Assessing the Enabling Environment for ICTs for Health in Nigeria: A Review of Policies - SEPTEMBER 2014
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Assessing the Enabling Environment for ICTs for Health in Nigeria: A Review of Policies Prepared by the United Nations Foundation in Support of ICT4SOML SEPTEMBER 2014 | 1
2 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA
Table of Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . 4 Summary of Recommendations
List Of Acronyms And Abbreviations. . . . . . . . . . . 5 and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 31
Important Definitions. . . . . . . . . . . . . . . . . . . . . . . 6
Strategy and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . 31
List of Figures and Tables. . . . . . . . . . . . . . . . . . . . 7
Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 31
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 32
Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . 8 Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 32
background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Saving One Million Lives . . . . . . . . . . . . . . . . . . . . . . . . . 9 Appendix 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
report objectives . . . . . . . . . . . . . . . . . . . . . . . . . 12 full list of documents reviewed . . . . . . . . . . . 34
how to read this report . . . . . . . . . . . . . . . . . . . 12
Appendix 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 list of key informant organizations . . . . . . . . 35
literature search . . . . . . . . . . . . . . . . . . . . . . . . 14
key informant interviews . . . . . . . . . . . . . . . . . . 14
Nigeria ICT for Health
Enabling Environment . . . . . . . . . . . . . . . . . . . . . 15
Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 16
Strategy and Investment . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 19
Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 21
Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 23
summary of findings . . . . . . . . . . . . . . . . . . . . . . 23
Global Benchmarks for
Comparison and Lessons . . . . . . . . . . . . . . . . . . . 28
Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 28
Strategy and Investment . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 29
Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 29
Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 30
Acknowledgements
The United Nations Foundation would like to sincerely thank the Saving One Million Lives
(SOML) Secretariat, the Federal Ministry of Health and the Federal Ministry of Communica-
tions Technology for their leadership and support in the strategic application of technology
to save lives – especially those of women and children. The contributions made throughout
the landscape and inventory processes, including establishing contacts between the Infor-
mation and Communication Technology for Saving One Million Lives (ICT4SOML) team and
industry stakeholders, have been invaluable. We would like to thank, in particular, Dr. Kelechi
Ohiri and Seyi Ibidapo of the SOML office.
We would also like to thank all partners and key informants who contributed to the landscape
and inventory for ICT4SOML. The resulting outputs, including this report, would not have
been possible without the input of all key health and ICT stakeholders in Nigeria. A special
thanks is due to Dr. Funke Fashewe of the Clinton Health Access Initiative, Dr. Dauda Suleiman
of Futures Group, Dr. Farouk Jega of Pathfinder International, Dr. Ahmad Abdulwahab of
PRRINN and Mr. Felix Uduh of the National Primary Health Care Development Agency.
In closing, we would specifically like to acknowledge United Nations Foundation staff and
consultants who contributed to the authorship, design and implementation of this report.
Thanks are due to Dr. Patricia Mechael, Dr. Ime Asangansi, Jonathan Payne, Avrille Hanzel
and Nadi Nina Kaonga, as well as consultants from Health Systems Consult Limited: Alozie
Ananaba, Nkata Chuku, Uche Nwachukwu and Bamidele Aderibigbe.
ICT4SOML LEAD
COORDINATING PARTNER
4 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA
List Of Acronyms And Abbreviations
ANC Antenatal Care
ARV Antiretroviral
eHealth Electronic Health
EHR Electronic Health Record
EMR Electronic Medical Record
FCT Federal Capital Territory
FMCT Federal Ministry of Communication Technology
FMOH Federal Ministry of Health
GSMA Groupe Speciale Mobile Association
HIS Health Information System
HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
ICT Information and Communication Technology
ICT4SOML Information and Communication Technology for Saving One Million Lives
ITU International Telecommunications Union
JSI John Snow, Inc.
LGA Local Government Authority
LMIC Low- and Middle-Income Country
MCH Maternal and Child Health
MDG Millennium Development Goal
mHealth Mobile Health
MNCH Maternal, Newborn and Child Health
NACA National Agency for the Control of AIDS
NAFDAC National Agency for Food and Drug Administration and Control
NCC Nigeria Communications Commission
NCH National Council on Health
NHIS National Health Insurance Scheme
NHMIS National Health Management Information System
NIGCOMSAT Nigerian Communications Satellite
NIMR National Institute of Medical Research
NIPOST Nigerian Postal Service
NIPRD National Institute for Pharmaceutical Research and Development
NITDA National Information Technology Development Agency
NPHCDA National Primary Health Care Development Agency
ORS Oral Rehydration Salts
OSSAP Office of Special Assistant to the President
PATH Program for Appropriate Technology in Health
PHC Primary Health Care
SHC Secondary Health Care
SMS Short Message Service
SOML Saving One Million Lives
SURE-P Subsidy Reinvestment and Empowerment Programme
UN United Nations
USPF Universal Services Provision Fund
WHO World Health Organization
| 5
Important Definitions
Electronic health (eHealth) refers to the use of information and communication technology
(ICT) in support of health and health-related fields, including health care services; health
surveillance; health literature; and health education, knowledge, and research. The definition
introduces a range of services such as electronic health records to ensure continuity of
patient care across time, mobile health (mHealth) services, telehealth, health research,
consumer health informatics to support individuals in health decision making, and eLearning
by health workers. In practical terms, eHealth is a means of ensuring that correct health
information is provided in a timely and secure manner via electronic means for the purpose
of improving the quality and efficiency of health care delivery and prevention programs.
mHealth services, in particular, focus on the application of mobile and other wireless tech-
nologies for health systems strengthening.
An eHealth Strategy can serve as an umbrella for planning and coordinating different
national eHealth efforts while considering fundamental elements in terms of regulatory, gov-
ernance, standards, human capacity, financing and policy contexts. A good National eHealth
Strategy presents a set of interventions that the health sector plans to use to facilitate the
efficient and effective delivery of services. Without an overarching national level strategy,
ICT initiatives are left at the hands of individual organizations without coordination and a
guarantee that they are in the best interest of clients. A national level eHealth strategy with
sector-wide participation and ownership is an effort to fill this gap.
Frameworks serve as guides, rules or well-defined approaches towards addressing a
particular matter. An eHealth framework is specifically concerned with applying ICT in a
health system. Different frameworks exist and can range from being general, and providing
comprehensive approaches to governing the regulatory environment and guiding imple-
mentations within that context, to being specific, and focusing on a particular aspect of
eHealth, such as data standards.
A health information system (HIS) is a system that collects, transmits, stores and manages
health-related data. The data can be patient-specific (or row-level data) or aggregate.
Reports can typically be generated from an HIS. If a system is primarily being used to inform
and support health management practices, the system is referred to as a health manage-
ment information system.
An architecture is a conceptual framework that is used to inform data collection, trans-
mission, storage and sharing. Architectures show the integration of many components
into a whole, as well as the interoperability that enables these components work together.
Interoperability is the ability of an application or platform to establish a data exchange with
another application or platform. For interoperability to occur, both services must use the
same standards [for communication].
Standards serve as rules or guidelines that ensure consistency in the context in which they are
applied. Standards can exist around data, processes and systems. The standards development
process is variable (e.g., government-mandated versus stakeholder-based). As such, it is
possible for multiple standards to exist and formal-alignment among the different standards.
A policy refers to a course or principle of action adopted or proposed by an organization
or individual while strategy refers to the method or plan chosen to bring about this desired
course or principle of action. While compliance has multiple meanings, the report primarily
uses it to mean adherence (to policy and legislation).
6 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA
List of Figures and Tables
Figures
figure 1. current status of the nigeria ict for health enabling
environment according to the who-itu stages/extent of development . . 15
figure 2. timeline of national policies and strategies . . . . . . . . . . . . . . . . 20
Tables
table 1. soml program areas and targets . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
table 2. components of the ict for health enabling environment . . . . . . 13
table 3. summary of information on key roles of fmoh
departments and agencies within the context of ict for health . . . . . . . 17
table 4. summary of information on key roles of fmct
departments and agencies within the context of ict for health . . . . . . . 18
table 5. summary of enabling environment, highlighting
strengths, gaps and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
| 7
Executive Summary
Committed to reducing maternal and child mortality, the Federal Government of Nigeria is
implementing the Saving One Million Lives (SOML) initiative. The initiative will scale up pri-
mary health care services and will focus on ten program areas, including maternal and child
health, routine immunization, essential medicines, nutrition, malaria, elimination of mother-
to-child transmission [of HIV/AIDS], private sector engagement, quality improvement, fiscal
space analysis and data management. The federal government has recognized the oppor-
tunity that information and communication technologies (ICT) present to help accelerate
the achievement of SOML’s goals. Consequently, the Federal Ministry of Health with support
from the United Nations Foundation, along with GSMA, the Government of Norway and
other partners, have launched ICT4SOML – Information and Communication Technology
for Saving One Million Lives. Through ICT4SOML, ICT for health tools that address SOML’s
program areas will be scaled up and the ICT for health enabling environment in Nigeria will
be strengthened.
In order to understand the current state of affairs of the enabling environment, a compre-
hensive two-phase baseline assessment was designed. The initial assessment includes a
landscape and inventory analysis and the policy review. The findings of the initial assess-
ment will help ensure that activities within ICT4SOML are informed and contextualized to
the Nigerian environment. This report, in particular, presents the findings from the policy
review. This review has been structured around the eHealth enabling environment frame-
work from the World Health Organization and International Telecommunication’s National
eHealth Strategy Toolkit. The seven core components of the framework are leadership and
governance; strategy and investment; legislation, policy and compliance; standards and
interoperability; workforce; infrastructure, and services and applications.
Through this framework, the strengths and gaps in the enabling environment for applying
ICTs for Health in Nigeria are analyzed and discussed, using information from the following
sources: reports on SOML and ICT4SOML activities, including the accompanying inventory
report; national policies and strategies; international eHealth policies and strategies and
key informant interviews. Recommendations in each of the seven component areas have
been outlined, including recommendations based on a review of eHealth policies in similar
jurisdictions as well as international best practices.
Notable strengths in the existing environment include inter-ministerial involvement in and
commitment to ICT for health, acknowledgement of infrastructure and regulatory gaps and
numerous on-going implementations. However, a lack of harmonization, no strategic long-
term financing mechanisms and an inadequate policy and regulatory environment hinder
progress in realizing sustained and effective ICT for health enabling environment. Therefore,
it will be important to improve coordination and put appropriate mechanisms in place to
foster progress.
As an immediate next step, the findings and recommendations in this report will be reviewed
by key stakeholders, including policy makers and other stakeholders working on improving
Nigeria’s enabling environment. Based on the review and other contextual considerations,
a national, overarching framework should be developed. This framework should build upon
and capitalize on the policies and strategic drivers already in place to support ICT for health
activities. In addition, the framework should provide standards for eHealth implementation,
and a proper governance structure to provide an enabling environment for eHealth in Nigeria.
8 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA
Introduction
background
Approximately one million women and children die from preventable causes every year in
Nigeria. Of those deaths, roughly 33,000 women die from pregnancy-related causes, and
of the 946,000 children who die before their fifth birthday, 241,000 are newborns1. Nigeria
is constrained by an inequitable distribution of resources and inadequate health services.
Despite efforts to address maternal and child health challenges, Nigeria has among the
highest rates of maternal and child mortality in the world2, with 560 maternal deaths per
100,000 live births3 and 125 deaths of children under 5 years of age per every 1,000 live
births4. In recognition of the effort to accelerate progress in reducing maternal and child
mortality and to meet the health-related Millennium Development Goals (MDGs) 5, the
Federal Government of Nigeria has implemented several initiatives to help address some
of the health system challenges, including Saving One Million Lives (SOML).
Saving One Million Lives
SOML aims to scale up access to essential primary health services and commodities
and focuses specifically on the health and wellbeing of Nigeria’s women and children.
The vision of the initiative is to create an environment where all women, children and
caregivers are equipped with information to be able to mitigate death and have access
to quality health services when and where needed.
With a focus on improving health outcomes and having significant impact, clear and
ambitious targets have been established6. SOML has been divided into ten program
areas. Each program area has established targets (refer to Table 1). All targets are aligned
with the MDG 2015 timeframe.
1. http://www.countdown2015mnch.org/documents/2012Report/Nigeria_Report_2ed.pdf
2. http://www.unicef.org/nigeria/children_1926.html
3. http://data.worldbank.org/indicator/SH.STA.MMRT
4. http://data.worldbank.org/indicator/SH.DYN.MORT/countries
5. N
igeria Revised National Health Policy (2004). Available from: http://www.gnhc.gov.bt/wp-content/
uploads/2012/04/nationalHpolicy.pdf
6. http://www.soml.org.ng/index.php
| 9
table 1. SOML Program Areas and Targets
PROGRAM AREA TARGETS
Reduce maternal mortality ratio from 545/100,000 live births to 250/100,000 live births
Reduce the neonatal mortality rate from 40/1,000 live births to 14/1,000 live births
Increase the proportion of births attended to by a skilled birth attendant from 38.9% in
Maternal and 2008 to 85%
Child Health
Increase the proportion of pregnant women attending 4 or more antenatal care (ANC)
visits from 45% in 2008 to 80%
Increase the number of upgraded primary healthcare facilities from 1,000 MSS sites in
2012 to 5,000 sites
Increase number of infants receiving DPT37/Pentavalent vaccines in target Primary
Health Care facilities and communities to 87%
Routine Immunization
Increase percentage of coverage of oral polio vaccine to 87%
80% of under-five diarrhea episodes treated with oral rehydration salt (ORS) and zinc
80% of under-five malaria episodes treated with artemisinin-based combination therapy
Essential Medicines
within 24 hours
80% of under-five pneumonia episodes treated with cotrimoxazole or amoxicillin
Cure rates: Consistently achieve a cure rate of 75% of children admitted for acute malnu-
trition from 71.4%
Case fatality rates: Consistently achieve a death rate of less than 10% of children being
Nutrition treated for acute weight-loss
Exclusive breast feeding for at least 80% of children under the age of 6 months
100% of children under the age of 5 receiving vitamin A
Increase the utilization rates of children under the age of five years sleeping inside the
mosquito nets from 29% in 2010 to equal or greater than 80%
Increase the utilization rates of pregnant women sleeping inside mosquito nets from 65%
in 2010 to at least 80%
Malaria
Increase the uptake of all eligible pregnant women receiving two doses of Intermittent
Preventive Treatment from 5% in 2008 to equal or greater than 80%
Improve the uptake of prompt diagnosis and treatment of children under the age of
five with fever cases or suspected malaria cases using effective antimalarial from 33$ as
recorded in 2008 to at least 80%
10 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAIncrease access to antiretroviral (ARV) prophylaxis for all HIV positive pregnant women
from 22% to 90%
Elimination of Mother-
Increase access to ARV prophylaxis for all HIV exposed infants from 8% to 90%
to-Child Transmission
[of HIV/AIDS]
Increase access of HIV positive pregnant women to quality infant feeding counselling to 90%
Increase access of HIV exposed infants to early infant diagnosis service to 90%
To increase the amount of data and information reported and available on private sector clin-
ical services, financing, and operational management for improved health system planning
Private Sector
Engagement To implement business models that identify and coordinate private sector providers
to achieve increased knowledge, improved quality of services, and economies of scale
through shared resources, leading to increased investment-grade enterprises
Quality Improvement Target(s) Forthcoming
Supporting departments within FMOH & NPHCDA in using the report to develop the 2015
health budget
Fiscal Space Analysis
Having 30-40% of donors in the Development Partners Group use tool as basis for aid grants
Increase in the Federal Government’s allocation to health
Phase 1: Scale-up of SOML in 20 states with the lowest reporting rates (0-25% as of
August 2013) by December 2014; 80% reporting in other states.
Data Management
Phase 2: Scale-up in the remaining 17 states by December 2015; 80-100% reporting in all states.
7
ICT4SOML
The Nigeria Federal Ministry of Health (FMOH) has expressed interest in strategically and
systematically using information and communication technology (ICT) to improve maternal
and child health8. Accordingly, in support of the Nigeria FMOH, the United Nations (UN)
Foundation, Government of Norway, GSMA and other key partners in Nigeria are working
together to leverage ICTs for health (or electronic health, otherwise called eHealth). An initial
focus has been placed on the SOML initiative through an effort entitled “ICT4SOML”.
ICT4SOML has two main goals9:
1. To support the scale-up of high priority ICT for health projects through working groups
targeting specific SOML program areas
2. To strengthen the ICT for health enabling environment in Nigeria through the
development of a national framework that addresses gaps in the enabling environment
7. Diphtheria, Pertussis and Tetanus
8. G
SMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/
mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014
9. ICT4SOML Highlight Report. Available from: http://hingx.org/Share/Attachment/1569/ICT4SOML_Highlight%20
Report_v4.pdf
| 11report objectives
A two-phase assessment of ICT for health in Nigeria was conducted to facilitate the design
The primary of ICT4SOML, to inform policy and enabling environment strengthening activities. Phase 1,
purpose of this which consisted of a landscape analysis, inventory and policy review, will help ensure that all
activities within ICT4SOML are informed and contextualized to the Nigerian environment10.
report is to provide
This report presents the findings from the policy review of Phase 1 and is a complement to
policy makers the previously published Landscape and Inventory review.
and other key
stakeholders with The primary purpose of this report is to provide policy makers and other key stakeholders with
an understanding an understanding of the current ICT for health enabling environment in Nigeria as it relates to
legislation, policy and compliance. The report identifies gaps in the ICT for health enabling envi-
of the current ICT ronment, especially those gaps which are on the critical path to scaling up high priority ICT for
for health enabling health interventions, and provides recommendations to ameliorate these gaps. Understanding
environment in the current state of affairs can better shape the ICT4SOML goals and define the magnitude of
Nigeria as it relates strategic investment needed to achieve the goals. The findings of this report, in conjunction
to legislation, policy with the landscape and inventory report, are intended to support policymakers and other key
stakeholders in refining the broader ICT4SOML and SOML goals and to develop addressing
and compliance.
gaps and enriching the enabling environment. Cultivating a strong ICT for health enabling envi-
ronment enables a high performance health system that supports both near-term SOML goals
and sets the foundation for long-term sustainability and improved health outcomes.
how to read this report
The “National eHealth Strategy Toolkit” by the World Health Organization (WHO) and
International Telecommunications Union (ITU) forms the framework for this report. The
toolkit describes seven components in a national electronic health (eHealth) environment11
(refer to Table 2).
10. Ibid.
11. W
HO-ITU National eHealth Strategy Toolkit (2012). Available from: http://www.itu.int/
pub/D-STR-E_HEALTH.05-2012
12 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAtable 2. Components of the ICT for Health Enabling Environment
COMPONENT DESCRIPTION
Leadership and Oversee and coordinate eHealth activities at the national level,
governance ensuring alignment with national health goals and priorities
Responsible for planning and engaging all stakeholders involved
Strategy and
in ICT for health activities and aligning and procuring financing
Investment
for ICT for health
Legislation, policy Covers national policies and legislation for ICT for health in
and compliance terms of development, alignment and regular review
Empower health workforce to use ICT for health through educa-
Workforce
tion and training programs
Standards and Introduce standards and ensure their use for enhanced interop-
interoperability erability and integration
Refers to the physical infrastructure, services and applications
Infrastructure
that form the foundation for ICT for health implementations
Services and Devices and tools utilized by end users to collect, transmit,
applications access and maintain health information
As adapted from the 2012 WHO-ITU eHealth Strategy Toolkit12, Table 4
This report focuses on legislation, policy and compliance; standards and interoperability;
leadership and governance; strategy and investment; and workforce. The concurrently
published report, “Assessing the Enabling Environment for ICTs for Health in Nigeria: A
Landscape and Inventory”, focused on infrastructure and services and applications and is a
complement to this report. Together, the two reports will provide a complete picture of the
current ICT for health enabling environment in Nigeria.
Following the methodology section, the report has been divided into three sections:
• N
igeria ICT for Health Enabling Environment: Using the WHO-ITU framework, this
section provides information on each of the components for enabling environment.
Each component has its own stand-alone section that contains an overview and
analysis for that component. Therefore, readers can focus on specific components
by reading the accompanying section. For example, readers interested in standards
information can read the “Standards and Interoperability” section only.
• G
lobal Benchmarks for Comparison and Lessons: This section provides an overview of
global trends and focus areas. In addition, the policies of selected countries have been
used to highlight different approaches, common themes and options for Nigeria to
address gaps in her enabling environment. For consistency, the WHO-ITU framework
has been loosely applied to this section.
• G
aps and Recommendations: The gaps identified through the assessment of
the ‘Nigeria ICT for Health Enabling Environment’ are featured in this section.
Recommendations are provided for each identified gap. In efforts to help inform the
development of the National ICT for Health Framework, special attention has been
made on legislation, policy and compliance and standards and interoperability.
12. Ibid.
| 13Methodology
The potential of
The source documents and information featured in this report were obtained through a
ICTs to improve search of the literature and key informant interviews. Guiding questions used to inform
health has been the search and interviews were derived in accordance with the WHO-ITU framework13.
recognized by both The questions covered the structure, interaction and role of entities in the health system,
the public and service delivery, health care financing system and basic funding mechanisms and health
private sectors with system challenges – keeping in mind that relevance to ICT4SOML was a priority. After
analysis, gaps were identified and recommendations formulated.
evidence of success
of ICT for health literature search
initiatives in Nigeria
and globally. Source documents were obtained through desk research and key informants. For the Nige-
ria-specific documents, literature searches included “Nigeria” as a key word. Key informants,
including representatives from the FMOH and UN Foundation, were specifically asked to
provide recommendations on policy guidelines to review. Global benchmark countries were
first identified by key informants with extensive technical expertise in the global ICT for health
sector. Countries were selected based on their relevancy to informing identified gaps in Nige-
ria’s enabling environment and strength of their enabling environment. To identify how Nigeria
compared to countries with a similar contexts and to learn from approaches in these com-
parable countries, a few countries were included for their similarity to Nigeria on geography,
socioeconomic status and health indicators. [See appendix for full list of source documents.]
key informant interviews
Key stakeholders within the ICT and health sectors in Nigeria who were deemed as being
most relevant to SOML and ICT4SOML success were selected for informant interviews.
[See appendix for complete list of key informants.] Interviews were conducted with the key
stakeholders in May 2014. Interviews lasted no longer than one hour. In addition to exploring
the structure, interaction and role of entities in the health system, service delivery, health care
financing and funding mechanisms and health system challenges, cross-sector engagement
was also examined. Transcripts of the interviews were analyzed for important themes and
trends. Informants were also asked to provide recommendations on relevant policies, reports
and other documents to review.
13. Ibid.
14 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIANigeria ICT for Health
Enabling Environment
The potential of ICTs to improve health has been recognized by both the public and private
sectors with evidence of success of ICT for health initiatives in Nigeria and globally, but
scale-up and sustainability have proven to be challenging. The ICT sector has evolved faster
than the policies that guide the use of ICTs for health, presenting significant challenges to
projects moving towards institutionalization14.
The WHO-ITU Toolkit describes a framework for stages of development of the national
ICT for health enabling environment (see appendix for a description of the stages). For the
purposes of this report, Nigeria is considered to be transitioning from ‘experimentation and
early adoption’ to ‘developing and building up’15. Countries at the developing and building
up stage are directed (a) to strengthen existing systems, (b) to ensure that guidelines and
policies are in place and enforced, and (c) to establish funding and planning mechanisms for
full transition of the enabling environment and long-term success.
figure 1. C
urrent Status of the Nigeria ICT for Health Enabling Environment
According to the WHO-ITU Stages/Extent of Development
Current Status ESTABLISHED ICT ENVIRONMENT
of Nigeria ICT
Desired Trajectory
of Nigeria ICT
MAINSTREAMING
SCALE UP
DEVELOPING &
BUILDING UP
II. III. ESTABLISHED ENABLING
EMERGING ENABLING
ENVIRONMENT ENVIRONMENT
FOR eHEALTH FOR eHEALTH
I.
EARLY
ADOPTION
EXPERIMENTATION
EMERGING ICT ENVIRONMENT
For more information on the stages/extent of development, please refer to the WHO-ITU
eHealth Strategy Toolkit.16
14. N
igeria National Information and Communication Technology (ICT) Policy [Draft] (2012). Available from:
http://www.researchictafrica.net/countries/nigeria/Nigeria_National_ICT_Policy_(draft)_2012.pdf
15. W
HO-ITU National eHealth Strategy Toolkit (2012). Available from:
http://www.itu.int/pub/D-STR-E_HEALTH.05-2012
16. W
HO-ITU National eHealth Strategy Toolkit (2012). Available from:
http://www.itu.int/pub/D-STR-E_HEALTH.05-2012 [see Table 2]
| 15A summary table outlining the findings from the review of the enabling environment can
be found at the end of this section. In addition, more detailed information on each of the
components of the enabling environment explored below are located in the appendix.
Leadership and Governance
Understanding organizational arrangements by identifying the key stakeholders and how
they interact with one another and external actors is important for assessing and strate-
gically supporting the implementation of programs. Given the multidisciplinary nature of
digital health, the FMOH and Federal Ministry of Communication Technology (FMCT) each
play important roles in its governance.
The Nigerian health care system is divided into primary, secondary and tertiary levels. Local
government areas (LGAs) are responsible for primary health care; States oversee secondary
care facilities, and the federal government is responsible for tertiary health care. In addition,
the federal government, through the FMOH, provides high-level health sector leadership
and is responsible for the overall strategic oversight for healthcare in the country. The
FMOH, which is headed by the President-appointed Honorable Minister of Health, has ten
departments and six agencies through which it carries out its functions. The departments
and agencies all play different roles in ICT for health leadership, the most relevant, along with
two special presidential programs, have been outlined in Table 3.
16 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAtable 3. Summary of Information on Key Roles of FMOH Departments and Agencies within the Context of ICT for Health
DEPARTMENT/AGENCY KEY ROLE
Department of Health Planning,
Leadership for national health information systems
Research and Statistics (DPRS)
Department of Provides governance for tertiary health centers and hospital information
Hospital Services systems
Department of
Oversees epidemiology and surveillance information systems
Public Health
Oversees the National Products Supply Chain Management Programme
Department of Food
(NPSCMP) which has a technical working group responsible for harmoniz-
and Drugs
ing and supporting an electronic logistic management information system
National Primary Health Care Develop- Provides oversight for primary health care policy and Midwives Services
ment Agency (NPHCDA) Scheme; has its M&E and ICT units
Provides oversight for food and drugs; has a mandate for the National
National Agency for Food and Drug
Mobile-based Authentication Service; oversees drug and medicines
Administration and Control (NAFDAC)
database
National Health Insurance Scheme Oversees health financing; e-NHIS database involving clients, health
(NHIS) maintenance organization, providers and insurance companies
National Agency for the Control of AIDS Provides national leadership for HIV/AIDS activities, including monitoring
(NACA) and evaluation and health information systems strengthening
National Institute of Medical Research Oversees medical research and uses a medical research information
(NIMR) system
National Institute for Pharmaceutical Leadership for pharmaceutical research, and national database for
Research and Development (NIPRD) locally sourced drugs and biological products
Subsidy Reinvestment and Empow-
Chairs the ICTs for supply chain and mobile conditional cash transfer
erment Program – Maternal and Child
(mCCT) working groups
Health (SURE-P MCH)
Office of Special Assistant to the Pres-
Provides leadership/governance for MDGs, MDGs tracking and the MDGs
ident on the Millennium Development
information system
Goals (OSSAP-MDG)
Established in 2011, the FMCT oversees ICT-related policy formation, implementation monitoring and evaluation, as well as
the supervision and oversight of most government ICT-related projects and initiatives. The FMCT seeks to improve infrastruc-
ture, optimize use of existing resources and build capacity. Similar to the FMOH, the FMCT exerts its operations through its
departments and agencies. Table 4 provides a summary of those entities.
| 17table 4. Summary of Information on Key Roles of FMCT Departments and Agencies within the Context of ICT for Health
DEPARTMENT/AGENCY KEY ROLE
Leads the formulation and supervises the implementation of the
Department of e-Government National ICT Policy; coordinates and supervises ICT programs across all
ministries
Falls under the auspices of e-Government and is meant to enhance ICT
infrastructure to improve the efficiency and effectiveness of government
Galaxy Backbone operations through a common services platform, offshore VSAT hubs,
data center, metro fiber backbone and multiple redundant Internet
gateways
Oversees the National IT Policy and enacts services through the NITDA
National Information Technology
Act (2007); tasked to enter into strategic alliances with the private
Development Agency (NITDA)
sector and international organizations
Responsible for coordinating policies in conjunction with the
Department of Planning, Research
e-Government; involved in reviewing and updating master plan and
and Statistics
road maps in ICT sector
Universal Services Provision Fund Tasked to enhance accessibility and availability of telecommunications
(USPF) and ICT infrastructure and services throughout Nigeria
Responsible for creating enabling environment for competition among
Nigerian Communications Commission
industry operators and maintain accountability of these organizations to
(NCC)
ensure efficient distribution of quality and affordable services
Nigerian Communication Satellite Manages commercial viability of the Nigeria Communication Satellite
(NIGCOMSAT) and intentions to support a national telemedicine initiative
Beyond the departments and agencies listed under the FMOH and FMCT, there is the
National Council on Health (NCH) and the National Planning Commission17. The NCH serves
as an advisory board on health issues and will become the highest policy-making body for
healthcare in the country upon passage of the pending National Health Bill. In 2013, the
NCH issued a mandate for the routine reporting of data from all primary health facilities into
the national data warehouse administered by the FMOH Department of Health Planning,
Research and Statistics (DPRS). The National Planning Commission, which reports directly
to the President, is responsible for setting national priorities and goals and engendering
consensus across government agencies.
In part due to the number of relevant government departments and agencies, health ICT
leadership is decentralized and often roles are not clearly defined. Competing programs
and priorities within government further complicate the development of a coordinated
cross-ministerial health ICT strategy, which contributes to lack of transparency, fragmenta-
tion, market risk, and high costs.
The establishment of an inter-ministerial governing body for ICT for health with represen-
tation from all levels of the health system would provide a platform for sustained strategic
alignment of health ICT activities. Such a platform would also serve to improve cross-sector
communication and collaboration by facilitating shared learning, promoting transparency
and partnerships, and encouraging adoption of best practices.
17. http://www.nationalplanning.gov.ng/?view=featured
18 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAStrategy and Investment
Strategy, or the deliberate application of ICTs in alignment with national health goals, and
its drivers informs how investments can be made to best support the application of ICT Key strategic
for health and, subsequently, to enable the achievement of national health goals. There is drivers of ICT for
currently no formal eHealth strategy or framework in Nigeria. However, as part of ICT4SOML,
health include
there is a plan to support the development of a National eHealth Framework focused initially
on maternal and child health use cases. The framework will coordinate and strategically
political will and
direct the activities of the leadership and stakeholders as they work to address health system commitment, and
challenges through the strategic application of ICTs within the health system. health system
needs and
Key strategic drivers of ICT for health include political will and commitment, and health sys-
tem needs and opportunities. From the perspective of the Nigerian government, ICTs are an
opportunities.
important enabler to achieve its strategic goals and vision for a healthy nation, as illustrated
in the Vision 2020, the drive to meet the MDGs, the National Health Strategic Development
Plan, and the push for Universal Health Coverage in Nigeria. These strategic visions are key
strategic drivers within the health system that underpin the application of ICTs. In addition,
the government and its partners have announced a vision to improve ICT infrastructure
(e.g. the National Broadband Plan) and build capacity in the use of ICTs as part of efforts
to catapult Nigeria to the league of top 20 economies by 2020. Over time, the ICT sector
has shown sustained growth with technology becoming more affordable and the general
population having taken advantage of this, as evidenced by the continuous increase in the
mobile phone penetration.
The burden of financing health care services is borne by individual households who typically
pay out-of-pocket for their health care18. Despite primary health care (PHC) facilities consti-
tuting the majority of health care facilities in Nigeria and having a central role in maternal and
child health, many are underfunded, understaffed, lacking essential equipment and drugs,
and poorly managed19.
Two funding schemes have been proposed—NHIS and the National Health Bill—to help
address shortages in funding and could serve as long-term funding mechanisms for ICT
for health. The National Health Bill, in particular, will be most relevant to ICT4SOML, given
its focus at the PHC level. Other funding sources should be advocated for, identified and
explored to establish a portfolio of short- and long-term financing opportunities. The result-
ing variety of funding sources, mechanisms and incentives should be aligned with the health
system and ICT for health priorities and needs.
The work being done through ICT4SOML can and should take the key drivers under
consideration, along with serving as an advocacy tool for identifying sustainable financing
mechanisms for ICT for health20. The drivers can be used to help inform the framework;
potentially viable sources of funding (and funding considerations) should also be included in
the framework. The resulting framework can then serve as a foundation for an overarching
national eHealth policy and accompanying strategy.
Legislation, Policy and Compliance
Legislation, policy and compliance addresses the legal and regulatory measures, public
policy, and observance of rules and regulations related to ICT for health. There are numerous
existing policies and strategies that describe activities related to ICT for health in Nigeria,
some of which have been enacted and others that have not yet been signed off by the rel-
evant ministry or included in the Gazette of the Federal Republic of Nigeria. Twelve national
18. G
SMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/
mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014
19. http://www.who.int/pmnch/countries/nigeria-plan-chapter-3.pdf
20. S
ustainable Financing for Mobile Health (mHealth): Options and opportunities for mHealth financial models in
low and middle-income countries (2013). Available from: http://mhealthalliance.org/images/content/sustain-
able_financing_for_mhealth_report.pdf
| 19policies and strategies (drafts and fully endorsed documents) have been identified for their
direct applicability to the ICT for health enabling environment.
The earliest and most broadly encompassing of these documents is the National Health
Policy of 2004. As time has progressed, the relevant documents become more specifically
geared towards ICT for health (refer to Figure 2). To illustrate this point, the most recent
documents, which are still being drafted, directly address ICT for health. In addition, a minis-
terial committee housed within the FMCT has been working towards harmonizing ICT policy
across the different sectors.
figure 2: Timeline of National Policies and Strategies
National National Human Nigeria Global FCT eHealth
Health Policy Resources for Health Health Initiative Policy and Policy
Strategic Plan Strategy Implementation
Strategies
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
FMOH Integrated National Strategic National ICT Health Information
Disease Surveillance Health Development Policy Draft System Policy and
and Response Policy Plan Framework Strategic Plan:
2014-2018 (draft,
Strategies for not yet endorsed)
Strengthening the
Secondary Health Care National eHealth
Delivery Service Policy Draft
For more information on each of the documents, please refer to the appendix.
There are several gaps that should be addressed to strengthen current and inform future
A ministerial policies and plans with respect to use of ICTs to improve health system performance:
committee multi-regulation, mal-alignment, stakeholder engagement and legal framework. While the
FMCT has been tasked with harmonizing ICT policies across sectors, multi-regulation still
housed within the
poses a problem in the ICT for health environment. For example, not all policies are in
FMCT has been alignment with the national health plans or existing policies and do not build upon previous,
working towards related policies. In addition, most policies do not have accompanying strategic documents
harmonizing ICT to guide planning and implementation. Furthermore, there is no clear guidance on how to
policy across the formally engage stakeholders and ensure that all tools can integrate with the key tools and
different sectors. systems currently being used by the government in the health domain. In addition, without
an appropriate legal framework, the government is unable to properly enforce compliance to
policy and regulations, and as such, activities to address the gaps may yield limited success.
It is recommended that a national eHealth policy be developed that builds off existing
momentum and policy precedent, while simultaneously addressing the above gaps. Such
an informed policy would setup an enabling environment for the coordinated, systematic
and strategic scale-up of ICT solutions for health. The policy must also setup systems for
sustained accountability and compliance, policy revisions, reviews of ICT for health imple-
mentations, guidelines for stakeholder engagement, and a legal framework addressing
patient safety and privacy21.
21. P
atient Privacy in a Mobile World: A Framework to Address Privacy Law Issues in Mobile Health (2013). Available
from: http://www.trust.org/contentAsset/raw-data/03172beb-0f11-438e-94be-e02978de3036/file
20 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAStandards and Interoperability
Adoption of health informatics standards is a prerequisite for interoperability of health
information systems. Setting standards and technical guidelines for collection, storage and Adoption of
exchange of health information facilitates access to accurate data in a timely, secure fashion, health informatics
enabling continuity of care across place, provider, and encounter and leading to a health
standards is a
system that can monitor itself and continuously improve.
prerequisite for
The Federal Government of Nigeria has recognized the importance of standards and interoperability of
interoperability and has mandated their use in several policies, including the National Health health information
Policy, Strengthening Secondary Health Care Service Delivery, the Integrated Disease Sur- systems.
veillance and Response Policy, the National Strategic Health Development Plan Framework,
the Nigeria Global Health Initiative Strategy, the National ICT Policy, and the FMCT eHealth
Policy. Despite this, the application of standards and interoperability best practices in Nigeria
faces many challenges, including limited uptake of health informatics standards, limited
capacity and awareness, lack of engagement in international standards development pro-
cesses, limited coordination and alignment across public and private actors, and inadequate
governance structures.
No national body has been appointed with developing endorsing specific health informatics
standards within Nigeria22. Nigeria generally does not participate in international health infor-
matics standards development activities, such as those led by the International Organization
for Standardization Technical Committee on Health Informatics, Health Level 7, or Integrating
the Health Enterprise. Nigeria also lacks national guidelines and requirements for privacy,
security, and auditing of health information, which results in each department and agency
being responsible for their own, often conflicting, policies.
Officially appointing a transparent body to administer and develop health informatics stan-
dards for Nigeria would go a long way to addressing the poor uptake23, and there are some
signs of a growing appetite for this. In late 2013, the National Council for Health approved
a resolution that appointed the FMOH Department of Health Planning Research and Sta-
tistics as the official administrator of the 250-indicator primary health center report, which
all 37,000 health facilities in the country are required to submit into the National Health
Management Information System (NHMIS) each month. But this does not go far enough.
A national body would govern reporting indicators, clinical documentation requirements,
interoperability and integration requirements, architectural guidelines, as well as privacy,
security, and auditing requirements.
Workforce
The ICT for health workforce consists of health workers who are trained to use ICT systems
and ICT workers who are skilled at building, implementing, maintaining, and scaling up these Appropriate
systems along with the infrastructure required to support them. The federal government is incentives should
committed to capacity building within the ICT and related sectors, but ICT skills training in
the health sector, in particular, is lacking. One of the more significant challenges has been
be identified and
recruiting ICT-trained individuals out of the more lucrative private sector. used in conjunction
with training and
It will be crucial to provide training on basic ICT skills to ensure technical literacy24, and ensure implementation.
that supervisors and decision-makers are aware of end-user needs. However, it appears that
such capacity building has not yet taken place; there is no plan or strategy.
A plan and partnerships should be identified to help carry out capacity building as a
part of SURE-P and other programs. Best practices and lessons learned can and should
be documented and used to help develop a coordinated plan or strategy that will meet
22. T
he Standards Organization of Nigeria was established in 1971 to administer and serve as technical lead for
standards development activities in-country for industry, but health was excluded from its mandate.
23. T
he State of Standards and Interoperability for mHealth (2013). Available from:
http://www.mhealthalliance.org/images/content/state_of_standards_report_2013.pdf
24. http://nphcda.org/making-a-difference-with-the-midwives-services-scheme/
| 21capacity-building needs among intended end-users in the health system. A means to carry
out capacity building is through formal institutions (i.e., schools, continued education).
Institutional capacity training for trainers and trainees, alike, should be strengthened. Core
competencies should be established and integrated into a training curricula. Also, appropri-
ate incentives should be identified and used in conjunction with training and implementation.
Infrastructure
Infrastructure is concerned with the physical infrastructure (e.g., connectivity, electricity,
The telecom- hardware, directory services) and software components (e.g., electronic health records
munications (EHRs)/electronic medical records (EMRs), health information datasets) that contribute to
the ICT for health enabling environment.
sector in Nigeria
has undergone The telecommunications sector in Nigeria has undergone significant growth25. Over 62% of
significant growth. the population has access to a mobile phone26 and there are over 173 million mobile phone
subscriptions27. While, broadband subscriptions remain low, forecasting indicates that such
services will become more affordable. Through the Galaxy Backbone initiative, a national fiber
optic backbone (for broadband) will be present in even the most rural areas of the country28.
However, the capacity for software development remains limited. Furthermore, with limited
financing for the health system, maintaining the health infrastructure (i.e. facilities, medical
equipment) has been a challenge. Additionally, traditional grid electricity supplies are not
fully reliable. [Please refer to the report, “Assessing the Enabling Environment for ICTs for
Health in Nigeria: A Landscape and Inventory”, for more details on infrastructure in Nigeria.]
Although the public and private sectors are taking steps to improve infrastructure related
to ICT for health, a digital divide exists between rural and urban areas. There are high costs
to both consumers and corporations; to consumers the costs are in obtaining services and
for corporations, expanding services is costly. Incentives should be identified to promote
expansion of affordable services to rural areas. Also, sustainable health financing mecha-
nisms should be established and a sub-set flagged for the improvement and maintenance of
facilities, power, Internet and other infrastructure.
Services and Applications
Services and applications refer to the actual ICT tools and systems used in the delivery
The ICT for and administration of health, consisting of individual electronic health information, health
health enabling care communications and collaboration, healthcare service delivery, health information
and knowledge and healthcare management and administration. Projects in Nigeria span
environment is
all of the aforementioned uses. Specific examples of types of tools include hospital-based
‘developing and EHRs, decision-support tools, disease surveillance tools, patient monitoring and care and
building up’. distance learning applications. The concurrently published report, “Assessing the Enabling
However, obstacles Environment for ICTs for Health in Nigeria: A Landscape and Inventory”, described 84 ICT for
remain to further health projects at varying levels of scale and technological maturity. Most eHealth services
accelerate progress in Nigeria are SMS-based, data applications, pre-loaded applications or accessible through
web-based portals. The majority of services have been directed towards maternal and child
and transition to health. Furthermore, there is a precedent for national coverage – as 22 of the initiatives
the next stage of reported nationwide coverage. Moreover, most states have more than 20 on-going ICT for
evolution. health implementations. It is important to note that fragmentation is an issue and rigorous
evaluations have only been conducted on a small number of projects.
Despite FMCT attempts to harmonize ICT policy and initiatives, the current lack of har-
monization across projects translates to a lost opportunity for capturing data in national
25. G
SMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/
mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014
26. Ibid.
27. http://www.ncc.gov.ng/index.php?option=com_content&view=article&id=125:art-statistics-subscriber-data&-
catid=65:cat-web-statistics&Itemid=73
28. h
ttp://www.researchictafrica.net/publications/Evidence_for_ICT_Policy_Action/Policy_Paper_6_-_Understand-
ing_what_is_happening_in_ICT_in_Nigeria.pdf
22 | ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIAinformation systems to further enhance decision-making. In addition, the fragmentation
underlines the inability to systematically and securely share health information amongst
providers and facilities for such activities as referrals and longitudinal patient care. Minimal
reporting and interoperability requirements, along with secure and integrated reporting and
project portals, should be established.
summary of findings
The ICT for health enabling environment is well on its way to ‘developing and building up’
from ‘experimentation and early adoption’. The awareness, interest and commitment to ICT
for health is present in both the public and private sector, as evidenced by growing govern-
ment leadership, multiple policies addressing elements of ICT for health, and the numerous
services and applications already being implemented in the country.
However, many obstacles remain to further accelerate progress and transition the health ICT
system to ‘scale-up and mainstreaming’, the next stage of evolution identified in the WHO- It is recommended
ITU eHealth Strategy Toolkit. There is no unifying ICT for health strategic framework and no that a national
platform exists to support sustained dialogue and collaboration across public and private
sectors. Existing implementations and policies are fragmented. In the private sector, there
eHealth policy be
has been significant growth in ICT services offered, but in order for the sector to continue to developed that
flourish, investments must be made to improve infrastructure especially to less economically builds off existing
developed regions. Sustainable financing mechanisms need to be identified, and the private momentum and
sector can and should be engaged in this endeavor. As progress continues, efforts should policies.
be made to ensure the systematic alignment of ICT for health with health sector strategies
and priorities.
The following table outlines the findings from the review of the Nigeria ICT for health
enabling environment. Strengths, gaps and recommendations to address those gaps are
included. Additional information on the gaps identified through this analysis, along with
recommendations, are discussed in more detail in the final section of this report.
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