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Background: The growth of Information and Communication Technology in Kenya has facilitated implementation of a large number of eHealth projects in a bid to cost-effectively address health and health system challenges. This systematic review aims to provide a situational analysis of eHealth initiatives being implemented in Kenya, including an assessment of the areas of focus and geographic distribution of the health projects. The search strategy involved peer and non-peer reviewed sources of relevant information relating to projects under implementation in Kenya. The projects were examined based on strategic area of implementation, health purpose and focus, geographic location, evaluation status and thematic area. Results: A total of 114 citations comprising 69 eHealth projects fulfilled the inclusion criteria. The eHealth projects included 47 mHealth projects, 9 health information system projects, 8 eLearning projects and 5 telemedicine projects. In terms of projects geographical distribution, 24 were executed in Nairobi whilst 15 were designed to have a national coverage but only 3 were scaled up. In terms of health focus, 19 projects were mainly on primary care, 17 on HIV/AIDS and 11 on maternal and child health (MNCH). Only 8 projects were rigorously evaluated under randomized control trials. Conclusion: This review discovered that there is a myriad of eHealth projects being implemented in Kenya, mainly in the mHealth strategic area and focusing mostly on primary care and HIV/AIDs. Based on our analysis, most of the projects were rarely evaluated. In addition, few projects are implemented in marginalised areas and least urbanized counties with more health care needs, notwithstanding the fact that adoption of information and communication technology should aim to improve health equity (i.e. improve access to health care particularly in remote parts of the country in order to reduce geographical inequities) and contribute to overall health systems strengthening.
A search of peer reviewed and non-peer reviewed sources of relevant information was performed. The search for peer reviewed literature was conducted in PubMed, Embase, Web of Science, Econlit, SocIndex, Toc Premier, Cochrane Database of Systematic Reviews, INASP, LISTA, CAB Abstracts, Directory of Open Access Journals, EBSCOhost (incorporating Academic Search Complete) and Google Scholar. This however was not sufficient as there were large number of eHealth projects in Kenya that were not reported in peer reviewed literature. Therefore, to ensure all relevant information was captured, a search was extended to non-peer reviewed sources including web-based portals for eHealth, profit and not-for-profit organizational websites, newspaper articles, and blogs. The search was also extended to eHealth implementers who had not yet published information, government documents and organizations reports such as those of WHO, m-Health alliance and International Development Research Centre (IDRC) among others. The first search strategy was performed on all documents related to eHealth projects under implementation in Kenya in peer reviewed sources. The search terms used with AND/OR included; These search terms and key words were used so as to capture all the relevant projects in Kenya. Since eHealth is the use of use of information and communication technologies (ICT) for health [1], the key words were selected so as to address all strategic areas of implementation. The strategic areas included telemedicine, health information systems (including electronic health records), mHealth (health through the use of mobile devices) and eLearning (including distance education or learning) as defined in the Kenya National eHealth Strategy) [14]. All strategic areas of eHealth implementation were included in order to develop a comprehensive registry of projects considering this was the first situational analysis in Kenya. For the non-peer reviewed online databases, a similar search strategy using the same keywords and concepts as in the peer reviewed strategy was used as shown in Table 1. A search for relevant documents on web-portals was also undertaken including profit and not-for-profit organizations websites and blogs documenting eHealth projects in Kenya consisting of 3–5 steps as illustrated in Table 1. The next step, which can be deemed as subjective, was initiated through our research network in Kenya where personal communication with some eHealth implementers was sought to gather information relating to their innovation. Finally, hand searches of cited references in documents and reports obtained were finally used to augment the search. Opinion pieces, publications and letters to the editor lacking relevant data were excluded. The search strategy consisted of seven steps illustrated in Table 1 and involved eHealth initiatives being implemented in Kenya. Search strategy used (Source: authors’ synthesis) Since, the ICT sector and the adoption of eHealth initiatives in Kenya is fairly nascent [8], the time period was not specified. All publications selected and information included in this study had to have been implemented in Kenya with clear details of the specific eHealth application under implementation. The retrieved records from each search were screened for eligibility. Conflicting opinions were resolved through discussion amongst the authors. The description of data extracted from the eligible publications involved description of eHealth application; strategic area of project implementation (either mHealth, telemedicine, health information systems or eLearning as defined in the Kenya National eHealth Strategy) [14]; and geographic location of the project. Other descriptive criteria included thematic area or domain of the project as informed by previous research undertaken by Kallander et al. [22] and Labrique et al. [23]; project implementation period; specific health focus and evaluation status. The data on the funding source was also extracted where applicable. In instances where necessary data was not clearly stated, communication was initiated with the relevant publication authors to seek clarification and if possible share missing data. However, due to the sensitive nature of this information, most private projects were not prepared to disclose the information deemed as delicate. In light of the vast number of projects identified, efforts were made to classify the specific areas of eHealth project implementation through development of different categories. The categories facilitated assessment of the extent to which eHealth projects focused on specific facets of eHealth at the expense of others. The categorization consisted of four parts. First was the strategic area; second, the thematic area; third, the health area of focus; and finally the geographic location of all the projects being implemented. The strategic areas of project implementation were adopted from the Kenya National eHealth Strategy 2011–2017 [14] namely, telemedicine, health information systems, mHealth and eLearning. Due to overlap with other areas, the strategic area referring to health information for citizens was not analysed separately but included in other project implementation areas. The second categorization centred on thematic areas was adopted from prior research work that highlighted the most common applications in mHealth and eHealth [22, 23]. The twelve most common applications of mHealth as described by Labrique et al. [23] provides a robust framework that was applied in this study to categorize eHealth projects in Kenya. These includes: (1) client education and behaviour change communication; (2) sensors and point-of-care diagnostics; (3) registries and vital event tracking; (4) data collection and reporting; (5) electronic health records; (6) electronic decision support such as information, protocols, algorithms, checklists; (7) provider-to-provider communication such as user groups, consultations; (8) provider work planning and scheduling; (9) provider training and education; (10) human resource management; (11) supply chain management; and (12) financial transactions and incentives (i.e. use of mobile money transfers and banking services to pay for health services and incentivise patients). The health focus category entailed the specific health areas of projects focus including malaria, HIV/AIDS, tuberculosis, primary care, health care financing among others. Whilst the project geographic location category adopted, details the specific setting in which the project was executed. Most eHealth projects were designed to be implemented in specific geographical locations with a few projects implemented nationally. This study produced geo-coded maps and plotted all identified projects based on their strategic area of implementation. The maps were layered based on urbanization illustrating the number of residents living in towns with at least 2000 inhabitants [24] and marginalised counties as identified by the Commission on Revenue Allocation (CRA) [25]. The marginalised counties were identified based on the County Development Index (CDI) developed by the CRA which is a composite index consisting of indicators that measures the state of health (for example, health, education and infrastructure are all weighted at 28%, and the level of poverty in a county indicator at 16%) [25, 26]. Based on these different criteria, the following fourteen counties are classified as marginalised with CDI ranging from 0.27 to 0.52. The counties are Turkana, Mandera, Wajir, Marsabit, Samburu, West Pokot, Tana River, Narok, Kwale, Garissa, Kilifi, Taita Taveta, Isiolo and Lamu.
