Nigeria Health ICT Phase 2 Field Assessment...

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Nigeria Health ICT Phase 2 Field Assessment FindingsPrepared by the United Nations Foundation in Support of ICT4SOML

MARCH 2015

FEDERAL MINISTRY OF HEALTH

2 | NIGERIA HEALTH ICT PHASE 2 FIELD ASSESSMENT FINDINGS

Table of Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1 . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

phase i – key findings from policy review & inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

phase ii field assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2 . Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

sample selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3 . Main Findings of the Field Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

federal level findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

state, lga & facility-level summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1. Akwa Ibom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2. Bauchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

3. Abuja - Federal Capital Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

4. Imo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

5. Kano . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

6. Lagos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

7. Sokoto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

component findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

recommendations and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

5 . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

6 . Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

annex 1: Key Findings From Federal Implementing Forms . . . . . . . . . . . . . . . . . . . 50

annex 2: State-level Summaries (N=7 States) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

annex 3: LGA-level Summaries by State (N=3 per State) . . . . . . . . . . . . . . . . . . . . . 60

annex 4: Facility-level Summaries by State (N=126; 7 per State) . . . . . . . . . . . . . . . 65


Acknowledgements

We would like to thank Dr. Kelechi Ohiri, the Lead of the Saving One Million Lives (SOML) Secretariat for the support in facilitating this field assessment. We acknowledge the immense co-operation and support from personnel of the Information Communication Technology for Saving One Million Lives (ICT4SOML) initiative. This work would not have been possible without Dr. Ime Assangansi, Emeka Chukwu, Dr. Shehu Salihu, and Olasupo Oyedepo.

Our deep-seated appreciation goes to all the key informant organizations at the Federal, State, LGA and Facility levels. At the Federal level, we want to particularly thank Wuraola Adebayo (Federal Ministry of Health), Dr. Utibeabasi Urua (National Primary Healthcare Development Agency – NPHCDA), Jimmy D. Unwaha (Instrat Global Health Solutions Ltd.), Jerome Shaguy (Health Information Systems Program – HISP), Oluwafemi Adedipe (Subsidy Re-investment Empowerment Programme – SURE-P MCH), Kadumi Huck (National Agency for the Control of AIDS – NACA), Dr. Habeeb Salami (Pathfinder International Nigeria), and Patrick Adah (Africare Nigeria). We appreciate the DPRS/HMIS Officers from the 7 states, M&E Officers from 21 LGAs and key informants from 126 health facilities surveyed in this field assessment.

We sincerely appreciate the very warm co-operation and support from members of the United Nations (UN) Foundation Team, particularly Carolyn Florey, Abigail Manz, Dr. Patricia Mechael, Jonathan Payne and Hima Batavia.

Finally, we like to appreciate the Principal Investigator/Consultant, Dr. Iwara I. Arikpo and members of his research team, particularly, Prof. Martin Meremikwu (Co-PI), Ekpereonne Esu (Data Analyst), Ideba Mboto, Ememobong Aquaisua, Susan Oburota, Edward Odey, Anthony Okoro, Nuria Nwachukwu (State Supervisors), Data Clerks and all the Data Collectors from the surveyed states.

ICT4SOML LEAD

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Abbreviations

ANC Ante-natal Care

API Application Programming Interface

CCT Conditional Cash Transfer

CHEW Community Health Extension Worker

CHO Community Health Officer

DC Data Collector

DQH Data Quality Assurance

eHealth Electronic Health

FCT Federal Capital Territory

FHI Family Health International

FIP Federal Implementing Partners

FMCT Federal Ministry of Communication Technology

FMOH Federal Ministry of Health

GoN Government of Nigeria

GSMA Groupe Speciale Mobile Association

HF Health Facility

HIS Health Information System

HISP Health Information Systems Program

HMIS Health Management Information System

ICT4SOML Information & Communications Technology for Saving One Million Lives

IEC Information Education and Communication

ITU International Telecommunication Union

LGA Local Government Area

LMIS Logistic Management Information System

M&E Monitoring and Evaluation

mCCT Mobile Conditional Cash Transfer

MCH Maternal Child Health

mHealth Mobile Health

MNCH Maternal, Newborn and Child Health

NACA National Agency for the Control of AIDS

NGO Non-governmental Organization

NHIS National Health Insurance Scheme

NHMIS National Health Management Information System

NPHCDA National Primary Health Care Development Agency

PATHS2 Partnership for Transforming Health Systems Phase II

RBM Roll Back Malaria

SMOH State Ministry of Health

SMS Short Message Service

SOML Saving One Million Lives

SOPs Standard Operating Procedures

SURE-P Subsidy Re-investment and Empowerment Programme

UNICEF The United Nations Children’s Fund

WHO World Health Organization


List of Figures and Tables

Figures

figure 1: WHO/ITU eHealth Strategy Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

figure 2: Policy Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

figure 3: Landscape and Inventory Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

figure 4: States Showing Level of Health ICT Activity . . . . . . . . . . . . . . . . . . . . . . . . . . 16

figure 5. State-level ICT-related Infrastructure and Equipment Needs/Gaps . . . . . . . 39

figure 6. LGA-level ICT-related Infrastructure and Equipment Needs/Gaps . . . . . . . 39

figure 7. DHIS2 Training Across 7 Sample States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

figure 8. HMIS Training at the State and LGA Levels Over the Last 3-6 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

figure 9. Proportion of Health Facilities Submitting Data on Time Across LGAs in the Month Previous to the Assessment . . . . . . . . . . . . . . . . . . . . . . 42

figure 10. Forms Not Available in Health Facility in the Past Month (N = 126) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Tables

table 1. Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

table 2. Analysis Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

table 3. M&E Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

table 4. Funding for Internet and Power Supply Across Health Systems . . . . . . . . . . . 44


Executive Summary

In October 2012, the President of Nigeria, Dr. Goodluck Jonathan, launched the “Saving One Million Lives (SOML)” program. The national program was designed in response to the United Nations Commission for Life-Saving Commodities global initiative to reduce the millions of preventable deaths of women and children in low and middle income countries, due to a lack of access and availability of life-saving health commodities, and to continue realizing progress on the Millennium Development Goals (MDGs) and lay the foundation for Universal Healthcare post-2015.

The SOML Initiative has since made efforts to scale up primary health care services focusing on evidence-based and cost-effective interventions under ten program areas, including maternal and child health, routine immunization, essential medicines, nutrition, malaria, elim-ination of mother-to-child transmission [of HIV/AIDS], private sector engagement, quality improvement, fiscal space analysis and data management.

As part of the SOML, the Federal Ministry of Health (FMOH) and Federal Ministry of Com-munity Technology (FMCT), launched a sub-initiative with support from the United Nations Foundation, along with GSMA, the Government of Norway and other partners focused on leveraging the growth in mobile, wireless and information technologies to increase access, improve quality and reduce costs of healthcare administration and service delivery. This sub-initiative, called Information Communication Technologies for Saving One Million Lives (ICT4SOML), aims to establish a national Health ICT Framework for Nigeria, and scale-up four key enabling ICT platforms: National Health Management Information System (NHMIS), Mobile Supply Chain Management (mSCM), Mobile Conditional Cash Transfer (mCCT) and Demand Generation.

The planning for ICT4SOML has been a two-step research process, guided by the WHO/ITU eHealth strategy toolkit, which outlines the key components to consider when establishing a national eHealth strategy that responds to country health development goals, reflects country priorities and draws a sound plan to monitor implementation and manage risks. The first step reviewed the existing policy landscape to enable a national Health ICT Framework, and the current status of existing Health ICT implementations across the country. The sec-ond step was a field assessment across the Federal, State LGA and facility levels to assess the current state of ICT infrastructure and services and applications and accompanying support structures, including workforce capacity, standards and interoperability, and funding availability, in addition to examining the current status of the identified platforms for scale.

The field assessment consisted of key informant interviews and surveys conducted at the national level, in six states (Akwa Ibom, Bauchi, Imo, Kano, Lagos, and Sokoto) and the Federal Capital Territory (FCT). In each of the six states and the FCT, three LGAs and seven health facilities within each LGA were surveyed. Federal-level interviews were conducted with relevant program leads or their authorized representatives. State level interviews were conducted with Directors of Planning Research and Statistics (DPRS), and LGA level inter-views were conducted with Monitoring & Evaluation (M&E) officers. Facility level interviews were conducted with facility heads or a designated representative such as an M&E (or Record) Officer, Nurse, or Facility Administrator.

Findings from the field assessment showed that infrastructure, including electricity, con-nectivity and ICT equipment including computers, mobile phones/telephones, printers etc. are sufficiently available at the Federal, State and LGA levels, but inadequate at the facility level. While a primary source of electricity is available across the health system, frequent interruptions in power are common, combined with poor network coverage impacting Inter-net connectivity. Improving infrastructure is recommended as a key priority to ensure that investments in Health ICT services and applications and workforce capacity are not wasted due to limited uptake and poor user experience.

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The District Health Information Software Version 2 (DHIS2) is the most highly penetrated service and application, used for national health information reporting in Nigeria. The FMOH adopted DHIS2 as the National Health Management Information System (NHMIS), and has since deployed it across the federal, state and LGA levels. Availability of DHIS2 at the facility level is limited, and where available, paper-based systems are still in use. To support the adop-tion of DHIS2, there have been significant investments in workforce capacity, training M&E officers at the federal, state and LGA levels on DHIS2, and establishing processes including monthly or quarterly M&E meetings at each health level to discuss the implications of the data collected. In the next phase of DHIS2 implementation, the Federal Ministry of Health (FMOH) is encouraged to develop a workforce strategy that outlines additional health cad-res that require DHIS2 training, and those that require sensitization. The assessment found that health information officers are being designated at the state and LGA levels, though in its initial stages of ramping up. As part of the national Health ICT Framework, imagining the short to medium term scope of this cadre as new skillsets in data management and analysis are required, will be critical to ensure workforce capacity aligns with new systems.

No other Health ICT applications have achieved scale in Nigeria, although case studies exist in select states, such as Kano for the management of human resources, and routine immuniza-tion planning and coverage, Sokoto and Lagos for electronic stock management, and Abuja for tracking antenatal care attendance, patient appointments and managing HIV patient data. As part of developing the national Health ICT Framework, identifying and approving national platforms to manage key components of health administration and service delivery, drawing from the experience of introducing and scaling DHIS2, is recommended.

These efforts should be complemented by investments in improved standards and interop-erability. Currently, states, LGAs and facilities largely use government-approved formats for FMOH DPRS monthly reporting requirements for primary health centres. However, while most FMOH and State Ministry of Health (SMOH) respondents did not view the availability of standard operating procedures (SOPs) as a challenge, most LGA’s and facilities did, indicating that further effort to raise awareness and orient them on governance structures across the health system is required. The standards and interoperability recommendations of the WHO/ITU eHealth strategy toolkit will become increasingly important as additional national Health ICT platforms are introduced, and require guidance for integration into other reporting systems.

Currently, approximately 65% of facilities provide patients incentives, usually in the form of free drugs and mosquito nets. Cash is uncommon, and mobile money systems to deploy incentives are being used by only one facility. Similarly, mobile health messaging is com-monly used amongst facilities; 81% of facilities reported using mobile health messaging to engage with clients and community, largely reporting that it led to communication improve-ments. Poor network coverage and cost are still challenges impacting widespread adoption of mobile messaging for demand generation strategies.

Mobile money also has the capacity to impact the deployment of funding across the health system and strengthen healthcare financing efforts. The assessment examined the availabil-ity of ICT budgets across the health system, finding that items such as Internet, power supply and IT support are being prioritized within budgets, but are often not approved and released. Funding to support Internet and mobile top-up was consistently cited as a key challenge, impacting the effective use of Health ICT applications.

The recommendations included in this report, focused on improving basic ICT infrastructure at the facility level, drawing from the experience of scaling DHIS2 to introducing additional national health ICT platforms, and leveraging existing assets such as M&E officers and M&E meetings to establish standard operating procedures across the health system should be used when establishing Nigeria’s National Health ICT framework.


1 . Introduction

According to the United Nations Population Fund and World Health Organization, Nigeria is ranked 197 out of 200 countries on health indicators, with some of the highest rates of maternal and child mortality in the world. It has been reported that 241,000 newborns die every year in Nigeria from preventable and treatable causes. Further, according to UNICEF, 839,500 children under five (U5) and 52,925 women of childbearing age die every year in Nigeria from preventable causes. Targeted efforts are required by all stakeholders across the health system to improve public health outcomes in Nigeria, to realize progress on the Millennium Development Goals and lay the foundation for Universal Healthcare.

In 2012, the UN Commission for Life-Saving Commodities was established to reduce the millions of preventable deaths of women and children in low and middle income countries, due to a lack of access and availability of life-saving health commodities. In Nigeria, President Goodluck Jonathan responded to this global initiative by launching the “Saving One Million Lives” (SOML) program in October 2012. The SOML initiative is a program to scale up access to essential primary health services and commodities and to prevent the deaths of one mil-lion women and children under five in Nigeria by 2015. The program builds on international efforts on child and maternal survival — such as UN Secretary General’s Every Woman, Every Child campaign, the June Child Survival Call to Action in Washington DC, among others.

In the last few years, mobile, wireless and information technologies have been recognized as essential tools for increasing access, improving quality and reducing costs of healthcare administration and service delivery. Key stakeholders, comprising of mobile operators, device vendors, healthcare providers, content players, foundations and governments, have made progress by launching mobile, wireless and information technology services and applications, establishing policies and national strategies, and developing eHealth funding mechanisms across several countries. Part of this effort has been driven by the UN Foun-dation in partnership with the SOML Secretariat to support the Federal Ministry of Health (FMOH) and the Federal Ministry of Communication Technology (FMCT) to establish a strategic plan to scale-up ICTs to support the achievement of the SOML goals and enable Nigeria’s Health ICT environment post MDG. This sub-initiative is called ICT4SOML.

To establish the ICT4SOML strategic plan, a two-phase research plan was designed based on the World Health Organization (WHO) and International Telecommunication Union’s (ITU) National eHealth Strategy Toolkit (See Figure 1). The toolkit describes seven components that enable a national electronic health (eHealth) environment. This includes: leadership and governance, strategy and investment, legislation, policy and compliance, workforce, standards and interoperability, infrastructure, and services and applications. (See Figure 1)

The first phase, conducted in August 2014, assessed the enabling environment for Health ICT in Nigeria by conducting a policy review and landscape analysis and establishing an inventory of existing Health ICT initiatives. Both assessments included primary and second-ary research methods, namely literature reviews and key informant interviews with national government stakeholders and federal implementing partners. The policy review focused on five components of the WHO/ITU framework: legislation, policy and compliance, standards and interoperability, leadership and governance, strategy and investment and workforce. The landscape analysis and inventory focused on two components of the WHO/ITU framework: infrastructure and services and applications. Together, the two reports provided a compre-hensive overview of the current enabling environment for Health ICT in Nigeria. The findings from phase one have been used to ensure that the activities within the ICT4SOML initiative are well informed and contextualized within the current Nigeria ICT environment.

The second phase, conducted between December 2014 – January 2015 is a field assessment to evaluate ICT infrastructure and capacity within health administration offices, and service delivery facilities. The field assessment, designed to collect data from a cross-section of

To establish the ICT4SOML strategic plan, a two-phase research plan was designed based on the World Health Organization (WHO) and International Telecommunication Union’s (ITU) National eHealth Strategy Toolkit.

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stakeholders at the federal, state, local government area (LGA) and facility level, focuses on five components of the WHO/ITU framework: infrastructure, services and applications, workforce, standards and interoperability, strategy and investment. The scope of each com-ponent, in the context of this assessment is outlined below:

Infrastructure: This section assessed the availability of basic ICT equipment, including telephone, internet and email, and additional equipment including computers, tablets, phones, DHIS2 user guides, printers, photocopiers, scanners, internet modems, calculators, generators and other internet sources. The assessment also reviewed which stakeholders provided ICT equipment, and if ICT maintenance and support was available. Further, the availability, source and reliability of power/electricity to support ICT equipment were sur-veyed. At the facility level, details on computer and mobile operating systems and Internet providers were assessed.

Services and Applications: Federal agencies and implementing partners, states, LGAs and facilities were requested to report the details of Health ICT applications used to support health administration and service delivery, and how it is maintained, updated and improved based on user feedback.

Workforce: This section assessed the number of available staff within each health cadre (i.e. doctor, nurses/midwives, CHO, community health extension worker (CHEW), records/M&E officer, pharmacist, lab scientist/technician, at the federal, state, LGA and facility level, followed by the number trained on DHIS2 and available Health ICT applica-tions. The frequency of capacity building activities and the level of support available for health staff to manage Health ICT applications and databases was also assessed. Lastly, the number of designated and filled health officer positions at the federal and state levels were also surveyed.

eHealth Components

Leadership and Governance

Strategy and Investment

Strategy and Investment

Legislation, Policy,and Compliance

Infrastructure

Services and Applications

PHASE 1 — POLICY AND INVENTORY (MARCH - SEPT 2014)

Landscape and Inventory Review: Comprehensive snapshot of existing ICT health implementations in Nigeria

Policy Review: Strengths and gaps in the enabling environment

PHASE 2 — FIELD ASSESSMENT(DEC - FEB 2015)

Field Assessment: Appraise the current state and experience of relevant ICT for health implementations and capacity across the system — federal, state, LGA, and facility levels — from service delivery, health administrative and costing perspective

Workforce

Standards andInteroperability

figure 1: WHO/ITU eHealth Strategy Toolkit


Standards and interoperability: This section assesses the current status of provisions for data management, specifically to support FMOH DPRS monthly reporting requirements for primary health centres. At the federal level, this includes the availability of standard operating procedures (SOP) for managing the data collected, including cleaning, quality control, analysis, and presentation for targeted audiences. At the federal and state levels, reporting formats used, frequency of M&E meetings to discuss the implications of data collected, how HMIS data is used to improve service delivery quality and the availability of integrated data warehouses were assessed. Lastly, at the state and LGA levels, reporting frequency and formats were surveyed.

Strategy and Investment: This section assessed the availability of budgets for ICT items, including Internet, power supply, IT equipment (computers, laptops, netbooks), mobile devices, and IT repairs, and the frequency that budgets were approved, the percentage of funds that were released, and the source(s) of funding at the federal, state, LGA and facility levels.

The assessment also includes an evaluation of the current status of four key enabling platforms that were identified and recommended for scale-up as part of ICT4SOML. Estab-lished working groups, composed of relevant FMOH representatives, Federal Implementing Partners (FIPs) and industry partners, are supporting these efforts. The four platforms are:

National Health Management Information Systems (NHMIS): In 2013, the Nigeria National Council on Health approved the District Health Information System Version 2.0 (DHIS2) as the NHMIS for health service data reporting. Data collected from this assessment on the current penetration, adoption and capacity for DHIS2 will support the FMOH Department of Research, Planning and Statistics (DPRS), who is responsible for leading the NHMIS strategy development, roll-out and training, and phased integration into a single server.

Mobile Conditional Cash Transfer (mCCT): In January 2014, a working group was estab-lished to lead the scale-up of mCCT to more effectively enable the deployment of cash incentives for pregnant women. Federal Implementing Partners (FIPs), SURE-P and Path-finder International are co-chairs of this working group, and are also collaborating with IBTC bank and mobile operator aggregators to lead pilots. The data from the assessment will support the scale-up of mCCT by understanding the current status of facilities using incentives to improve health outcomes.

Mobile Supply Chain Management (mSCM): In September 2014, the mSCM technical working group merged with an existing supply chain group. The new committee is focused on harmonizing supply chain management (SCM) tools. They aim to identify uniform indicators and develop requirements for an electronic logistics management information system (eLMIS) possibly using mobile technology. The data from the assess-ment will support this working group in prioritizing states for roll out, and drawing from existing examples where mSC tools are being used.

Demand Generation: The objective of this working group is to generate demand and awareness for improved uptake of health services, and identification and follow up with women demonstrating pregnancy risk factors using mobile messaging. The working group is currently co-chaired by Mobile Alliance for Maternal Action (MAMA) the family health department of FMOH. The data from this assessment will support this working group understand select demand generation activities taking place at the facility level.

Lastly, as part of the recommendations from the phase 1 policy review for the GoN to establish a centralized body to develop national health informatics guidelines and standards, the assessment also examined how health care managers and care providers use data to support planning and service delivery.

This report outlines the findings from the field assessment, which are organized by the WHO/ITU recommended component areas and health system levels. This is followed by recommendations and a proposed budget to fill gaps in ICT infrastructure and equipment availability across the health system. Alongside the phase 1 findings, the phase 2 findings

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will be used to support the development of the national Health ICT Framework as well as a roadmap and budget for the digitization of the Nigerian health system.

phase i – key findings from policy review & inventoryThe policy review illustrated that Nigeria is transitioning from the level of “experimentation and early adoption” to “developing and building up” according the WHO/ITU national eHealth strategy toolkit (See Figure 2) . Nearly 20 relevant departments and agencies across the Ministry of Health and Ministry of Communication Technology were identified, in addition to twelve policies and strategies including components relevant to the use of ICT for health, signifying significant interest and support at the federal level. However, fragmented policy development was found to be hindering cohesive and accelerated scaled implementation, calling for the need to establish a centralized body to consolidate efforts and develop a single strategic framework and lead the development of health informatics standards. This effort should be complemented through the creation of an adequate and efficient funding mechanism to sustain investments in digital health for the next five to ten years in Nigeria.

figure 2: Policy Review

EMERGING ENABLING

ENVIRONMENTFOR eHEALTH

EMERGING ICT ENVIRONMENT

ESTABLISHED ICT ENVIRONMENT

EARLYADOPTION

SCALE UP

EXPERIMENTATION

DEVELOPING & BUILDING UP

CURRENT STATUSOF NIGERIA ICT

I.

II. III.ESTABLISHED

ENABLING ENVIRONMENTFOR eHEALTH

MAINSTREAMING

DESIRED TRAJECTORYOF NIGERIA ICT

National Health Bill: If passed, National Council of Health (NCH) to become highest policy-making body; may provide source of funding for ICTSOML

Inter-ministerial Governing Body for ICT for Health: Central body needed to align the ~20 relevant health & ICT departments & agencies

Harmonizing ICT for Health Policies: 12 policies identified; harmonized policy must align with national health plan

National Health ICT Coordination Platform: Transparent body to develop and administer standards

Alongside the phase 1 findings, the phase 2 findings will be used to support the development of the national Health ICT Framework as well as an roadmap and budget for the digitization of the Nigerian health system.


The Landscape and Inventory assessment found that the GoN is investing in the building blocks required to scale ICT implementations within the health system across the country. However, current implementations identified are “silo-ed,” lacking coordination across similar services and applications, and missing alignment with national policy objectives. Eighty-four (84) projects were identified, 24 of which had nation-wide coverage. Call centres were most commonly national-based programs. Most states were found to have over 20 projects, 37% of which use SMS. Across projects, Health Information Systems (HIS) and patient education programs were most common, and health financing and disease surveillance programs were least common.

figure 3: Landscape and Inventory Review

Scale-Up

NationallyavailablemHealthservices

Pilot

Proof of Concept

5

28

24

27

• Disease focus: 75% of projects focused on MNCH; paucity of malaria and nutrition projects (27%)

• State: Every state has 20+ projects

• Geographic reach: 32% of projects have national coverage; most commonly call-centers

• Technology: 37% of projects use SMS

• Infrastructure: 3 of 8 operators - MTN, Airtel and Glo - share 83% of market

• Health System Function: HIS, Communication, Patient Education most common; Health financing and disease surveillance, least common

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phase ii field assessmentThe overall goal of the field assessment is to evaluate the current state of relevant Health ICT implementations and their related user experience, in addition to identifying opportunities and gaps in ICT infrastructure, resources, and capacity across the health system.

The specific objectives of the ICT4SOML Phase II assessment are to:

1. Assess the gap between current and full implementation of identified platforms for scale (i.e. DHIS2, mCCT, mSC and demand generation)

2. Map the health system’s current experience with regards to Health ICT

3. Assess current Health ICT capacity and human resource needs, including those required for scaled implementation

4. Use data collected to set baselines for tracking ICT4SOML activities and implementation progress

5. Identify and assess Health ICT success factors for high performing states, LGAs, facilities and users

6. Provide recommendations to support the scale up of ICT4SOML interventions from its current state to coverage targets

This report provides the overall findings of the field assessment and maps them against these objectives for application to the development of the Nigerian National Health ICT Framework, Roadmap and Budget for scaling digital health.


2 . Methodology

Structured Key Informant (KI) interviews and rapid surveys were administered to relevant stakeholders across the federal, state, LGA and facility levels. At the federal level, nine stakeholders, including representatives from the Federal Ministry of Health (specifically, NPHCDA, and NHMIS, NACA) and relevant ICT4SOML Federal Implementing Partners (FIPs) such as SURE-P MCH, Pathfinder International, Instrat Global, Africare, HISP Nigeria, eHealth Systems Africa, were included in the assessment. Seven states (one from each geopolitical zone), three LGAs from six states, and four LGAs from one state, Sokoto (22 in total), and seven facilities from each LGA (126 in total) were included in the assessment. Kano was the 7th state added to the study, but coverage was limited to the state and LGA levels. Of the states chosen, three are those with high Health ICT activities, two with moderate Health ICT activities and one with little to no Health ICT activities (see Figure 4).

20 PROJECTS

SURVEYED STATES(PHASE II)

21 - 22 PROJECTS23 - 24 PROJECTS25 - 26 PROJECTS27+ PROJECTS

SOKOTO

ZAMFARA

NIGER

KWARA

OYO

OGUN

OSUN

ONDO

DELTA

IMOANAMBRA

ENUGU

RIVERSBAYELSA

EKITI

FCT

LAGOS

KATSINA

KANO

JIGAWA YOBE

BORNO

ADAMAWA

TARABA

BENUE

GOMBE

BAUCHIKADUNA

NASSARAWA

CROSS RIVER

AKWA IBOM

ABIA

PLATEAU

KOGI

EBONYI

EDO

KEBBI

figure 4: States Showing Level of Health ICT Activity

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sample selection Selection of health facilities in the assessment was based on three criteria: rural/urban, public/private, and level of Health ICT activity. Of the 126 health facilities surveyed, 50% were rural while 50% were urban, since half of the Nigerian population comprise of rural dwellers (See Table 1). In addition, 5 out of the 7 facilities per LGA surveyed were public facilities. In cases where a selected LGA did not have up to 2 private facilities to meet the inclusion criteria , six public facilities were surveyed. Facilities with no Health ICT projects were considered to have “low activity.” Facilities with 1–2 Health ICT projects were considered to have “moderate activ-ity,” while those with 3 or more Health ICT projects were considered to have “high activity.”

Federal-level interviews were conducted with Health ICT program leads/heads or their authorized representatives. State level interviews were conducted with Directors of Plan-ning Research and Statistics (DPRS), while LGA level interviews were conducted with M&E officers. Facility level interviews were conducted with facility heads or their designated representatives such as the M&E (or Record) Officer, Nurse, or Facility Administrator.

Primary data collection was started and completed in December 2014. Other sources of data for this field assessment were obtained from reports, surveys, desk review, etc.

The data collection plan for the assessment was designed to align with the objectives of the field assessment and the main components of the WHO/ITU eHealth Strategy Toolkit (See Table 2). These components are: infrastructure, services and applications, workforce, standards and interoperability, strategy and investment, and platforms for scale (i.e. stock management and conditional cash transfers), and data use. Transcripts of the interviews and survey data were analysed for important themes and trends.

table 1. Sampling

HEALTH SYSTEM LEVEL

SAMPLE SIZE

METHODKEY INFORMANT

DATA COLLECTOR

LIMITATIONS

Federal 9 Structured qualitative key informant interviews

MOH & Imple-menting Partners

Principal Investigator

Few interviews with federal agencies

State 7 Structured qualitative key informant interviews

State Director of Planning and Research Statistics

State Supervisor (ICT4SOML)

No data on workforce from Bauchi. 1 week delay in Lagos

LGA 22 Structured qualitative key informant interviews

LGA M&E officer State Supervisor (ICT4SOML)

Facility 126 Structured qualitative key informant interviews

Facility head, M&E officer or Nurse Facility Administrator

Data collectors guided by PRS Director / State HMIS Officer

NUAHP strike; some interviews led over phone. Kano not included

Facilities with no Health ICT projects were considered to have “low activity.” Facilities with 1–2 Health ICT projects were considered to have “moderate activity,” while those with 3 or more Health ICT projects were considered to have “high activity.”


table 2. Analysis Framework

OBJECTIVESTYPE OF INFORMATION REQUIRED

SOURCE

1

Assess the gap between current and full implementation of Health ICT interventions

Baseline information on the current state of Health ICT interventions vis-à-vis targets

Health ICT Assessment tools (all levels)

Secondary reports

2

Map the health systems current experience with Health ICT

% of HWs trained on relevant software e.g. DHIS2

% Facilities with required ICT infrastructure (e.g. software, hardware, Internet, etc.)


3

Assess current ICT capacity and human resource needs, including those required for scaled implementation

Facilities with adequate ICT staff and systems

Availability of ICT infrastructure at state and facility levels


Secondary reports

4

Use data collected to set baseline for Health ICT activities and implementation tracking

Current state of Health ICT program

Program monitoring against performance indicators


Secondary reports

5

Identify and assess Health ICT success factors for high performing States, LGAs, facilities and users

Information on infrastructure, reporting rate, etc.


6

Provide recommendations, roadmap, and budget to support the scale up of Health ICT interventions from its current state to coverage targets

Reports on Phase I & II assessments


Secondary reports

The field assessment encountered a few minor challenges, including the strike by the National Union of Allied Health Professionals (NUAHP), which made it very difficult to secure interviews for KIs in the affected facilities. Tertiary facilities under the FMOH (teaching hos-pitals and federal medical centres) were especially impacted, resulting in having to conduct some interviews by phone. The research team also faced challenges setting up interviews with select federal agencies despite numerous notifications, and follow-up calls and emails. Data on ICT and Health ICT budgets was difficult to secure from both public and private organizations. Respondents were generally vague in their answers, noting that budgets were funded, but not sharing specific values or percentages. There were also some data gaps as information was not available for select sections in select states. For example, workforce data was not available in Bauchi state. Despite these challenges, the overall field assessment process was successful.

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3 . Main Findings of the Field Assessment

federal level findingsThis section outlines key findings from interviews held with the FMOH and eight select FIPs and government agencies/initiatives that reported on the current state of ICT infrastructure and capacity within the health facilities it supports. The FIPs interviewed were: Instrat Global Health Solution Limited, Health Information Systems Program, Pathfinder International Nigeria, eHealth Systems Nigeria and Africare. The government agencies/initiatives were: NPHCDA, SURE-P Maternal and Child Health Programme, and NACA. The FMOH is largely responsible for providing policy guidance, planning and technical assistance, establishing health management information systems, disease surveillance, drug regulation, vaccine management and training health professionals. The following is a detailed summary of the data from federal level surveys — see Annex 1 for detailed findings.

The assessment found that the FMOH and FIPs are significantly investing in improving ICT infrastructure and capacity across the WHO/ITU national eHealth strategy toolkit component areas. These findings align with the phase 1 policy and landscape reviews. Basic infrastructure and equipment, including computers, mobile phones, printers and modems, and maintenance support is available for FMOH administration staff, and ICT budgets are being established, approved and released to continue to improve availability. Capacity build-ing initiatives focused on training M&E officers on DHIS2, the approved NHMIS, and training HIS staff on statistics, software & database maintenance, and epidemiology are taking place at scale at the federal level. Health ICT applications are being piloted and tested, generating the evidence base to inform national decision-making on introducing additional platforms at scale. Processes are in place and in operation for reporting and sharing health information across the health system, enabling the FMOH to focus on data quality, and analysis to inform planning and decision-making. ICT equipment, with Internet and power supply being a key priority, is being included in budgeting processes. This strong foundation at the federal level is important to enable the development of the National Health ICT Framework, and imple-ment targeted interventions across the state, LGA and facility levels.

The gap at the federal level lies between FMOH and FIP initiatives and priorities, and state and facility level realities, highlighting the pressing need for leadership and governance structures like a national Health ICT framework to enable harmonization. The availability and reliability of ICT infrastructure and capacity is variable across states and facilities, preventing widespread uptake of Health ICT applications. For example, there is a 60% gap in computer needs at the facility level. There are various Health ICT applications being used at FIP sup-ported facilities, inconsistencies in data formats and data storage protocols, and differences in priorities for ICT budgets, and how data is being used to support health administration and service delivery. Though the FMOH reported supporting states with DHIS2 training materials, only two of seven states surveyed reported high rates of DHIS2 training for state M&E officers. While the health information officer is a growing cadre, there is room to improve this to support the widespread rollout of Health ICT initiatives.

Ensuring that all states, LGAs and facilities have computers, mobile phones, telephones, printers, access to reliable and consistent power, and network coverage, is the first building block to activate other components in the WHO/ITU national eHealth strategy toolkit. With-out this component, investments in deploying Health ICT applications at scale, alongside supportive workforce capacity building and governance structures through standards and interoperability, will be wasted due to a poor user experience. These efforts must then be accompanied by short and medium term funding strategies to enable the longevity of infra-structure and capacity building investments. Currently, although ICT equipment and support

Ensuring that all states, LGAs and facilities have computers, mobile phones, telephones, printers, access to reliable and consistent power, and network coverage, is the first building block to activate other components in the WHO/ITU national eHealth strategy toolkit.


is being included in state, LGA and facility budgets, “non-approvals” and “non-full” release of funds are preventing the health system from activating its full potential in Health ICT.

DHIS2 is currently the only Health ICT platform being implemented at scale in Nigeria. Its availability is high at the federal and state level, but declines across LGAs and facilities, indicating that further effort is required to achieve widespread adoption across the health system. The deployment of DHIS2 has been supported by training and processes such as M&E meetings to discuss the implications of the data, and realize the potential of health information to improve planning and implementation. There is a need for nationally implemented Health ICT applications across other applications of technology in health care, including platforms to manage human resources, commodities, health messaging, and payments to support budget releases and incentive programs. Establishing a suite of national Health ICT applications will be accompanied by the need for an integration strategy, which is currently not viewed as a challenge by the health system stakeholders, since DHIS2 is the only Health ICT application widely available. Across each component, there are examples amongst FIPs and states that the FMOH can draw from to inform deci-sion-making. Kano is using a platform called ‘“Kano Connect”’ to manage human resources and a dashboard to manage routine immunization and Sokoto is using an electronic LMIS for supply chain management.

The Health ICT initiative has a strong foundation to build from, but will be faced with the challenge of changing existing processes and behaviours to harmonize efforts. State-spe-cific and FIP-specific strategies will be required, using this assessment to take stock of what exists against the WHO/ITU national eHealth toolkit, and mapping the gaps against national priorities, followed by data-driven planning and implementation strategies.

Infrastructure: Basic ICT infrastructure (i.e. telephone, Internet and email) was found to be in place in all states and the majority of LGA health administration offices, mostly sup-plied by the FMOH and FIPs. In FIP supported facilities, the availability of mobile phones was more likely than working computers. However, frequent interruptions in power supply are a challenge across the health system, impacting the uptake of Health ICT tools, such as health messaging to support demand generation. This aligns with findings from the landscape review, where electrical power instability and network coverage was affecting the deployment and uptake of identified Health ICT initiatives. Furthermore, support to maintain ICT equipment was found to be scarce, and only available at the national level from ICT staff in the MOH and external consultants.

Services and Applications: At the federal level, DHIS2 is the primary approved Health ICT application for reporting of routine health services in Nigeria. Government agencies, including the National Agency for the Control of AIDs (NACA) and National Primary Health Care Development Agency (NPHCDA), and FIPs, including Africare and FHI 360 reported the use of DHIS2 within its supported LGAs and facilities. Within the past year, the FMOH has provided states and LGAs operational manuals for DHIS2. Three FIPs reported using DHIS2 within supported facilities. Across the health system, 17 Health ICT applications were reported, in comparison to the 84 identified in the landscape review. Health ICT applications reported by FIPs included Clinipak, CommCare, mCCT, ICT for Supply Chain (JSI/USAID Deliver), Routine Immunization Supportive Supervision (RISS), Logistics Management Information System (LOMIS) and Ebola Sense Follow-up. The GoN Subsidy Reinvestment and Empowerment Program for MCH (SURE-P) and FIP, eHealth Systems Nigeria, reported the most Health ICT activity. Data within Health ICT applications reported are typically protected by restricted server access and external back-ups or cloud storage.

Workforce: The FMOH oversees 774 M&E officers and they have all been trained on DHIS2. Further, the FMOH reported that sufficient capacity building, focused on statistics, software & database maintenance, and epidemiology has taken place over the last year for HIS staff within the FMOH, with support and input from external partners. This was less true for FIPs, where only two of eight surveyed reported that sufficient capacity building had taken place for HIS staff at supported facilities. For HIS staff at the national

There is a need for nationally implemented Health ICT applications across other applications of technology in health care, including platforms to manage human resources, commodities, health messaging, and payments to support budget releases and incentive programs.

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and state levels, it was found that there is sufficient assistance available to design, man-age, and support HIS software and databases. FIPs reported the availability of health information officers in varying degrees; two reported that less than 50% of health offices had a health information officer, two reported that more than 50% of health offices had a health information officer, and one reported that all health information offices have a health information officer.

Standards and Interoperability: The FMOH receives data from states and LGA’s in a GoN approved format. While national SoP documents for data management, including data collection, cleaning, quality control, analysis, and presentation for targeted audi-ences, were identified, they are only partially implemented at the MOH level, and fully implemented amongst five FIPs and government agencies/initiatives. At the federal level, partial implementation may be due to fragmentation in policies mandated for standardizing data, and the lack of a national body to unify standards and lead consistent and scaled implementation. Further investigation is required to examine if SOPs at the federal level, and amongst FIP and government agencies/initiatives align. With state reporting rates achieving a high of 60%, the FMOH can begin to focus efforts on Data Quality Assurance (DQA). M&E meetings, which are held with states annually, may be one platform to commence this effort.

Strategy and Investment: In 2014, a key informant indicated that the FMOH budgeted NGN 750,000 for Internet and server power supply, which was supported through internal and external funding. The majority of FIPs reported fixed budgets for ICT-related items, including Software, Internet, power supply, IT equipment, mobile phones and IT repairs.

Platforms for Scale

NHMIS: Six of the eight respondents supply HMIS forms to supported facilities, all of which use the data most often to follow-up with clients. Health information captured is used to support health service delivery management, continuing monitoring and evaluation at the federal level, and amongst health managers and care providers, but less commonly to advocate equity and increased resources to disadvantaged groups and communities, by documenting their disease burden and poor access to services. Key challenges reported in using technology for health data management are internet pene-tration, network coverage, reliable power supply, training health workers on technology systems, and a lack of data capture standards at the facility level.

SCM: Amongst FIP-supported facilities, commodities are mostly supplied by NGOs, and in two cases drug revolving funds. There have been no stock-outs of commodities at the national level in the last six months, and less regularly amongst three FIPs in the last three months. Five of the eight respondents reported that supported facilities track stock-outs, three of which use electronic methods to send stock-out notifications. Six FIPs use LMIS forms, three of which are GoN endorsed. Three FIPs submit reports using an electronic LMIS, but only one, eHealth Systems Nigeria, reported that the electronic system has contributed to improved availability of commodities, specifically, vaccines. Challenges affecting the potential impact of LMISs are poor network coverage and technical illiteracy amongst health workers.

mCCT: Five of eight FIPs and government agencies provide incentives to its supported facilities, four of which give cash, and two of which (SURE-P MCH and Pathfinder Interna-tional) use mCCT. Incentive beneficiaries are generally captured on the computer and on paper; one FIP uses a mobile phone/tablet. All five respondents noted that the incentive has improved work and client visits. To improve the adoption of mCCT, the respondents recommended that the FMOH focus on increasing the number of mobile money agents, improving network coverage, and reducing mobile money transaction costs. Beneficiaries still need to be sensitized on the security and convenience of mobile money to drive behaviour change and adoption.


Demand Generation: Five FIPs and government agencies/initiatives are using health messaging to educate pregnant women, send appointment reminders and coordinate care amongst health workers in a closed user group. Four respondents reported that health messaging has contributed to improvements; however, poor network coverage and illiteracy are still barriers to uptake.

Key Outputs

Investing in improving ICT infrastructure, including broadband network coverage, and reliable power supply, is paramount to establishing the foundation to implement a National Health ICT strategy in Nigeria. In the absence of these building blocks, investments in scaling specific services and applications, platforms and workforce training programs risk being wasted, as health workers and beneficiaries lose momentum from the poor user experience of using inconsistent Health ICT applications.

The FMOH has begun to lay the foundation for standardized reporting of routine primary health services in Nigeria, by approving DHIS2 as the platform of choice for service data reporting, and establishing the mechanisms required to support uptake. M&E officers at the national level are being trained on DHIS2, an expertise being filtered down the health system. Materials are being developed to support state-level training, and DHIS2 is beginning to be used at the LGA level, and amongst public, private and FIP-supported facilities. Although the implementation of SOPs for DHIS2 is limited and funding support unclear, the FMOH providing leadership in platform selection, and beginning to establish supportive policies to guide the adoption of the platform, is enabling state-level implementation. Extending this process to other key ICT for health verticals, including supply chain management, disease surveillance, health messaging, human resources management and health data management, should be an important priority for the FMOH as they engage in developing the national Health ICT framework.

state, lga & facility-level summariesThis section outlines the findings across seven states, and the LGAs and facilities surveyed within each state. These seven states are: Akwa Ibom, Bauchi, Abuja, Imo, Kano, Lagos, Sokoto. The findings are organized by the five components from the WHO/ITU eHealth strategy toolkit as well as platforms for scale. For each state, key challenges, priorities and success factors are also presented. Detailed summaries of this data is presented in Annexes 2–4.

There is significant variation in each of the WHO/ITU national eHealth strategy toolkit com-ponents areas across the states, reflecting differences in state priorities and expertise and socio-economic and disease profiles. Each state is addressing the components of the WHO/ITU national eHealth framework, exhibiting strengths, and areas for improvements. Akwa Ibom and Bauchi are excelling at operationalizing M&E processes and deploying DHIS2, which may account for its high reporting rates of health information from facilities and LGAs. Abuja and Kano reported more consistent availability of power, which may have a relationship to its high Health ICT activity. In Imo and Sokoto, where basic infrastructure is not as highly available in facilities, DHIS2 has not been deployed. However, the majority of facilities in Imo are using incentives and mobile health messaging to drive demand for health services, and in Sokoto, the state government is using an electronic LMIS, which has reportedly led to improved avail-ability of health commodities. These variances indicate that implementing a National Health ICT framework will require state specific strategies, to understand the scope of existing state initiatives that can be leveraged, and identify distinct gaps and needs to address.

For example, although all states and the majority of LGAs have basic ICT infrastructure, additional equipment and technical support, maintenance, and reliable power and Internet are still challenges preventing widespread adoption of Health ICT applications. Limited deployment of electronic DHIS2 at the facility level has meant the need for a consistent supply of paper-based tools, and often transportation for LGA M&E officers to visit facilities to collect data. Across states, the challenge of available working tools and transportation has

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an impact on consistent reporting, and thus the availability of health information to support performance monitoring and planning. While investments in capacity building on DHIS2 for M&E officers have been made, training and/or sensitization for other health cadres have been null, which is most challenging at the facility level. A few respondents noted the need for health statisticians as additional Health ICT platforms and applications are deployed, the volume of incoming data may require new skillsets. Government-approved reporting formats are widely used across states, illustrating initial penetration of data standards. However, the majority of states did not highlight the availability of SOPs as a challenge, in comparison to LGAs and facilities, indicating that there is still a gap in implementation of comprehensive governance structures, possibly related to data management and utilization.

Similar to the FMOH, SMOH’s must prioritize the implementation of basic infrastructure, reliable power and Internet, to establish the foundation for Health ICT applications and platforms to operate on. This foundation can then be used to guide an iterative and parallel process of testing Health ICT applications, training relevant health workers, and establishing governance structures based on findings from pilot programs. Within states, this phased approach across LGAs and facilities should align with short to medium term funding plans, such that investments in ICT equipment and capacity building can be sustained and max-imized. Deploying computers with Internet access, modems, and mobile phones, without on-going funds to purchase broadband and data plans, is a waste of investments. The implementation of a national and state Health ICT framework relies on the planning and implementation of dependent variables, including infrastructure, capacity and governance, to support widespread adoption.

Similar to the FMOH, SMOH’s must prioritize the implementation of available basic infrastructure, reliable power and Internet, to establish the foundation for Health ICT applications and platforms to operate on.


1. akwa ibom

Key Findings

Infrastructure: Basic infrastructure (i.e. telephone, internet and email) is available at the state level, in 25% of LGAs and just over half of facilities. Support for ICT equipment maintenance is available across the state level and in 25% of facilities. All LGAs have IT support, but not on site, and 29% of facilities have IT support, of which two facilities have on-site support. There is a need for phones, modems, tablets and DHIS2 guides. At the state, LGA and facility levels, the primary power source is a national or community grid, however, frequent or prolonged power interruptions are common. The state, all LGAs and 81% of facilities have a back-up power source, which is most commonly a generator.

Services and Applications: DHIS2 is operational at the state and LGA levels and in a quarter of facilities. At the LGA level, DHIS2 is used on computers with Internet access to collect and send HMIS data to the SMOH and FMOH. Respondents reported that DHIS2 is very useful, making data entry work easier, but is challenged by power supply issues. The data collected using DHIS2 is used for planning health outreaches, such as immu-nization drives, monitoring and analysis and decision-making. LMIS for stock management was reported as a Health ICT application, but it is not fully installed at the state level. A Health ICT application used for pharmacy management called Metropos is functional in one facility. Overall, there is very little support for HIS staff in designing, managing and supporting health ICT software and databases.

Workforce: 60% of state M&E officers and 83% of LGA M&E officers are trained on DHIS2. DHIS2 training for other health cadres has been null. Limited capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year. In contrast, HMIS training has taken place at 2 of 3 LGAs in the last 6 months, and 62% of facilities reported that Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) have taken place in the last one year, provided by the government and facilities. Less than 50% of state and LGA health offices have a designated health information officer.

Standards and Interoperability: The state receives data from its LGAs in the government-approved format, and the three LGAs receive monthly summary forms from facilities. In the last month, prior to the assessment, 100% of all LGAs in the state and 96% of the total number of public and private facilities (517) submitted com-plete core data sets to the state. Whereas, across the three LGAs surveyed, 96% of public facilities and 21% of private facilities submitted complete core data sets to the LGA health office. The state has a data warehouse, similar to the NHIS office, with a user-friendly reporting utility accessible to various users, including the LGA M&E officers. The state submits data to the FMOH using an electronic web-based platform; LGAs submit data to the state, one of which uses an electronic method by updating in place; 100% of facilities submit data to the LGA using the monthly summary forms and 19% also use a second method, such as SMS or electronic spread sheets. States hold monthly M&E meetings with LGAs, LGAs hold monthly meetings with facilities, and 62% of facilities hold regular data review meetings.

Strategy and Investment: Budgets for IT equipment and power supply were found at the state level; internet and mobile devices in one LGA and 57% of facilities reported an ICT budget. External funding for ICT-related items is most common at the state level, and less common at the LGA (1 of 3) and facility (10%) levels.

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Platforms for Scale:

NHMIS: At the state level, health informa-tion is systematically used to advocate equity and increased resources to dis-advantaged groups and communities (e.g. by documenting their disease burden and poor access to service). Furthermore, health managers and care providers at all levels use health informa-tion for service delivery management, continuous monitoring and evaluation, but rarely use it to set resource allocation in annual budget processes.

SCM: Stock at the state and LGA levels is managed using paper-based tools. Two facilities reported using electronic meth-ods to manage stock. Stock-outs have been less regular in the last 3 months at the state and LGA levels and amongst 67% of facilities. Seven facilities have not experienced any stock-outs in the last 6 months. The state receives stock monthly and supplies stock to 501 facil-ities monthly. Similarly, the three LGAs receive stock monthly and collectively supply stock to 32 facilities monthly. Facilities often receive commodities from multiple sources; 71% reported receiving commodities from the MOH, 10% from the client drug revolving fund, 10% from NGOs, and 29% from other sources, such as hospital management. The state, LGAs and all facilities (with the exception of one) do not use an electronic LMIS to submit reports.

mCCT: No incentives at the facility level are delivered using mCCT.

Demand generation: 76% of facilities give patients incentives, mostly in the form LLINs and free drugs. 67% of facili-ties in the state reported that incentives have improved work and client visits. 29% of facilities send mobile health messages mostly targeting the community, and all reported that mobile health messages have led to improvements.

Challenges

CHALLENGE STATE LGA (N=3)

FACILITY (N=21)

Inadequate personnel

Yes 100% 90%

Lack of ICT capacity

Yes 100% 100%

Lack of ICT infrastructure (computers, internet, email, telephone)

Yes 100% 100%

Lack of adequate training opportunities

Yes 67% 90%

Lack of working materials including reporting forms

Yes 100% 81%

Lack of standard SOPs

No 67% 62%

Lack of transportation

No 100% 86%

Lack of funding Yes 100% 86%

Priority Areas

• Basic ICT infrastructure at the LGA and facility levels

• DHIS2 deployment at the facility level

• DHIS2 training and sensitization amongst other health cadres

• Improve availability of health information officers

• Implementing electronic LMIS across the health system

• Reliable power sources

Success Factors

• There are frequent M&E meetings at the state and LGA levels, which may be related to high timely reporting rates from LGAs and public facilities.


2. bauchi

Key Findings

Infrastructure: There is basic ICT infrastructure at the state and LGA levels and approximately a quarter of facilities. Support for ICT equipment maintenance at the state and LGA level was not reported. 14% of facilities reported having access to IT support, however, there is no IT support available at LGAs. There is a need for chairs, desks and computers. At the state and LGA levels and within 71% of facilities, the primary source of power is a national or community grid, however, frequent or prolonged power interruptions are common. The state and all LGAs use a generator as a back-up power source, whereas the 14 facilities with a back-up power source most commonly use a generator, followed by solar or inverter power.

Services and Applications: DHIS2 is operational at the state and LGA levels and in 76% of facilities. At the state and LGA levels, DHIS2 is used on computers with Internet access for HMIS reporting. However, LGAs have lim-ited access to technical support for DHIS2, and there are no systems in place to facilitate feedback or updates on the platform, in comparison to the state level that do have both available. The state reported that DHIS2 supports access to data to monitor LGAs and self-identify service delivery gaps, and one LGA noted that DHIS2 was important to simplifying data reporting activities. At the facility level, DHIS2 is primarily used on paper, and similar to LGAs, there is no technical support available or mechanisms to facilitate feedback or updates. A Health ICT patient data collection application called SWIFT Practice is functional in one facility. Overall, there is very little support for HIS staff in designing, managing and supporting health ICT software and databases.

Workforce: 54% of LGA M&E officers are trained on DHIS2. Data on DHIS2 training at the state level was not available. Sufficient capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year, but was dependent on donor/external funding. HMIS training has taken place at 2 of 3 LGAs in the last 6 months, and 29% of facilities reported that Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) have taken place in the last one year, provided by the government. 100% of state and LGA health offices have a designated health information officer.

Standards and Interoperability: The state receives data from its LGAs in the government-approved format, and the three LGAs receive monthly summary forms from its facilities. In the last month, prior to the assessment, 100% of all LGAs, and 96% of all facilities submitted complete core data sets to the state. Whereas, across the three LGAs surveyed, only 60% of facilities submitted core data sets to the LGA health office. No private facilities submitted data. No data warehouse exists at the state level. The state submits data to the federal level using an electronic web-based platform; LGAs submit data to the state, one of which uses an electronic method by updating in place; 100% of facilities share health information with LGAs, using monthly summary forms, or in some cases, other paper formats. States hold quarterly M&E meetings with LGAs, two LGAs hold quarterly meetings with facilities and 81% of facilities hold regular data review meetings.

Strategy and Investment: No funding data was available in Bauchi.

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NHMIS: At the state level, health infor-mation is occasionally used by LGA and state health management teams to set resource allocation in annual budget pro-cesses and by health managers to inform health service delivery management, monitoring and evaluation. However, health data is regularly used to advocate equity and increased resources to disad-vantaged groups and communities (e.g. by documenting their disease burden and poor access to service).

SCM: Stock at the state and LGA levels is managed using paper-based methods. One facility reported using electronic methods to manage stock. Stock-outs have been regular at the state level (monthly), but less regular in the last 3 months amongst LGAs and 62% of facilities. Four facilities are experienc-ing stock-outs regularly, either monthly or weekly. The state receives and sup-plies commodities based on supply and demand, and does not follow a regular schedule. One LGA receives stock annu-ally, and another every six months. Only one LGA reported supplying stock to 98 facilities monthly. Facilities often receive commodities from multiple sources; 71% reported receiving commodities from the SMOH, 43% from the client drug revolving fund, and 33% from NGOs. The state, LGAs and all facilities with the exception of 2, do not use an electronic LMIS to submit reports.

mCCT: One facility is using mobile money to distribute incentives.

Demand Generation: 67% of facilities give incentives to clients, mostly in the form of LLINs and free drugs, and all reported that the incentives improved work and client visits. 24% of facilities send mobile health messages to clients and health workers, mostly targeting the commu-nity, and all reported that mobile health messages have led to improvements.

Challenges


FACILITY (N=21)


Yes 33% 86%


Yes 100% 95%


No 67% 95%

Lack of Health ICT Integration

No N/A 10%


Yes 67% 100%


Yes 100% 38%


No 33% 24%


No 100% 81%


Priorities

• Basic ICT infrastructure at the facility level

• ICT equipment support and IT support across the state health system

• DHIS2 training amongst M&E officers at the state and LGA levels

• Private facility reporting rates

• Budget data documentation and management

• Reliable power sources

• Consistent and more frequent commodity supply schedules

Success Factors

• Widespread coverage of DHIS2 across the health system, which may contribute to high timely reporting rates


3. abuja - federal capital territory

Key Findings

Infrastructure: There is basic ICT infrastructure available at the state level, amongst 2 of 3 area councils and approximately 40% of facilities. There is no government support available to maintain ICT equipment at the state and LGA levels, but the SMOH hires the services of private personnel. No area council (equivalent of LGAs) has on-site IT support, but two have on-call access. 55% of facilities have IT support. There are no significant ICT equipment needs, according to the assessment. At the state level, one area council and 55% of facilities, the primary source of power is from generators. Within two area councils and 45% of facilities the primary source of power is a national or community grid. The state, two area councils and all facilities have access to back-up power. In the 14 days prior to the assessment, power was often available (less than 2 hours of interruptions per day) at the state level, within two area councils and 70% of facilities.

Services and Applications: DHIS2 is operational at the state and LGA levels, and within one facility. At the state and LGA levels, DHIS2 is provided by the FMOH and FHI360, is used on computers with Internet access, and have both technical/maintenance support and a mechanism in place to facilitate product feedback. The SMOH maintains DHIS2 at the area council level. Other Health ICT applications in use were reported at the LGA and facility levels. MADEX, a mobile application provided by the Midwives Service Scheme (MSS) and SURE-P, is used by all three area councils to capture maternal and child health data, to support both initiatives. At the facility level, Clinipak is used by four facilities to capture antenatal care (ANC) data, E-clinic is used at one facility to capture patient data, Commcare is used at one facility to capture ANC attendance, deliveries, family planning and immunizations, e-NNRIMS is used at one facility to capture HIV-related data, eHealth software is used at one facility to facilitate appointments, and lastly, Sol Tech is used at one facility to capture patient data. However, there is limited support available for state health ICT staff in designing, managing and supporting databases and Health ICT software.

Workforce: 85% of area council M&E officers are trained on DHIS2. Data on DHIS2 training at the state level was not available. Limited capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the SMOH in the last year. HMIS training has taken place at 2 of 3 LGAs in the last 6 months, and 50% of facilities reported Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) have taken place in the last one year provided by the government. 100% of state and area council health offices have a designated health information officer.

Standards and Interoperability: The state receives data from its area councils in government approved and partner developed program based formats, and area council’s receive monthly summary forms from facilities. In the last month prior to the assessment, no area council facilities submitted complete core data sets to the state. Only 32% of the total facilities across three area councils submitted core data sets in the month prior to the assessment, the majority being public facilities. No data warehouse exists at the state level. The state submits data to the federal level using an electronic web-based platform; area councils submit data to the state by using an electronic method of updating in place and electronic spreadsheets; 100% of facilities share health information with area councils, the majority using monthly summary forms, and two using electronic spreadsheets. States hold monthly M&E meetings with area councils, area councils hold monthly M&E meetings with facilities and 45% of facilities hold regular data review meetings.

Strategy and Investment: At the state level, budgets for ICT-related equipment, including IT equipment, power supply and IT repairs were identified. One area council had a budget for Internet, IT equipment and IT repairs. At the state level, budgets are supported by external funding, but not at the area council level. No budget data was available at the facility level.

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NHMIS: At the state level, health informa-tion is typically used to facilitate monthly M&E meetings with area councils. At the area council level, health information is used to take corrective measures at the facility level and support planning for routine immunization, outreach activities, commodity distribution, and outbreak monitoring. At the facility level, health information is generally used for planning routine immunization activities, outreach and drug purchase. While health data is only occasionally used to inform budget development, it is frequently used by health providers and health care managers at all levels to inform health service delivery manage-ment, M&E, and to advocate equity and increased resources to disadvantaged groups and communities (e.g. by docu-menting their disease burden and poor access to service).

SCM: Stock at the state, area council and facility levels is managed using paper-based tools. Stock outs have been less regular in the last 3 months at the state level and at 35% of facilities. 65% of facilities have experienced no stock-outs in the last 6 months. Area councils did not report on the frequency of stock-outs. There was no data at the state and area council levels on the frequency that commodities are received and supplied. Facilities often receive commodities from multiple sources; 74% reported receiving commodities from the drug revolving fund and 32% from client self purchase. The SMOH has a limited presence as a commodity supplier for facilities in Abuja. No level in the state uses an electronic LMIS, and no facilities use an LMIS in general.


Demand Generation: 20% of facilities give incentives, mostly in the form of LLINs and free drugs. Three of the four reporting facilities noted that incentives have improved work and client visits. No facilities send mobile health mes-sages to clients or health workers.

Challenges


FACILITY (N=21)


Yes 100% 60%


Yes 67% 85%


Yes 67% 85%


No N/A 80%


Yes 33% 15%


No N/A 45%


No 100% 70%


Priorities


• ICT maintenance and IT support across the health system

• Operationalizing DHIS at the facility level

• DHIS2 training amongst M&E officers at the state level

• Improving timely reporting from LGAs

• Budget documentation and management at the state level

• Transportation required for LGAs to collect data at facilities

Success Factors

• High availability of working computers with internet, and access to IT support at the facility level

• Reliable power supply and considerable Health ICT applications at the facility level

• Reliable supply of commodities, even at the facility level, where no LMIS is in use


4. imo

Key Findings

Infrastructure: There is basic ICT infrastructure at the state level, in a quarter of LGAs and approximately a quarter of facilities. However, many staff members in the health department reported having to purchase their own second hand laptops, despite several requests to the FMOH. Support for ICT equipment maintenance is available at the state level, and in 25% of LGAs. IT support is not available at the LGA level and minimally at the facility level (19%). In one LGA, computer repairs are completed using personal funds. There is a need for com-puters and modems across the state. At the state level and 29% of facilities, generators are the primary source of power, whereas, within LGAs and 48% of facilities, the primary source of power is a national or community grid. There is no back-up power available at the LGA level, and only within 52% of facilities, most of which are generator powered. In the 14 days prior to the assessment, power was sometimes available (i.e. frequent or prolonged interruptions for more than 2 hours per day) at the state and LGA levels and within 57% of facilities.

Services and Applications: DHIS2 is operational at the state and LGA levels, but not at the facility level. At the state level and LGA levels, DHIS2 is provided by the FMOH, is used on computers with Internet access, and is supported by mechanisms to facilitate product feedback and updates. While technical support for DHIS2 is available at the state level, it is not available at the LGA level. State respondents noted that M&E and HMIS officers at various LGAs need training and retraining on DHIS, and LGA respondents commented that poor Internet service and a lack of funds to top-up the modem prevented consistent data uploads. Two facilities reported the use of an Health ICT application called Service Expansion for Early Detection of HIV and Sustain-able Care (SEEDS), used to facilitate HIV patient registration.

Workforce: 100% of M&E officers at the state level and 3 of 5 LGA M&E officers are trained on DHIS2. DHIS2 training for other health cadres has been null, and there has been a request to train Officers In Charge (OIC) at the facility level on DHIS2. No capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year. HMIS training has taken place at 2 of 3 LGAs in the last 6 months, and 24% of facilities reported Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) in the last one year, provided mostly by donors. There are no health information officers at the state or LGA health offices.

Standards and Interoperability: The state receives data from its LGAs in government-approved formats, and LGAs receive monthly summary forms from facilities. In the last month prior to the assessment, 27% of 1355 facilities submitted complete core data sets to the state, most of which were public facilities. 96% of all LGAs also submitted complete core data sets to the state and 33% of facilities submitted complete core data sets to the three sampled LGAs. At the state level, a data warehouse exists equivalent to the one at the NHIS office, but does not have a reporting utility. The state submits data to the federal level using an electronic web-based platform; two LGAs submit data to the state by electronic updating in place; 86% of facilities share health infor-mation with LGAs, the majority using monthly summary forms. States hold monthly M&E meetings with LGAs, one LGA holds monthly M&E meetings with facilities and another holds bi-annual meetings. 54% of facilities hold regular data review meetings.

Strategy and Investment: Budgets for ICT-related items, including Internet, IT equipment and IT repairs from the last year were identified at the state level and 57% of facilities had ICT-related budgets. One LGA reported budgeting for Internet last year, but the budget was not approved. At the state level, budgets are supported by external funding, but not at the LGA level and rarely at the facility level.

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NHMIS: Health information obtained from LGAs is used by the state to monitor the performance and coverage of various health interventions, such as vaccine dis-tribution programs. While health data is only occasionally used to inform budget development, it is frequently used by health providers and health care manag-ers at all levels to inform health service delivery management, monitoring and evaluation, and to advocate equity and increased resources to disadvantaged groups and communities (e.g. by docu-menting their disease burden and poor access to service).

SCM: Stock at the state, LGA and facility levels is managed using paper-based methods. Stock-outs are regular (i.e. every month) at the state level, at one LGA and 24% of facilities. 43% of facilities have had no stock-outs in the last six months. The state has not received any stock from the SMOH in the last one year, and stock is supplied when it is available. One LGA receives and supplies stock bi-annually, one LGA receives stock bi-annually and supplies stock quarterly, and one LGA receives stock annually and supplies stock bi-annually. 62% of facilities receive commodities from sources, other than the MOH, NGOs, client self-purchase and drug revolving fund. Examples include hospital management boards, LGA health units and the SURE-P ini-tiative. No level in the state uses an electronic LMIS, and only two facilities use an LMIS in general.


Demand Generation: 91% of facilities give patients incentives, mostly in the form of educational materials, LLINs and soaps and tissues, and all reported that the incentive has improved work and client visits. 91% of facilities use mobile health messaging, mostly tar-geting the community, and all reported that it has led to improvements.

Challenges


FACILITY (N=21)


Yes 100% 60%


Yes 100% 85%


Yes 67% 85%

Lack of Health ICT integration

No 33% N/A


Yes 100% 100%


Yes 100% 15%


Yes N/A 100%


Yes 100% 70%

Lack of funding Yes 100% N/A

Priorities

• Basic ICT infrastructure at the LGA and facility levels

• Operationalizing DHIS2 at the facility level

• Hiring and training health information officers at the state level

• Budget documentation and management at the LGA level

• Harmonizing stock supply schedules

• Introducing an LMIS at the facility level

Success Factors

• High training of M&E officers on DHIS2, which may have an impact on high timely reporting rates from LGAs and public facilities

• High penetration of demand generation programming at the facility level


5. kano

Key Findings

Infrastructure: There is basic ICT infrastructure available at the state level and LGA level. There is no facility level data available in Kano. Support for ICT equipment maintenance is available at the state level and LGA level. There is no IT support available at the LGA level. There is a need for internet connectivity, scanners, photocopiers, calculators and filing cabinets. At the state level and within two LGAs, the primary power source is a national or community grid, and the back-up source is a generator. In the 14 days prior to the assessment, power was always available at the state level and in one LGA. The other two LGAs had power available sometimes (i.e. frequent or prolonged interruptions for more than 2 hours per day) and often (i.e. interruptions for less than 2 hours per day).

Services and Applications: DHIS2 is operational at the state and LGA levels. At the state and LGA levels, DHIS2 is provided by the FMOH and PATHS2, is used on computers with Internet access, and have technical support and mechanisms in place to facilitate product feedback and updates. Respondents noted that the application was user friendly and it was easy to transmit data, but were challenged by network fluctuations at the LGA level and a loss of data during updating at the state level. At the state level, a Health ICT application focused on human resources for health, provided by the FMOH and PATHS2 is being used to capture the profiles of 20,000 health workers. Another Health ICT mobile application, called Kano Connect, provided by the SMOH, Bill and Melinda Gates Foundation, and Dangote Foundation, is being used to capture routine immunization data from health workers. Another Health ICT application, Routine Immunization Dashboard, provided by eHealth Africa and NSTOP is used to report routine immunization data. Lastly, an Health ICT application used on computers with Internet, called National Health Workforce Registry, provided by the FMOH, is being used to capture staff information at health facilities.

Workforce: 100% of M&E officers at the state level and 5 of 48 LGA M&E officers are trained on DHIS2. DHIS2 training for other health cadres has been null. Sufficient capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year, but is largely dependent on external support and input. HMIS training has taken place at LGAs less than a year ago. Training for Kano Connect, HRHIS, and RI Dashboard has taken place amongst select CHOs, CHEWs, M&E officers, envi-ronmental officers, routine immunization focal persons, dental technicians, clinical assistants, food and hygiene officers, cold chain officers, x-ray assistants, and medical laboratory assistants. 100% of state and LGA health offices have a health information officer.

Standards and Interoperability: The state receives data from its LGAs in government-approved and part-ner-developed formats and LGAs receive monthly summary forms and other formats from facilities. However, respondents noted that there is constantly a shortage of monthly summary forms, impacting reporting. In the last month prior to the assessment, 24 of 44 LGAs submitted complete core data sets to the state, and no facilities submitted reports to the state. At the LGA level, 45% of facilities submitted complete core data sets to the LGA. There is no data warehouse at the state level. The state submits data to the federal level using an electronic web-based platform and LGAs submit data to the state by electronic updating in place. States hold quarterly M&E meetings with LGAs, and LGAs hold monthly meetings with facilities.

Strategy and Investment: Budgets for ICT-related equipment, including mobile phones and power supply was identified at the state level, but was not available at the LGA level. At the state level and amongst 2 of 3 LGAs, external funding supports budgets.

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NHMIS: Health information is commonly used to compare data across months and years to identity potential issues, and for planning purposes, including routine immunization outreaches, and drug and equipment purchases. While health data is only occasionally used to inform bud-get development, it is frequently used by health providers and health care manag-ers at all levels to inform health service delivery management, monitoring and evaluation and to advocate equity and increased resources to disadvantaged groups and communities (e.g. by docu-menting their disease burden and poor access to service).

SCM: Stock at the state and LGA levels is managed using paper-based methods. Stock-outs are less regular at the state level (i.e. within 3 months) and amongst 2 of 3 LGAs surveyed. The state receives stock quarterly and supplies stock monthly, whereas two LGAs receive and supply stock monthly. The state and LGAs do not use an electronic LMIS.

Demand Generation: A mobile phone component is often included as part of radio and television campaigns. How-ever, respondents noted that mobile campaigns are expensive to maintain, and are challenged by network fluctua-tions and language barriers.

Challenges


FACILITY (N=21)


Yes 100% N/A


Yes 100% N/A


Yes 100% N/A


Yes 33% N/A


No 100% N/A


No 100% N/A


Yes N/A N/A


Yes 100% N/A

Lack of funding Yes 100% N/A

Priorities

• DHIS2 training amongst M&E officers at the LGA level

• Integration and harmonization of Health ICT applications

• Improve reporting rates at the LGA and facility levels

• Budget documentation and management at the LGA level

Success Factors

• High availability of basic ICT infrastructure, complemented by reliable electricity and equipment support, may contribute to Kano’s high Health ICT activity


6. lagos

Key Findings

Infrastructure: There is basic ICT infrastructure at the state level, in 2 of 3 LGAs and just over half of facilities. Support for ICT equipment maintenance is available at the state level, and in a quarter of LGAs. There is no external IT support available at LGAs; staff fix their equipment when required. 33% of facilities have access to IT support. There is a need for photocopiers in the state, according to the assessment. At the state and LGA levels, and amongst 57% of facilities, the primary power source is a national or community grid. 38% of facilities use generators as its primary power source. Back-up power sources are available at the state and LGA levels, and amongst 95% of facilities, usually through a generator or sometimes solar power at the facility level. In the 14 days prior to the assessment, power was often available (i.e. interruptions for less than 2 hours per day) at the state level, within one LGA and 19% of facilities, and sometimes available (i.e. frequent or prolonged interruptions for more than 2 hours per day) in two LGAs and 57% of facilities.

Services and Applications: DHIS2 is operational at the state and LGA levels, and in 43% of facilities. At the state and LGA levels, DHIS2 is provided by the SMOH/FMOH, and is used on computers with Internet access. The state and one LGA have technical support for DHIS2, and the state and all LGAs have systems in place to facilitate product feedback and updates. Respondents noted that DHIS2 makes collating reports easier, since graphs can be easily plotted on dashboards. Other Health ICT applications reported include Births-Deaths software to capture registered births and deaths in the state, which is used on a computer, and was reported as not user-friendly, but is in the process of being modified. At the facility level, Health ICT applications reported include Smart Doctor, a HIS used to treat patients, store information including billing, diagnosis, lab investiga-tion and dispensing, GENE, used to capture patient data and facilitate patient billing and E-Health Software, used to manage patient data and hospital operations.

Workforce: 18% of M&E officers at the state level and 4 of 22 LGA M&E officers are trained on DHIS2, in addition to approximately 25 doctors and 20 nurses. The SMOH has been training DHIS2 “mentors,” who are super users and have administrative access. Sufficient capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year, but is largely dependent on external support and input. HMIS training has taken place at 2 of 3 LGAs in the last 3 months, and 29% of facilities reported Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) in the last one year, provided by governments, donors and facilities. 100% of state and LGA health offices have an health information officer.

Standards and Interoperability: The state receives data from its LGAs in government approved and partner developed formats, and LGAs receive monthly summary forms from facilities. In the last month prior to the assessment, 35% of all facilities, all of which were private, and 80% of all LGAs submitted complete core data sets to the state, and 80% of facilities submitted complete core data sets to sample LGAs. At the state level, a data warehouse exists equivalent to the one at the NHIS office, but with limited reporting utility. The state submits data to the federal level using an electronic web-based platform; LGAs submit data to the state by electronic updating in place, and one also uses electronic spreadsheets. 95% of facilities share health information with LGAs, the majority using monthly summary forms, and one using an electronic spreadsheet. States hold monthly M&E meetings with LGAs, two LGAs hold monthly meetings with facilities and one does not hold meetings, and 71% of facilities hold data review meetings.

Strategy and Investment: Budgets for ICT-related equipment, including Internet, IT equipment, power supply and IT repairs were identified at the state level. 2 of 3 LGAs had budgets for Internet and power supply and 38% of facilities had an ICT budget. At the LGA level, 2 of 3 receive external funding, in addition to 14% of facilities.

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NHMIS: HMIS data is used to support program planning and data quality assur-ance. All budgets are informed by health information collected. In addition, health information is systematically used by health providers and health care manag-ers at all levels to inform health service delivery management, monitoring and evaluation, and to advocate equity and increased resources to disadvantaged groups and communities (e.g. by docu-menting their disease burden and poor access to service).

mSCM: Stock at the state level, within two LGAs and 81% of facilities is managed using paper-based methods. One LGA and three facilities use electronic methods to man-age stock. There have been no stock-outs at the state level and in one LGA in the last 6 months, and less regularly at 2 of 3 LGAs in the last 3 months. The state receives stock from the FMOH and NGOs irreg-ularly, and supplies stocks monthly. Two LGAs receive stock quarterly, one of which supplies quarterly and the other which supplies monthly. One LGA receives stock monthly and did not report on supply frequency. All LGAs receive supply from a mix of the SMOH and NGOs. Facilities receive commodities often from multiple sources; 62% of facilities receive commod-ities from the MOH, 29% from NGOs, 10% from client self-purchase and 24% from other sources such as medical represen-tatives and private companies. The state uses an electronic LMIS to submit reports, which was reported to improve supply availability. No LGAs or facilities use an electronic LMIS to submit reports.


Demand Generation: 62% of facilities give incentives, mostly in the form of free drugs, like anti-malarial treatment, TB drugs, ARTs, paracetamol, deworm-ing drugs. 78% of the facilities that give incentives reported that it improved conditions, whereas 15% reported no effect, and 8% reported negative effects. 24% of facilities send mobile health mes-sages, mostly targeting the community,

and all reporting that they have led to improvements. The state launched a mobile DHIS2 campaign, designed to encourage using text messaging to report issues. Challenges faced with the program was unreliable power and Inter-net and poor staff technical literacy.

Challenges


FACILITY (N=21)


No 100% 71%


No 100% 71%


No 100% 81%


Yes N/A 5%


No 33% 57%


Yes 33% 19%


No 33% 43%


No 100% 57%


Priorities


• Operationalizing DHIS at the facility level

• Improved IT support at LG A and facility levels

• Training M&E officers on DHIS at the state and LGA levels

Success Factors

• High basic ICT infrastructure available across the state’s health system, which may have an impact on high availability of DHIS2 at the facility level, relative to other states


7. sokoto

Key Findings

Infrastructure: There is basic ICT infrastructure at the state and LGA levels, but is limited at the facility level (18%). Support for ICT equipment maintenance is available at the state and LGA levels. There is IT support avail-able to all four LGA’s, but only a few facilities (9%). Respondents reported a need for over 700 phones across the state’s health system. At the state level and within three of four LGAs and 62% of facilities, the primary power source is a national or community grid. 29% of facilities use generators as its primary power source. There are frequent and prolonged power interruptions (i.e. more than 2 hours per day) during working hours at the state level, across all LGAs, and in 73% of facilities.

Services and Applications: DHIS2 is operational at the state and LGA levels, and is provided by the FMOH to the state, and by T-SHIP to the LGA. Technical support and processes for facilitating product feedback and updates is available at both levels. Internet fluctuations were reported to impact the utility of the application. At the facility level, 86% reported the use of paper-based HMIS forms, which are submitted to LGA M&E officers, who then use DHIS2 to send the data to the SMOH and FMOH. A Health ICT application, provided by NPHCDA, focused on analysing service delivery bottlenecks in facilities is available, but not working. At two LGAs, e-NN-RIMS, provided by SACA, is being used to capture HIV patient data from facilities.

Workforce: 44% of M&E officers at the state level are trained on DHIS2, in addition to 7 doctors. No DHIS2 training data was available at the LGA level. Limited capacity building (i.e. statistics, software and database maintenance, and epidemiology) has taken place for health ICT staff at the MOH in the last year. HMIS training has taken place at 75% of LGAs in the last 3 months, and 50% of facilities reported Health ICT related capacity building activities (i.e. data collection, self-assessment, analysis and presentation) in the last one year, provided by governments and donors. 100% of state and LGA health offices have a health information officer.

Standards and Interoperability: The state receives data from its LGAs in government approved formats and LGAs receive monthly summary forms from facilities. In the last month prior to the assessment, no LGAs or facilities submitted complete core data sets to the state. Whereas, 90% of facilities, most of which are public, submitted complete core data sets to the sample LGAs. At the state level, a data warehouse exists equivalent to the one at the NHIS office, but with limited reporting utility. The state submits data to the federal level using an electronic web-based platform; LGAs submit data to the state by electronic updating in place, and one also uses electronic spreadsheets. 100% of facilities share health information with LGAs, the majority using monthly summary forms, and two also using other formats. States hold M&E meetings with LGAs irregularly, three of four LGAs hold monthly meetings with health facilities and one does quarterly, and 76% of facilities hold regular data review meetings.

Strategy and Investment: Budgets for ICT-related equipment, including mobile phones and power supply were identified at the state level. There was no budget data available at the LGA level. 18% of facilities had ICT budget related items. External funding is received at the state and LGA levels, in addition to 14% of facilities.

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NHMIS: At the LGA level, health information is used to review staff performance and provide feedback to directors and officers in charge, review routine immunization program performance which is discussed at monthly meetings, review data quality and assurance, and plan for interventions, such as community outreaches. At the facility level, health information is used to monitor immunization coverage, the sta-tus of pregnant women and to plan for community outreaches and sensitization. Health data is only used to inform a few budgets, and is used to advocate equity and increased resources to disadvantaged groups and communities (e.g. by docu-menting their disease burden and poor access to service). Health managers and care providers at secondary and tertiary facilities use health data to inform service delivery and M&E.

SCM: Stock at the state level is managed using paper-based and electronic tools. LGAs and all facilities, with the exception of one, use paper-based methods. There have been less regular stock-outs at the state level, in 50% of LGAs and 43% of facil-ities. One LGA and 29% of facilities have had no stock-outs in the last six months, and another LGA and 19% of facilities, have stock-outs every month. The state receives stock quarterly, and supplies stock bi-monthly, whereas three of the four LGAs receive and supply stock monthly. Stock at the state and LGA levels is supplied from a mix of the FMOH, SMOH, NGOs and NACA. Facilities receive commodities often from multiple sources; 43% of facilities receive commodities from the MOH, 95% from NGOs, 10% from client self-purchase and 14% from the drug revolving fund. The state uses an electronic LMIS to submit reports, which was reported to improve supply availability. No LGAs or facilities use an electronic LMIS to submit reports


Demand Generation: 68% of facilities give incentives, mostly in the form of free LLINs, MAMA kits and free drugs, such as anti-malarials and birth control. All

facilities reported that incentives have led to improved work and client visits. 19% of facilities send mobile health messages to the community, which have shown to lead to improvements. The state reported that mobile health messages are sent as part of mass media campaigns, but are challenged by irregular power supply and poor network service.

Challenges


FACILITY (N=21)


Yes 75% 95%


Yes 75% 95%


Yes 75% 95%


No N/A 10%


Yes 75% 90%


Yes 75% 48%


Yes 75% 90%


Yes 75% 90%


Priorities


• Consistent power across the health system

• Training M&E officers on DHIS at the state and LGA levels

• Consistent M&E meetings at the LGA level

• Better use of health data to inform planning

Success Factors

• Sokoto uses an electronic system for stock management, which may have an impact on less regular stock-outs at the state and LGA levels.


component findings This section outlines the assessment findings by the components of the WHO/ITU national eHealth strategy toolkit. Five components are included: infrastructure, services and applica-tions, workforce, standards and interoperability and strategy and investment.

Infrastructure: In this assessment, infrastructure includes core infrastructure, including the electrical grid and cellular and Internet connectivity, and ICT equipment which con-sists of hardware, such as computers, mobile phones, tablets, and general services such as email, that build on top of a reliable infrastructure.

Basic ICT infrastructure (i.e. telephone, internet and email) and working computers are in place at the federal and state levels, supported by the FMOH, SMOH and FIPs. At the LGA level, approximately 78% of health offices surveyed reported availability of basic ICT infra-structure, and 100% reported the availability of working computers (See Figure 5-6). There is a discrepancy of basic ICT infrastructure availability at the facility-level, as less than half have working computers and functional Internet. Where computers are available, MS Win-dows is the dominant operating system, and, where mobile phones are available, Android and other Java-enabled (such as Symbian) operating systems are the most common.

Across the health system, there is a significant need for phones, computers and modems, and a particular need for DHIS2 guides, calculators, scanners and photocopiers at the LGA level. There are occasional stock-outs of job aids at the state (47%), LGA (41%) and facility (27%) levels, impacting timely reporting.

While the availability of electricity and power was identified across the health system, prolonged daily outages (~2 hours per day) were also as common. At the federal, state and LGA levels, the main sources of electricity are the national grid, generators or invert-ers, whereas solar power was found to be more common at the facility level.

Support for ICT equipment repairs and maintenance is lacking across the health system, with the exception of the federal level, where ICT staff within the MOH and external con-sultants have adopted this role. Four of the seven states (Abuja, Bauchi, Sokoto, Kano) reported support for ICT equipment repairs and maintenance as non-existent.

The assessment found that states and LGAs find the health information captured by DHIS2 useful in supporting program planning, such as outreaches, monitoring performance for key initiatives such as routine immunization, and identifying where to target LGA or facility level support, based on gaps in health service delivery management.

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figure 5. State-level ICT-related Infrastructure and Equipment Needs/Gaps

figure 6. LGA-level ICT-related Infrastructure and Equipment Needs/Gaps

0 10 20 30 40 50 60 70 80 90 100

Modems

DHIS2 Guide

Computers

Tablets

Phones

Printers

Photocopiers

Scanners

Calculators

Filing Cabinets

Generators

Tables

Chairs

Need

Available

0 100 200 300 400 500 600 700 800 900 1000

Modems

DHIS2 Guide

Computers

Tablets

Phones

Printers

Photocopiers

Scanners

Calculators

Filing Cabinets

Generators

Tables

Chairs

Need

Available


0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Other HealthWorkerDoctorNurseCHOCHEWM&E

O�cerPharmacistLabScientist

T U T U T U T U T U T U T U T U

T = Trained U = UntrainedState LGA Facility

Across the workforce trained on DHIS2, 73% are M&E o�cers. Considerations should be made for what other cadres of health workers should be trained or made familiar with DHIS2

figure 7. DHIS2 Training Across 7 Sample States

Services and Application: DHIS2 is the most widely used, supported and maintained Health ICT application across the federal, state and LGA levels, to manage health infor-mation. However, in contrast, DHIS2 is only available in approximately 25% of facilities surveyed. Respondents shared positive experiences with DHIS2, noting its friendly user interface and value to easing work requirements. The key challenge that respondents face with DHIS2 is Internet fluctuations and a lack of consistent Internet top-up funds, preventing reliable data upload.

Overall, FIPs reported 17 different Health ICT applications being used across supported facil-ities, none of which have achieved widespread coverage. Health ICT applications to consider for further evaluation include: Clinipak360 (decision support and health data collection), mCCT (payments / conditional cash transfers), ICT for Supply Chain (supply chain man-agement), births-deaths software (birth/death registration), RISS (immunization reporting), Kano Connect (immunization reporting) and HRHIS (human resources management).

| 41

figure 8. HMIS Training at the State and LGA Levels Over the Last 3-6 Months

Workforce: Training on DHIS2 has been largely limited to M&E officers, based in LGAs, but overseen by the FMOH. Federal KIs reported that 774 M&E officers have been trained (See Figure 7). While, most other health cadres (i.e. lab scientist, pharmacist, CHEW, CHO, nurse, doctor) have not been trained on DHIS2, respondents reported a pressing need amongst nurses at the state, LGA and facility levels. In contrast, there is limited trained capacity to support other Health ICT applications across the states, with the exception of Kano, where select health cadres have received training on Kano Connect.

The majority of states (5 of 7) reported having full-time health information officer posi-tions in all health offices. HMIS capacity building has been taking place at the state and LGA levels (See Figure 8). Respondents reported that over the last 6 months, 100% of states and 38% of LGAs have led capacity building efforts. At national and state levels, there is support available for HIS staff to design and manage HIS software and databases.

6 Months Ago

3 Months Ago

Other

1 Year Ago

6 Months Ago

3 Months Ago

58%

22%

16%

4%

HMIS STATE TRAINING HMIS LGA TRAINING

Akwa Ibom,Kano

Abuja, Bauchi,Imo, Lagos,

Sokoto

29%

71%

Standards & Interoperability: At the federal level, there are national written SoPs for data management which majority of the FIPs have implemented. Between the FMOH and states, and states and LGAs, data is mostly received in the GoN approved standard format. In some cases at the state level, FIP-developed program formats are also used. Data is sent between states and the FMOH electronically, using the national web-based platform, whereas between facilities and LGA’s, paper-based forms are still the norm. A national data warehouse exists for reporting, and is accessible to various users including the LGA M&E officers. Figure 9 shows the proportion of health facilities that submitted their core datasets in the month previous to the assessment. The survey found higher on-time reporting from public facilities (79%) versus private facilities (27%).

M&E meetings are held at the state level annually to review and apply collected data to planning efforts, and LGAs are given feedback monthly on data quality (See Table 3). State-level respondents reported that HMIS data is used for supporting quality


improvement, planning and budgeting, policy making and evaluation, disease surveil-lance and human resource redistribution, but it is seldom used for advocacy purposes.

HMIS reporting forms and registers were found to be inadequate in all survey states. None of the states had SURE-P forms/registers available. One hundred and ten facilities reported having HMIS forms. Figure 10 shows stock-out of HMIS forms in the past one month. Com-munity monthly summary sheets, daily registers for out-patient and in-patient care were not available in 20 or more facilities in the month preceding the field assessment.

table 3. M&E Meetings

FREQUENCY OF MEETINGS

STATE LGA

MONTHLYAbuja, Akwa Ibom, Imo, Lagos

68%

QUARTERLY Bauchi, Kano N/A

IRREGULAR Sokoto N/A

NEVER N/A 14%

figure 9. Proportion of Health Facilities Submitting Data on Time Across LGAs in the

Month Previous to the Assessment

0

200

400

600

800

1000

1200

Submitted CompleteData Last MonthTotal Health Facilities

Public Private

693

545 (79%)

287 (27%)

1057

| 43

figure 10. Forms Not Available in Health Facility in the Past Month (N = 126)

Strategy and Investment: The FMOH reported budgeting and receiving a total of 750,000N for internet and power supply for the national DHIS2 server in the previous year, partly supported by external partners.

All States surveyed had budgets for ICT-related items in the previous year. This included IT equipment (computers, laptops, and netbooks), IT repairs, power supply and Internet. Budgets for mobile devices (tablets, mobile phones) were less frequent. The amount of funding available for Internet monthly was found to be N5,000 in Akwa Ibom and Imo States. In both states, the M&E officers reported needing N20,000 to 30,000N monthly for internet. Funds for calls and SMS were limited, with the exception of Abuja and Akwa Ibom. In general, the GoN contributes 60-85% of the funding with the rest contributed by donors. Five of the seven survey states reported receiving external funding for health from the GoN and external partners (See Table 4).

At the LGA level, internet and power supply were the most frequently budgeted ICT- related items. Three LGAs reported they had funded budgets for ICT-related items with amounts ranging from 2,500N to 60,000N.

At the facility level, internet and power supply are the most frequently budgeted ICT- related items. Only 20 facilities had their budgets funded, 11 of which had their total bud-gets released. The average budget amount was N2.87 million (40,000 to 10 million naira).

0 5 10 15 20 25 30 35 40

HF Daily Registerfor In-Patient Care

HF Daily Registerfor Out-Patient Dept

HF Daily Register for Growth Monitoring

HF Daily Register for Family Planning Service

HF Daily Registerfor Immunization

HF Daily Register for Labour Delivery Record

HF Daily Registerfor ANC

Community Monthly Summary Sheet

NUMBER OF FACILITIES


table 4. Funding for Internet and Power Supply Across Health Systems

HEALTH SYSTEM

FEDERAL STATE LGA FACILITY

COMMON BUDGET ITEMS

Internet Supply and Power Supply

IT Equipment, IT Repairs, Internet and Power Supply

Internet and Power Supply

Internet and Power Supply

BUDGET AMOUNT

750,000 N/A 2,500 - 60,000 40,000 - 10,000,000

FUNDING SCOPE

N/A 2 States 3 LGAs 20 Facilities

RELEASED FUNDING

N/A Not fully released 50% released in 1 11 facilities total amount released, 2 facilities 46-70% released

FUNDING SOURCE

Government and external

Government (60-85%) and donors

Government (80-100%), NGOs (5-100%), individuals (0-5%) in 9 LGAs

Goverment (60-100%) and donors (30-60%) for 9 facilities

Platforms for Scale

NHMIS: LGA and State health management teams use health ICT data to inform annual targets and budgets. In Abuja, Akwa Ibom and Lagos, health ICT data was reportedly used to systematically promote equity and increased resources for disadvantaged groups and communities, whereas in Sokoto state, this only happens on an ad hoc basis. Care providers and health managers at all levels use health information in varying degrees for health service delivery management, continuous monitoring, and periodic evaluation.

mSCM: At the federal level, the FMOH and NGOs supply commodities. The FMOH and NGOs supply commodities to all states, with the exception of Bauchi, which is supported by NGOs and the SMOH. Two states, Imo and Sokoto, reported receiving commodities from the SMOH and FIPs, in addition to the FMOH and NGOs. No stock-outs of commodities were experienced at the national level in the last 6 months. At the state level, stock-outs varied across the states, from monthly (Imo and Bauchi) to within the last three months (Akwa Ibom, Abuja, Sokoto and Kano). Only Lagos State reported experiencing no stock-outs in the past 6 months. At the LGA level, SMOHs commonly supply commodities (51%), followed by NGOs (29%) and the FMOH (14%). At the facility level, the FMOH supplies to less than half, followed by NGOs (29%). A quarter of facilities reported having drug revolving funds, where they manage commodity purchasing. All states, and the majority of LGAs and facilities use paper-based tools to manage stock. In Sokoto State, 5% of LGAs and 6% of facilities reported using electronic methods to manage stock. In terms of stock reporting, two states (Lagos and Kano) reported using electronic LMIS to submit reports. In Lagos, respondents noted that the electronic LMIS has led to better stock availability. While in Kano State, though electronic LMIS has helped in stock management, it was found that it is a slower process because direct data information capture officers have to visit facilities to collect data.

mCCT: Only one facility is using mobile money to deploy cash incentives to clients. There is a large opportunity to use mobile money to facilitate incentives, in addition to the timely release of ICT budgets.

| 45

Demand Generation: Eighty-one of 126 facilities reported providing incentives to clients. Incentives are usually free services, discounted bills for clients, free drugs, free commod-ities such as LLINs, vaccines, and are rarely monetary. In some instances, clients are given household equipment as incentive. Seventy-five facilities reported that incentives improved the experience of patient visits. Mobile health messaging is less common amongst facilities; 31% are using mobile health messaging targeting the community. States reported the mobile health messaging is used as part of mass media campaigns, but is challenged by cost, network fluctuations and inconsistent power supply.

recommendations and conclusions The following are recommendations based on the findings from the field assessment, and the policy and inventory reviews previously conducted. These recommendations should be used to inform the development of Nigeria’s National Health ICT strategy and roadmap.

Infrastructure: Equipping all states, LGAs and facilities with basic infrastructure, including computers with Internet access, mobile phones/telephones, and power supply, alongside provisions for technical support and maintenance and processes to facilitate product updates and feedback is the primary priority for the GoN FMOH as it establishes and imple-ments its national Health ICT framework. Without this building block in place, investments in Health ICT platforms and applications, and support mechanisms including workforce capac-ity building and standards and interoperability will be wasted due to limited uptake because of poor user experience. This process might include establishing a “standard package” of ICT equipment required at each health system level, in addition to short and medium term strategies to allocate funding and facilitate payments to ensure ongoing and consistent connectivity. This “standard package” can then be used as a benchmark to facilitate future monitoring and evaluation and health system performance assessments.

Services and Applications: DHIS2 is currently the only nationally approved Health ICT application in Nigeria that has achieved broad adoption at the state and LGA levels. This only represents one of the numerous possible applications of technology in health care. While uptake of DHIS2 is still limited at the facility level, and a transition from paper to electronic methods is required, the GoN has illustrated the capacity to establish the support structures, including investments in workforce capacity building, training mate-rials, and monitoring and evaluation processes, to introduce an Health ICT platform at scale. The GoN should draw from this experience, to begin establishing national Health ICT platforms to digitally manage other components in the WHO/ITU national eHealth framework, specifically human resources, supply management, health messaging, and payments. Currently, the adoption of HRHISs and LMISs is limited across states. There are case studies in Kano, Sokoto and Lagos that the GoN can learn from as it establishes the national Health ICT framework. As part of this effort, an increased emphasis on integration of Health ICT applications and platforms will be required. Currently, this is not viewed as a challenge in most states, except Kano, since only DHIS2 is available. Further, as additional national Health ICT platforms are selected, it is important that other Health ICT technology providers are encouraged to align their products. For instance, Health ICT technology providers should align their systems with DHIS2 data points, using the required APIs to enable data integration. In cases where national approved Health ICT applications are not required, such that states, LGA and facilities can make independent decisions, guidelines and support mechanisms are required to execute fair agreements with technology solution providers, such that sensitive citizen health data is protected in the event of deciding to change providers, inability to pay etc. This support is also required when facilities decide to adopt and deploy free and open-source solutions, to avoid cases where health data is trapped inside software that users have little knowledge on.


Workforce: Currently, capacity building efforts have been focused on training all M&E officers on DHIS2. Training M&E officers on DHIS2 can improve reporting rates, as found in Akwa Ibom and Imo. However, other health cadres have not been formally trained on DHIS2, which is most challenging at the facility level. Other cadres of health staff like doctors, nurses, and pharmacists do not need in-depth training on DHIS2, but a basic knowledge to enable them to query the system for informative health data to assist them in their work. A plan is required to select additional health cadres that require compre-hensive training and those that require sensitization for the purposes of using the data to inform planning and health service delivery management. HMIS training at the LGA level and Health ICT capacity building at the facility level is taking place, illustrating that equip-ping health cadres with ICT skills is considered a priority. As part of the national Health ICT framework, plans for systematic training that aligns with implementation priorities will be required to maximize investments. Timing capacity building with the introduction of ICT infrastructure, equipment, applications, or standards is required to prevent disinterest and changing priorities amongst health cadres and facilities. Lastly, there is growth in the health information officer cadre, though further investments in hiring to fill positions across states and LGA’s is required. As part of the national health ICT framework, plan-ning for the expansion of the roles and responsibilities of this cadre, as additional Health ICT applications and platforms are introduced, and the volume of data increases, will be critical to plan for phased approaches in skills development.

Standards and Interoperability: Introducing standards and interoperability to facilitate the adoption of Health ICT applications and platforms for scale is in its initial stages. States, LGAs and facilities are using government-approved formats for reporting, yet SOPs to govern data management and utilization still appear to be scarce. M&E meetings, which take place either monthly or quarterly across states, LGAs and facilities, are being used to discuss the implications of health information collected. They are a valuable platform that the GoN should use to obtain the data required to establish relevant SOPs, and implement them.

Strategy and Investment: Specific funding data at all levels was largely unavailable in the field assessment, and in cases where it was, budgets were often not approved or released. However, the assessment found that ICT-related items, especially Internet, power supply and IT support, are being prioritized in budgets. As part of establishing a national health ICT framework, short-term funding plans are required for initial capital investments to improve basic ICT infrastructure and medium term funding plans to support ongoing connectivity. One, without the other, risks wasting large investments in ICT infrastructure. The second priority is to explore mechanisms, such as mobile money, to facilitate the deployment of funds to states, LGAs and facilities to purchase broadband and data, when required. Investments in improving reliable power supply and network coverage are inadequate if not complemented by processes for the health system to access it.

| 47

Platforms for Scale

As part of the national ICT for health framework, outlining how each level of the health sys-tem should use data captured from DHIS2 and other applications and platforms to support health service delivery management and decisions will be critical to maximizing investments. Currently, the assessment found that states and LGAs find the health information captured useful in supporting program planning, such as outreaches, monitoring performance for key initiatives such as routine immunization, and identifying where to target LGA or facility level support, based on gaps in health service delivery management. Systematizing these procedures may require the addition of new health cadres, such as health statisticians and data scientists to comprehensively analyze the data and unlock actionable findings.

The assessment found that there is limited adoption of platforms supporting supply manage-ment, however, since paper-based reporting processes are strong and DHIS2 penetration is high at the state and LGA levels, there is sufficient foundation to transition supply management to a digital system. The use of mobile money is non-existent and mobile health messaging is limited. Introducing these platforms at scale will require investments in mobile-specific capac-ity building, in addition to collaboration with network operators to improve coverage. Further testing and/or review of the evidence base for mobile money and mobile health messaging in Nigeria is required to understand its scope in the national health ICT framework.


5 . References

Emont, S., & Emont, N. (2007). Advancing eHealth: Opportunities & Challenges for the Health e-Technologies Initiative. White Mountain Research Associates, L.L.C.

Federal Republic of Nigeria. (2013). ICT4SOML: Leveraging ICTs to Save the Lives of One Million Women and Children in Nigeria - Situational Analysis. FMOH, mHealth Alliance, Intel, GSMA.

FMOH. (2012). Saving Newborn Lives in Nigeria: NEWBORN HEALTH. Federal Ministry of Health, Nigeria.

GSMA & PwC. (2012). Touching lives through mobile health: Assessment of global market opportunity. GSMA and PwC.

The World Bank. (2014). 2014 World Development Indicators. Washington DC: The World Bank.

UN Foundation. (2014). Assessing the Enabling Environment for ICTs for Health in Nigeria: A Landscape and Inventory. United Nation Foundation.

UN Foundation. (2014). Assessing the Enabling Environment for ICTs for Health in Nigeria: A Review of Policies. United Nation Foundation.

UNFPA/WHO. (2011). Nigeria Global Health Initiative Strategy 2010 - 2015. UNFPA; WHO.

UNICEF. (n.d.). UNICEF Nigeria. Retrieved October 8, 2014, from UNICEF: http://www.unicef.org/nigeria/children_1926.html

WHO-ITU. (2012). National eHealth Strategy Toolkit. Geneva: World Health Organization and International Telecommunication Union.


6 . Annexes

annex 1: Key Findings From Federal Implementing Forms

EHEALTH COMPONENT

EHEALTH SYSTEMS

HISP NIGERIA INSTRAT INT’L NACAEHEALTH COMPONENT

NPHCDA PATHFINDER INT’L SURE-P MCH AFRICARE

Infrastructure: Working computers in supported facilities

No Yes No Yes Infrastructure: Working computers in supported facilities

Yes No No Yes

Infrastructure: Mobile devices in supported facilities

Yes Yes Yes Yes Infrastructure: Mobile devices in supported facilities

Yes Yes Yes No

Infrastructure: Main ICT provider

NGO/Partner Not applicable NGO/Partner Govt., NGO/Partner Infrastructure: Main ICT provider

Govt., NGO/Partner Not applicable NGO/Partner NGO/Partner

Services & Applications

RISS, LOMIS, Ebola Sense Follow up, Tracking App

Not applicable CliniPAK DHIS2Services & Applications

DHIS2 ComCare CliniPAK, mCCT, ICT for Supply Chain

DHIS2

Services & Applications: Data protected by

Restricted server access & external backups

Not applicable Restricted server access & cloud storage



Restricted server access & cloud storage



No information on data protection

Workforce: Health Information Officer

All health offices have designated health information officer position

Not applicable Less than 50% health offices have designated health information officer position

No information on health information officer position


More than 50% health offices have designated health information officer position


Less than 50% health offices have designated health information officer position

No information on Health information officer position

Workforce: ICT Capacity

Sufficient ICT capacity building for health staff has taken place in the last 1 year, but donor-decided

No information on ICT capacity building for health staff

Limited ICT capacity building for health staff has taken place in the last 1 year



Sufficient ICT capacity building for health staff has taken place in the last 1 year & Govt-driven

No ICT capacity building for health staff has taken place in the last 1 year



Standards & Interoperability: SoPs

Written SoPs for data mgt. fully implemented


Written SoPs for data mgt. partially implemented







Standards & Interoperability: Shared Data Formats

Partner-developed program-based, Email

GoN-approved std. & Partner-developed program-based

GoN-approved std. GoN-approved std. Standards & Interoperability: Shared Data Formats

GoN-approved std. GoN-approved std. & Partner-developed program-based

GoN-approved std. Partner-developed program-based, Printed

| 51

6 . Annexes

annex 1: Key Findings From Federal Implementing Forms

EHEALTH COMPONENT

EHEALTH SYSTEMS



Infrastructure: Working computers in supported facilities

No Yes No Yes Infrastructure: Working computers in supported facilities

Yes No No Yes

Infrastructure: Mobile devices in supported facilities

Yes Yes Yes Yes Infrastructure: Mobile devices in supported facilities

Yes Yes Yes No

Infrastructure: Main ICT provider

NGO/Partner Not applicable NGO/Partner Govt., NGO/Partner Infrastructure: Main ICT provider

Govt., NGO/Partner Not applicable NGO/Partner NGO/Partner

Services & Applications

RISS, LOMIS, Ebola Sense Follow up, Tracking App

Not applicable CliniPAK DHIS2Services & Applications

DHIS2 ComCare CliniPAK, mCCT, ICT for Supply Chain

DHIS2



Not applicable Restricted server access & cloud storage








All health offices have designated health information officer position

Not applicable Less than 50% health offices have designated health information officer position

No information on health information officer position




Less than 50% health offices have designated health information officer position

No information on Health information officer position


Sufficient ICT capacity building for health staff has taken place in the last 1 year, but donor-decided


Limited ICT capacity building for health staff has taken place in the last 1 year



Sufficient ICT capacity building for health staff has taken place in the last 1 year & Govt-driven














Standards & Interoperability: Shared Data Formats

Partner-developed program-based, Email

GoN-approved std. & Partner-developed program-based

GoN-approved std. GoN-approved std. Standards & Interoperability: Shared Data Formats

GoN-approved std. GoN-approved std. & Partner-developed program-based

GoN-approved std. Partner-developed program-based, Printed


EHEALTH COMPONENT

EHEALTH SYSTEMS



Standards & Interoperability: Data Warehouse

There is an integrated data warehouse at the national office with reporting utilities accessible to various users

No information on national data warehouse




There is an integrated data warehouse at the national office with limited reporting utilities accessible to various users

No data warehouse at the national



Strategy and Investment: Budget for ICT-related items

Internet, IT equipment, Power supply, Mobile devices, IT repairs

No information on budget for ICT-related items

Internet, Power supply, Mobile devices, IT repairs




Mobile devices Internet, IT equipment

Internet, Power supply, IT repairs

National Health Information Systems: HMIS Forms

HMIS forms provided to supported facilities

Not applicable HMIS forms provided to supported facilities




No HMIS forms provided to facilities



National Health Information Systems: ICT4Health Information

ICT4Health information regularly used to promote equity

Not applicable ICT4Health information used to promote equity on ad hoc basis

ICT4Health information systematically used to promote equity


ICT4Health information used to promote equity on ad hoc basis




National Health Information Systems: Program Datasets

Program datasets mimics some national approved indicator sets

Not applicable Program datasets mimics all national approved indicator sets

Program datasets mimics all national approved indicator sets


No information Program datasets mimics all national approved indicator sets



Mobile Supply Chain Management: Stock-outs

Program tracks stock-outs

Program tracks stock-outs using Paper

No stock-outs handled

Program tracks stock-outs using Electronic


No stock-outs information




Mobile Supply Chain Management: LMIS Forms Used

Partner-developed GoN health program endorsed

Not applicable GoN health program endorsed


No information Partner-developed Partner-developed GoN health program endorsed

Demand Generation: Incentive for Supported Facilities

There is cash incentive for supported facilities

Not applicable No incentive for supported facilities



Not sure of incentive for supported facilities

There is (mobile money) incentive for supported facilities

There is (cash & mobile money) incentive for supported facilities

There is incentive for supported facilities

| 53

EHEALTH COMPONENT

EHEALTH SYSTEMS









There is an integrated data warehouse at the national office with limited reporting utilities accessible to various users







Internet, Power supply, Mobile devices, IT repairs




Mobile devices Internet, IT equipment

Internet, Power supply, IT repairs



Not applicable HMIS forms provided to supported facilities




No HMIS forms provided to facilities





Not applicable ICT4Health information used to promote equity on ad hoc basis

ICT4Health information systematically used to promote equity








Not applicable Program datasets mimics all national approved indicator sets



No information Program datasets mimics all national approved indicator sets




Program tracks stock-outs



Program tracks stock-outs using Electronic


No stock-outs information





Partner-developed GoN health program endorsed

Not applicable GoN health program endorsed


No information Partner-developed Partner-developed GoN health program endorsed



Not applicable No incentive for supported facilities



Not sure of incentive for supported facilities

There is (mobile money) incentive for supported facilities

There is (cash & mobile money) incentive for supported facilities

There is incentive for supported facilities


annex 2: State-level Summaries (N=7 States)

COMPONENT AKWA IBOM BAUCHI FCT IMO COMPONENT KANO LAGOS SOKOTO

Infrastructure Basic ICT infrastructure available at State level and only in 25% of LGAs

Basic ICT infrastructure at State level and in all LGAs


Basic ICT infrastructure at State level and only in 25% of LGAs

Infrastructure Basic ICT infrastructure at State level and in all LGAs.

Basic ICT infrastructure at State level and in all LGAs.


Infrastructure: ICT Equipment Maintenance

ICT equipment maintenance support is only available at state level and in 25% of LGAs and at a minimal level

Support for ICT equipment maintenance at state and all LGA offices





ICT equipment maintenance support is only available at state level and in a 25% of LGAs and at a minimal level


Infrastructure: Power Supply

Frequent or prolonged power interruptions of more than 2 hours per day during working hours at MOH





Power supply is always available without interruptions.

Power supply is often available with interruptions of less than 2 hours a day.


Infrastructure: Recording Tools

Stock-outs of recording tools which affect the recording of required information


Occasional stock-outs of recording tools, but this does not affect the recording of required information



Recording tools are always available



Services & Applications: DHIS2

DHIS2 is available and operational at State and LGA levels.

DHIS2 is available and operational at State, LGA level and in most facilities surveyed.







Services & Applications: Other ICT4Health Apps

LMIS is also available but not fully installed; NNRMS; Metropos (the only functional & available in one facility).

SWIFT Practice available and functional in only one health facility


HRHIS (for managing HWs); National Health Workforce Registry

Births-Deaths Software; E-Health Software

Bottleneck Analysis Tool

Services & Applications: Data Protection

Highly restricted access to server & external backup






Highly restricted access to server, external backup and cloud storage


| 55

annex 2: State-level Summaries (N=7 States)


Infrastructure Basic ICT infrastructure available at State level and only in 25% of LGAs



Basic ICT infrastructure at State level and only in 25% of LGAs

Infrastructure Basic ICT infrastructure at State level and in all LGAs.










ICT equipment maintenance support is only available at state level and in a 25% of LGAs and at a minimal level








Power supply is always available without interruptions.

Power supply is often available with interruptions of less than 2 hours a day.








Recording tools are always available





DHIS2 is available and operational at State, LGA level and in most facilities surveyed.








LMIS is also available but not fully installed; NNRMS; Metropos (the only functional & available in one facility).

SWIFT Practice available and functional in only one health facility


HRHIS (for managing HWs); National Health Workforce Registry

Births-Deaths Software; E-Health Software

Bottleneck Analysis Tool








Highly restricted access to server, external backup and cloud storage




Services & Applications: Health Information

Health information used for continuous M&E at the state level








Workforce: DHIS2 Training

60% of M&E officers trained on DHIS2. Training of other HW cadres on DHIS2 largely deficient.

No information on trained HWs on DHIS2.








Less than 50% of health offices have a designated and filled full-time health information officer position

100% of health offices have a designated and filled full-time health information officer position


No full-time health information officer position





Standards & Interoperability: Data Received

Data is received from LGAs mostly in the GoN approved standard format


Data is received from LGAs mostly in GoN approved standard and Partner developed program-based formats



Data is received from LGAs mostly in GoN approved standard and Partner developed program-based formats and Emails



Standards & Interoperability: Data Submission

100% of LGAs submitted complete (core) dataset the previous month







No information on data submission from LGAs

Standards & Interoperability: M&E Meeting Frequency

M&E Meetings with LGAs: Monthly

M&E Meetings with LGAs: Quarterly






M&E Meetings with LGAs: Irregular

Strategy and Investment: Budget

Budget for IT equipment & power supply last year


Budget for IT equipment, power supply & IT repairs last year

Budget for Internet, IT equipment & IT repairs last year


Budget for Internet, IT equipment, Power supply, Mobile devices & IT repairs last year

Budget for Internet, IT equipment, power supply & IT repairs last year


Strategy and Investment: External Funding

Gets external funding on health

No information Gets external funding on health





Strategy and Investment: Budget Proposals

Few budget proposals are backed up by Health ICT information

Some budget proposals are backed up by Health ICT information





Majority of budget proposals are backed up by Health ICT information


| 57





















Less than 50% of health offices have a designated and filled full-time health information officer position



No full-time health information officer position











Data is received from LGAs mostly in GoN approved standard and Partner developed program-based formats and Emails











No information on data submission from LGAs









M&E Meetings with LGAs: Irregular


Budget for IT equipment & power supply last year


Budget for IT equipment, power supply & IT repairs last year

Budget for Internet, IT equipment & IT repairs last year



Budget for Internet, IT equipment, power supply & IT repairs last year
















Majority of budget proposals are backed up by Health ICT information




National Health Information System: Health ICT Information Use

Health ICT information is systematically used to promote equity

Health ICT information is regularly used to promote equity






Health ICT information is used to promote equity only & on ad hoc basis

National Health Information System: Use of Health Information for Service Delivery

Health managers & care providers use of health information for service delivery, M&E At all levels

Health managers use of health information for service delivery, M&E Occasionally






Health managers (occasionally) & care providers (at tertiary & secondary levels) use health information for M&E & service

Mobile Supply Chain Management: Stock Management

Stock managed with Paper







Stock managed with Paper & Electronic

Mobile Supply Chain Management: Stock-out

Stock-out experienced less regularly within the last 3 months

Stock-out experienced regularly every months





No stock-outs experienced in the last 6 months


Mobile Supply Chain Management: Use of electronic LMIS in the state

No No No No Mobile Supply Chain Management: Use of electronic LMIS in the state

No information Yes Yes

Demand Generation: Health Messaging

SMS & presentations used to pass health messages

Jingles & billboards used to pass health messages

No information on health messaging technology

SMS used to pass health messages


Print & electronic media

Mobile campaign initiative with DHIS2 mobile used to pass health messages

Jingles & IEC materials used to pass health messages

Demand Generation: Problems of using technology for health messaging

Poor network Poor power supply & funding for recharge

No information Poor network & funding for recharge


Poor network & funding for jingles

Poor power supply Poor power supply & Poor network

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Health ICT information is used to promote equity only & on ad hoc basis



Health managers use of health information for service delivery, M&E Occasionally






Health managers (occasionally) & care providers (at tertiary & secondary levels) use health information for M&E & service









Stock managed with Paper & Electronic








No stock-outs experienced in the last 6 months


Mobile Supply Chain Management: Use of electronic LMIS in the state

No No No No Mobile Supply Chain Management: Use of electronic LMIS in the state

No information Yes Yes


SMS & presentations used to pass health messages

Jingles & billboards used to pass health messages

No information on health messaging technology

SMS used to pass health messages


Print & electronic media

Mobile campaign initiative with DHIS2 mobile used to pass health messages

Jingles & IEC materials used to pass health messages


Poor network Poor power supply & funding for recharge

No information Poor network & funding for recharge


Poor network & funding for jingles

Poor power supply Poor power supply & Poor network


annex 3: LGA-level Summaries by State (N=3 per State)

EHEALTH COMPONENT

AKWA IBOM BAUCHI FCT IMOEHEALTH COMPONENT

KANO LAGOS SOKOTO

Infrastructure: Working Internet

All LGAs have working internet in computers


2 of 3 LGAs have working internet in computers




2 of 3 LGAs have internet in computers, 1 working


Infrastructure: IT Support

There is IT Support in all LGAs

No IT Support in all LGAs


Have IT Support in some LGAs





Infrastructure: Power Interruptions

All LGAs experience prolonged interruptions of more than 2 hours daily


1 of 2 LGAs often has power with less than 2 hours interruptions daily



Some LGAs often have power with less than 2 hours interruptions daily




2 of 3 LGAs experience occasional stock-out of recording tools

2 of 3 LGAs experience stock-outs that affect recording of health information

2 of 3 LGAs always have recording tools

Facilities in LGAs cannot meet reporting requirements due to lack of recording tools


All LGAs experience occasional stock-out of recording tools

Some LGAs experience occasional stock-out of recording tools

Some LGAs always have recording tools

Services & Applications: DHIS2 Availability

DHIS2 available and working on any computer with internet








Services & Applications: Technical Support for DHIS2

All LGAs have technical support for DHIS2

2 of 3 of LGAs have no technical support for DHIS2


No technical support for DHIS2





Services & Applications: Health Information Use

Use health information for M&E









10 of 12 M&E Officers trained on DHIS2







No data available

Standards & Interoperability: Facility Data

Receive data from facilities in monthly summary forms





Receive data from facilities in monthly summary forms & other printed formats



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annex 3: LGA-level Summaries by State (N=3 per State)

EHEALTH COMPONENT


KANO LAGOS SOKOTO




2 of 3 LGAs have working internet in computers




2 of 3 LGAs have internet in computers, 1 working






Have IT Support in some LGAs











Some LGAs often have power with less than 2 hours interruptions daily




2 of 3 LGAs experience occasional stock-out of recording tools

2 of 3 LGAs experience stock-outs that affect recording of health information

2 of 3 LGAs always have recording tools

Facilities in LGAs cannot meet reporting requirements due to lack of recording tools


All LGAs experience occasional stock-out of recording tools

Some LGAs experience occasional stock-out of recording tools

Some LGAs always have recording tools














No technical support for DHIS2






















No data available







Receive data from facilities in monthly summary forms & other printed formats




EHEALTH COMPONENT


KANO LAGOS SOKOTO

Standards & Interoperability: Dataset Submission

96% of public facilities submitted core dataset to LGA the previous month

No complete data 93% of public facilities submitted core dataset to LGA the previous month






Standards & Interoperability: Health Information Displays

Graphs & maps largely used at both LGA and facilities to display health information.

Graphs & maps used at some LGA and facilities to display health information.

No graphs & maps used at both LGA and facilities to display health information. Graphs in one LGA only.

Graphs & maps rarely used in LGA and facilities to display health information.


Graphs & maps sometimes used in LGA and facilities to display health information.



Standards & Interoperability: Data sent to State

2 of 3 LGAs use Form002 Quarterly Summary to send data to State

Data sent to State via DHIS2 web platform

Data sent to State via DHIS2 web platform & electronic spreadsheets

2 of 3 LGAs sent data to State via DHIS2 web platform





Strategy and Intestment: Budget

1 of 3 LGAs has budget for Internet & mobile devices

No information 1 of 3 LGAs has budget for Internet, IT Equipment and IT Repairs

Unsure Strategy and Intestment: Budget

No information 2 of 3 LGA have budget for Internet & Power supply

No information

Strategy and Intestment: External Funding

1 of 3 LGAs has external funding

No information No external funding No external funding Strategy and Intestment: External Funding

2 of 3 LGAs have external funding


All LGAs have external funding

National Health Information System: HMIS Training

2 of 3 LGAs had HMIS training 3 months ago





LGAs had HMIS training less than 1 year ago


75% of 3 LGAs had HMIS training 3 months ago


Stock-outs less regularly in the last 3 months

2 of 3 LGAs experience stock-outs less regularly in the last 3 months

No information on stock-outs

Stock-out information non-stable




50% of LGAs experience stock-outs less regularly in the last 3 months

Mobile Supply Chain Management: Stock Received

Receive stocks monthly

Timing of re-stocking: irregular

No information 2 of 3 LGAs receive stocks 6-monthly


2 of 3 LGAs receive stocks monthly

2 of 3 LGAs receive stocks quarterly


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EHEALTH COMPONENT


KANO LAGOS SOKOTO



No complete data 93% of public facilities submitted core dataset to LGA the previous month







Graphs & maps largely used at both LGA and facilities to display health information.


No graphs & maps used at both LGA and facilities to display health information. Graphs in one LGA only.

Graphs & maps rarely used in LGA and facilities to display health information.


Graphs & maps sometimes used in LGA and facilities to display health information.




2 of 3 LGAs use Form002 Quarterly Summary to send data to State


Data sent to State via DHIS2 web platform & electronic spreadsheets






Strategy and Intestment: Budget

1 of 3 LGAs has budget for Internet & mobile devices

No information 1 of 3 LGAs has budget for Internet, IT Equipment and IT Repairs

Unsure Strategy and Intestment: Budget

No information 2 of 3 LGA have budget for Internet & Power supply

No information

Strategy and Intestment: External Funding

1 of 3 LGAs has external funding

No information No external funding No external funding Strategy and Intestment: External Funding



All LGAs have external funding







LGAs had HMIS training less than 1 year ago


75% of 3 LGAs had HMIS training 3 months ago


Stock-outs less regularly in the last 3 months


No information on stock-outs

Stock-out information non-stable




50% of LGAs experience stock-outs less regularly in the last 3 months



Timing of re-stocking: irregular

No information 2 of 3 LGAs receive stocks 6-monthly


2 of 3 LGAs receive stocks monthly

2 of 3 LGAs receive stocks quarterly



annex 4: Facility-level Summaries by State (N=126; 7 per State)

EHEALTH COMPONENT AKWA IBOM BAUCHI FCT EHEALTH COMPONENT IMO LAGOS SOKOTO

Infrastructure: % of facilities with a working computer

57% 24% 50% Infrastructure: % of facilities with a working computer

24% 52% 18%

Infrastructure: % of facilities with working internet

52% No complete information 40% Infrastructure: % of facilities with working internet

No complete information No complete information No complete information

Infrastructure: % of facilities with IT Support

29% 14% 55% Infrastructure: % of facilities with IT Support

19% 33% 9%

Infrastructure: Service Interruptions

81% experience prolonged interruptions of more than 2 hours daily







Infrastructure: Recording Tools Availability

33% recording tools for disease & health information always available








24% of facilities use DHIS2 at facility level


DHIS2 yet be operational at facility level






81% use health information for M&E







Workforce: M&E Officer Training

No useful evidence of M&E officers trained at facility level







Workforce: ICT4Health Capacity Building

62% has ICT4Health capacity building for staff in the last one year; provided by government & facilities

29% has ICT4Health capacity building for staff in the last one year; provided mostly by government



24% has ICT4Health capacity building for staff in the last one year; provided mostly by donors

29% has ICT4Health capacity building for staff in the last one year; provided by government, donors & facilities

50% has ICT4Health capacity building for staff in the last one year; provided by government & donors

Standards and Interoperability: Data Review Meetings

62% of facilities hold regular data review meetings

81% of facilities hold data review meetings, most of which are irregular



54% of facilities hold data review meetings, most of which are regular




57% had budget on ICT-related Items

No budget information on ICT-related Items from 91% of facilities

No budget information on ICT-related Items






10% of facilities have external funding

No external funding for facilities






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annex 4: Facility-level Summaries by State (N=126; 7 per State)


Infrastructure: % of facilities with a working computer

57% 24% 50% Infrastructure: % of facilities with a working computer

24% 52% 18%

Infrastructure: % of facilities with working internet

52% No complete information 40% Infrastructure: % of facilities with working internet

No complete information No complete information No complete information

Infrastructure: % of facilities with IT Support

29% 14% 55% Infrastructure: % of facilities with IT Support

19% 33% 9%










































62% has ICT4Health capacity building for staff in the last one year; provided by government & facilities




24% has ICT4Health capacity building for staff in the last one year; provided mostly by donors

29% has ICT4Health capacity building for staff in the last one year; provided by government, donors & facilities

50% has ICT4Health capacity building for staff in the last one year; provided by government & donors


62% of facilities hold regular data review meetings









No budget information on ICT-related Items from 91% of facilities

No budget information on ICT-related Items















National Health Information Systems: Health Information Displays

48% use up-to-date graphs & maps to display health information








95% of facilities have the HMIS forms in stock







Mobile Supply Chain Management: Supplies

62% get supplies from the MOH

Get supplies from the MOH, NGO and by Drug Revolving

55% get supplies by Drug Revolving


Most supplies from the MOH and by Drug Revolving

Most supplies from the MOH and NGO


Demand Generation: % of Facilities to offer Incentives

76% of facilities give incentives to clients







Demand Generation: Incentives Offered

Most incentives in the form of LLINS and free drugs






Most incentives in the form of LLINS, free drugs & money (SURE-P)


29% send health messaging to clients & health workers


No form of health messaging to clients & health workers





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62% get supplies from the MOH

Get supplies from the MOH, NGO and by Drug Revolving

55% get supplies by Drug Revolving


Most supplies from the MOH and by Drug Revolving


















Most incentives in the form of LLINS, free drugs & money (SURE-P)




No form of health messaging to clients & health workers






PHOTO CREDITS

COVER: Carolyn Florey, United Nations Foundation at Pathfinder, SURE-P clinic in Gobi, NigeriaINSIDE FRONT COVER: Carolyn Florey, United Nations Foundation at Pathfinder, SURE-P clinic in Gobi, NigeriaPAGE 7: Carolyn Florey, United Nations Foundation at Pathfinder, SURE-P clinic in Gobi, NigeriaPAGE 15: Innocent Akwe @ a SURE-P PHC in Gwagwalada, Abuja PAGE 23: Emeka Chukwu @ a PHC in NasarawaPAGE 38: Carolyn Florey, United Nations Foundation at Pathfinder, SURE-P clinic in Gobi, NigeriaPAGE 47: Ememobong, Field Team Lead for Kano & Sokoto, at a training of health workers by eHealth Africa in Kano PAGE 49: Carolyn Florey, United Nations Foundation at Pathfinder, SURE-P clinic in Gobi, NigeriaPAGE 69: Ememobong, Field Team Lead for Kano & Sokoto, at the testing of Closed User Group Phones by eHealth Africa in Kano

70 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Nigeria Health ICT Phase 2 Field Assessment...

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