The digitalization of healthcare services and their integration into patient care presents significant challenges regarding the competencies required in both social and healthcare sectors (31). A key factor contributing to the limited success of digital health initiatives across parts of Africa like Ghana is the insufficient education and training of healthcare managers, which directly impacts the quality of care provided (21). Research has shown that many healthcare managers rely on self-directed learning to navigate digital health tools (32), resulting in a fragmented knowledge base and contributing to a lack of consistency across the sector. This gap in digital competencies among healthcare managers is increasingly recognized, particularly in the context of rapidly evolving digital healthcare environments (33). The digital transformation of healthcare requires managers to adapt to the changing demands of the workforce, including staff and managerial roles (34).

Further research (34–36) underscores the need for healthcare managers to receive comprehensive support and training in adopting and implementing digital technologies within their organizations. Effective digital transformation hinges on equipping those responsible for service delivery, such as healthcare managers, with the necessary skills. Enhancing the digital skills of healthcare managers is essential, as they are typically responsible for training and mentoring junior staff in the use of new systems (37). When digital competency is lacking at the managerial due to inadequate training (36), the resulting deficiencies inevitably cascade down through the hierarchical structure of healthcare organizations, especially in Africa, where organizational hierarchies are more pronounced. Thus, healthcare managers must develop the capabilities and contextual competencies required to effectively utilize complex digital tools in a dynamic environment while enhancing digital health literacy to inform strategic and operational decision-making (37).

Digital health is increasingly recognised as a driver of healthcare innovation, particularly in supporting patient engagement in primary care (30). Although digital innovation within Africa's healthcare ecosystem is expanding, its reach and scale remain limited, constraining population-level impact (38). Much of this innovation is led by profit-oriented private sector actors, particularly in South Africa, Kenya, and Nigeria, where digital solutions have emerged to address gaps in public healthcare provision (39). These initiatives span access to medical knowledge, quality monitoring, and clinical decision support, and are frequently associated with visionary leadership and effective digital management (40–42).

Extending these innovations beyond the private sector to benefit broader populations remains a significant challenge (30). Achieving scale requires active public-sector engagement and digital managers capable of translating innovation into system-wide practice (43, 102). While strong management is central to developing flexible, patient-centred healthcare systems (10), persistent gaps in digital management capacity continue to constrain innovation and limit the overall impact of digital health initiatives across areas, especially Sub-Saharan Africa (28).

Low levels of basic digital competence among healthcare managers raise critical questions not only about skills gaps but also about the capacity of health systems to absorb and sustain digital transformation (21). Although digital health initiatives are often framed as system-enhancing interventions, existing evidence suggests that many managers remain insufficiently prepared to lead within digitally transformed environments, limiting their ability to align technological change with organisational and system-level objectives (28, 44). This misalignment helps explain why digital innovations frequently remain fragmented or confined to pilot projects, despite their technical feasibility. Where managers possess the requisite digital and leadership competencies, transformations are more likely to be embedded and sustained, reinforcing the central role of managerial capability in advancing digital health integration across African contexts (45).

However, the effectiveness of managerial capability is shaped by wider structural conditions. While earlier reviews have identified leadership competencies relevant to digital transformation (46), less attention has been paid to how these competencies are enacted within integrated healthcare ecosystems, particularly at the frontline of service delivery. Digital integration is contingent on consistent funding mechanisms, supportive regulatory frameworks, and alignment with national health policies, without which even competent managers face limited scope to drive system-wide change (46, 47). Collaboration between governments, international organisations, and private-sector stakeholders is therefore necessary but insufficient in isolation; its impact ultimately depends on managers who can translate strategic intent into operational practice, coordinate across organisational boundaries, and sustain integration over time (42).

The Covid-19 pandemic accelerated the adoption of telemedicine platforms across African healthcare systems, positioning remote consultation and prescribing as practical responses to mobility restrictions and service disruption (48). While several studies report rapid uptake and short-term benefits of telemedicine during the COVID-19 period, others highlight difficulties in sustaining these services once emergency conditions receded, particularly where managerial support and integration into routine workflows were limited. Telemedicine enabled healthcare organisations and individual clinicians to deliver care remotely, reducing reliance on in-person visits and partially mitigating infrastructure and workforce constraints, particularly in settings with limited specialist availability and long travel distances (49–53). While countries such as Kenya and Nigeria experienced notable growth in telemedicine services (54), evidence from the pandemic period suggests that telemedicine's rapid uptake was often driven by necessity rather than strategic integration. As a result, although telemedicine became a dominant digital solution for training and consultations during this period (55, 56), its longer-term embedding within healthcare systems remains uneven across contexts.

The literature indicates that variation in telemedicine outcomes is closely linked to managerial capability rather than technological availability alone. Successful implementations highlight the role of managers to align innovation with organisational workflows and professional practice (57). In contrast, managerial resistance remains a significant barrier in many African healthcare settings, where telemedicine is sometimes perceived as undermining the doctor, patient relationship or adding administrative burden without clear benefits (58, 59). These perceptions reflect broader challenges associated with procedural change and role redefinition, which require active managerial leadership to address (60). Where such leadership is absent, telemedicine initiatives are more likely to stall at the implementation stage, reinforcing the view that managerial readiness is a critical determinant of whether telemedicine transitions from a crisis-driven response to a sustainable component of healthcare delivery (57).

With the global rise in mobile phone usage, including rapid adoption across East and West Africa, mobile technology has been widely discussed as a potential response to structural challenges in healthcare financing and access (61, 62). Kenya's M-Pesa is frequently cited as a leading example, transforming mobile devices into “mobile banks” and enabling healthcare payments for populations without access to formal banking systems (5, 41, 63). Empirical evidence from Kenya suggests that mobile payment systems have reduced financial barriers for low-income patients accessing healthcare services (9, 64). However, evidence from other African contexts indicates that uptake and impact remain uneven and highly context-dependent, shaped by regulatory environments, digital literacy, and organisational capacity (65). In the absence of such systems, healthcare organisations continue to face increased administrative workloads and higher operating costs associated with cash-based transactions and manual billing (66). While studies from rural settings report improved financial sustainability following the adoption of mobile payment systems, these findings are not consistently replicated across regions, suggesting that positive outcomes cannot be assumed universally (5, 41).

Although electronic payment systems are often presented as broadly beneficial for patients, healthcare organisations, and governments, the strength of empirical evidence varies across settings and implementation models (67). Studies highlight that effective management plays a decisive role in whether digital payment platforms are successfully embedded into routine practice or remain parallel systems with limited operational impact (61, 63). While normative accounts emphasise the role of managers in advocating for regulation, data protection, and inclusive practices, empirical findings suggest that these functions are unevenly realised in resource-constrained healthcare systems (68). Where managerial capacity is limited, digital payment initiatives may reinforce exclusion, generate trust concerns, or face resistance from frontline staff. Expanding digital payment access at scale should therefore be understood as an aspirational objective rather than an empirically established outcome, contingent on the presence of capable frontline managers who can align technology, regulation, and organisational practice (61, 62).

One of the most transformative advancements in global healthcare has been the adoption of electronic health records (EHRs), which hold significant potential for enhancing healthcare delivery efficiency and accuracy (69, 70). The rising emphasis on patient safety and improved outcomes has further driven EHR adoption in many countries (71). Studies have shown that EHR systems improve service quality, efficiency, safety, and patient outcomes (72). EHRs represent an opportunity for healthcare organisations to enhance patient care quality and safety, reduce operational costs, and streamline workplace efficiency (71). Specific benefits of EHR adoption include reduced time and costs related to patient flow (73), remote access to medical records, faster record retrieval (69), and addressing unique regional healthcare challenges (74, 75).

Despite these advantages, African countries have encountered significant challenges in EHR adoption, particularly regarding interoperability. Interoperability is the ability of diverse EHR systems to communicate and exchange data effectively is critical to EHR success (69). Many EHR systems currently in use within African healthcare settings are isolated, creating “islands of information” that limit the seamless flow of patient information between and within different healthcare organizations (24, 57). However, studies have highlighted that health information technology interoperability, while challenging, has seen positive results in hospital settings with effective digital managers who advocate for more connectivity between different departments of the hospital (76). Competent managers and effective digital technology deployment are tightly interconnected and essential for EHR success (77). Skilled managers facilitate EHR adoption by establishing a clear strategic vision, and engaging stakeholders.

With a population exceeding one billion, Africa has substantial potential to address its healthcare challenges, with Artificial Intelligence (AI) playing a pivotal role in this transformation (9, 78). AI-driven data science tools already contribute to enhanced patient care and hospital experience (79). The healthcare landscape is evolving rapidly, marked by innovations such as virtual nursing, AI-assisted intensive care, patient education through chatbots, and predictive care tools (80). In Africa, notable AI applications have emerged across various sectors. For example, Nigeria's Hello Tractor (81) improved agricultural mechanization and productivity. AI-powered educational platforms, such as Kenya's M-Shule (103), and Nigeria's Ubenwa have all made use of AI.

Successfully embedding AI in healthcare requires understanding the role of trust in AI as it influences the process of change (82). Implementation strategies across healthcare organizations must be developed to address AI-specific capacity-building challenges, and policies and regulations are essential to guide effective AI deployment. Achieving these aims necessitates collaborative investments among healthcare organizations, government entities, and industry partners (83). Given the novelty of AI and its complex challenges, skilled managers are required to champion the technology and facilitate its acceptance by frontline healthcare workers and patients (104). Without digital managers who understand the potential of AI to change the healthcare landscape in Africa, the effective implementation of AI initiatives will be limited (78).

The common thread among these digital innovations is the crucial role of effective implementation strategies attuned to the healthcare ecosystem, creating innovative pathways to enhance current systems (84, 85). Effective digital management must recognize technology's “transformative power” (86) in facilitating digital healthcare innovations (87). By fostering a culture of technological progress, effective managers ensure that digital solutions align with organizational goals and patient needs (88), and promote equity and enhance the efficiency of service delivery (21, 29, 37, 89, 90).

To effectively guide digital health initiatives, managers must possess adequate educational qualifications. Informatics skills and competencies are essential for managers to make informed decisions about digital health services, and these can be developed through targeted education and training (32). For Effective managers to become commonplace within the African healthcare context, there is a need for strategic planning at all levels of the healthcare system towards efforts to allocate resources for training to enhance digital literacy among staff and continuously evaluate performance (14, 46). Strategic interventions to improve the digital competencies of managers will facilitate high-quality care delivery, enhance healthcare outcomes and prepare organizations to adapt to future technological advances, thus positively impacting broader populations (47, 86).

Normative accounts of digital transformation emphasise the role of managers in fostering data-driven cultures and evidence-informed decision-making through analytics and digital tools (47, 86). However, empirical evidence suggests that such practices remain unevenly distributed, particularly in resource-constrained and rural healthcare settings. Strategic collaboration with technology providers may support the development of accessible and contextually appropriate solutions, yet the effectiveness of such collaborations depends on managers' digital literacy and institutional support (91). Ensuring equitable access to mobile-friendly and low-bandwidth solutions therefore remains a necessary, though not sufficient, condition for improving managerial decision-making across diverse geographical contexts.

There is a need to move away from a uniformed approach to management and recognize that cultural differences and norms significantly shape the views of managers on technology (99). These cultural differences can influence aspects such as decision-making styles and openness to adopting new digital solutions, or put simply, ‘Africans see things differently’ (3). By tailoring managerial practices to local cultural contexts, managers can foster more meaningful engagement with technology and enhance its adoption within their communities (100). Management training programs should emphasize cultural diversity, empowering managers to adapt their strategies to local norms, whilst creating “local-global blends” of knowledge to account for global best practices (9). Such culturally sensitive approaches respect the unique aspects of African cultures and improve the relevance and sustainability of digital health initiatives, thereby maximizing their impact on patients.

Fragmented management structures and siloed information systems continue to constrain digital health integration across African healthcare systems. Interoperability management has been proposed as a collaborative approach to enabling secure and efficient data exchange across organisational units (101). While conceptual and case-based studies suggest that networked managers can facilitate organisational learning and information sharing, empirical evidence of system-wide interoperability gains remains limited (69). Interoperability frameworks should therefore be understood as normative models whose effectiveness depends on managerial capacity, institutional incentives, and sustained coordination rather than technical standards alone (47).

Evidence from the reviewed literature suggests that digital health initiatives in African healthcare systems are most effective when embedded within supportive managerial, regulatory, and organisational environments rather than introduced as standalone technological solutions. However, empirical findings also indicate that policy ambitions frequently outpace implementation capacity, resulting in fragmented systems, pilot dependence, and uneven uptake. Policymakers should therefore exercise caution in assuming that digital technologies will automatically deliver efficiency or equity gains. Instead, digital health strategies should be aligned with investments in managerial capacity, governance coherence, and institutional readiness, recognising that managerial capability is a necessary but not sufficient condition for successful system integration.

From a practice perspective, healthcare managers occupy a critical intermediary role between policy intent and frontline implementation. While normative frameworks often position managers as change leaders, the literature highlights persistent constraints, including limited training, workload pressures, and weak incentives, which can undermine their ability to operationalise digital reforms. Practice-oriented policies should therefore prioritise targeted management development, realistic implementation timelines, and context-sensitive support mechanisms, particularly in resource-constrained and rural settings. For donors, training institutions, and technology partners, this implies shifting emphasis away from technology deployment alone toward sustained investment in managerial learning, interoperability practices, and organisational change processes that can support long-term, system-wide impact.