Leveraging Innovation in the Global Health System

Using findings from the previous chapter, this section explores how new technologies and innovative management strategies in global healthcare can help to improve clinical diagnosis, treatment, and disease management in Nigeria’s PHC system. The chapter delves deeper in health innovation and related concepts like technology adoption and quality of care, including health financing, staff training, health facility development and care user orientation/experience among others. On this premise, findings generated from the interview data offer an insight into the individual perception of all interviewees, and for validation purpose, the primary information has to be gleaned and weighted with relevant literature on the subject.

Literature review in Chapter 2 of this research contains a thorough analysis of leadership theories, health innovation strategies, and the role of technology in healthcare management based on three different positions vis-a-vis: (a) internal (b) sector-based, and (c) national. The following section therefore expounds the findings to ascertain their validity as well as alignment with the existing academic literature on the subject.

On this backdrop, the main purpose of conducting this in-depth analysis is to improve the body of knowledge in innovative health management strategies—specifically for enhancing PHC delivery in Nigeria. Accordingly, this chapter addresses the main research objective; to explore the health management strategies currently being utilised in the Nigerian PHC system in order to recommend an innovative way of enhancing healthcare delivery to the Nigerian populace.

Moving forward, the author will evaluate different themes identified in the findings section and group them into three different analytical levels: (a) internal (b) sector-based, and (c) national.

Investigative Stages (Identified Themes)

Internal

• The Concept of Health Innovation
• The Context of Innovation
• Adopting and Implementing Innovations in Healthcare Organizations
• Readiness for Health Innovation
• Strengthening the capacity of digital health leaders for the development and implementation of national digital health programmes
• Digital Health Strategy, Regulation and Governance
• Digital Health for Non-communicable Diseases

Sector-based and National

• Partnership with Private- and Public-sector Institutions
• Implementing Digital Health
• Digital Health Architecture Design
• Interoperability and Governance Model
• Digital Health Innovations, Big Data Analytics and Future Trends

5.1 Internal

5.1.1 A Discourse on the Concept of Health Innovation

The term “innovation” is no longer a new concept in academic circles. The term was integrated into healthcare terminology as a concept adopted from other fields. Thus, innovation in healthcare is interchangeably used as it applies in business, marketing and technology, Generally, innovation refers to a new idea, device, or method, as well as an act or process of launching new ideas, devices, or methods. Health innovation therefore falls under a broad category of social innovations applied to solve health problems with more efficient and effective systems and/or process (Mitchell & Kan, 2019).

According to Schweitzer et al (2015), social innovation within organizations is used to encourage new approaches towards poverty alleviation, education, and many human development problems. Although social innovation basically starts with system-level changes (Dube et al., 2014), the World Health Organization (WHO) acknowledge that ‘health innovation’ is an important tool for enhancing the quality, effectiveness, efficiency, safety, sustainability, and/or affordability of health care. In addition to these comprehensive definitions, McSherry and Douglas (2011) assert that health innovation includes “new or improved” health practices, system, policies, technologies, products and services—as well as the chosen methods of delivery—that result in improved healthcare. Rabeh (2014) identified some factors that should not be neglected in healthcare innovation vis-a-vis: (a) the level of patients’ education (b) improvement in healthcare research and development (R&D) (c) level of access to care (d) quality of care (e) patients’ perception of health providers/facilities (f) individual satisfaction etc. In other words, the main purpose of health innovation is to improve the ability of health systems to cater for the health needs of individuals and households. Health innovation therefore aims at providing optimal health care services via technology- and IT-based systems (Rogers., 1995; Bartholomew et al., 2001).

Theoretically, innovations in healthcare are expected to provide effective solutions and significant changes (improvements) in systems, technologies, health policies, products, services and delivery methods—for the ultimate goal of improving health care. Thus, the basic areas of healthcare innovation are categorised under (a) education (b) outreach (c) diagnosis (d) treatment (e) prevention (f) research quality and delivery, as well as (e) free access to healthcare services (Wensing et al., 1998).

5.1.2 The Concept of Innovation: New or significantly different?

To clearly understand the concept of innovation in healthcare, it is pertinent to first explain what it is not (Sirilli. & Evangelista., 1998). Grol and Wensing (2001) asserted that health innovation was necessitated by problems of efficiency, quality, effectiveness, safety, affordability and/or sustainability in healthcare service delivery. The scholars further argued that solutions arising from problems in healthcare may be considered an innovation. Their basis for the argument was based on claims that the solutions provide substantial relief from a difficult situation by introducing new or significantly different ideas, concepts, approaches, services, work processes, technologies, or products. But De Brentani (2001) disagrees that all solutions are innovations. The researcher explained that every innovation in an organization should not be considered a solution because some solutions to organizational problems, especially in the health sector, are merely developments within the field. For example, technological advancements such as Global Positioning System (GPS), email, and smartphones are some of the numerous solutions to the world’s communication problems that have proven useful in global healthcare. Therefore, advancements in the global health system sought to constantly address growing issues in the field of health (Tierney et al., 2010).

On this premise, Grönroos (2006) emphasized that global healthcare is continuously changing and adapting. This implies that solutions in healthcare cannot be taken as innovations unless it adds something new or significantly different from other existing solutions in the field (Biege et al., 2013). Thus, most scholars have erroneously used innovation as a general term in their studies. The misconception has led to poor understanding and wrong usage of the term in healthcare innovation studies. And without clarity on what innovation truly is, it becomes impossible to develop and properly identify new innovations in healthcare (Wutzke et al., 2016).

Omachonu and Einspruch (2010) offered a clear definition of innovation and how it applies to healthcare. In their study titled “Innovation in Healthcare Delivery Systems: A Conceptual Framework,” the academics based their analysis on technological innovations which opens opportunities for improve quality of health care products and enhance work process in health organizations. Further, the scholars defined ‘product innovation’ as any idea or technology that leads to the launch of new goods and services within a business environment. ‘Process innovation,’ according to Omachonu and Einspruch (op cit)., 2010), involves the enhancement of activities leading to the production of goods and services. Both Rogers (2003) and Greenhaigh (2004) agreed that developments in health technologies and clinical practices are evidence-based improvements with enormous benefits for care users.

5.1.3 Adopting and Implementing Innovations in Healthcare Organizations

Länsisalmi et al (2006) identified three major aspects of innovation and defined the concept as: (i) a novelty (ii) a part of an application and (iii) a general term for the intended benefit of using a new solution. The scholars explained further that an ‘intended benefit’ of every health innovation should revolve around the care receiver. But Hemphälä and Magnusson (2012) emphasized that stakeholder considerations should not be ignored, too. And ‘stakeholder considerations’ are very important whenever organizations are either adapting with an existing strategy or adopting an entirely new solution (Langley et al., 2009). With these components in mind, Blank and Valdmanis (2015) noted that the ‘innovation process’ is best grasped by assessing the wants, needs, and expectations of all stakeholders in the health innovation ecosystem. Although care users are always at the forefront, other equally important stakeholder groups include care providers, health organizations, innovative companies, governments, health regulatory bodies, and physicians (Herzlinger., 2006). But to properly diffuse innovation in healthcare, data used in this research shows that health innovation must address the following three key questions when it occurs in organizations vis-a-vis:

(i)      How is care user perceived?

(ii)     How is the care user heard?

(iii)    How are the needs of care users provided?

Figure 5.1: Telecare, Telehealth and other Convergent Services

Source: The Author (2021)

Thairu et al (2013) argued that meeting the needs of patients is not the end of innovative health management processes because, even after the criteria are met, there will always be new problems to be identified—at the right time—and properly addressed. The process of diffusing innovation in healthcare organizations is both social and interactive in nature, thus, highlighting the importance of communication, knowledge exchange, and collaboration between stakeholder groups within healthcare systems. As such, the process of adopting and implementing healthcare innovations requires a lot of individuals, challenges, and other factors that are specific to the socio-cultural, political, economic, institutional, and policy-related context of a particular system (Herzlinger., 2006; Langley et al., 2009; Hemphälä & Magnusson., 2012).

The Harvard Business Review explains that healthcare innovation is complex and can be understood from three different perspectives or categories: (a) technology (b) consumer focus and (c) business models. Under these identified categories, some of the major factors that determine whether a strategy is accepted and implemented in organizations are:

• The interest of stakeholders
• Funding of the health system and related cost of healthcare
• Health policies and government regulations
• Competition among players (competitors) in the health sector, and
• Other factors that influence adoption of healthcare technologies (such as accountability among health administrators, users’ perspective of health facilities, competence of health professionals etc) (Rogers., 2003; Greenhalgh et al., 2004; Omachonu & Einspruch., 2010; Wutzke., 2016).

Each of these factors have significant impact on whether an organization should (or not) consider changes in people, process and technologies as an innovation, including if such solutions to problems should be accepted and adopted in the field of healthcare. In other words, change management in organizations cannot be successful unless stakeholder groups see a relative advantage in adopting and implementing the innovative strategy. But Rogers (2005) suggested that business managers should not rely on the perceived advantage of a particular innovation while adopting or implementing new strategies—because ‘relative usefulness’ on its own does not guarantee results. Other innovation-related factors to be considered in healthcare management include the complexity, capacity, trialability, compatibility, observability, and risks of adopting and implementing change. Additionally, the ease of reinventing innovations should not be ignored (Anyika., 2014; Ahmed & Mesbah., 2015; Ajibade, O. & Ibietan., 2016; Aransi., 2019). Thus, stakeholders are most likely to adopt and implement innovations if they possess both individual and organisational capacities to do so. However, Awosika (2014) points out that’s such capacities must be (a) compatible with stakeholders’ interests (b) very easy to be adopted (c) simple for small-scale testing (d) observable (e) well-refined to aid achievement of stakeholders’ needs, and (f) requires little or no risks.

Evidence-based studies (Bartholomew., 2001; Biege et al., 2013; Ballini et al., 2015; Blank & Valdmanis., 2015) show that the initial step in solving an organizational problem is to create a plan for change. This first step is followed by adequate preparation for change because there is often an anticipation that change within healthcare systems will produce short and long-term results. But in real-world situations, changes don’t always result in a solution to existing problems—much less an innovation. To buttress this fact, Castellacci (2006) argues that a change in management strategy may, in fact, produce little to no improvement. And in some cases, changes may unexpectedly spring forth negative outcomes. For these reasons and more, leaders of healthcare organizations should not presume ‘change’ (whether big or small) as characteristically ‘innovative’ (Day et al., 2003).

Furthermore, it is important to observe the impact of change. For example, healthcare administrators and stakeholders have a responsibility—in an ideal health system—to unanimously analyse perceived and actual results of innovation to ascertain whether outcomes are positive or negative. The ability to categorize results as a success or failure is one of the key steps required to develop new innovations and resultantly improve delivery of healthcare services (De Brentani., 2001; Dubé et al., 2014). But beyond fulfilling these criteria, Gallouj and Savona (2009) pointed out that newly introduced ideas, methods, and products—including the process of introducing innovations in healthcare—expose healthcare administrators to an extra burden of resistance from groups affected by the change. Therefore, an innovation must be something truly new or at least significantly different and with less negative impact on groups within the organization—although the possibility is quite thin.

Generally, healthcare innovations should be applicable to health systems and care processes in health organizations. Moreover, innovations in health care should add something new to the existing body of knowledge—with care users (patients) at the centre stage. According to Gallouj and Weinstein (1997), health leaders should also consider the external demands of stakeholders, investors, policy regulators, consumers and competitors at all times, as well as scrutinize activities within health systems to ensure accountability. On this backdrop, Greenhalgh et al (2004) agreed that innovation in healthcare is complex, always evolving, and largely dependent on an interwoven network of factors and considerations. Thus, allowing a flexible or broad use of the term ‘innovation’ makes it ‘an overly inclusive concept’ and limits the potential of exploring new horizons—as well as the possibility of adopting result-oriented innovations. A clear understanding of the innovation concept (i.e. what innovation is and what it is not), including the challenges to adopting and implementing change in healthcare organizations, make it easier to conceptualise what health systems truly need to introduce large-scale and long-lasting changes that drive efficiency and effectiveness in care delivery (Hemphälä & Magnusson., 2006).

5.1.4 Readiness for Health Innovation

The current level of readiness for health innovation in Nigeria is relatively uncertain. But in reference to a state-level pilot programme implemented by the National Council on Health (that is, the apex decision-making body on health issues) in Gombe state, the successful completion of a community-based distribution (CBD) of injectable contraceptives has increased the drive to scale-up intervention across the country. The CBD of injectable contraceptives programme supervised by community health extension workers (CHEWs) was integrated in the national task-shifting policy to encourage more people to use contraceptives. Purpose for the scale-up is to ensure that benefits from the pilot programme are shared throughout the country. The health innovation strategy is considered crucial in Nigeria due to the low contraceptive prevalence rates (CPR). According to findings in the health innovation readiness research, less than 10% of respondents use modern methods of contraception such as pills, condoms, implants and intrauterine devices. Additionally, contraceptive usage in urban and rural areas vary in the ratio of 24:10 respectively as of December 2019. Further, a 2013 demographic and health survey (DHS) showed that only 3% of married women in Nigeria used an injectable contraceptive. The low usage was identified as a major cause of high maternal mortality ratio of 576 per 100,000 live births. Low contraceptive prevalence was also linked to over 32% of maternal deaths among women aged between 15 and 19 (Kress et al., 2016; Ebenso et al., 2018; Olu et al., 2019).

In 2014, more experienced midwives were integrated to scale-up the CBD of injectable contraceptives in partnership with CHEWs, and by 2017, several states in Nigeria had started a community-level distribution of injectable contraceptives under the supervision of a national NGO. But notwithstanding the achievements of this health innovation, there are some systemic factors that impede or facilitate expansion beyond the initial pilot sites (Onwujekwe et al., 2019).

Generally, the benefits of scaling up health interventions for the populations cannot be overemphasized. Health innovation scale-up is crucial for achieving the United Nations’ Universal Health Coverage (UHC) and millennium development goals (MDGs). Although scaling up has been described by different scholars in various ways, it is widely agreed to mean ‘efforts geared towards improving the scope and magnitude of health interventions to benefit more people in terms of number and geographical distribution.’ Importantly, the scale-up process requires commitment (that is, adequate funding, availability of human and material resources, and political will). But in many Low- and Middle-Income Countries (LMICs), including Nigeria, there is dearth of effective legal and administrative mechanisms (that is, policies and structures that support scale-up of proven interventions) (Ngoc et al., 2018; Ebenso et al., 2018; Labrique et al., 2018).

A strong political and a conducive policy framework are requisite for every country to successfully scale-up health innovation. Unfortunately, health administrators in Nigeria most times embark on scale-up without adequate preparations such as an appraisal of health system readiness to deliver the innovations. Considering that the strength and absorptive capabilities determine the scale-up performance of health systems, the identified administrative incompetence among Nigerian health administrators limits the availability and proper utilization of interventions that have yielded positive results in both low- and high-income countries. Other health system challenges include inadequate human resources and poor remuneration for health workers (Wilcox et al., 2019),

5.1.5 Strengthening the capacity of digital health leaders for the development and implementation of national digital health programmes

Stakeholders in the global healthcare system are clamouring for maximization of health innovation (that is, integration of digital health delivery processes) to advance quality of care and improve health of individuals and households. Strengthening the capacity of digital health providers is important in primary health care (PHC) delivery due to the deepening penetration of mobile phones and other digital technologies. Therefore, according to WHO (2019), there are huge opportunities for health providers to leverage those digital and electronic health (e-health) methods and innovations to accelerate Universal Health Coverage (UHC), Millennium Development Goals (MDGs), and Sustainable Development Goals (SDGs). In the Nigerian context, health administrators are yet to fully harness the numerous benefits of digital technologies towards strengthening the health systems—due to perilous challenges in the weakened health sector. Some of the critical challenges include but not limited to bare resources, weak human capacity, low infrastructural investment, high cost of scaling-up, and weak health systems governance among other factors. According to the World Bank (2016), lack of systems thinking and a functional design have negatively affected efforts geared towards coordinating activities of digital health leaders and this setback is responsible for the persistent fragmentation and non-interoperability of many applications.

The 2016 African forum of World Health Organization (WHO) emphasized on the importance of utilizing innovative health management approaches to promote better health outcomes in Africa. A remarkable aspect of such innovations is the integration of ICT systems and services in healthcare delivery—simply referred to as Digital Health (DH). In line with WHO description of digital health, it embodies all activities and concepts linked to ICT and healthcare delivery such as mobile health (m-Health), Electronic Health Records (EHR), Health Information Technology (HIT), and telehealth. It is worth noting that most African countries have deployed DH applications to facilitate various healthcare delivery programmes thereby advancing actualization of UHC, MDGs and SDGs among African economies, including Nigeria. For example, the International Telecommunication Union (ITU) and WHO Regional Office for Africa (WHOAFRO) in 2017 officially agreed to collaborate towards establishing platforms to scale-up DH for UHC, MDGs and SDGs. Further, the ITU and WHOAFRO signed an agreement to build a strong and resilient workforce that can leverage ICT infrastructure and improve partnership with major stakeholders in the continental health sector. The aim was to achieve sustainable adoption and implementation of DH among African health systems. Some highlights from the ITU-WHOAFRO collaboration are:

• Capacity building for the health workforce
• Interoperability
• Partnership with private- and public-sector institutions, and
• Provision of medical devices for digital health.

The ITU-WHOAFRO partnership provides an opportunity for health leaders to explore DH as a comprehensive, easy-to-use and coherent approach to healthcare delivery. The usefulness of DH as an integrated, people-centred innovation in global healthcare cannot be ignored. DH is crucial for the attainment of UHC, MDGs and SDGs. Towards this objective, the 2017 WHO ‘Observatory for e-Health’ and the World Health Assembly (WHA) resolution on DH implored stakeholders in the global health system to increase investments in DH capacity development and strengthen performance of health workers. But it is arguably true that DH systems and services alone cannot deliver better health outcomes unless the workforce utilizing such health innovations (that is, health personnel) in every country are adequately equipped with the necessary skills and competences. Likewise, there is need for capacity building among the technical staff involved in the DH implementation process. These steps will ensure rational use of DH systems and other technical tools in scaling-up for sustainable outcomes in health care delivery. The author found there is low level of DH learning capacity among the workforce that are able to operate digital health systems in Nigeria, specifically those health workers functioning at country- or scalable-levels. However, there is ongoing effort to unite digital health leaders and build participants’ capacity among key ICT companies, NGOs, International Organizations, experts, donors and Ministries of Health (MoH) in charge of monitoring the development and implementation of digital health programs at both state and national levels. According to the Federal Ministry of Health (FMoH) (2014), the capacity building project among leaders of DH initiatives in Nigeria is categorized into eleven modules and seven thematic areas vis-a-vis:

(a) Understanding digital health

(b) Digital health platform applications design

(c) National digital health strategy development

(d) Digital health interventions identification and requirements analysis

(e) Data use and analytics

(f) Development, deployment, maintenance and scale up

(g) Monitoring and evaluation.

The eleven modules

Eleven modules identified at the DH capacity development workshop held in Abuja and across the six geo-political zones of Nigeria between 20th – 30th November 2019 are as follows:

• Introduction to Digital Health
• Digital Health Strategy, Governance and Regulations
• Digital Health for non-communicable diseases (NCDs)
• Global Goods
• Partnership models with telecom companies
• Implementing Digital Health
• Digital Health Architecture Design
• Interoperability Framework
• Monitoring, Evaluation and Learning
• Digital Health Innovations, Big Data Analytics & Future Trends, and
• Global Health Security.

Learning strategies utilized during the lectures include face-to-face interactive teaching sessions, high-level panel discussions, and question and answer sessions that enhanced exchange of ideas/knowledge between programme facilitators and participants.  Among the list of consultants who implemented the module are knowledge experts from the Federal Ministry of Health (FMoH), Federal Ministry of Communications & Digital Economy, WHO Country Office, Nigeria, Office of the Nigerian President Abuja, Nigeria, as well as development partners and ICT professionals in the Nigerian health sector. A total number of 182 participants across the 36 states and Federal Capital Territory, Abuja registered for the human capacity building programme held to launch a national DH architecture in Nigeria. The major purposes were to set a strategic roadmap (SRM) for DH discussions, enhance understanding of DH concepts/terminologies among stakeholders in the Nigerian health sector, and appraise efforts made towards deploying DH applications in the country. According to the WHOAFRO keynote address that highlighted the huge benefits and vast opportunities from using DH to achieve UHC and other national health objectives across 45 countries in Africa, the continent is experiencing rapid development in ICT. Mobile phone penetration and internet usage in Africa scored about 81% and 25% respectively against .99.7% and 47.1% at the global level. The wide disparity between Africa and the world highlights the need to support innovative health management strategies, and specifically use of digital health to strengthen health systems for UHC and SDGs across the continent. Results show that about 30 out of the 47 countries in Africa are currently implementing country-specific e-Health strategies, including Nigeria.

However, the major challenges to digital health in Nigeria are (a) inadequate infrastructure to sustain development of health technologies, and (b) paucity of well-trained DH personnel. The identified setbacks include but not limited to (i) non-interoperability of various DH technologies (ii) lack of cooperation among DH stakeholders (iii) difficulties in monitoring and managing DH programmes (iv) the expensive requirements/procedures for scaling-up (v) uncoordinated investments etc. These challenges are responsible for the limited impact of health systems and have therefore negatively affected systems thinking in Nigeria. This circumstance calls for immediate efforts to improve uptake of DH in Nigeria in line with recommendations from the 2016 WHO eHealth survey titled ‘Global Diffusion of e-Health.” Stakeholders in the Nigerian health sector have also underscored the need for capacity building on digital health technologies as well as the proper documentation of digital health achievements, and importantly, the integration of economic evaluation studies while crafting a suitable investment model for implementing DH in Nigeria. Also, evidence-based research indicates that individuals should be at the forefront of digital health initiatives in the country so as to improve access to healthcare services (Wilson et al., 2014). In other words, the focus of implementing DH in Nigeria should be to eliminate time- and location-based barriers. On this premise, facilitators of DH technologies that support health service delivery across Nigeria should ensure that strategies are aligned with existing systems—and efforts should be coordinated to ensure that DH projects are not only sustainable but also adaptable, scalable and cost-effective in the context of every existing local system.