHO, 2022). health financing across Africa by reducing inefficiencies and ensuring that resources reach those who need them most. Explore blockchain to record transactions 14 ES Abr 1 2 3 4 5 6 7 Con Ref Anx Blockchain technology is an innovative management for essential commodities digital solution that has the potential to like medicines or vaccines, blockchain can transform systems and processes in low- provide real-time visibility, reducing capacity settings by providing secure, stockouts and counterfeiting, which are transparent, and tamper-proof record- prevalent in many low-resource settings keeping. Originally developed to enable (OECD, 2021; UNDP, 2023). cryptocurrency transactions, blockchain operates as a decentralized ledger where data Despite its promise, the application of is stored in interconnected blocks and blockchain in African contexts must validated by a network of users. This consider existing infrastructural and distributed nature ensures that records technical limitations. Limited internet cannot be altered retroactively, offering connectivity, low levels of digital literacy, and unparalleled security and transparency. high implementation costs pose significant Blockchain’s features, such as real-time barriers to the widespread adoption of tracking and automated transactions through blockchain systems. However, targeted use smart contracts (see Annex A for more cases in areas like financial inclusion, where details), have expanded its applications mobile platforms are already thriving, show beyond finance to sectors like healthcare, promise for leveraging blockchain to agriculture, and governance (Nakamoto, complement existing technologies. By focusing 15 2008; World Bank, 2022). on scalable and context-specific solutions, blockchain has the potential to enhance In low-capacity contexts, blockchain offers transparency, efficiency, and trust in critical significant potential to address systemic systems, even in resource-constrained challenges such as inefficiency, corruption, environments (GSMA, 2023; Transparency and lack of trust in public systems. For International, 2022). instance, in health financing, blockchain can ensure that funds are transparently distributed There are a growing number of examples of to facilities and beneficiaries, minimizing how blockchain technology is already being leakages and fraud. By creating immutable used in the African continent. The following records of transactions, it enables three examples from Ethiopia, Ghana and South governments and donors to track resources Africa (box 1) offer lessons from the fields of from allocation to expenditure, building trust education, land registry and financial regulation and accountability. Similarly, in supply chain that can be extended to the health sector. Explore blockchain to record transactions Box 2: Examples of successful use of blockchain from outside the health sector in Africa Ethiopia, Blockchain for Education and Identity Management: Ethiopia has partnered with IOHK, the company behind the Cardano blockchain platform, to implement a blockchain-based solution for education. The Ethiopian government is using the technology to create a tamper-proof system for storing and verifying educational records for 5 million students and 750,000 teachers. This initiative ensures transparency and reduces fraud in academic credentials, enabling students to share verifiable records with institutions or employers. The use of blockchain in identity management also opens opportunities for future applications in other sectors, such as health and public administration (IOHK, 2022). Ghana, Blockchain for Land Registry: Ghana’s government has implemented blockchain technology to address inefficiencies and corruption in land registration. Through a partnership with Bitland, a blockchain platform, the initiative digitizes land records, making them transparent and tamper-proof. This system helps reduce disputes over land ownership, enhances trust in land transactions, and ensures secure documentation of property rights. The use of 16 blockchain in this context demonstrates its potential for improving governance in sectors with historical inefficiencies and fraud (Bitland, 2021). South Africa, Blockchain for Financial Regulation: The South African Reserve Bank (SARB) has explored blockchain technology through Project Khokha, which tests distributed ledger technologies (DLT) for interbank payments. Using the Ethereum-based Quorum blockchain, the project demonstrated that blockchain could facilitate secure, real-time settlement of high-value financial transactions. The initiative aims to improve the efficiency and transparency of South Africa’s financial system while reducing operational costs for financial institutions. Project Khokha highlights the potential for blockchain to modernize critical infrastructure in financial governance (SARB, 2022). ES Abr 1 2 3 4 5 6 7 Con Ref Anx Make use of FinTech innovations to send money to facilities 17 Make use of FinTech innovations to send money to facilities FinTech, short for financial technology, refers population have a registered mobile money to the innovative use of technology to account (GSMA, 2023). improve and automate the delivery and use of financial services. It encompasses a wide range The widespread adoption of mobile money in of applications, including mobile payments, East and Southern Africa has been driven by digital banking, blockchain, cryptocurrencies, its ability to address financial exclusion. In a and artificial intelligence in finance. FinTech aims region where large segments of the population to make financial systems more accessible, lack access to traditional banking services, efficient, and inclusive by leveraging digital mobile money offers an accessible alternative platforms and tools to cater to the needs of that requires only a mobile phone and basic individuals, businesses, and institutions. From network coverage. This has enabled even rural mobile money services like M-Pesa in Kenya to and low-income communities to participate in global online payment systems like PayPal, the formal economy, facilitating remittances, FinTech has revolutionized how people manage, savings, and microloans. Governments and invest, and exchange money. By bridging gaps in businesses have also embraced mobile money traditional financial systems, it has become a key for tax collection, social transfers, and driver of financial inclusion, particularly in e-commerce, further embedding the technology underserved regions. into daily life. With ongoing innovations, such as the integration of mobile money with health and Mobile money applications have become education financing systems, its role continues widespread. The use of mobile money has to expand, transforming how financial services 18 grown exponentially in East and Southern Africa, are accessed and utilized across the region becoming a cornerstone of financial transactions (World Bank, 2022; GSMA, 2023). across the region. Since the introduction of M-Pesa in Kenya in 2007, mobile money Many health service providers still don’t have platforms have transformed the way individuals access to financial services and are not and businesses access financial services, making use of mobile money technology. particularly in areas with limited banking Despite the urgent need to deliver services, infrastructure. Countries like Tanzania, Uganda, many healthcare providers still don’t have access and Zimbabwe have followed suit, adopting to bank accounts, making it difficult to procure mobile money services such as Airtel Money, emergency drugs, cleaning products, equipment, MTN Mobile Money, and EcoCash. The or pay a stipend to community health workers for convenience of transferring money, paying bills, outreach services. Especially in remote areas, it and accessing credit through mobile phones has may be difficult to access a physical banking made these platforms indispensable. As of 2023, branch to withdraw cash. However, despite other Sub-Saharan Africa accounts for over 70% of options becoming increasingly available at low global mobile money transactions, with millions cost, these are generally not utilized. Benefits of of active accounts contributing to economic exploring mobile money options are outlined in activity and financial inclusion. These are served table 1. When considering the introduction of by over 130 live mobile money service providers. such a service, benefits need to be weighed In some countries such as Ghana, Kenya, and against the costs, such as fees from mobile Zimbabwe, over 60 percent of the adult banking providers. ES Abr 1 2 3 4 5 6 7 Con Ref Anx Table 1: Benefits of using mobile money for facility payments Reach In countries with high cell phone coverage, mobile money can be used to send a mobile balance directly to facilities, even in otherwise hard to reach areas without banking services infrastructure. Facility managers would otherwise rely on ‘in kind’ support from district administrations, or travel long distances to collect cash, which is both inefficient and dangerous. Stewardship Government can have full oversight over which facilities have received how much. A dashboard at the ministry of health can be set up through which transfers to providers are made and monitored. In a decentralized environment, this role can be given to the administration at the state or provincial level. Efficiency in cash The ministry of health will have full insight into the balance at the management facility mobile wallets. This allows them to understand cash flow needs and supports the efficient management of funds at HQ level (in a cash strapped environment, balances can be moved where they are most urgently needed). Transparency and Use of smart cards or mobile money allows for automated 19 accountability accounting and reporting on actual use of funds at the facility level. This strengthens transparency, allows for monitoring of fund use in real time, and provides a digital audit trail, which is a significant advantage over the use of manual systems needed when using cash. Furthermore, manual systems require manual reporting, which comes at a significant time lag and is prone to human error. Efficiency In most cases the use of mobile money is faster, cheaper to deploy and less risky than the use of cash. Financial inclusion A non-health benefit to using mobile money is financial inclusion and building credit history for suppliers. These are important aspects to building a financial sector in countries and can serve to protect financing and facilitate savings. For businesses, credit history is an important aspect for potential future loans. Explore machine learning and artificial intelligence for risk mitigations and efficiency gains 20 ES Abr 1 2 3 4 5 6 7 Con Ref Anx AI and ML are transforming accounting and dashboards and visualizations help identify key reporting by automating complex processes trends, providing a deeper understanding of and enhancing data accuracy. These financial performance. Predictive analytics technologies can process vast amounts of powered by machine learning can anticipate financial data, identifying patterns and financial risks or opportunities, giving decision- anomalies that are difficult for human auditors makers the foresight to act strategically. This to detect. For instance, AI-powered tools advanced level of reporting improves automate repetitive tasks such as data entry, transparency, strengthens stakeholder transaction reconciliation, and expense confidence, and facilitates data-driven categorization, reducing the risk of manual decision-making processes (KPMG, 2024). errors. Machine learning algorithms, which improve with time and data, adapt to emerging AI and ML can play a central role in risk financial trends and provide increasingly mitigation. By continuously monitoring financial accurate insights. By automating routine transactions, AI can detect fraudulent activities or accounting processes, organizations can save irregularities in real-time, flagging suspicious time, reduce costs, and ensure greater reliability patterns before they escalate. ML algorithms in their financial records (KPMG, 2024). analyze historical data to identify systemic vulnerabilities, offering recommendations to AI and ML can be used for tracking of strengthen internal controls. These technologies resource utilization within providers. For also support compliance with financial regulations example, if it can help with estimating how by ensuring accurate and consistent reporting, 21 physicians and nurses spend their time across reducing exposure to legal or reputational risks. As different services produced. Similarly, the same AI and ML tools become more sophisticated, they can be done for utilities and supplies, which provide essential safeguards that enhance would significantly improve the precision of governance and protect financial systems from costing work. The time spent with a patient could potential threats (EY, 2024). be a proxy to some of these computations. Similarly, FinTech applications can also help track AI and ML are increasingly being adopted payments for individual workers and help across Africa to enhance accounting, compare them across providers, specializations, reporting, and financial risk management. Here regions, and more importantly compare with are three country-specific examples: performance and efficiency indicators. } South Africa: Financial institutions like First AI and ML significantly improve reporting National Bank (FNB) are leveraging AI and ML by providing real-time analytics and to strengthen risk management. FNB has predictive capabilities. These technologies embarked on data-driven initiatives aimed at enable organizations to generate up-to-date enhancing insights across risk business units, financial reports, offering stakeholders improving efficiency, and addressing complex actionable insights and a clearer understanding risks such as financial crimes and cyber of their financial position. AI-driven threats. By integrating AI and ML, FNB aims Explore machine learning and artificial intelligence for risk mitigations and efficiency gains to streamline operations and bolster its decision-making processes and risk risk mitigation strategies (BusinessTech management in the financial industry Africa (2023)). (Forbes Africa (2023)). } Kenya: The microinsurance company Pula These examples illustrate the growing utilizes AI to provide insurance solutions for integration of AI and ML in Africa’s financial smallholder farmers. By analyzing on-the- sectors, strengthening efficiency, accuracy, ground and satellite data, Pula employs AI to and risk mitigation in accounting and determine premiums and assess risks, reporting practices. Similarly, these tools enabling affordable insurance products. This can be employed in health financing where approach has facilitated over $120 million in budget and expenditure reports can be insurance payouts, aiding farmers in populated according to need and map out risk recovering swiftly from crises (Time (2023)). profiles. For example, they can be used to mitigate the cost of verification and counter- } Nigeria: The financial sector is exploring verification in results-based financing AI for credit risk assessment and financial operations in health. forecasting. AI technologies are being implemented to predict stock prices, perform credit scoring, and model complex financial instruments, thereby enhancing 22 ES Abr 1 2 3 4 5 6 7 Con Ref Anx Conclusion Maturing technologies offer transformative adoption. For example, a mobile payment opportunities to address health financing platform will have limited impact if large challenges by enhancing efficiency, portions of the target population lack access transparency, and inclusivity. Tools such as to mobile devices, connectivity, or don’t have mobile money platforms, biometric systems, the necessary digital literacy. Contextualizing and blockchain are already demonstrating their technology deployment allows systems to potential in other sectors across the Africa harness its full potential while minimizing risks, region. By leveraging these technologies, ensuring that solutions address root causes of health financing systems can foster efficiency, health financing challenges rather than transparency, and accountability, and ensure introducing new complexities. Conversely, that funds reach intended beneficiaries. technologies that are poorly aligned with the For instance, mobile money can facilitate needs, infrastructure, or capacity of health access to resources by remote providers or systems can lead to wasted resources, enable previously unbanked populations to implementation failures, or even exacerbate participate in health insurance schemes, while existing inefficiencies (see box 2 for risks). blockchain’s tamper-proof ledgers can provide For example, deploying advanced tools like needed accountability and transparency. blockchain or AI without adequate These advances can address prevailing health infrastructure, such as reliable internet and financing bottlenecks in the region. However, electricity, can render the technology the success of these technologies hinges on unusable. Similarly, insufficient training for their alignment with the specific needs, health workers and administrators can result in 23 capacities, and infrastructure of the context underutilization or misuse of the systems. in which they are deployed. Overly complex solutions may also alienate end users, particularly in low-capacity settings Ensuring that these technologies are where simpler tools may be more effective. context-appropriate is essential for their Additionally, introducing technologies without effectiveness and sustainability. Introducing addressing data privacy and security risks can advanced digital tools into low-capacity undermine trust among stakeholders and leave settings without adequate infrastructure, such health systems vulnerable to breaches. as reliable internet, electricity, or trained Therefore, careful selection, piloting, and personnel, risks creating additional challenges alignment with local needs, resources, and rather than solving existing ones. Similarly, governance structures are critical to ensure that cultural and socio-economic factors must be new technologies enhance rather than hinder considered to ensure equitable access and health financing systems (World Bank, 2022). Conclusion Box 3: Consider risks with introducing new technologies Source: World Bank ITS Lab. Introducing disruptive technologies into existing systems carries significant risks that can undermine their intended benefits if not carefully managed. One major risk is the displacement or marginalization of those who lack the resources or skills to adapt to new technologies. For instance, in low-capacity settings, health workers or administrators who are not adequately trained in using advanced tools may struggle to adopt them, leading to reduced efficiency and potential exclusion from the system. Additionally, the rapid introduction of disruptive technologies can outpace the development of regulatory frameworks, resulting in unregulated or improper usage, which could compromise data security, privacy, and fairness. Without adequate safeguards, these technologies may unintentionally deepen inequities, particularly for marginalized populations who may not have access to the infrastructure required to benefit from them (UNDP, 2023; OECD, 2021). Disruptive technologies can also destabilize existing systems, creating unintended operational or financial challenges. Integrating new technologies often requires substantial upfront investments in infrastructure, training, and system upgrades, which can strain already limited budgets, especially in resource-constrained contexts. The 24 transition phase may lead to disruptions in service delivery as institutions adapt to new systems, potentially reducing trust among stakeholders. Furthermore, the long-term maintenance of these technologies can impose ongoing financial burdens, particularly if they rely on proprietary platforms or specialized technical support. If these costs are not anticipated or planned for, the sustainability of the technology and its benefits may be jeopardized (World Bank, 2022; Transparency International, 2022). Another key risk is the potential for misuse or abuse of disruptive technologies, particularly in contexts with weak governance or oversight. Technologies like blockchain, artificial intelligence, or digital identification systems, while offering significant benefits, can also be used to reinforce centralized control or surveil populations if deployed without adequate transparency or accountability measures. Corruption or manipulation of the systems could further erode trust, particularly in environments where public confidence in institutions is already low. Additionally, over- reliance on technology without addressing underlying structural issues, such as inefficiencies or inequities in governance, may result in superficial solutions that fail to address the root causes of systemic challenges. These risks underscore the importance of a cautious, inclusive, and well-regulated approach to the introduction of disruptive technologies (OECD, 2021; WHO, 2022). ES Abr 1 2 3 4 5 6 7 Con Ref Anx Considering legacy systems in reforms is if the underlying problem is a lack of capacity critical to ensure continuity and maintain the or poor governance, the technology will not functionality of existing processes while deliver its intended outcomes. PDIA advocates transitioning to improved systems. Legacy for a problem-focused, iterative process that systems often form the backbone of operations involves understanding the local context, in many organizations, storing essential historical engaging stakeholders, and testing small-scale data and facilitating core functions that cannot interventions to learn and adapt solutions as be abruptly discontinued. Disregarding these needed. This ensures that reforms are both systems during reforms risks creating operational context-specific and sustainable, addressing disruptions, data loss, and gaps in service the functional problems rather than imposing delivery. Integrating new technologies with generic or misaligned technological tools legacy systems allows for a gradual and (Andrews, Pritchett, and Woolcock, 2017). manageable transition, enabling organizations to leverage the strengths of both while minimizing Introducing emerging technologies into the downtime and inefficiencies. For instance, in public sector often faces significant political health financing, integrating digital payment economy challenges that can delay or platforms with existing paper-based systems undermine their adoption. Resistance from ensures that critical functions such as record- entrenched interests is a common barrier, as the keeping and fund disbursement continue without transparency and efficiency brought by interruption. Maintaining continuity also helps technologies like blockchain or digital platforms build trust among stakeholders, including staff can threaten existing power dynamics, and beneficiaries, who may be resistant to particularly in environments where corruption or 25 sudden changes. Effective reforms should aim patronage networks are prevalent. Bureaucratic for interoperability and scalability, ensuring that inertia and fragmented decision-making new solutions enhance rather than replace or processes within government institutions can compromise legacy systems. further slow the adoption of these technologies, as various stakeholders may have conflicting Reforms in public systems, including health priorities or lack alignment on implementation financing, are most effective when driven by strategies. Additionally, limited technical clearly identified problems rather than being capacity and inadequate infrastructure often led by pre-selected technological solutions. require substantial investments, which can be This approach aligns with Matt Andrews’ politically contentious in resource-constrained Problem-Driven Iterative Adaptation (PDIA), contexts. Public mistrust in government which emphasizes starting with a clear initiatives, particularly in regions with weak understanding of the problems governance, can also hinder adoption, as citizens to be solved rather than jumping to solutions. may be skeptical of the motives behind Technology-driven reforms often risk technological reforms. Finally, external donor or addressing symptoms rather than root causes, private sector involvement in funding or resulting in misaligned interventions that fail to implementing technology projects may raise generate sustainable change. For example, concerns about sovereignty and control, introducing a sophisticated information complicating political buy-in and creating friction management system may seem appealing, but among key actors (OECD, 2021; UNDP, 2023). References Arewa, O. B. (2022). Disrupting Africa: Technology, Law, and Development. Oxford University Press. Andrews, M., Pritchett, L., and Woolcock, M. (2017). Building State Capability: Evidence, Analysis, Action. Oxford: Oxford University Press. African Development Bank (2021). A Practical Guide to Value for Money in the Health Sector in Africa. Available at: https://www.afdb.org/en/documents/practical-guide-value-money-health-sector-africa- december-2021. African Development Bank (2022). Strategy for Quality Health Infrastructure in Africa 2022-2030. Available at: https://www.afdb.org/sites/default/files/documents/publications/strategy_for_quality_health_ infrastructure_in_africa_2022-2030.pdf. African Development Bank (2018). World Health Day: Strengthened Health Systems and Sound Financing Key to Achieving Health for All. Available at: https://www.afdb.org/en/news-and-events/world-health-day- strengthened-health-systems-and-sound-financing-key-to-achieving-health-for-all-17992. Ayang, M. (2024, January 10). Govt says biometrics used to aid and abet massive health insurance fraud in Kenya. Biometric Update. https://www.biometricupdate.com/202401/govt-says-biometrics-used-to-aid- and-abet-massive-health-insurance-fraud-in-kenya 26 Biometric Update (2023). Biometric Technologies in Healthcare. Available at: https://www.biometricupdate.com. Bitland (2021). Blockchain Solutions for Land Registration in Ghana. Available at: https://bitland.world BusinessTech Africa (2023). AI and Machine Learning Are Reimagining Risk Management in FNB. Available at: https://www.businesstechafrica.co.za/business/banking-and-finance/2023/03/30/ai-and-machine- learning-are-reimagining-risk-management-in-fnb/. Distor, K. et al. (2023). Emerging Technologies in Africa: Artificial Intelligence, Blockchain, and Internet of Things Applications and Way Forward. Technological Forecasting and Social Change, 186, 122115. Eastleigh Voice. (2023). SHIF reverts to biometric system to curb corruption, enhance efficiency. https://eastleighvoice.co.ke/Social%20Health%20Insurance%20Fund%20(SHIF)%20scheme/99968/shif- reverts-to-biometric-system-to-curb-corruption-enhance-efficiency EY (2024). Why AI is Both a Risk and a Way to Manage Risk. Available at: https://www.ey.com/en_uk/insights/ assurance/why-ai-is-both-a-risk-and-a-way-to-manage ES Abr 1 2 3 4 5 6 7 Con Ref Anx Forbes Africa (2023). How Artificial Intelligence Affects the Financial Sector in Africa. Available at: https://www.forbesafrica.com/finance/2023/12/04/how-artificial-intelligence-afects-the- financial-sector-in-africa/. GSMA (2024). State of the Industry Report on Mobile Money 2024. Available at: https://www.gsma.com/ solutions-and-impact/connectivity-for-good/mobile-for-development/gsma_resources/state-of-the- industry-report-on-mobile-money-2024/. GSMA (2024). State of the Industry Report on Mobile Money Sub-Saharan Africa, West Africa & Asia. Available at: https://www.gsma.com/solutions-and-impact/connectivity-for-good/mobile-for- development/gsma_resources/state-of-the-industry-report-on-mobile-money-sub-saharan-africa-west- africa-asia/. GSMA (2024). The Mobile Economy Sub-Saharan Africa 2024. Available at: https://event-assets.gsma.com/ pdf/20231017-GSMA-Mobile-Economy-Sub-Saharan-Africa-report.pdf. GSMA (2021). Global Mobile Operators and GSMA Team up to Build Blockchain to Transform Back-Office Roaming. Available at: https://www.gsma.com/newsroom/press-release/global-mobile-operators-and- gsma-team-up-to-build-blockchain-to-transform-back-office-roaming/. 27 GSMA (2023). State of the Industry Report on Mobile Money 2023. Available at: https://www.gsma.com/ solutions-and-impact/connectivity-for-good/mobile-for-development/gsma_resources/state-of-the- industry-report-on-mobile-money-2023-2/. Integrated Biometrics. (2022). Afya Research Africa uses Integrated Biometrics’ Columbo to Deliver Data- Driven Healthcare to Rural Kenya. https://integratedbiometrics.com/press-releases/afya-research-africa- uses-integrated-biometrics-columbo-to-deliver-data-driven-healthcare-to-rural-kenya IOHK (2022). Cardano Partners with Ethiopia for Blockchain Solutions. Available at: https://iohk.io Kærgård, N., & Jammeh, T. K. (Eds.). (2017). Mobile Money and Financial Inclusion in Africa. Springer. KPMG (2024). AI in Financial Reporting and Audit. Available at: https://assets.kpmg.com/content/dam/ kpmg/xx/pdf/2024/04/ai-in-financial-reporting-and-audit-web.pdf. NIMC (2023). NIMC Set to Provide Identity Verification Services to Insurance and Pension Sectors. Available at: https://nimc.gov.ng. Nakamoto, S. (2008). Bitcoin: A Peer-to-Peer Electronic Cash System. Available at: https://bitcoin.org References Nzioka, C. (2023). How to Pay for NHIF Through M-Pesa. Available at: https://discover.hubpages.com. OECD (2019). State of the Art in the Use of Emerging Technologies in the Public Sector. OECD Working Papers on Public Governance No. 31. Paris: OECD Publishing. OECD (2019). Blockchain Technologies as a Digital Enabler for Sustainable Infrastructure. OECD Environment Policy Papers No. 16. Paris: OECD Publishing. Onyango, J. O., Odero, et al. (2022). Implementation of fingerprint technology for unique patient matching and identification at an HIV care and treatment facility in western Kenya: cross-sectional study. JMIR mHealth and uHealth, 10(1), e33533. Stout, M. (2021). To What Extent Can Blockchain Help Development Co-operation Actors Meet the 2030 Agenda? OECD Development Co-operation Working Papers No. 95. Paris: OECD Publishing. South African Reserve Bank (SARB) (2022). Project Khokha: Exploring Blockchain for Financial Transactions. Available at: https://www.resbank.co.za Time (2023). How Thomas Njeru is Transforming African Agriculture Through Insurance. Available at: https://time.com/7023557/thomas-njeru/. 28 Transparency International (2017). Diagnosing Corruption in Healthcare. Berlin: Transparency International. Available at: https://ti-health.org/wp-content/uploads/2017/01/Diagnosing-Corruption-in-Health- Updated.pdf. United Nations Development Programme (UNDP) (2021). A Shared Vision for Digital Technology and Governance: The Role of Governance in Ensuring Digital Technologies Contribute to Development and Mitigate Risks. New York: UNDP. Available at: https://www.undp.org/publications/dfs-shared-vision-digital- technology-and-governance-role-governance-ensuring-digital-technologies-contribute-development- and-mitigate-risk. United Nations Development Programme (UNDP) (2022). #Web3for2030: How Can Web3 Help Achieve the Sustainable Development Goals? New York: UNDP. Available at: https://www.undp.org/publications/ web3for2030-how-can-web3-help-achieve-sustainable-development-goals. United Nations Development Programme (UNDP) (2022). Digital Strategy 2022–2025. New York: UNDP. Available at: https://www.undp.org/publications/digital-strategy-2022-2025. United Nations Development Programme (UNDP). (2023). Digital Entrepreneurship in Africa. United Nations Development Programme. ES Abr 1 2 3 4 5 6 7 Con Ref Anx World Health Organization (WHO) (2021). Global Strategy on Digital Health 2020–2025. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789240020924. World Health Organization (WHO) (2021). Digital Technologies for Health Financing: What Are the Benefits and Risks for Health Systems? Health Financing Working Paper No. 19. Geneva: WHO. Available at: https:// www.who.int/publications/i/item/9789240031005. World Health Organization (WHO) Regional Office for Africa (2022). Atlas of African Health Statistics 2022: Health Situation Analysis of the WHO African Region. Brazzaville: WHO Regional Office for Africa. Available at: https://www.afro.who.int/publications/atlas-african-health-statistics-2022-health-situation- analysis-who-african-region-0. World Health Organization (WHO) Regional Office for Africa (2012). Health Systems in Africa: Community Perceptions and Perspectives. Brazzaville: WHO Regional Office for Africa. Available at: https://www.afro. who.int/sites/default/files/2017-06/english---health_systems_in_africa---2012.pdf. World Health Organization (WHO) (2019). WHO Guideline Recommendations on Digital Interventions for Health System Strengthening. Geneva: WHO. Available at: https://apps.who.int/iris/bitstream/hand le/10665/311941/9789241550505-eng.pdf. World Health Organization (WHO) (2021). Health Policy and Systems Research in Sub-Saharan Africa: Current 29 Trends and Key Lessons on How to Improve the Use of Evidence in Health Policy. Geneva: WHO. Available at: https://apps.who.int/iris/handle/10665/342843. World Bank (2023). Digital-in-Health: Unlocking the Value for Everyone. Available at: https://www.worldbank. org/en/topic/health/publication/digital-in-health-unlocking-the-value-for-everyone. World Bank (2023). Digital Progress and Trends Report. Available at: https://www.worldbank.org/en/ publication/digital-progress-and-trends-report. World Bank (2023). Digital Health Interventions: An Evidence Gap Map Report. Available at: https:// documents.worldbank.org/en/publication/documents-reports/documentdetail/858961624292229020/ digital-health-interventions-an-evidence-gap-map-report Annex A: Key concepts and features of blockchain Decentralization. allow decentralized systems to be developed that share the information and interconnect to In traditional data management systems, data ensure that all nodes in the network contain are centralized in databases and controlled by the same information. In these decentralized centralized business services or governmental systems, there is no core authority that agencies. The simplest form of such a dictates what information can be accessed by centralized system can be described by a other participants in the network; every traditional client-server model where each participant in the network can access the client in the system, whether a personal history of transactions or confirm new computer, a smart phone or an internet- transactions. connected sensor, joins with a centralized server. Every time a Google search is performed for example, the query is sent to a Cryptography. centralized server that responds to the client with the relevant information required. Cryptography is a method of developing Centralized systems, despite being widely techniques and protocols to prevent a third implemented, have a number of vulnerabilities party from accessing and gaining knowledge of that mean that they are vulnerable to attack by the data from private messages during a 30 potential hackers that can easily block access communication process. to the system (for example through denial of service attacks), system upgrades can lead to Key terms related to cryptography include: the halting of entire systems (recently Banks have been reported to have suffered during  Encryption: This is a process of converting failed upgrades such as the case of the TSB: plaintext (normal text) to ciphertext TSB IT meltdown cost bank £330m and 80,000 (random sequence of bits). customers reported in 2018 in the UK). Additionally, loss of access to information can  Decryption: The inverse process of occur if the centralized system is shut down encryption, i.e., conversion of ciphertext and, in the worst case, where there is to plaintext. corruption in the system either by unforeseen events or by the actions of a malicious agent.  Cipher: The mathematical function of conversion, i.e., a cryptographic Where the users of a system have a common algorithm which is used to convert interest in having undisturbed access to plaintext to ciphertext. information stored on and interaction with a system with which there is a higher availability  Key: A small amount of information of services and reaction time to accessing the that is required to trigger the output services, modern networking technologies of the cryptographic algorithm. ES Abr 1 2 3 4 5 6 7 Con Ref Anx There are mainly three different ways to Transparency. perform cryptographic algorithms, namely, symmetric-key cryptography, asymmetric-key Effective identity management is a key cryptography, and hash functions. component of working with distributed ledger technologies. We are used to interacting with information technology systems and storing 1. Symmetric-Key Cryptography: In this our data in a wide range of diverse systems. encryption method, we take a single key The technological advantages of including into application. This common key is used privacy and security in our online interactions for both the encryption as well as the within the internet is a key requirement from decryption process. Using a common single many users to make it clearer what access third key creates a problem of securely party organizations should have to our personal transferring the key between the sender data and what use these third parties can make and the receiver. It is also called Secret-Key of our data. There is a long history in the Cryptography. development of cryptographic techniques that enable privacy to be achieved in online service use. Successful encryption methods include 2. Asymmetric-Key Cryptography: public and private key generation to secure This encryption method uses a pair of keys, the information transfer over the internet. 31 an encryption key, and a decryption key, Such open-source techniques can be used as named public key and private key part of blockchain technology to provide both respectively. The key pair generated by security and transparency in the use of DLT this algorithm consists of a private key based systems. A person’s identity is hidden and a unique public key that is generated via complex cryptography and is a clear using the same algorithm. It is also called component in being able to follow a transaction Public-Key Cryptography. history without knowing the individual behind the transaction. 3. Hash Functions: This type of encryption The use of private keys will ensure that the doesn’t make use of keys. It uses a cipher client’s real identity remains secure, whilst to generate a hash value of a fixed length the transactions of that person can still be from the plaintext. It is nearly impossible viewed by following the chain of blocks that for the contents of plain text to be are associated with this secure key. A user recovered from the ciphertext. has the possibility of controlling access to the information by deciding who can has access to the decryption-enabling public key. Such aspects are central to one of the advantages of DLT use: that there is the possibility to control both system user identity Annex and what system information is visible to which network. Since a change in any block results in system users. Transparency can be achieved in significant changes in the hash pointers to all that all system users, where they have a previous and subsequent blocks, the DLT common business collaboration goal for system ensures the immutability of the system. This use, have an interest in being trusted as immutability also provides the added benefit of stakeholders in the business transactions and providing the possibility to audit all changes in transaction transparency can be achieved the life of the blocks. through the DLT use. Smart contracts. Immutability. Smart contracts formalize the rules of the set Immutability means that, once a transaction of transactions on the blockchain. Distributed has been entered into the blockchain, it cannot ledgers enable the coding of simple business be tampered with and changed at a later date contracts that will execute when specified without the change being transparent to all conditions are met. In the case of health permissioned users. Blockchain technology can service provision these could define who is achieve this property by implementing providing what financing under what conditions cryptographic hash functions. The blockchain is for the provision of which specific goods or a linked list (the ledger) that contains data and services with which outcomes. Ethereum is an 32 a hash pointer that points to its previous example of an open source blockchain project block, hence creating the chain of blocks. The that was built specifically to realise this hash pointer is like a pointer (that indicates possibility. the location of linked information) but instead of just containing the address of a previous Automated addition and processing of data. block, it also contains the hash of the data Internet of Things (IoT) allows for automating inside the previous block. data on the chain. The Internet of Things describes a network-controlled management This is the key to the immutability property of of certain types of electronic devices with the blockchain technology. An attempted change ability to transfer data over the network in the content of a block will automatically without the need for human interaction. For result in the content of the hash pointer of the instance, for a health service delivery use case, block resulting in a break with the link to the the physiological parameters measured previous block. Without the ability to access all continuously by medical devices can be used as nodes in the distributed network and a part of an auditable treatment process, a synchronously update all references to the packaged temperature sensor as part of the altered block, the system can identify blocks cold-chain tracking of the shipping of that do not belong to the chain of changes and temperature sensitive pharmaceuticals during so reject the admission of that block into the distribution, or patient adherence to track the ES Abr 1 2 3 4 5 6 7 Con Ref Anx appropriate uptake and usage of medication Developing digital identity standards is proving by patients. Smart contracts make the to be a highly complex process. Technical automation of remote systems management challenges aside, a universal online identity possible. A combination of software, sensors, solution requires co-operation between private and the network can facilitate an exchange of entities and the local government. An data between objects and mechanisms. The advantage of blockchain use in health care is result increases system efficiency and that the identify management system can improves cost monitoring. The access and more easily navigate legal systems and identity control of multiple web connected devices management methods (e.g. fingerprint, face (for monitoring, measurement or quality recognition, personal smartcard or identity control) could be a natural extension of a license/passport). hospital’s existing network infrastructure, as an example of how IoT connected to a blockchain can be utilised in UHC. The use of IoT within healthcare could run the gamut of applications, from predictive maintenance of medical treatment to data analytics measuring the outcomes of a treatment program’s impact - and mass-scale automated systems management - to give quantifiable reporting on the outcomes of the provision of 33 health-related project funding. Identity management. Blockchain requires stakeholder identity management in service provision to ensure the auditing transparency of what events have been undertaken by whichever player in the system. The ability to verify identity is the lynchpin of auditing the transactions that happen as part of smart contracts. The distributed ledger offers enhanced methods for proving who someone is, along with the possibility to digitize personal documents. Having a secure identity is an important aspect for online interactions, especially given health records or contact tracing confidentiality. LEVERAGING MATURING TECHNOLOGIES FOR HEALTH FINANCING NEEDS IN EAST AND SOUTHERN AFRICA Return to text, click here Record that service Capture patient Provide Service was perfomed Message to patient Inform budget allocation Service Provider ID and service from Benefit (type, time, date, to confirm details of (or payment for record on Package name, ID, phone service performed purchasing agency) blockchain number of patient App Distributed Ledger Mobile Messaging ID connector Identification of service Purchasing Agency Message to Record response Receive notification Perform manual Patient Administrator for (Y/N) and patient ID and add entry to verification Administration Follow-up on blockchain HMIS process Yes: Distributed Ledger Service Distributed Ledger performed Identification of person No: Service not performed Patient Digital Confirm identification Recieve N/A: Patient did NOT respond details of service (fingerprint, name, Service or has NO Phone provided phone number) Populate confidential medical records ID connector Mobile Messaging Distributed Ledger