Telehealth After USAID: Building Sustainable Systems in Sub-Saharan African Health Services
The article examines telehealth’s evolving role in African health systems following USAID’s dissolution and shrinking donor funding. While telehealth has expanded access during health crises and in remote communities, many initiatives remain donor-dependent, fragmented, and poorly integrated into national systems. Over-reliance on external platforms risks weakening domestic health workforces. This article advances three priorities for sustainable integration; it advocates for establishing domestic ownership and financing of telehealth systems, strengthening the domestic health workforce through training and retention, and legitimizing community health workers as frontline telehealth facilitators.
Introduction: An Overview of Telehealth in Sub-Saharan Africa
Telehealth, defined as the provision of healthcare services remotely via telecommunications and information technology, has fundamentally transformed service delivery over the past two decades. Historically, telehealth promised to extend specialist expertise to rural and underserved areas where geography, infrastructure, and workforce constraints prevented timely access to care. Today, telehealth serves multiple critical functions: synchronous video consultations, asynchronous store-and-forward diagnostic modes (where images, reports, and patient data are transmitted for later review), chronic disease monitoring, and rapid deployment of specialized knowledge during crises.
The majority of digital health funding in Africa originates from external donors, with telehealth initiatives often established as pilot projects or time-limited interventions. While such external support has been instrumental in demonstrating potential, it has also created precarious dependency. The dismantling of USAID presents a significant strategic risk to the continuity of health services. While telehealth offers a critical tool for access to care and infectious disease resilience, an over-reliance on external telehealth models risks undermining domestic health workforce development. When telehealth reinforces dependency rather than builds capacity, the central question becomes: how can African countries transition from externally supported telehealth delivery to a model that strengthens local medical training, anchors telehealth within national health systems, and enhances both everyday care and epidemic preparedness?
Telehealth in Epidemics and Pandemics
Telehealth’s utility has been most profoundly demonstrated during public health crises. While telehealth has been deployed in response to natural disasters and regional epidemics for decades, its global adoption was dramatically accelerated by the COVID-19 pandemic. The global crisis created an urgent need: healthcare systems were overwhelmed, travel was severely restricted, and both patients and providers feared infection in clinical settings. In this context, telehealth shifted from a niche service to a core component of healthcare delivery.
This crisis-driven adoption was strategically necessary to reduce pressure on hospitals, limit hospital-acquired infections, and ensure that patients with chronic conditions continued to receive care amid lockdowns. Several African countries adopted temporary regulatory flexibilities during the COVID-19 pandemic to expand access to telemedicine. These included relaxing cross-border consultation requirements, permitting electronic prescriptions, and expediting approval of telemedicine protocols.
Beyond the COVID-19 pandemic, telehealth has proven instrumental in deploying specialized expertise to crisis-affected areas lacking sufficient local capacity. During the Ebola virus outbreak, telehealth platforms connected local healthcare workers with international experts to guide case management, infection control, and public health surveillance. This remote support bridged critical knowledge gaps and augmented frontline responders’ skills without requiring large-scale foreign deployment. Remote support for contact tracing and coordination of community health workers (CHWs) also demonstrated how digital tools could strengthen epidemic response in resource-constrained settings.
Digital Infrastructure and Telehealth Implementation
Despite telehealth’s clear benefits, many programs remain implemented as vertical projects; disease-specific or intervention-specific programs operating independently of broader health systems. Consequently, as funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) and other donor streams concludes and funding priorities shift, these initiatives face collapse due to weak health system integration, limited financial leadership, and resource shortages.
Digital infrastructure shapes implementation challenges across regions. East Africa has emerged as a relative leader in digital health innovation. Kenya’s widespread adoption of mobile money through M-PESA created both technical infrastructure and population-level digital literacy, facilitating telehealth expansion. The region is supported by relatively widespread mobile internet penetration and growing technology sectors. West Africa presents a contrasting picture, characterized by large populations, diverse linguistic landscapes, and highly variable infrastructure and governance capacity. Ghana has made notable progress in policy frameworks for telemedicine and in integrating digital tools into its National Health Insurance Scheme. However, Nigeria, Senegal, and other countries in the region face challenges, including lower rural internet penetration than in East Africa, multiple language requirements that complicate platform design, and health systems stretched thin by endemic disease burdens.
Southern Africa encompasses both the continent’s most economically developed nation and countries facing significant infrastructure challenges. South Africa’s relatively sophisticated healthcare system, strong telecommunications infrastructure, and established private health sector have enabled large-scale telehealth deployment. Concurrently, underfunded public clinics in remote provinces lack reliable internet connectivity. These regional differences underscore that telehealth implementation strategies cannot be uniformly applied across sub-Saharan Africa. What remains consistent, however, is the imperative to anchor telehealth within domestic health systems and rework models that collapse when external support ends.
The Post-USAID Landscape: Strategic Priorities for Resilient Integration
Though external aid through USAID helped African countries manage infectious diseases, the vertical project-based implementation model has fostered a cycle of dependency that undermines long-term sustainability and local ownership. The dissolution of USAID has exposed a landscape of donor-dependent initiatives characterized by fragmented services and limited integration. To transition telehealth from fragmented, donor-funded projects to sustainable components of national health systems, three foundational, interconnected priorities must guide African countries: ensuring government ownership of health systems, strengthening domestic health sector workforces, and legitimizing community work as an adequate medical response.
Rwanda’s experience with TRACnet, a national mobile phone– and web-based health information system that collects and reports HIV/AIDS treatment data for disease surveillance, demonstrates how deliberate transition planning can enable a successful shift from donor to government management. Established in 2004 with PEPFAR funding, TRACnet gradually transferred to government ownership, achieving full national ownership by 2015 through explicit transition clauses in donor agreements, concrete capacity-building milestones, and incremental budget assumption schedules. This model offers lessons for other African nations seeking to transition donor-funded programs to sustainable national ownership. African governments must negotiate clear transition frameworks from the outset, specifying timelines (five to seven years), capacity targets, and financial assumption schedules. These frameworks should include explicit handover mechanisms that designate government ownership upon achievement of milestones, creating accountability for both donors and host governments.
Blended financing models offer a sustainable pathway beyond donor dependency: integrating telehealth into national health insurance benefit packages creates predictable revenue while expanding access. Digital health services can be integrated into national insurance systems, as demonstrated by Ghana’s implementation of mobile platforms within its National Health Insurance Scheme, which expanded digital access to administrative services and insurance processes. These transitions must be supported by governance structures that define data ownership, clarify vendor accountability, and establish national oversight mechanisms for telehealth systems. Countries can also leverage innovative domestic funding sources, exemplified by Zimbabwe’s Postal and Telecommunications Regulatory Authority (POTRAZ) universal service fund, which collects telecommunications sector revenues to expand digital infrastructure in underserved areas. Through such mechanisms, governments can establish recurring funding streams independent of donor cycles.
Moreover, the sustainability of telehealth systems depends not only on infrastructure but on whether they strengthen, rather than bypass, domestic medical training and workforce development. WHO’s digital health strategy emphasized the need to build a digitally capable health workforce and integrate digital health competencies into education and training systems. This includes competencies in digital health, data stewardship, and telehealth governance, ensuring clinicians can operate effectively within increasingly technology-enabled systems. When telehealth is used mainly to import external expertise without parallel investment in local capacity, it can expand short-term access but may do less to strengthen underlying workforce capacity.
Telehealth can be leveraged for workforce development through tele-education, mentorship, and remote clinical supervision. Project ECHO is a well-established tele-mentoring model that uses case-based learning and specialist support to extend care to frontline clinicians. In the United States of America, early evidence suggests it strengthens clinical competence among rural providers while enabling them to manage patients locally. Medical schools and training institutions should embed competencies in digital health, remote consultation protocols, and data ethics into pre-service education rather than treating them as supplemental skills. This integration ensures that all healthcare professionals understand digital systems as core practice infrastructure rather than peripheral tools.
Retention remains a critical challenge. When telehealth expansion is not aligned with domestic workforce strategies, it can shift clinician engagement toward externally managed platforms in ways that do not reinforce local workforce stability. Governments can mitigate this risk by tying telehealth deployment to retention incentives such as rural posting benefits, salary supplements, and structured career advancement pathways. Ethiopia’s Health Extension Program exemplifies structured training and the integration of community-based providers, expanding access while reinforcing the national system.
To extend telehealth beyond urban centers, CHWs represent critical infrastructure, yet most operate without formal recognition or a clear scope for practice with digital health tools. CHWs are the first point of contact for patients in rural and underserved areas. Governments must establish licensing or certification frameworks that authorize CHWs to use telehealth platforms for specified functions, such as vital sign measurement, symptom reporting, facilitating remote consultations, and data collection, while clarifying which activities require clinician supervision.
Formal licensing also creates accountability mechanisms, establishes standardized training requirements, and clarifies CHW integration within primary health-care referral chains. Performance-based financing models, including payments for data quality and telehealth utilization, can align incentives while ensuring CHW retention and effectiveness. By emphasizing transitions to domestic ownership and legitimizing the workforce through CHW empowerment, African nations can position telehealth not as a donor-dependent intervention but as a strategic pillar for resilient, autonomous, and equitable healthcare delivery. These roles must operate within clearly defined governance frameworks that protect patient data, delineate the scope of practice, and ensure appropriate clinical oversight. Critically, African governments must graduate CHWs from their current status as volunteers to salaried workers. This policy change recognizes their essential contribution and ensures sustained engagement.
Conclusion
Telehealth has become a critical tool for improving access to care and strengthening resilience to infectious diseases in African states, yet its potential to strengthen health systems depends fundamentally on how governments facilitate policy implementation. Across the continent’s diverse regions (East Africa’s mobile-first innovations, West Africa’s regulatory development, and Southern Africa’s inequality challenges), the central risk remains consistent: reliance on externally driven telehealth platforms can weaken rather than strengthen domestic health workforce capacity. Sustainable pathways forward require systematic attention to three interconnected priorities: establishing domestic ownership and financing of telehealth systems through deliberate frameworks and country-led capacity milestones; strengthening the domestic health workforce by embedding telehealth competencies into training, supervision, and retention strategies; and legitimizing community health workers through formal licensing, structured training, and sustainable compensation models. To avoid deepening structural dependency, African states must harness telehealth not merely as a crisis-response tool but as a strategic pillar for resilient, autonomous, and equitable healthcare delivery that strengthens, rather than supplants, domestic capacity. Across all three priorities, regulatory and governance frameworks will ultimately determine whether telehealth strengthens autonomous health systems or reinforces structural dependencies.
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Godfrey Musuka is an International Public Health Consultant and Senior Research Fellow with 3ieimpact. He has worked for UNICEF, ACHAP (a partnership between the Government of Botswana, the Gates Foundation, Merck, and the Merck Company Foundation), and ICAP at Columbia University. Godfrey holds the following qualifications: DVM, MSc (Med), MPhil, and a PhD in Epidemiology and Public Health from the School of Pharmacy & Biomedical Science at the University of Portsmouth, United Kingdom.
Admore Jokwiro is a public health physician and digital health leader, currently serving as Chief Medical Officer at ZimSmart Villages. With over a decade of experience in public health informatics, digital health, and health systems strengthening, he is a CDC USA Public Health Informatics Fellow and a Hubert Humphrey Fellow at Emory University (USA). He holds an MBChB qualification from the University of Zimbabwe, an MS in Data Science from Eastern University, USA, and a Master’s in EHealth Management from the Rome Business School.
Elliot Mbunge is a mentor, researcher, and innovator specializing in Information Technology. His research focuses on health informatics, information technology, machine learning, digital technologies, and ICT for development. Professor Mbunge continues to drive technological advancements and sustainable digital transformation for the betterment of societies through research, education, capacity building, and community engagement.
Valamar Malika Reagon, DrPH, MPH, MLA, is a global health systems strategist and former hospital administrator with leadership experience at the U.S. Centers for Disease Control and Prevention across multiple countries. Her expertise spans health systems strengthening and implementation in resource-constrained settings, with particular focus on AI governance and equitable technology adoption. She works to build accountable health infrastructure through effective governance of health data and organizational change.
Fannuel Wamambo is a technical consultant specializing in the adoption of open-source technologies in resource-constrained environments. Wamambo has 15 years of experience working in fintech, healthcare systems, and research projects. He holds an MSc in Information Systems (NUST, Zimbabwe) and a BSc Honours in Computer Science (UZ, Zimbabwe).
Tafadzwa Dzinamarira is a public health expert and a lecturer at the University of Pretoria’s School of Health Systems and Public Health. He holds a Master of HIV/AIDS Management, a Master of Public Health, a PhD in Public Health Medicine, and a Master of Arts in International Relations and Diplomacy.
Image Credit: Doctor 4U UK, CC BY 2.0, via Flickr