With the third-highest infant mortality rate in the world, the Nigerian healthcare system is in desperate need of an overhaul. Digitising health recording in the country might just be the boost it needs.
Anas Baba stared at the Samsung tablet on his desk. A patient covered in red hijab sat across him and watched him in silence.
Hunching forward, his fingers slid along the intense blue glow on the screen, touching and swiping as he entered the patient’s demographics, complaint, and the symptoms she was experiencing.
Until September last year, Baba, a community health extension worker in northern Kano state, used only paper-based registers to capture these details, tedious work that stretches until midnight and sometimes took weeks, he says.
His flaky, yellowed health facility is surrounded by wind-blown millet stalks in Sumaila local government area, nestled some 80 kilometres away from the northern Nigerian city of Kano.
The standard method of hand-written data collection is cumbersome and susceptible to loss and damage. By extension, there is a complex web of recording, transferring, verifying and validating data and health information between local and state officials.
“I can now take patient data and offer them better treatment options,” says the 35-year-old health worker, referring to the CliniPAK, a solar-powered mobile health record system with servers that enables health workers to capture and upload data using tablets.
This tablet-based solution was brought to rural health facilities like Baba’s by Instrat Global Health Solutions (also known as Instrat GHS), a company founded in 2010 by Okey Okuzu, a Nigerian who was the former director of strategy and innovation at Swiss pharmaceutical firm Novartis.
What are the challenges?
Long waiting time, laborious data management systems primarily based on paper, poor infrastructure, shortage of personnel, and a lack of political will have made hindered the effectiveness of the primary healthcare system in Nigeria.
The fallout from the inefficiency is troubling, particularly for women and children: Nigeria has a maternal mortality rate of 814 deaths per 100,000 live births, compared to the UK and the US’s respective rates of nine and 14 per 100,000.
With adequate planning, investment and reliable data, some of these deaths can be prevented, but Nigeria’s health information system—largely reliant on paper-based systems to organise, store and integrate patient records and health information—remains one of the major drawbacks. This hampers planning and reduces the chance of creating a more coordinated central system to disseminate data for planning and collaboration.
In Kano state alone, there are about 1,200 health facilities, 44 health departments in all local councils, six zonal offices across the state and 10, 000 staff under the Kano State Primary Health Care Management Board, says Dr Nasir Mahmoud, the executive secretary of the board.
Mahmoud explains that the “wide, diverse and complicated structure” of the agency makes coordination a “big challenge”.
“It is against that background that we definitely need innovative ways to be able to track activities of the agency and healthcare delivery services,” he adds.
Can technology bridge the gap?
This information gap is what Instrat GHS, a social enterprise with offices in Montclair, NJ in the US and the Nigerian capital of Abuja, wants to close.
The mobile health solutions enterprise initially ventured into health informatics using SMS technology and mobile phones. Seeing as this measure was well received by patients, doctors, and ministry of health workers, the company saw a rich untapped opportunity across the country.
Partnering with Cambridge, MA-based Vecna Cares Charitable Trust to modify its CliniPAK, Instrat brought this electronic health data management system for Nigerian users.
With support from US chipmaker, Qualcomm’s Wireless Reach initiative, Instrat and Vecna Cares kicked off the CliniPAK pilot in two remote public primary health centres in Abuja in September 2013.
Now, community health workers like Baba can easily capture patients’ demographic and clinical data at the point of care and almost immediately uploaded to a cloud from their tablets.
The touch-screen interface in tablets is designed to manage primary healthcare workflows and involves inputs that can make the adoption of the technology smoother for health workers who are used to a standard paper-based system.
After entering patient demographics, complaint and symptoms, health workers are guided to dropdown menus for diagnoses and treatment options which are tailored to the diagnoses commonly seen in Nigeria. And since the CliniPAK provides diagnosis guidance, it is easier for the users to make recommendations based on existing symptoms and previous treatment. This eliminates the need to repeat medication when it is not working.
The tablets are connected using either satellite technology in areas without connectivity infrastructure, or 3G network, to help move data to the CliniPAK central server. This server, which is typically stationed in a clinic or hospital, then aggregates and syncs data and stores all information in remote servers from where local health authorities and the central government can access them.
CliniPAK's success in lies in its capacity to help health providers and authorities access information that is reliable, timely, and accurate.
“Looking at the very diverse and complicated structure that we have, it is for that reason that we collaborate with many organisations including Instrat to be able to get [medical] information and data timely and also in a more systematic way,” Dr Mahmoud of the Kano State Primary Health Care Management Board, tells TRT World in an interview at his office.
“It has proved very useful at least in the areas where we piloted this innovation; we have been seeing some improvement and quality of reporting and data. It is much better compared to when this kind of innovation is not there.”
Video training for better services
Besides promoting facility-based electronic information management, Instrat also saw that most health workers in these remote facilities needed refresher training in delivering basic healthcare services.
Under a USAID-funded program, Instrat worked with UK-based charity Medical Aid Films and USAID’s mPowering Frontline Health Workers to provide a scripted video-based health worker training application known as VTR Mobile.
These videos loaded on tablets help healthcare workers understand how to, for example, evaluate and care for a baby with high temperature.
Another video teaches them how to care for a newborn and other issues healthcare workers frequently face in Nigeria.
Instrat GHS was able to expand to more remote areas without electricity and connectivity infrastructure thanks to support from the International Partnership Program funded by the UK Space Agency to deliver sustainable solutions in areas of education, agriculture, water and sanitation, and energy to countries around the world.
“We provide training for the health workers before they start using the tablets and we visit them weekly to track what they are doing and to fix any issues,” says Rukayya Umar Yazid, Instrat’s director of business development in northern Nigeria.
Instrat now operates in eight states out of Nigeria 36 states with a footprint in over 150 health facilities. Funding also comes from state and local governments who are willing to expand the services to more facilities in their areas. Plans to expand into new states are underway and should materialise in the next few weeks, Yazid adds.
Introducing an electronic health record system in a country that is heavily reliant on paper-based documentation seems to be making significant inroads in the delivery of healthcare services to people.
For one, it means patient records can now be stored electronically, meaning they are safer and easier to access and retrieve.
Electronic data collection also cuts down on waiting time and reduces the forms patients have to fill out. It also fosters better policies and better collaboration among various healthcare providers.
Despite the progress recorded so far, some challenges remain.
For the hundred facilities that have adopted the electronic health data management system and the video-based training on tablets, there are still more than a thousand that have yet to be reached.
Also, the tablets are not enough to reach all the facilities in the state where Instrat operates. In Kano, for example, only nine out 44 local government areas are using the new system. Unless the state government accepts to partner with the mobile health solutions enterprise and scale up the project to other locations, progress might stall.
Back to Sumaila local council, where a population of more than 300, 000 people depend on farming and livestock for their livelihoods, Ummi Addo, 20, has not been feeling too well as of late.
When she visited community health worker Anas Baba, she knew she wouldn’t have to stay too long before he tends to her.
“Since he started using the [tablet] computer he easily checks to see the medicine to give to me because the computer helps him see what drugs are available for my symptoms,” Addo, a resident of the community, says.
Hearing this, Baba couldn’t hold back his happiness.
“The tablets have made it easy for me to give specific treatment and cut down on how much time patients spend when they come here."