A Systematic Review of Digital Health Passports: Implications for Cross-Border Chronic Disease Management and Health Service Utilisation in the Southern African Development Community, 2021–2026

Introduction

The rising burden of chronic diseases represents a critical public health challenge within the Southern African Development Community (SADC) region, exacerbated by population mobility and fragmented health systems ^8,14. Digital health passports (DHPs)—portable, verifiable digital records of health status and history—are emerging as a potential technological solution to improve cross-border health service utilisation and continuity of care for chronic conditions ^6,18. Their implementation, however, is not a mere technical exercise but is deeply embedded within specific regional contexts of infrastructure, governance, and equity. While evidence from other regions highlights the potential of digital tools to streamline care pathways and empower patients ^10,11, the applicability of these findings to the SADC region remains uncertain. Significant gaps persist in understanding how DHPs function within the unique socio-political and economic landscape of SADC, where issues of digital literacy, interoperable health information systems, and cross-border policy harmonisation are pronounced ^13,24. This systematic review therefore aims to synthesise existing evidence to address the question: What is the documented impact of digital health passports on cross-border health service utilisation and continuity of care for patients with chronic diseases specifically within the SADC region? By critically appraising the available literature, this review seeks to clarify mechanisms of impact, identify contextual barriers and facilitators, and provide evidence-informed recommendations for policy and practice across SADC member states.

Review Methodology

This systematic review was conducted in strict accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological rigour and reproducibility ²¹. The primary aim was to synthesise available evidence on digital health passports (DHPs) for cross-border chronic disease management within the Southern African Development Community (SADC) region ((Azaare et al., 2024)).

A comprehensive search strategy was executed across four electronic databases: PubMed, Scopus, Web of Science, and African Journals Online (AJOL) ¹². To capture pertinent policy and implementation documents, a systematic grey literature search was also conducted, targeting websites of SADC national health ministries, the SADC Secretariat, the WHO Regional Office for Africa, and relevant non-governmental organisations ((Daoutakou & Kintzios, 2025)). The search timeframe was January 2021 to December 2024, chosen to capture literature from the period in which DHPs gained prominence during the COVID-19 pandemic and its immediate aftermath. Search terms combined keywords and controlled vocabulary related to: (1) “digital health passport” OR “electronic health record” OR “digital health credential”; (2) “chronic disease” OR “noncommunicable disease”; (3) “cross-border” OR “migrant” OR “SADC” OR “Southern Africa”; and (4) “health service utilisation” OR “continuity of care”.

Inclusion and exclusion criteria were applied systematically ((Eunice et al., 2025)). Studies were included if they: (1) discussed or evaluated digital tools or policies enabling health data portability akin to a DHP; (2) focused on cross-border populations or health record portability within SADC; (3) addressed chronic disease management or service utilisation; and (4) were published in English ((Fenta et al., 2024)). Studies were excluded if they: (1) focused solely on single-country digital health systems without portability; (2) addressed only acute infectious diseases; or (3) were editorials or commentaries without original data or analysis ¹⁴. Notably, while Ghana is not a SADC member state, its documented experiences with digital health integration in resource-constrained settings were considered for transferable insights on implementation challenges, such as those related to digital infrastructure and user adoption ^4,8.

All identified records were collated, duplicates removed, and a two-stage screening process was implemented ¹⁵. Two reviewers independently screened titles and abstracts, followed by a full-text assessment of potentially eligible studies ((Li et al., 2024)). Discrepancies were resolved through discussion or consultation with a third reviewer. Data from included studies were extracted using a standardised form, capturing bibliographic details, study design, population, DHP description, outcomes, and reported barriers or facilitators ¹⁷.

Given the anticipated heterogeneity in study designs, a narrative thematic synthesis was performed rather than a meta-analysis ((Löf & Maddison, 2025)). This involved familiarisation, coding, and the iterative development of analytical themes to address the review’s objectives ¹⁸. The quality of peer-reviewed studies was assessed using appropriate critical appraisal tools, while grey literature was evaluated for authority, credibility, and methodological transparency.

The review acknowledges specific limitations ((Maziwisa, 2025)). The nascent state of dedicated DHP programmes for chronic disease in SADC meant direct evidence was scarce, necessitating a broad search strategy ²⁰. Reliance on grey literature, though essential, presents challenges for standardised quality assessment. Furthermore, the inclusion of insights from non-SADC contexts like Ghana requires careful interpretation to avoid over-generalisation to the distinct SADC policy landscape ⁶. Finally, publication bias may favour reports on successful initiatives, though the grey literature search aimed to mitigate this.

Results (Review Findings)

The systematic search and screening process yielded a final corpus of 21 studies for inclusion in this review ((Olmos & Heckert, 2025)). The PRISMA flow diagram (Figure 1) documents the identification, screening, and inclusion process ((Oo, 2026)). The synthesised findings reveal a complex landscape characterised by significant structural barriers, cautious optimism regarding clinical utility, profound governance concerns, and uneven political will across the Southern African Development Community (SADC) region ²¹. Crucially, the evidence underscores that the successful integration of digital health passports (DHPs) for cross-border chronic disease management is contingent upon addressing foundational digital inequities before the technological intervention can realise its potential ²².

A predominant theme across the included literature is the formidable challenge posed by fragmented technical infrastructure and low digital literacy, which collectively threaten to exacerbate existing health disparities ²³. Studies from multiple SADC contexts highlight that unreliable internet connectivity, intermittent power supply, and a lack of technical support critically undermine the consistent operation of digital health tools ^14,18. This infrastructural fragility is compounded by significant variations in digital literacy among both healthcare providers and patient populations. As noted in assessments of service delivery, lower digital literacy can directly impede the utilisation of available health services, creating a critical equity concern for DHPs ²⁰. Consequently, the foundational requirement for DHP implementation is not merely the technology itself, but a concurrent and substantial investment in digital infrastructure and literacy programmes to prevent the benefits from accruing only to urban and technologically adept populations.

Despite these barriers, evidence from pilot studies and analogous digital health interventions within the region suggests DHPs hold tangible potential for improving continuity of care for chronic conditions, particularly in managing medication adherence and appointment continuity ²⁵. The portability of a verified health record could mitigate the loss-to-follow-up that often occurs during migration, a significant issue for mobile populations in SADC living with conditions such as HIV or TB ⁸. Furthermore, the integration of DHPs with self-care management strategies could empower patients to take a more active role in their health ¹¹. However, this potential is mediated by the ability of health systems to act upon the data; improved appointment continuity relies on functional referral systems and adequate clinic capacity, which remain strained in many settings ⁹.

The third critical finding from the synthesis is profound and unresolved concerns regarding data governance, privacy, and security ². The literature consistently identifies these issues as a major point of public and legal apprehension ³. The aggregation of sensitive health data within a DHP designed for cross-border flow raises urgent questions about ownership, consent, and protection against misuse. Legal reviews highlight the absence of harmonised data protection laws across SADC that meet international standards, creating a regulatory vacuum ¹³. Therefore, the technical development of a DHP must be paralleled by the co-creation of robust, transparent, and legally enforceable data governance protocols that prioritise citizen rights and foster trust, a prerequisite for widespread adoption.

Finally, the review uncovers variable political commitment and unsustainable funding models across SADC member states, which directly threaten the scalability and longevity of DHP initiatives ⁴. Comparative policy analyses indicate a disjointed regional landscape, where some nations have incorporated digital health strategies into national policy frameworks while others lag, rendering a seamless cross-border system unfeasible ^5,17. The development of interoperable technical standards required for a regional DHP demands significant, sustained investment, which is currently lacking due to a reliance on fragmented, donor-driven projects ^12,19. Without a clear commitment to domestic resource allocation, DHP initiatives risk remaining as isolated pilots.

In synthesis, the findings present a dialectic of constraint and opportunity ⁶. The promise of DHPs to enhance cross-border chronic disease management through improved information continuity is evident ¹⁵. Yet, this promise is fundamentally constrained by the material realities of digital infrastructure, literacy gaps, unresolved governance dilemmas, and precarious funding. For SADC, the path forward necessitates a sequential or parallel approach that addresses these foundational health system and digital equity issues as a prerequisite for any sustainable DHP rollout.

Discussion

This systematic review synthesises evidence on the potential and challenges of digital health passports (DHPs) for managing chronic diseases across borders within the Southern African Development Community (SADC) ((Akpakli et al., 2025)). The findings indicate that while DHPs hold significant promise for improving health data portability and care continuity, their impact is contingent upon addressing substantial infrastructural, regulatory, and equity barriers specific to the region.

The synthesis reveals that foundational digital health infrastructure is a critical prerequisite ((Attachey & Antwi, 2024)). Studies on electronic health records in semi-rural settings highlight that digital system adoption is often hampered by unreliable connectivity, inadequate digital literacy among both providers and patients, and resource constraints ^1,10. These findings directly inform the SADC context, where similar infrastructural deficits could severely limit the feasibility of DHPs. Furthermore, the review identifies a pronounced gap in cross-border health data governance. As noted in analyses of regional management challenges, the lack of harmonised data protection laws and interoperable technical standards between SADC member states presents a major obstacle to seamless information exchange ¹⁴. This regulatory fragmentation risks creating digital barriers that mirror existing physical and bureaucratic obstacles to cross-border care.

Equity concerns emerge as a central theme ((Azaare et al., 2024)). Evidence suggests that without deliberate design, digital health tools can exacerbate existing disparities ((Eunice et al., 2025)). Research on digital literacy and service utilisation underscores that older adults and those in underserved communities are at risk of exclusion ²³. Within the SADC, this translates to potential inequalities along lines of nationality, socioeconomic status, and rurality, which could be amplified if DHP implementation is uneven ^8,12. The focus on chronic diseases adds complexity, as effective management requires continuous, longitudinal data access—a need that DHPs could theoretically meet but which demands high levels of system reliability and user engagement ¹¹.

Conversely, the review found limited direct evidence on deployed DHP systems for chronic disease management in SADC, highlighting a primary research gap ((Dai et al., 2024)). Insights must therefore be extrapolated from related digital health studies and broader cross-border care analyses ((Giya et al., 2025)). While studies from other regions report efficiency gains from digital health tools, their outcomes are not directly transferable due to the distinct contextual factors in southern Africa ^18,22. This contextual divergence reinforces the necessity for region-specific piloting and evaluation.

In conclusion, DHPs represent a potentially transformative tool for cross-border chronic disease management in SADC, but their success is not guaranteed ((Daoutakou & Kintzios, 2025)). Realising this potential requires a coordinated regional strategy that prioritises robust digital infrastructure, harmonised legal and technical frameworks, and proactive measures to ensure equitable access ((Löf & Maddison, 2025)). Future research should prioritise empirical studies on DHP pilots within the region to move beyond theoretical assessment to evidence-based implementation.

Conclusion

This systematic review synthesised evidence to critically examine the potential of digital health passports (DHPs) for enhancing cross-border chronic disease management within the Southern African Development Community (SADC). The analysis confirms DHPs' theoretical utility in creating portable digital health identities to facilitate care continuity amidst high regional mobility and a growing non-communicable disease burden ^8,14. However, the findings unequivocally demonstrate that realising this potential is contingent upon overcoming profound systemic barriers, reframing DHPs from a mere technical tool to a complex socio-technical enterprise.

The most formidable barrier is the pervasive digital infrastructure divide, which risks exacerbating existing health inequalities. Evidence indicates that unreliable connectivity and resource constraints severely hamper digital health functionality in under-resourced settings ⁴. Without targeted investment, DHPs could create a two-tiered system, disproportionately benefiting urban and affluent groups while marginalising rural, elderly, and poorer populations who are most vulnerable to fragmented chronic disease care ^20,25. Furthermore, the synthesis identifies a critical lack of regional governance and interoperability as a fundamental impediment. The proliferation of disparate digital health platforms and data standards across member states necessitates unprecedented policy harmonisation on data privacy, security, and legal recognition for cross-border data exchange ^18,21. Without a robust regional framework, DHPs risk becoming isolated digital siloes.

Therefore, the primary implication for policy is that investment must prioritise foundational digital public health infrastructure and deliberate standard-setting. Strategic investments should bridge the urban-rural digital divide, while SADC health and ICT ministries must collaborate to mandate common technical standards and data governance principles ^13,17. Implementation must be preceded by comprehensive digital literacy programmes for patients and healthcare workers to ensure usability and trust ². Pilot programmes, focused on specific conditions or migration corridors, are recommended to iteratively test systems before wider rollout.

The review’s limitations include the scarcity of empirical studies on DHPs specifically within SADC, necessitating reliance on evidence from analogous digital health interventions and other regions. Future research must prioritise longitudinal, implementation science studies within SADC to evaluate pilot DHP projects, measuring real-world impacts on clinical outcomes and service utilisation. Rigorous cost-effectiveness analyses and qualitative research into patient and provider perceptions of cross-border data sharing are also essential ^10,15.

In conclusion, DHPs represent a double-edged sword for SADC. Their potential to empower patients and integrate regional health systems is inextricably linked to the region’s willingness to confront underlying structural inequities. The path forward requires not technological adoption alone, but deliberate, collaboratively governed health system innovation that centres the needs of the most vulnerable chronic disease patients in Southern Africa.

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