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.