Insights from The Lancet report on Nigeria
This is an excerpt of the paper “The Lancet Nigeria Commission: investing in health and the future of the nation”, focused on the topic above.
The Lancet Nigeria Commission: investing in health and the future of the nation
The Lancet
Prof Ibrahim Abubakar, PhD, Sarah L Dalglish, PhD, Blake Angell, PhD, Olutobi Sanuade, PhD, Seye Abimbola, PhD, Aishatu Lawal Adamu, FWACP, et al.
March 15, 2022
Executive Summary
by Joaquim Cardoso MSc.
Servant Leader of “The Health Strategy Institute”
@ The Public Health Unit
March 17, 2022
What is the value of access to media and technology?
Access to media and technology is essential in improving health seeking behaviour.
- Access to these platforms is associated with awareness of the value and availability of services.
- Access to mass media tends to be lower in rural settings than in urban settings resulting in inequitable access to evidence-based health information.
More efforts are needed to address inequities brought on by information and technological barriers.
- Broadcasting infrastructure via radio or digital signal should be prioritised to reach women in remote areas, particularly individuals who are unable to read.
- Electronic mass media can play a big role in targeting education and efforts to increase awareness.
Furthermore, much work needs to be done to educate Nigerians nationwide on non-communicable disease.
- For instance, patients with cancer tend to present with advanced disease, even among people with high literacy.
- Integration of basic preventive and curative non-communicable diseases education programmes into print or digital mass media can improve attitudes towards non-communicable disease prevention, diagnosis, and treatment, coupled with training of community health workers and other health workers involved in primary care.
Digital data for decision making
Digitising aspects of service delivery can promote access and cost-effectiveness. There are over 190 million active mobile phone lines in Nigeria, or about one per inhabitant, with mobile internet subscriptions of 105 million per month.170
The growth and penetration of mobile communications provides millions of people in rural areas access to reliable communication and data transfer technology.
- The handiness, widespread adoption of, and people’s attachment to their mobile phones makes it an attractive platform for delivering health programmes and services.
- In the hands of trained health workers, mHealth devices can assist with record keeping, obviating the need for paper-based forms, and reducing wait times with electronic administration systems.
The increased use of digitised data will increase its visibility, accountability, and speed of work and communication among facilities and between levels of government.
- mHealth devices can also facilitate the quality of service delivery by developing algorithmic clinical guidelines and job aids that could be uploaded and used from mobile phones on which health workers can access user-friendly guidelines and protocols, especially at the PHC level.
Although national electronically-enabled guidelines, protocols, and standard of care could be developed centrally, they require space for local adaptation (taking into consideration local disease patterns, human resources for health availability, and task shifting realities), supported by training and mentoring to achieve desired improvements in quality of care.172
What is the business case?
The benefits of digitising health information systems in a middle-income country such as Nigeria outweigh the investments necessary for its actualisation, and commitment to such a system will eventually lead to increased data quality and usage. 173,174
The case for mobile phones
Computers might not always be the optimal choice of health information system hardware.
- First, mobile phones are the most used information and communication technology device in Nigeria,146 and most health-care workers know how to use smartphones.
- Second, software such as DHIS2 supports data entry via the DHIS2 web portal, mobile Android app, or direct import, meaning that mobile technology hardware such as smartphones can be used for direct data entry by clinicians in facilities, Community Health Extension Workers in communities, or even officers in LGA offices for transmission to a computer in which accountability for it can be assured.
- Third, data entered through phones is more likely to be cloud-stored compared with data entered on a computer so that the loss or theft of a phone is less likely to result in large amounts of data being lost.
- Fourth, due to frequent and long-lasting power outages in Nigeria, computers could be impossible to use for real-time data entry, whereas phones and tablets by contrast have long-lasting batteries and require less energy for recharge.
- Fifth, phones offer more options for connectivity than computers.
- Finally, for data capture in remote areas, the portability of small mobile devices is an asset particularly when health-delivery materials (eg, vaccines) must also be transported.
The case for mobile data entry
Mobile data entry by different people onto the same database speeds up reporting,126 and can make the process more convenient for time pressed and overworked health workers.
- Although it could increase fragmentation in the short term, the degree of fragmentation is substantially less than with paper-based records currently in use.
The case for Electronic Information Systems (Electronic Health Records)
To aid progress towards routine use of electronic information systems — whether they are facility based or used for collection of population level data on health and the determinants of health
- investment in homegrown health information and communication technology solutions, generation and dissemination of high-quality evidence, and standardised evidence-based guidelines for the adoption and implementation of electronic health information systems are necessary.
- As the benefits of electronic systems are realised by a growing number of actors in the health sector, demand for health information and communication technology will increase.121
Necessary skills @ Health Ministry Level
Nigeria needs health sector leaders who are versed in health policy and administration, health economics, one health, digital health, planetary health, and with vast understanding of what works in the Nigerian context.
What is the call of the report?
- We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems.
- A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation.
EXCERPT OF THE EXECUTIVE SUMMARY — Leapfrogging
Leapfrogging the health system into the 21st century
Nigeria’s health system was built in an ad hoc way, layering traditional community health systems with colonial medicine aimed at maximising resource extraction. This origin has resulted in inbuilt inequalities, a dysfunctional focus on curative care, and a detrimental social distance from users and communities. Post-independence policies to redress problems have only been partially implemented.
However, the current health system is sprawling, multifarious, disintegrated, and frequently inaccessible, with very minimal financial risk protection and low financial accessibility of services. Nigerians variously seek care from medical personnel and auxiliaries, community health workers, medicine vendors, marabouts and spiritual healers, traditional birth attendants, and other informal providers. The system relies on a mixture of quasi-tax-funding, fee-for-service, and minimal health insurance coverage.
What kind of health system do Nigerians deserve, and should the country’s leaders work towards? The core need of most Nigerians today is for accessible basic health services, and for this to be achieved, improvements in public sector delivery supported by an enhanced complementary private sector, including faith-based organisations, is the way forward.
We lay out a path for Nigeria to move towards a system that, although remaining diverse, better serves the needs of the population. Within this diversity, we believe there is an opportunity for a “one nation and one health” approach, whereby Nigeria guarantees a minimum standard and delivery of health care for all with an emphasis on strengthening public and private (including faith-based and non-profit) systems. Nigeria should also leverage the private sector for certain functions, such as expanding innovation, discovery, and manufacturing capacities to claim a leadership role on the African continent and globally. Government investment in private industry should be mission-driven, supporting innovation and claiming dividends for society from its investments.
Core functions of the health system require immediate attention, in particular, good quality health data.
This Commission strongly recommends better recording, storage, and use of data. Paper systems are unworkable.
A drive towards digitisation can result in major improvements, for both patient care and devolved health decision-making.
Mobile digital technologies should allow a relatively rapid expansion of population health data and linked existing datasets.
Human resources in rural and poor regions of the country are worsened by brain drain. We propose prioritising the optimal development and redistribution of health workers at all levels.
EXCERPT OF SECTION 4 — Subsection Digitisation
Section 4: health system reform — a pathway to universal health coverage
Digitisation
Digital data for health
Access to media and technology is essential in improving health seeking behaviour.
For example, inadequate access and exposure to print or digital mass media (eg, newspapers, magazines, television, radio, and mobile phones) is a consistent predictor of underutilisation of antenatal care services. 53,54, 166
Access to these platforms is associated with awareness of the value and availability of services.57,167
Access to media and technology is essential in improving health seeking behaviour.
Access to mass media tends to be lower in rural settings than in urban settings resulting in inequitable access to evidence-based health information.
More efforts are needed to address inequities brought on by information and technological barriers.168
Broadcasting infrastructure via radio or digital signal should be prioritised to reach women in remote areas, particularly individuals who are unable to read.
Electronic mass media can play a big role in targeting education and efforts to increase awareness.
Furthermore, much work needs to be done to educate Nigerians nationwide on non-communicable diseases.
For instance, patients with cancer tend to present with advanced disease, even among people with high literacy. This results in ineffective curative efforts, which contributes to a community perception that cancer is untreatable, and can lead to a vicious cycle of late presentation, high mortality rates, and distrust of the medical establishments, which are then only seen as a last resort.169
Integration of basic preventive and curative non-communicable diseases education programmes into print or digital mass media can improve attitudes towards non-communicable disease prevention, diagnosis, and treatment, coupled with training of community health workers and other health workers involved in primary care.
Digital data for decision making
Digitising aspects of service delivery can promote access and cost-effectiveness.
There are over 190 million active mobile phone lines in Nigeria, or about one per inhabitant, with mobile internet subscriptions of 105 million per month.170
The growth and penetration of mobile communications provides millions of people in rural areas access to reliable communication and data transfer technology.
The handiness, widespread adoption of, and people’s attachment to their mobile phones makes it an attractive platform for delivering health programmes and services.
In the hands of trained health workers,146 mHealth devices can assist with record keeping, obviating the need for paper-based forms, and reducing wait times with electronic administration systems.
The increased use of digitised data will increase its visibility, accountability, and speed of work and communication among facilities and between levels of government.171
mHealth devices can also facilitate the quality of service delivery by developing algorithmic clinical guidelines and job aids that could be uploaded and used from mobile phones on which health workers can access user-friendly guidelines and protocols, especially at the PHC level.
Although national electronically-enabled guidelines, protocols, and standard of care could be developed centrally, they require space for local adaptation (taking into consideration local disease patterns, human resources for health availability, and task shifting realities), supported by training and mentoring to achieve desired improvements in quality of care.172
The benefits of digitising health information systems in a middle-income country such as Nigeria outweigh the investments necessary for its actualisation, and commitment to such a system will eventually lead to increased data quality and usage.173,174
The benefits of digitising health information systems in a middle-income country such as Nigeria outweigh the investments necessary …
In Nigeria, private sector telecommunication companies, backed by international investment are constructing infrastructure for mobile internet access.
Regulatory support by the federal government is needed for its improvement in urban areas and expansion into rural and remote parts of the country.
The Federal Ministry of Health (FMoH) has invested in the implementation of a District Health Information System version 2 (DHIS2), which is an open access, cloud-based data management system for data collection, management, and analysis in use by ministries of health in 72 LMICs.175
Designed for use in integrated health information systems, it has the potential to increase effectiveness and efficiency of health information management systems.124,129
A major barrier to implementing DHIS2 software at the LGA level (ie, LGA health department office) and State Health Management Information System office level is a shortage of or absence of functional computers, internet connectivity, and budget support by states and local governments.174,176
Private hospitals and federal public hospitals, which as noted in panel 4 are not currently uploading data to DHIS2, tend to have functional computers and internet connections (even if only in the offices of senior personnel),122,177 and equipment which tend to be lacking in state level hospitals and PHC facilities. 177
Further work to improve the completeness and quality of data in DHIS2 is needed. An essential part of this work will be further transparency and accountability in audits and quality improvement programmes for DHIS2.
Computers might not always be the optimal choice of health information system hardware.
First, mobile phones are the most used information and communication technology device in Nigeria,146 and most health-care workers know how to use smartphones.126
Second, software such as DHIS2 supports data entry via the DHIS2 web portal, mobile Android app, or direct import, meaning that mobile technology hardware such as smartphones can be used for direct data entry by clinicians in facilities, Community Health Extension Workers in communities, or even officers in LGA offices for transmission to a computer in which accountability for it can be assured.
Third, data entered through phones is more likely to be cloud-stored compared with data entered on a computer so that the loss or theft of a phone is less likely to result in large amounts of data being lost. Fourth, due to frequent and long-lasting power outages in Nigeria, computers could be impossible to use for real-time data entry, whereas phones and tablets by contrast have long-lasting batteries and require less energy for recharge. Fifth, phones offer more options for connectivity than computers.
Finally, for data capture in remote areas, the portability of small mobile devices is an asset particularly when health-delivery materials (eg, vaccines) must also be transported.
Mobile data entry by different people onto the same database speeds up reporting,126 and can make the process more convenient for time pressed and overworked health workers.
Although it could increase fragmentation in the short term, the degree of fragmentation is substantially less than with paper-based records currently in use.
Health-care facilities at all levels, private and public, and State Health Management Information System offices and local governments, should be supported and incentivised to take advantage of collaborative opportunities presented by local and international hardware and software developers and engineers in testing and advancing innovative solutions to their health information and communication technology challenges.
To aid progress towards routine use of electronic information systems — whether they are facility based or used for collection of population level data on health and the determinants of health — investment in homegrown health information and communication technology solutions, generation and dissemination of high-quality evidence, and standardised evidence-based guidelines for the adoption and implementation of electronic health information systems are necessary.
As the benefits of electronic systems are realised by a growing number of actors in the health sector, demand for health information and communication technology will increase.121
Further, digitisation can enable the analysis and use of data by health workers who are also responsible for collecting the data, thus increasing the completeness and accuracy (ie, quality) of data and promoting local accountability,127 , 128 , 129 and encouraging motivation and commitment.
Although digitisation can ensure centralisation of data analysis and decision making, it can also promote its localisation and facilitate completeness, accuracy, and timeliness of data collected, beginning at the community level.
However, we understand that a reformed set-up of centrally determined but locally delivered systems cannot be achieved without the buy-in of ministers of health who will be saddled with the responsibility of midwifing this idea.
One key challenge of the Nigerian health system since 1960 is the nature of the qualifications and skillsets of previous health ministers, who are mostly not a good fit to provide the correct leadership and direction of the health sector in Nigeria.
For instance, many of the health ministers in Nigeria from 1960 to date have been trained medical doctors, but without broader public or systems training in many cases.
Others include a health economist, a professor of parasitology, an educationist, two Nigerian navy admirals, a civil engineer with a law degree, a lawyer who was also a pharmacist, and a reformist or teacher.
There is still a latent understanding in Nigeria that medical doctors are more suited for the office of a health minister.
As health-care delivery models have evolved, the skillset and portfolio needed in leadership positions to deliver the required improvements in the Nigerian health system need to be updated as well, with political leadership making these selections sensitised accordingly.
Nigeria needs health sector leaders who are versed in health policy and administration, health economics, one health, digital health, planetary health, and with vast understanding of what works in the Nigerian context.
Nigeria needs health sector leaders who are versed in health policy and administration, health economics, one health, digital health, planetary health, and with vast understanding of what works in the Nigerian context.
EXCERPT FROM THE KEY MESSAGES
DIGITISATION AND BETTER DATA STRATEGY, FUNDING AND DEVELOPMENT
We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems.
A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation.
Originally published at https://www.thelancet.com
