Health system readiness for digital point-of-care diagnostics for febrile illness across Africa: A realist review

Digital point-of-care (POC) diagnostics, including connected and molecular platforms, have the potential to strengthen clinical decision-making and disease surveillance, particularly for febrile illness across African health systems. Yet context-relevant evidence on health system readiness and the institutional conditions shaping their integration and sustainability is limited. Following RAMESES standards, we conducted a realist review to examine how, why, and under what circumstances digital POC diagnostics for febrile illness are integrated into African health systems. We systematically searched PubMed and CINAHL (2005–2025) and supplemented these with purposive searches of the grey literature. Qualitative and mixed-methods studies addressing implementation, integration, or readiness were included. Data were synthesized using context–mechanism–outcome (CMO) configurations to develop and refine the program theory. Seventeen studies from multiple African countries were included. Readiness for integration was explained by five interacting system levers: (1) usability and workflow compatibility; (2) workforce competence, trust, and confidence; (3) reliable infrastructure and connectivity; (4) governance, policy alignment, and financing; and (5) data systems that generate actionable value. When these conditions aligned, mechanisms such as perceived usefulness, confidence, institutional legitimacy, and responsiveness were activated, leading to sustained use, improved diagnostic pathways, and enhanced surveillance. Conversely, weaknesses, particularly in infrastructure, procurement, or data-use capacity, triggered frustration, distrust, and discontinuation. The integration of digital POC diagnostics into African health systems depends more on the health system’s readiness to promote trust, continuity, and data-driven action than on the performance of the tests themselves. A realist, system-focused approach is required to enable context-specific implementation and prevent the reinforcement of pre-existing inequities in digital health adoption.Author summary: Limited access to reliable diagnostics remains a major challenge across many African health systems, where febrile illnesses are often treated based on symptoms instead of confirmed diagnoses. Digital point-of-care (POC) diagnostics—portable devices that quickly test patients and send results electronically—are becoming more popular as tools to improve clinical decision-making and disease monitoring. However, for these technologies to work effectively, healthcare facilities need to be ready to integrate them into routine care. In this study, we conducted a realist review of the literature to understand the methods, rationale, and conditions under which digital POC diagnostics are integrated into African health systems. Through the synthesis of evidence from 17 studies across multiple countries, we identified five key factors influencing readiness: device usability, workforce competence and reliability, infrastructure dependability, the effectiveness of governance and financing, and the capacity of data systems to provide relevant information. The findings suggest that digital diagnostics are most effective when health systems foster trust, continuity, and data-driven decision-making, offering practical guidance for policymakers and implementers of digital health technologies.