South Africa’s health information systems (HIS) face persistent challenges of fragmentation, poor interoperability, and inefficiencies that limit their ability to deliver quality, accessible, and patient-centred care. Addressing these systemic issues requires innovative, scalable, and sustainable solutions tailored to local needs. Emerging technologies like blockchain, combined with advanced connectivity options such as Low Earth Orbit (LEO) satellites, offer a pathway to reimagine health data systems. Blockchain, as a decentralised and immutable distributed ledger, holds immense potential to enhance data security, transparency, and operational efficiency in healthcare.

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This article explores how blockchain technology can address South Africa’s HIT challenges by enabling patient-centred care, streamlining workflows, and ensuring ethical, scalable, and sustainable implementation.

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The Role of Blockchain in Health Information Systems

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In 2008, a significant technological advancement occurred with the release of Satoshi Nakamoto’s white paper on bitcoin. Nakamoto introduced a method to establish a secure monetary system using a distributed ledger called the blockchain. This innovation was a revolutionary and disruptive breakthrough. 

Immutability is a key concept in blockchain and one of the drivers to its use in the healthcare industry. Each new record in the blockchain contains a unique signature key.

In blockchain’s dispersed ledger, a digital asset is added to create consecutively aggregated blocks of data. Kendzierskyj & Jahankhani (2019) describe it as a “sequential inventory of transactions”. These blocks of data are almost immutable and are accessible to every member (node) in a decentralised peer-to-peer (P2P) network (Gökalp et al., 2018). There is emerging research showing that digital HIS based on blockchain technology can be more secure, transparent, streamlined and patient orientated (Gökalp et al., 2018). Like LEO satellites, blockchain is an artefact of the 4th Industrial Revolution because it is a technological advancement that fundamentally changes the humans live, work and relate to each other. It represents a new chapter in human development characterised by a technological advancement that merges the physical, digital, and biological worlds in ways that create both huge promise and potential peril. Blockchain’s functions force us to rethink the developmental path of our health system and how it can create, trade and enhance the value of patients and subsequently its stakeholders. We recognised blockchain’s relevance to HIT through its promotion of decentralised, inclusive, and secure platforms.

Since then, several actors in the healthcare industry have used the vast potential of blockchain to make healthcare data more tamperproof, secure and scalable. Several scholars have highlighted this technology’s potential to significantly enhance the sharing of data across a health system by offering a platform that increases efficiency, security and coordination of care while minimizing defragmentation caused by data silos (Heston, 2017). This all contributes to a health system that can deliver healthcare of greater quality, accessibility and decreased financial burden.

We argue that HIT built on a Blockchain architecture neatly fits into the clinical workflow to enhance patient-centered care and operational efficiency throughout the entire health system (Mettler, 2016). By providing healthcare professionals with transparent access to an accumulation of a patient’s latest medical data, increases adherence to guidelines and disease surveillance, and minimises medication errors (Mettler, 2016; Wright, O'Mahony, & Cilliers, 2017). This strives the value of healthcare professional by improving the ease of their clinical tasks and increasing their accountability (Gökalp et al., 2018). We envision this technology enabling a ‘touch map’ of a patient’s journey’ tracking their interactions with different healthcare services, thus providing health providers with a more holistic view of the patient. We can take lessons from Esonia’s e-Health Authority adopting Blockchain technology to store and validate health information that is accessible to authorised private companies, the government and citizens (Heston, 2017; Mettler, 2016).

HIT built on a blockchain architecture supports health records that are consistent. EHR stored in this platform can ideally be stored on a single network that is accessible to a patient’s interactions in the healthcare continuum. Alternatively, it could be stored on distinct networks according to the patients preferences. Either option would enable patients and providers to identify inaccuracies in their health records and any valid update to their records will be accessible to all nodes in the network (Gökalp et al., 2018). This not only contributes to patients’ trust of their health data and its limited accessibility, but it also enables the usability of this data to support decision making across the health system. At both the faculty level and system level, this would  guarantees that different health professionals and providers would constantly have up to date information about a patient’s treatment history and this would be continuously shared in this network (Gökalp et al., 2018).

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Smart Contracts

The use of smart contracts in Blockchain offers a considerable solution to rampant corruption across the entire supply chain spectrum to deliver HIT. This is especially relevant with the imminent implementation of the National Health Insurance bill as they would create a simplified and accountable environment where all interactions and transactions between stakeholders will be transparent and verifiable (Gökalp et al., 2018).

Smart contracts are paper-based contracted transformed into digital contracts that operate as a program code on blockchain. Similar to normal contracts, they facilitate and enforce an agreement between untrustworthy parties (Khan et al., 2021). However, smart contracts differ by using coded agreements to automatically control the transfer of assets between two parties under specific conditions and without the involvement of a supervisory third-party (Mosakheil, 2018). The execution of these transactions are traceable and irreversible because of the inherent nature of blockchain (Beillahi et al., 2022; Khan et al., 2021). This allows contracts that are time–defined or dependent on certain conditions. For example, a payment is made once a good or service is confirmed to be delivered, or specific data is sent upon a regulator’s request which reduces compliance burden (https://www.protokol.com/insights/effective-use-blockchain-for-business-process-management/). A McKinsey report suggesting that at least $50 billion can be saved in business-to-business transaction by 2021 highlights the potential financial sustainability of blockchain. Furthermore, because of blockchain’s dispersion and immutability, all nodes have a copy of the smart contract and tampering with it is impossible as this would require a consensual verification. These direct and computer-based transactions would eliminate several challenges associated with traditional contracts such as administrative costs, human errors and negligence, disputes and intermediatory parties who would control information and interactions while earning commission (Khan et al., 2021; Mettler, 2016).

Additionally, chore to Blockchain’s functionality is its ability to track a chain of historical actions between health providers, pharmaceutical, medical equipment suppliers and customers (Gökalp et al., 2018). Combining the traceability of blockchains with smart contracts ensures that the NdoH will be able to effectively track the prices, procurement agreements, and contracts with various stakeholders in the supply chain will eliminate unnecessary expenditure and intermediaries (Kassen, 2022). The potential shift of power in the healthcare market and supply chain provided by smart contracts demonstrates how extracting a disruptive technology through adjacent innovation can catalyse business innovation (Gökalp et al., 2018).

Hyperledger’s ‘Counterfeit Medicines Project’ has used Blockchain to curb the production of counterfeit drugs by detecting the origin and components of a product, and tracking the transfer of ownership at each intersection to a degree of transparency only available through this technology (Mettler, 2016). This enables viable means to track and identify products and services subject to poor quality, theft, fraud or price gouging from all vendors.

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Ethical & Cultural Sensitivity

A successful digital health information system depends on the extent to which it captures the values of users and stakeholders in the local context, and ensures patient-centered privacy, security, anonymity, ownership, and accessibility.

Yue et al., (2019) explore how Blockchain enables a deeper privatization and control of patient’s health data. Through data encryption and smaller P2P networks, patients can feel empowered to share their health data with health practitioners and providers without worrying that their information can be stolen or accessed without their knowledge (Gökalp et al., 2018). It is possible that the confidence of knowing that their information is being shared in a secure and discretionary environment breeds their ownership and agency to make better and informed decisions about their help (Gökalp et al., 2018).

The near-immutable quality of a Blockchain based HIS offers novel ways to actualise the ethical ownership of an individual’s health information. With health data sovereignty placed with the individual, they are able to practice more agency with this data. Healthbank, a Swiss digital startup, has realised this by launching a Blockchain platform that enables individuals to store and manage their health data in a secure environment (Mettler, 2016). This creates the precedence for individuals to ethically sell their data to private companies or for medical research. Gökalp et al., (2018 suggest that this technology could enable standardised research databases that offer up-to-date information about a patient’s health status and non-identifiable patient data such as age and gender. It also serves as a unique platform for individuals to manage and monitor how and when their data is being used throughout the research process. The feasibility of this functionality can be corroborated by studies from Linn and Koo and MedRec  revealing that patients in their studies were more prone to sharing their personal health data with a secure blockchain system (Gökalp et al., 2018). The extent of this trust would need further research in South Africa. This solution ensures that the advancement of medical products, services and research is reinforced to patient-centered ethical principles and emphasises the security and authenticity of patient data (Kendzierskyj & Jahankhani, 2019).

Scalability and Sustainability

Ensuring scalable and sustainable HIT will require it to be driven by locally relevant policy and protocols that standardise how data can be collected and used, is usable by healthcare providers and is resource efficient. It is vital that a blockchain based HIT does not proliferate in resemblance to cryptocurrencies. Rather, a single platform throughout the health system (and other government sectors) would maximise the benefits to “medical research, the financing of medical services, and the advancement of global health” (Heston, 2017).

Technological scalability refers to the capacity of a computing process to handle a wide range of capabilities. In blockchain, this refers to the network’s ability to support an increasing number of events, users, or data. A highly scalable blockchain network is able to reach consensus and validate transactions in a stable and efficient manner, regardless of how many new nodes join the network. As users add data or new nodes join the network, the blockchain grows, requiring increased storage and computational power for the validation process (Gökalp et al., 2018). If there are fewer nodes in the network with enough computational power to validate new data, this will increase centralisation or slow down the validation process (Gökalp et al., 2018). However, Mazlan et al., (2020) contends that in a healthcare system, it is not always necessary for every node to store a complete copy of the ledger. Instead, specific nodes can maintain only the essential information relevant to them, optimizing storage capacity and improving efficiency (Mazlan et al., 2020). Though a blockchain network with a large community (thus a high number of nodes) offers increased security and reliability, this would lead to increased computational requirements and degradation of the network and negatively affect the scalability and financial sustainability of the network (Mazlan et al., 2020). We propose the use of lightweight nodes (also known as partial nodes) which depend on the functioning of full nodes and the use of a smartcards for users to access the blockchain ledger (Mazlan et al., 2020; Mišić, Mišić, & Chang, 2019).

Several scholars have also noted that early adoption of blockchain in the healthcare sector have utilised features from cryptocurrencies, which are ill-fitting for the requirements of this sector. Most notable of these is the validation techniques such as Proof-of-Work (PoW), which requires a certain proportion of nodes solve a complex mathematical problem to validate transactions in order to add them to the blockchain (Mišić, Mišić, & Chang, 2019). These validation techniques are excessive in their computational and energy expenditure (Mišić, Mišić, & Chang, 2019). The high costs required for this form of validation makes them unscalable and unsustainable for healthcare sectors in LMICs. Mišić, Mišić, & Chang (2019) propose a collective signature validation process that requires a designated leader to validate a transaction and for it to have consensus by a specific set of “witnesses”. The selection of these nodes changes for every transaction which spreads the workload.

Crucial to blockchain technology is the use of a private encrypted key that cannot be recovered when it is lost (Gökalp et al., 2018). This is extremely inconvenient for healthcare data because of its long-lasting nature and losing parts of patient’s medical record would severely reduce the reliability and value of a digital HIS (Gökalp et al., 2018). To counter this, we propose that a patient’s data should be encrypted by a unique patient identification number or Master Patient Identifiers (MPIs). These are individual identifiers that follow patient’s journey throughout the health system. But rather than develop new MPIs, we could expand the MPIs used by the Western Cape’s Primary Health Care Information System (PHCIS) to the rest of the country (Zharima, Griffiths, & Goudge, 2023). Because the MPIs used in the PHICIS are administered by CLINICOM (a private vendor), this company can be contracted to store patient’s MPIs, thus enabling seamless integration and scalability across the continuum of care providers.