CHAPTER FOUR (RESEARCH FINDINGS)
4.0 DATA ANALYSIS
The author used NVivo 12+ to conduct a qualitative data analysis (QDA) of facts gathered from both primary and secondary sources. The software is widely used by researchers in different domains due to its relevance in organising and structuring study activities.
Generally, NVivo helps qualitative researchers to arrange, examine, and identify basic facts in unstructured, small or large volumes of data (sourced from open-ended survey responses, web content, interviews, journal articles, and social media platforms) that require thorough analysis. The analytical software is intended to help patients sort and glean non-numerical or unstructured information (e.g. text, audio, video, or image data), as well as examine relationships between variables. NVivo users can therefore maximize its search engine and query functions to enhance results from linking, shaping, and modelling activities. However, researchers need to have adequate knowledge and techniques for using NVivo tools and/or function.
Thus, information from research participants was analysed by converting interview transcripts to NVivo data files in order to create automated notes that enabled the author code unstructured (qualitative) data. The importance of a node in NVivo system is to store a place for references to code the text. Further with the knowledge/skills of coding under particular nodes, the author was able to highlight the text, identify particular nodes, and allocate different codes to various elements of the text. Figure 4.1 contains all automated themes developed with NVivo 12+ in order to model a tree node as shown in Figure 4.2 below. These diagrams/tables showcase the fundamental themes—such as healthcare, innovation, healthcare innovation, health technology, PHC systems—upon which the author conducted this academic inquiry. Based on these major concepts, the following sections are differentiated for an in-depth analysis of data.
Figure 4.1 NVivo Coding for Research Data
Source: Coding from NVivo 12+
4.1 INTRODUCTION
Figure 4.2: Major Themes on the Health Innovation Node
Analysis conducted based on NVivo 12+ thematic evaluation of the interview data suggests there is a link between technology adoption and quality of care. Although existing research books on innovation in Nigeria focused on the application of information communication technology (ICT) in business, education, finance, agriculture and e-commerce domains, the NVivo thematic analysis indicates that the value of digital health technologies in delivering essential health care solutions, especially in developing countries, is increasingly appreciated. Research findings also show that only few scholars have examined global trends in health innovation or how strategic healthcare management can improve healthcare delivery in Nigeria. Remarkably, some countries in Sub-Saharan Africa (e.g. Ethiopia, Malawi and Uganda) have developed locally appropriate health technologies and innovative country-specific solutions such as m-Health apps to improve performance of their health systems. Evidence-based studies also support claims that disruptive innovation in the health sector provide huge opportunities for both developed and developing countries to improve their economies through efficient, low-cost and sustainable healthcare solutions that are easily accessible to the masses (Christensen et al., 2015; Adebowale., 2018).
But health outcomes in Nigeria have declined in recent years due to low application of innovation and technology in healthcare management. This qualitative analysis used interviews, observations and focus group as research methods to collate primary data from Anambra State, Nigeria. The author developed and tested decision-support innovative health management strategies for improving PHC delivery, with focus on verifiable responses from health professionals about the current state of health facilities, level of technology adoption, and performance of community health workers in Nigeria. Data coding and analysis was performed in NVivo 12+.of the project.
4.3 Major Nodes (Themes) of Interview Data
Source: Automated Nodes from NVivo 12+
4.1.1 THE NIGERIAN PHC SYSTEM
The key themes that emerged from the NVivo analysis of interview data on the Nigerian PHC system are “innovation” and “technology”. Other related variables in the node as depicted in Figure 4.2 enhanced results from discussions with the interviewees. For example, all health administrators agreed that Nigeria operates one of the world’s most complex health care systems. Also, innovation and digital technology have not been explored to transform care management and deliver essential health services to individuals and households across the country. Results from the NVivo analysis of interview data therefore suggest there are three themes regarding care users and health managers’ perceptions of the Nigerian PHC system vis-a-vis: (a) variations in use (b) barriers to use, and (c) recommendations to improve use.
Table 4.1 NVivo Themes Relating to the Nigerian PHC System
| Themes | Categories | Codes |
| Variations in use | Users’ experiences | Positive experiences/benefits of using the system |
| Negative experiences in using the system | ||
| Limited users’ experiences | Type of facility | |
| Community/public health workers’ attributes | ||
| Barriers to use | Socio-political environment | Infrastructure available |
| Health workers’ strike | ||
| Political instability | ||
| Attitudes and behaviour | Expectations | |
| Lack of knowledge and skills-ICT | ||
| Issues related to the system | Network coverage | |
| Nature of the gadgets | ||
| Nature of the system | ||
| Recommendations to improve the system | Suggestions for enhancing usage | Integrate the system with others |
| Provide extra motivation for users, including performance-based remuneration | ||
| Provide basic ICT skills for users | ||
| Strengthen ICT infrastructure |
Source: Themes from NVivo 12+
Research data adds more to the body of knowledge on the value of digital technologies in promoting access to healthcare. Digital health—from the perspective of WHO—refers ‘a discrete functionality of digital technology explored by health systems across the world to achieve health objectives. Some of the huge benefits from digital health are evident in patient/care management, R&D, and growing support for low-ranked health workers (including community health workers and health volunteers), disease surveillance, as well as data collection and analysis, among other uses. Digital health and innovation are not only useful in developed economies but are particularly important in low resource settings. Thus, the intrinsic and extrinsic values of digital technologies are generally appreciated in developing countries for its ability to transcend geographical barriers while allowing individuals and households to access essential health services in real-time
“The Nigerian government is continually striving to adopt Universal Health Coverage (UHC) as an official policy target in order to ensure that Nigerians have unrestricted access to quality health care services—without financial constraints” (HA 3)
President Muhammadu Buhari in March 2014 convened a UHC summit to engage stakeholders in the health sector on discussions about the most viable options and strategies to achieve UHC in Nigeria. Although the attainment of national and global health objectives requires strategic analysis and strict implementation of strategies, every health administrator interviewed during the research agreed that Nigeria lacks the necessary infrastructure to deliver basic health care, especially to rural communities.
“In addition to establishing a strong and reliable infrastructure base, policymakers in the Nigerian health sector need to understand there is need to harness the potentials of digital technologies and strengthen health systems as country-specific healthcare delivery models are developed” (HA 1)
This is more so because a vibrant PHC system does not exist in a vacuum. Stakeholders in the innovation ecosystem must explore the huge opportunities from digital technology to build an infrastructure base that provides the backbone on which heath innovations draw support. It is therefore important to consider the readiness of information and communication technologies (ICT) users before rolling out technology-based health solutions. Further, policymakers should properly analyse the political and socio-cultural environment in which health innovation are to be implemented.
“Integrating new solutions into existing ones has been a difficult process in the Nigeria PHC system” (HA 5)
Public health in the country functions within a three-tiered administrative structure. The Federal Government (FG) controls affairs in University Teaching Hospitals and Federal Medical Centres. In the lower cadres, the state government coordinates affairs in general hospitals whereas the local government is responsible for dispensaries. As a major stakeholder in Nigeria’s health care system, the private sector provides medical services to a large number of citizens, too. But more importantly, successive Nigerian leaderships have—through various acts of parliament—formulated and implemented myriads of health policies to accommodate fast-evolving concerns in public healthcare.
“The WHO states that good corporate governance requires leaders to establish strategic policy frameworks and combine them with effective oversight, coalition-building, regulation, accountability, and unflinching attention to system-design” (HA 10)
“…But as of 2019, primary health facilities in Nigeria make up nearly 90% of health facilities. Both secondary and tertiary health facilities make up about 13% and 0.25%, respectively…There are more government-owned health establishment than privately-owned ones—with a ratio of 65% vs 35%” (HA 2)
While this is a clear indication that healthcare is not evenly distributed in the Nigerian PHC system, a fact buttressed by all interviewees, HA2 added that secondary health facilities are predominantly private owned. Further, the ratio of public to private health facilities is much higher in the northern part of Nigeria when compared to the southern part. This underscores negligence and gross incompetence on the part of political leaderships saddled with the responsibility of building infrastructure for a vibrant PHC system. Only few health programmes such as the National Health Insurance Scheme (NHIS) are widely adjudged to be effective, reliable and suitable for providing solutions to the wide-growing health needs of Nigerians.
Health care services under the NHIS are categorized as follows:
(a) Preventive care—which includes health education, family planning, and immunization
(b) Maternity Care—which covers up to 4 live births
(c) Outpatient Care
(d) Specialists Consultation
(e) Inpatient Care—which guarantees access to a standard ward for about 15 days per year
(f) Preventive Dental Care
Findings from the research data and other relevant studies in health management show the growth and long-term survival of Nigeria’s healthcare system rely on the successes of NHIS, whose major milestone is the continuous quality care rendered to children less than 5 years old and the disabled. Generally, the financial cost of PHC services in Nigeria is cheap and affordable although stakeholders in the system have not properly exploited developmental options offered by the application of innovative health management strategies.
“Provision of access to high quality health services should be a major concern and the main tasks of governments” (HA 1)
“Every country gets the kind of PHC system it deserves…The level and quality of healthcare available to individuals and households depends highly on factors such as economic conditions, advances in medical science, governmental budget, education, culture, size of the population, age pyramid, availability of local healthcare manpower etc” (HA 6)
On this backdrop, the identified challenges of Nigeria’s PHC system include: (a) inadequate infrastructure, especially at the local government level (b) unreliable data storage systems (c) dysfunctional surveillance mechanisms to assess performance of PHC service (d) low morale of doctors due to unavailability of modern health equipment (e) politicization of health service and the PHC system (f) corrupt practices among local government area (LGA) leaders, and, (g) poor remuneration for health workers, among other factors.
Good corporate governance is a primary feature of resilient PHC systems. While political leaders and policymakers in the healthcare sector are considered the core of governance, the relevance of non-state actors—from health practitioners to civil society groups—are crucial for every health system focused on achieving national health objectives such as improved health status of citizens, reduced financial risk to users of the PHC system, and improved health system responsiveness to people’s expectations.
“Patients are the reason for healthcare whether they live in the urban or rural areas, and they should be at the centre of it” (HA 4)
Technology is not an end by itself, but a means to an end. It does not have an agenda of helping healthcare per se. But inasmuch as the author might want to focus on the Nigerian PHC system and benefits of health innovations, it is important to point out that technology develops because of miniaturization, as well as to reduce financial costs production—not in anyway because it makes people well. Digital technologies in healthcare are widely used and appreciated because it can create more avenues for making money and reinvesting it. The success of health innovations therefore depends on the variations in use and barriers to adoption as explained in Table 4.1, including other systemic factors.
4..1.2 INNOVATION AND HEALTHCARE MANAGEMENT IN NIGERIA
Research data shows the PHC system in Nigeria lacks innovation and technology. Thus, the health administrators interviewed during this study agreed that stakeholders in the health sector need to increase funding for establishing fully functional facilities in some parts of the country. The interviewees also agreed that government should allocate more resources to improve access to tertiary health facilities, and more importantly, leverage private sector capacity in health innovations.
“The benefits of integrating digital technologies and adopting solution-based health management models suitable for the current development stage cannot be overemphasized” (HA 7).
This exploratory case study examined the relevance of health innovation and the application of health management technology such as Remote Patient Monitoring (RPM) systems in Nigeria. The competitiveness of Nigeria’s healthcare industry as well as the sustainability of adapted healthcare models were also analysed. Basically, the focus on healthcare innovation is to shed light on the potential gains of implementing innovations (disruptive or non-disruptive) in healthcare management for low-income individuals and households. But is this objective really realistic when health facilities across Nigeria are non-uniform?
“UHC strategy implemented in Nigeria has been irresponsive due to the variation in health facility distribution” (HA 1)
“Health workers at the private facility and very few of their counterparts in the public sector use innovative health management strategies—such as digital technologies—more than health workers in the public facilities” (HA 6)
Research findings show that developmental efforts to revive the Nigerian health sector—particularly through financial and technical support—have been under the control of foreign agencies and international donor organizations like the United States Agency for International Development (USAID), the World Bank, the World Health Organization (WHO), the International Monetary Fund (IMF), the United Nations Population Fund (UNFPA), and the Bill and Melinda Gates Foundation (BMGF) etc. Despite the achievements of these development partnerships, problems mitigating against the growth of Nigerian PHC system have persisted. And the overall quality of healthcare is at an all-time low. This reality raises some questions about the obligatory roles and performance of policymakers at the three tiers of government.
“Policymakers in the Nigerian health sector have implemented various strategies such as disease prevention programmes and incentives strategies among population…The federal government has also invested heavily on technological development intended to boost performance of the PHC system” (HA 2)
The Local Government Authorities (LGAs) have key roles to play in ensuring effective provision of basic health services to individuals and households in rural communities. The community-level leadership has mandate to coordinate and implement sector policies in the health care delivery process. Importantly, the LGAs in Nigeria has to be influential in order to undertake their implementation and coordination roles more effectively. But establishing a fully functional LGA framework and PHC system depends on whether and how the existing decentralisation policy in Nigeria allows local health administrators the independence they need to perform.
“The Nigerian PHC system performs below expectation because diffusion of integrated IT systems has been a Herculean task for health administrators at all levels of government due to various systemic challenges” (HA 1)
“Privatization of the healthcare system has proven not to be the solution despite the increasing public awareness (through social media) on the opportunities from an open market economy” (HA 4)
Research data from HA3, HA4, HA6, HA8, HA9 and HA10 buttressed the fact that decentralisation in public administration is intended to make significant contributions to governance. Moe importantly, the LGAs are structured to improve the effectiveness of health workers in various communities, evenly distribute social amenities, as well as encourage local people (that is, community members) to partake in decision making on issues relating to their human rights and existence as part of the larger society.
“The LGA system was created to strengthen democratic governance and make citizens the centre of their government focus” (HA 1)
The proximity interaction made possible by decentralising the government apparatus is effective in untying the blocks which undermine the ability of local government administrators and health workers in rural areas. The decentralised system of government therefore plays a mediating role whereby the federal/state governments become closer to the grassroot and respond to the needs and aspirations of rural communities—especially basic health services and other social amenities. Resultantly, citizens are empowered to oversee and question governmental decisions and actions thereby fostering transparency and accountability.
“Decentralisation of the governmental system has not been favourable to the PHC system in Nigeria because, in reality, decentralisation has created room for embezzlement of public fund, ethnicism, regionalism, uneven distribution of health resources etc. Decentralization also limits the ability of central government to influence policy determinations that could have allowed implementation of innovative health management strategies” (HA 3)
The NVivo analysis of interview data highlighted four sub-themes under barriers to using innovative health management strategies in Nigeria. The identified challenges were categorized under (a) attitudes and behaviour (b) socio-political environment (c) health system-based issues, and (d) poor infrastructure. Other barriers to UHC implementation include recurring and prolonged labour strikes from health workers, political instability, intermittent power (electricity) supply, and lack of commitment from political leaders. But innovation and technology drive healthcare more than any other force. In the nearest future, technology-driven health innovations will continue to improve healthcare delivery in dramatic ways. Also, health outcomes will most likely favour health systems that are able to adapt and keep up with the pace.
“Future technological innovation will constantly change healthcare services…Digital technologies (such as m-Health apps, new devices, more effective drugs and treatments, including an increasing social media support for better healthcare systems across the world, etc) will drive innovation in the global health system…But human factors will remain one of the strongest challenges of breakthroughs” (HA 1)
According to a 2019 WHO study, life expectancy in Nigeria is approximately 55 years—and this is one of the lowest in Africa. In global healthcare indices based on access to basic health care and quality of life, WHO also ranked Nigeria as low as 140 out of 195 countries within the years under consideration (1996 – 2015).
Stakeholders in the health innovation ecosystem therefore need to take the future seriously because, literally, it is all we have—and certainly everything posterity will have. Moreover, as time passes and the age pyramid in every country shows a staggering number of aging populations, the challenge of providing health care for the elderly tends to be more expensive and overwhelming. These realities, thus, underscore the need for governments to institutionalize a health system capable of improving the future. Stakeholders in the health innovation ecosystem, especially PHC system, should therefore put effort into future planning, not once, but continuously.
“Stakeholders in the Nigerian health sector can glimpse and debate the details of future trends in healthcare…What Nigeria needs is a strategic roadmap for improving the PHC system. It is also important to be very clear about the drivers (innovative health management strategies) so we can align with them and work together, actively, to ensure that we achieve the best health outcomes for society as a whole” (HA 8)
Further, the diffusion and adoption of innovation in healthcare are crucial policy matters for value creation. Policymakers in the Nigerian health sector therefore need a change of perception and attitude in order to improve the health system at different levels of government (namely federal, state and local), and in PHC centres.
“Innovation is a driving force in healthcare delivery. It speeds up value creation process and balances cost of production/usage while significantly increasing healthcare quality in health systems” (HA 7)
But notwithstanding the enormity of technical and financial support available for health systems to diffuse innovation, research data shows that outcomes have not generally been effective as expected. Some health innovations have even failed in some cases. Research respondents (HA2, HA5 and HA9) added that failure of health innovation programmes occurs because of the complexity of systems.
The Lancet conducted research on Healthcare Access and Quality Index in 2017 using technology-reliant tracking frameworks to monitor trends in treatable cancer; death-causing diseases such as tuberculosis and respiratory infections; heart disease; vaccine-preventable ailments (e.g. measles, tetanus, diphtheria, whooping cough, tetanus and measles); and several forms of maternal and neonatal disorders. Results from the health innovation study showed Nigeria performed abysmally low when compared to many African countries. Although the United Kingdom, North America, Australia and Asia showed improvement in health care indices during the period of observation, Africa and Oceania lagged behind in the provision of basic health care to individuals and households. In Nigeria, the current state of healthcare delivery is slow, costly and unavailable to many individuals and households. Health infrastructure is relatively dysfunctional, and doctors (including nurses and other health professionals) are poorly remunerated. Intervention of politics in healthcare administration has also constrained implementation of innovative health management strategies. Other endemic challenges within the health innovation ecosystem in Nigeria include incompetent administration and insufficient government funding. These lingering systemic problems stifle disruptive innovation which the country needs in this era of digital health.
Although this study is not focused on making comparisons between technological and human factors to exploring health innovations, these drivers are not aligned, mainly because technology is most unlikely to advance in ways that are optimal for effective delivery of healthcare on its own accord. Nigeria has many medical doctors, scientists, researchers and health practitioners competing at the world stage. But these highly-educated and well-talented medical professionals are jetting out of the country in hundreds and thousands every year—in search of more favourable work conditions. Also, a large number of affluent Nigerians (especially politicians) regularly travel abroad for medical treatment while the poor masses are left with no option than the low-quality health care services available at health centres or herbal homes.
Disruptive innovation in global healthcare has therefore given rise to more affordable, easily accessible and convenient-to-use health technologies. But the Nigerian health system is not dynamic enough to adapt with the capital-intensive and fast-paced digital transformations. The problem is not inadequate financial or technical support for health development programs; it is lack of political will to strictly implement recommendations from evidence-based research on local health issues (Adenuga et al., 2017; Adeloye et al., 2019).
Figure 4.4 Some Key Factors Affecting Healthcare Management in Nigeria
Source: The Author (2021)
“Nigerian leaders should allocate more resources to technological advancement, and the ICT-driven health system of the future should be integrated with all facilities and related institutions in the country to make information about innovations and users available to health professionals.” (HA 1)
“Nigerians need to maximize opportunities from m-Health apps. The government and health system should make health data accessible on users’ regular phones. Policymakers in the health sector should also explore other sustainable health management models that can motivate people to use PHC service at no financial risk …To improve health service delivery, Nigeria should consider using performance-based remuneration for health professionals at all levels of government” (HA 4)
Trends in global healthcare industry show that advancements in technology have led to a steady rise in the cost of medical services. Through innovative health management strategies, traditional players in the healthcare industry (such as giant tech companies in the United States, China and other European Union (EU) countries as well as highly innovative start-ups across the world) are shifting focus to sustaining health innovations and increasing investment in research and development (R&D). These efforts are required to produce more sophisticated, expensive and user-friendly devices. Thus, one of the research respondents, a doctor (D3) asserted that breakthroughs in health innovation continue to benefit a selected number of care users thereby widening the health care accessibility gap between developed and developing countries. Even without significant development in health technology adoption/usage in Nigeria, a large number of the population has limited or no access to quality health care services.
“Despite its enormous achievements, digital health cannot replace non-functional health systems in any way” (D 2)
Nigeria needs to break away from the traditional innovation-sustaining model of health care delivery to a more value-based approach that may require short-term financial risks in exchange for long-term success.
4.1.3 PHC ADMINISTRATION PROCESS IN FINLAND AND NIGERIA
Having a robust PHC administration framework is integral to the realization of national health objectives—with significant impact on health indicators such as span of life and quality of life. In Nigeria, the government and policymakers have repeatedly made decisions on health priorities based on political necessity or preference instead of local research findings. To understand the effectiveness of innovation in PHC administration—as shown in Figure 4.5, it is pertinent to analyse the general framework of innovation process in the Finnish health system.
- Finland
Figure 4.5 The Finnish framework of health innovation in Health Care Centres (HCCs)
Source: The Author (2021)
The Finnish PHC framework comprises of three elements: the enablers, processes and outcomes. The “enablers” refer to factors capable of influencing the efficiency of diffusing innovation within or across work units and departments. For clarity, innovation enablers in this context focus on roles played by health professionals (such as doctors, nurses, health administrators, policymakers and other health workers) who implement innovative ideas in healthcare administration. Thus, the enablers are considered as creative thinkers who integrate innovative ideas and methods in healthcare administration processes. The “process dimension of health innovation” refers to how health professionals implement the “enablers of innovation” in their various workplaces using their academic knowledge, work-related experience and expertise. The last element of Finnish PHC administration model is “the outcomes dimension” which explores the impact of creativity (health technology) and relevance of using innovative health management ideas to improve performance of health systems—as may be weighed with performance indicators.
In comparison with other European Union (EU) member countries, Finland represents the Nordic model of the social welfare which promotes implementation of a broad scope of social policies and universal health benefits. The Finnish social system thrives on people-oriented policies that support provision of free or subsidized health care programmes. Also, a large proportion of Gross Domestic Product (GDP) is allocated to basic social and health services. Further, gender equality and equitable distribution of income are other features of the Finnish system. It is therefore necessary to add that the Finnish health system allows public ownership of hospitals. Health administrators in Finland have a decentralized responsibility to oversee and ensure smooth functioning the health system without political influence or individual sentiments. These features have significantly reduced cost of care thereby providing individuals and households with equal access to basic health services. Remarkably, the Finnish model of care has been more effective for integrating high levels of tax-based financing and promoting collaboration between players in both public and private sectors. For example, the Finnish central government and local municipalities provide funding for public institutions, and both are responsible for financing health services. Interestingly, public financing in Finland gulps over 75% of health expenditure whereas private healthcare, including the public municipal but not occupational services, accounts for only 6% of total expenditure on healthcare management.
- Nigeria
Despite the numerous health development programmes implemented in Nigeria since 1960s, health administrators have shown no strong focus on innovation and integration of technology in health management processes. Political office holders and policy makers in the health sector made efforts to build new healthcare infrastructure and expand/upgrade existing facilities, but emphasis has been on curative medicine rather than preventive medicine. For these reasons, the PHC system was launched in the 1980s. Using the PHC approach, policy leaders initiated the National Basic Health Services Scheme (NBHSS) to improve healthcare delivery across Nigeria. Unfortunately, the NBHSS program failed due to implementation challenges and other systemic factors. The National Primary Health Care Development Agency (NPHCDA) was established in 1992 to sustain the PHC agenda, but similar to other health development programmes before and after, it failed to actualize the intended objectives.
“As of November 2021, only about 20% of the 34,173 health facilities listed in the National Health Facility Directory of Nigeria were functional” (HA 6)
According to D1, D3, D4 and D9, most of the PHC facilities in Nigeria lack the capacity to provide essential healthcare services.
“PHC facilities in Nigeria are disgracefully understaffed in addition to having issues. in addition to having issues such as inadequate equipment and uneven distribution of health workers” (D 5)
There is also an indication of dysfunctional infrastructure and lack of essential drug supply, according to (HA 8).
“In part, the major problem with PHC administration in Nigeria started with its hand over to the LGAs in the 1980s… Local government in Nigeria is at the lowest level of the pyramid and is considered the weakest link in governance” (HA 5)
Figure 4.6: The PHC Organogram in Nigeria
Source: Nimedhealth (2021)
While the impact of LGAs in PHC administration in Nigeria has been a subject of intense debate and argument, it is important to reference achievements from the implementation of Alma Ata Declaration in countries such as China, Thailand, Mexico and Cuba. On the other hand, Nigeria’s “PHC under one roof (PHCUOR)” was inaugurated in 2011 to address problems arising from the fragmented PHC structure, as well as to ensure that PHC services are well-integrated under one authority. Research data shows PHCUOR has performed below expectations, especially in changing the health status of Nigerians and exploring PHC potentials to achieve economic development.
“The federal government relies on fund from donor agencies to implement national health development programs” (D 6)
No country can make a significant breakthrough if sponsorship for implementing capital-intensive and technology-based health solutions comes only from foreign governments/donors. The risks to the security of data cannot be ignored. Furthermore, the inability of administrators in Nigeria to provide basic medical services in PHC centres have led to an influx of patients in both secondary and tertiary healthcare facilities. The administrative burden of this reality on secondary and tertiary levels of care is overwhelming.
“Part of the Alma Ata Declaration states that basic healthcare is a fundamental human right, so governments should be responsible for the health of the people” (HA 1)
Policymaker in Nigeria do not see health as a fundamental human right. This is one of the reasons why health administrators find it difficult to implement the Abuja Declaration, which contains a pledge by African presidents to set a target of earmarking at least 15% of their annual budget to improve the health sector.
“Policymakers have been unable to increase investment in healthcare notwithstanding ample evidence linking innovation and digital technology to improved health services” (D 2)
According to a nurse at the Anambra State Teaching Hospital identified as Nurse 5 (represented as N 5), health administrators in Nigeria have not maximized opportunities and benefits of health technology. Past and present healthcare management strategies adapted in PHC management have yielded insignificant results, too. Although the Alma Ata Declaration promotes collaboration with other related sectors of the economy in the development and implementation of PHC agenda, systemic challenges have made it impossible. Presently, performance of global health systems has been disrupted by the scourging COVID-19 pandemic and the wheels of Nigeria’s PHC system is further clogged with serious administrative, technical and financial problems—worsened by a deepening economic recession. These challenges underscore the need for innovative health management strategies capable of revamping health care services at this time of telehealth explosion. The health innovation dimension of PHC administration in Nigeria raises the question of whether the PHC system would be more effective if federal and state governments take over administrative powers from LGAs. According to the 2018 National Democratic Health Survey (NDHS), the Nigerian PHC system lacks infrastructure needed to integrate innovation and digital technology.
4.7 Distribution of Health Professionals in Nigeria
Source: NDHS (2018)
Research data from this study further indicates that the government and policymakers lack proven frameworks capable of merging virtual and in-person care. Moreover, health administrators are not well-empowered to maximize the huge untapped opportunities from consumer- and clinician-centred digital health tools.
The Nigerian PHC system is not properly rooted to adjust with changing clinical trials and maximize opportunities from health innovations. Besides, there are no effective strategies on ground to facilitate digital relationships and ease physician burdens” (D 7)
As D4, H2 and N1 rightly noted, the poor performance of data mining and storage systems in the Nigerian health sector makes it nearly impossible to forecast outcomes during a health crisis—and at other times. PHC administrators therefore lack reliable mechanisms to facilitate regular functioning of people, process and technology in healthcare organizations. Thus, the unavailability of effective management tools capable of reshaping health portfolios for growth is a major setback to the growth of PHC system in Nigeria.
“Sadly, PHC administrators are determined—on paper—to build a resilient and responsible supply chain properly streamlined for achieving long-term health needs of the populations” (H 2)
The question is: are the Nigerian government and public health administrators mentally, morally and financially motivated for progress? It is pertinent to note that recent improvements in the health sector are mainly championed by the Federal Government with quite little contributions from the 36 states. The local governments, which are closest to the largest segment of the Nigerian population, have made no appreciable efforts to enhance delivery of health care services, too.
The reality in Finland is totally different. The Finnish health system is not just more decentralized compared to other EU countries. With more than 335 municipalities providing two-third of overall public services as well as healthcare and other long-term care services (such as hospitals), the central allows administrative autonomy by reducing legislative control on municipal health service. Therefore, Finnish municipalities are very effective in implementing innovative health management strategies such as income tax, health investments, and efficiently organized care services. The decentralized hospital system (care management model) aligns with an aspect of the purchaser/provider model, which empowers municipalities to play the role of purchasers and the hospitals of the providers. PHC centres in Finland therefore render services such as dental care, child welfare, school healthcare, physiotherapy, psychology etc. Overall, the healthcare system in Finland is funded by taxes and benefits from the decentralized public governance structure. Emphasis in PHC administration is also on public participation, social equity, and geographical distribution of health resources.
On this premise, policymakers in Nigeria should increase domestic resources for health. In other words, budgetary allocation for PHC administration should be reviewed upwards, and healthcare resources should be redirected from curative services to preventive services in order to improve PHC infrastructures.
“Innovative healthcare management is one of the ways to encourage migration of health workers from urban areas to rural communities and ensure that everyone has access to basic healthcare services” (N 3)
This suggests that health administrators need to diffuse innovation and digital technologies to reduce the gross inequality in health status of Nigerians relying on the PHC system for survival. Political leaders and policymakers can also guarantee the people’s right to good health by signing and implementing necessary health development programmes/legislations.
4.2.1 TELEHEALTH INNOVATION IN NIGERIA
Figure 4.8: Automated coding of themes connected to telehealth
Telehealth is a very interesting field in global health care. Although the PHC agenda is focused improving the health of individuals, households and communities, the Nigeria PHC system is equally concerned with addressing the overall social and economic development of communities. According to H4, PHC also targets the social determinants of health with a spirit of self-determination and self-reliance.
“The PHC system is a whole-of-society approach that includes health promotion, disease prevention, treatment, rehabilitation and palliative care” (D 4)
Providing effective PHC services requires prompt use of personal health services to provide the best possible health outcome. But without health innovation, it would be nearly impossible to measure up with the growing demands for technology-based health services in urban and rural communities. In addition, the Nigerian PHC system performs poorly due to lack of clarity of roles and responsibilities among the three tiers of government.
“Health facilities (including PHC centres, health professionals, medical equipment) are inadequate in Nigeria—especially in rural areas” (N 1)
Although telehealth has considerably attracted political attention in Nigeria, the amount of attention varies among the states.
“To achieve success in modern-day healthcare management, the Nigerian PHC system should integrate high-tech routine surveillance, medical intelligence and data management systems as the driving force” (D 9)
Policymakers in Nigeria have a challenge to create and sustain an information-rich, patient-focused and technology-reliant health care system that can deliver quality care to every individual and household in all geographical locations. In addition to delivering basic healthcare services, the Nigeria health system has a mandate to maximize developments in health innovation such as medical and epidemiological surveillance to protect the public from health threats (including disaster outbreak, communicable diseases outbreak, and bioterrorism).
“Introducing telehealth in the Nigerian health sector is necessary, but the effort cannot succeed without adequate management joined with strong leadership principles” (HA 10)
Figure 4.9 An Ideal Telehealth Framework
Source: The Author (2021)
Nigeria has a population of more than 2 million people. A large number of the populations live in rural areas where there is limited access to basic health care services and essential social amenities whereas the well-equipped hospitals and scarce medical professionals cluster in urban areas. Therefore, geographical isolation and lack of basic necessities of life have increased the rate of urban migration which, in turn, overburdens healthcare organizations in the cities. This is one of the numerous reasons why telehealth has become the new order in global health systems—thanks to technological advancements.
“Telemedicine provides global health systems with health outcomes that cut down the cost of medicine by almost 90%” (D 4)
Telemedicine refers to the provision of health care services through various telecommunications and multimedia technologies programmed with an interface that allows communication between health providers and care users. Telemedicine involves use of computer technologies (capable of remote sensing and monitoring) and other telemetry devices to collect, store, retrieve and disseminate patient data through different ICT channels.
Governments at the federal, state and local levels have therefore focused on telemedicine for effective delivery of health care to the populace. But this effort has only been partly successful. Medical and clinical healthcare service is still unevenly distributed due to geographical isolation barriers necessitated by the different levels of economic development, business feasibility and telecommunication connectivity across the thirty-six (36) states in Nigeria. Thus, health administrators have been unable to maximize opportunities from internet-based telehealth systems, and consequently, unable to deliver quality and affordable health care to remote rural and poorer areas.
“Growth of the Nigerian healthcare system is hampered by several barriers such as health disparity, geographical distance of facilities, high cost of care, and long patient waiting time” (N 4)
“Technology adoption, more specifically telemedicine has the potential to revolutionize Nigeria’s healthcare system” (D 7)
A conducive health innovation ecosystem in Nigeria will remarkably give remotely placed physicians the opportunity to constantly communicate with patients and health workers in rural areas. Disruptive health innovation will also provide health professionals in urban areas with secure access to remote patient data thereby reducing time, cost and risks.
Some of the advantages of telemedicine include:
- Reduction of patient and family travel outside of the country.
- Improvement in health care coordination and continuity of care[1].
- Reduction in the need for—or frequency of—patient transfers between health care facilities.
According to research respondents (D1, D2, D4, D7, D9), diffusing telemedicine in the Nigeria healthcare system will, in many ways, augment rather than compete with physical hospitals. However, it should be noted that the main purpose of telemedicine is to cater for non-emergency conditions. When health professionals identify patients in need of physical examinations (including cases of medical emergencies), they are obligated to refer such care users to the appropriate clinics/hospitals immediately.
4.2.2 DISRUPTIVE INNOVATION IN THE NIGERIAN HEALTH SECTOR
Telemedicine and disruptive innovation are pivotal in the development of global health systems. Healthcare innovation is also accepted as the key to service transformation in the global health sector—basically because innovation enhances the process of health care delivery, reduces cost of care to an extent, and significantly improves quality of life.
“With telemedicine and disruptive innovation in healthcare, rural dwellers who have issues of transport to healthcare facilities will be able to receive quality care from the comfort of their homes” (D 8)
Findings from this study show that disruptive innovation might offer low-cost health care solutions that are simple to use and easily accessible to low-income earners. Therefore, disruptive innovation in the health sector of a developing country like Nigeria can also make a huge impact on meeting the health needs of a huge number of the population. But the major problem to health innovation in Nigeria is structural in nature.
“Generally, the entire world has gone digital. Everything can be done on a smartphone now. It’s quite inspiring that Nigerians are trying to embrace digital culture…We are not there yet” (N 5)
Healthcare administration at the state level is independently managed with minimal interference from the federal government. For example, Lagos state is Nigeria’s centre of commerce and arguably Africa’s business hub. The overpopulated city has the highest concentration of Small & Medium-scale Enterprises (SMEs) and multinational corporations—as well as healthcare organizations. With regard to the availability of health insurance schemes, Lagos and Anambra have well-coordinated health financing plans whereas other states depend on the out-of-pocket payment model. Thus, the cost, quality and process of delivering health care services are not synchronized, and for this reason, some states have more effective and well-organized primary health care (PHC) delivery systems than others.
“Electronic modes of communication, learning and training are now commonplace in many medical practices” (D 8}
There is need for disruptive innovation in the Nigerian health sector because a large segment of the population falls in the category of low-income earners. Low-cost healthcare solutions facilitated by health innovation and collaboration among the three tiers of government would therefore ease access to quality health care. But it must be noted that although technological advancements in health care delivery can offer huge life-transforming opportunities, the technologies have to be low-cost in order to be feasible and implementable in a developing country like Nigeria.
“Telemedicine is a very effective low-cost technological innovation offering huge benefits to both developed and developing countries” (N 3)
As one of disruptive innovations, telehealth does not only provide health education services at a distance. It offers a collaborative platform for sharing knowledge and expertise as well as enables community participation in health research. Rapid advancement in telecommunications within the African continent has opened up avenues for improving health care delivery to more individuals and households in rural communities—specifically through mobile health (m-Health) apps.
Mobile health (m-Health) is a terminology which refers to the delivery of medical/health care via mobile devices. Although this disruptive health innovation has gained attention for improving access to health care, it is pertinent to note that a large population of Nigerians are uneducated and cannot utilize the opportunity. Moreover, it is quite unlikely that the rapid expansion of virtual health and telemedicine across the world would be maximized health providers in many parts of Nigeria due to fluctuations in telecom network coverage.
“If Nigerians are to subscribe to telemedicine, it is common sense that the health system should have adequate infrastructure such as quality internet connection…For example, when a doctor is conversing with the patient through video app and the image and/or voice keeps buffering, none of them will enjoy such interruptions or appreciate the telemedicine platform” (D 10)
Notwithstanding the potential wave of groundbreaking disruptive innovations in emerging and developing markets, it is a likely future scenario that a larger number of Nigerians will embrace self-service telehealth apps that use artificial intelligence (AI) to deliver care services. Telehealth, as a hybrid model that involves certain levels of human interaction, has gained wide acceptance in Africa. The National Space Research & Development Agency (NASRDA) and Federal Ministry of Health (FMoH), Nigeria first introduced a telemedicine pilot project using two teaching hospitals and six Federal Medical Centres as a case study. Telemedicine therefore provides some sort of backup support for the small number of health professionals catering Nigeria’s fast-growing population.
4.3.3 TELEHEALTH AWARENESS IN NIGERIA
Telemedicine is categorized into two based on the timing of interaction between care users and healthcare providers. In the first category, asynchronous telemedicine refers to health technologies capable of storing and disseminating data/information from healthcare providers to patients anytime. Asynchronous telemedicine does not support real-time communication between care users and healthcare providers as does the synchronous telemedicine, which explores video conferencing capabilities to enable real-time audio-visual communication.
“Nigeria has one of the worst health indicators in the world” (N 6)
Various infectious diseases, infant mortality, maternal mortality, vector-borne diseases, and malnutrition are some of the major public health challenges in Nigeria and most African countries. According to Tulsi Chanrai Foundation (TCF), nearly 60,000 young mothers are dying due to challenges from inaccessible and poor maternal health care services—including other poor development indicators. Despite the prospects of telemedicine, there have been some provider- and user-related challenges limiting its adoption in Nigeria.
Use of telehealth is dependent on several factors such as internet connectivity and availability of electronic gadgets that include smartphones and tablets. These technologies allow care users to have direct access to healthcare professionals and health data.
“Nigerians are increasingly using phones and internet facilities across, even in remote communities. But most individuals cannot afford such facilities. Some of the privileged ones still have limited access to telecom networks and are therefore at a disadvantage to benefit from the ease of access to healthcare that telehealth promises” (D 6)
Mobile health (m-Health) devices such as the Lafiya Telehealth platform have made significant contributions toward solving Africa’s healthcare crisis. The platform provides an interactive high-definition video along with wearable sensors (medical device attachments) for patients and care users in private settings. Telehealth technologies are accessed via smartphones, tablets or computers, too. For example, medical professionals and health providers in Nigeria use the Lafiya Telehealth platform to monitor and transmit real-time patient data to providers. Information disseminated through the platform rages from biochemical assessments to changes in movement and balance.
“It is very expensive to set up an effective telehealth system due to the fact that telehealth is technology-driven. And this makes money a barrier from both providers and patients—especially those living in urban slums and rural communities” (D 4)
“There is no standard cost of care received through telemedicine. But there is a pervasive cultural perception among Nigerians that telehealth is for the wealthy” (N 8)
Research data from the interviewees affirms that m-Health devices are widely accepted among the affluent class, middle-income earners and educated Nigerians because the health innovations are less obtrusive and user-friendly.
Although some m-Health systems allow real-time communication via telephone and videoconferencing, others require use of touch screens to answer questions. As shown in Figure 4.8, telehealth systems are also used to monitor remote physical peripherals (such as blood/urine glucose level, pulse, asthma triggers/symptoms, weight, allergies, medication consumption, and even “intelligent toilets.” Telehealth in Nigeria comprises four different service modalities vis-a-vis: (a) Store-and-Forward (b) Remote Patient Monitoring (c) Live and Interactive Video and (d) Patient Engagement Mobile Apps. BeepTool (the Lafiya Telehealth manufacturer) has deployed the m-Health app to many African countries, including Nigeria, with a vision to creating a more intelligent patient care environment for low-income earners and the underprivileged across Africa—especially in Nigeria where nearly fifty percent (50%) of the entire population has no access to quality medical care. John Enoh (founder and CEO of the Lafiya Telehealth platform) is focused on enhancing PHC delivery to rural areas where there is shortage of doctors. The solar-powered and satellite-enabled device integrates AI systems to extract blood samples and conduct test on the spot.
Generally, telehealth systems (including m-Health apps) are programmed to perform the following functions:
(a) Store-and-forward (asynchronous): This function involves transmission of multimedia-based patient data between and among health providers to enhance clinical evaluation outside of a real-time interaction.
(b) Remote patient monitoring: This function involves dissemination/sharing of a patient’s health/medical information from a community setting to a remote health provider for monitoring and providing related support services.
(c) Live and interactive video (synchronous): This two-way function relies on real-time audio-visual interaction between health providers and care users. Channels of communication include desktop computers, laptops, smart phones, home monitoring gadgets etc.
(d) Patient engagement (user-friendly) mobile apps: This function involves use of wearable sensors as well as different mobile phone apps and other m-Health monitoring/communication devices to provide interactive health education and care support services (i.e. outreach activities).
Table 4.2: Telehealth in Nigeria (Anambra State)
| M-Health Awareness by Geographical Locations | URBAN AREA | 75% |
| RURAL AREA | 25% | |
| Socio-economic Setting of Patients | MIDDLE CLASS | 58.33% |
| LOWER CLASS | 41.67% | |
| Involvement in Telehealth Services | MEDICAL OFFICERS | 91.67% |
| SENIOR REGISTRARS | 8.33% | |
| Comfortable with Trying New Technologies (Patients & Health Workers) | VERY COMFORTABLE | 72.73% |
| SOMEWHAT COMFORTABLE | 27.27% | |
| Most Helpful Specialties | ENDOCRINOLOGY | 83.33% |
| CARDIOLOGY | 66.67% | |
| GASTROENTEROLOGY | 66.67% | |
| PAEDIATRIC INFECTIOUS DISEASES | 66.67% | |
| NEPHROLOGY | 50% | |
| DERMATOLOGY | 41.67% | |
| Prior Experience Using Telehealth | NEVER USED TELEHEALTH SERVICE | 91.67% |
| HAVE USED TELEHEALTH SERVICE | 8.33% | |
| Ability to Use Telehealth Specialty Care | MODERATE DIFFICULTY | 58.33% |
| MINIMAL DIFFICULTY | 25% | |
| GREAT DIFFICULTY | 16.67% | |
| Impact of Health Technology on Clinical Experience | HIGH INCREASE IN WORKLOAD | 8.33% |
| MINIMAL INCREASE IN WORKLOAD | 33.33% | |
| NO EFFECT | 8.35% | |
| MINIMAL REDUCTION IN WORKLOAD | 25% | |
| HIGH REDUCTION IN WORKLOAD | 25% |
Source: The Author (2021)
Telemedicine is widely embraced in countries such as the United Kingdom, Australia, Canada, the United States, and there is a growing interest in Nigeria, where problems of policy planning, corruption, telecom network, transport and access to healthcare facilities limit maximization of telemedicine. Although there are few telemedicine projects in Africa, most of them are only pilot tests or simply small-scale efforts in selected geographical locations. This study was limited by the small sample size of research participants (focus group). And health professionals who participated were concentrated in a few hospitals located within Anambra State, Nigeria.
Overall, healthcare workers representing part of the focus group reported very positive experiences with the telehealth platforms and quality of specialist responses. They also acknowledged the positive impact of innovative health management strategies on the process and quality of health care services. In the education domain, the research respondents agreed that telehealth systems improve the educational value of AI-powered technologies. These findings suggest a great opportunity for capacity-building and support[2] for health providers in Nigeria. Thus, future studies should focus on the impact of electronic consultations on larger populations of health providers and care users in order to better characterize long-term utility of telehealth systems—including how health innovations can be maximized to build capacity.
Nigeria and many emerging/developing countries are struggling with severe constraints to primary and sub-specialty care services. And the huge benefits of telehealth/telemedicine make health innovation a viable solution to the growing challenges facing PHC systems across the world. However, solutions to PHC problems in Nigeria should be multi-factorial because collaboration within health innovation ecosystems is one of the potential strategies to achieving primary care objectives.
4. CONTEXT: AN ENVIRONMENTAL ANALYSIS OF NIGERIA
- An Overview of the Study Setting
Nigeria is an emerging market in the African continent. The country experienced rapid population growth in the last decade, especially in the middle class, and some notable economic growth indices include rapid urbanization, high foreign direct investments (FDIs) as well as a relatively stable political environment. The World Bank described Nigeria as a regional power in Africa, and according to the global financial institution, Nigeria is one of the fast-growing and vibrant economies within the continent.
On this premise, the World Bank forecasts that Nigeria’s promising economy would develop into one of the top 20 global economies by 2050. But despite the favourable economic projection, Nigeria is currently in the middle of transition from very slow economic growth due to some socio-economic, political and institutional constraints. Findings from this research also indicate that ‘Africa’s most populated country’ has about 50% of its population in rural areas. Further, the median age is approximately 20 years, and according to recent demographic trends, Nigeria could become world’s most populous country by 2050 due to its landmark achievements in business, banking, e-commerce, science, technology etc. From the perspectives of health administrators, doctors, nurses and health workers, the Nigerian health sector ranks very low in global health indices.
However, using an economic growth milestone of sustained GDP growth of 4.8% (average) between 2009-2019, Nigeria has a strong potential for higher economic development in the future. But since President Muhammadu Buhari’s administration in 2016, the once-robust economy has experienced trade imbalance due to increasing exchange rate, falling oil prices and policy issues negatively affecting GDP per capita.
“Nigeria could face stronger sustainability challenges—against World Bank forecasts—unless the government institutionalizes major policy reforms in all sectors of the economy, especially the health sector” (HA 4)
Other major challenges to economic growth in Nigeria are systemic corruption, insecurity, and ethnocentrism which have impeded nationwide implementation of development projects. These endemic vices have also hampered efforts to improve basic infrastructure for development that could have favoured the health sector thereby attracting foreign direct investment (FDI).
“I think infrastructure development is a necessity. It provides the backbone for development in areas such as business, agriculture, education, science, technology and more” (D 2)
According to a health worker (part of the survey group) identified as HW5, Nigeria needs infrastructure development to eradicate poverty and equitably provide quality health services to individuals and households across the country.
“Nigeria is rich in human capacity and material resources, but notwithstanding the huge economic potentials, the country depends largely on the oil industry whereas opportunities from the health industry, R&D, agriculture and education, among others are neglected” (HW 9)
Nigeria’s monolithic economy therefore needs diversification considering that the oil sector in 2019 contributed over 80% of total exports but approximately only 10% to GDP growth. Moreover, as an economic and commercial hub in West Africa, Nigeria is recognized as the second-largest African export market.
“Diversification from oil is a necessity” (HW 6)
Although this economic growth objective looks unrealistic at the moment due to productivity issues in the country, provision of adequate financial and technical support for health organizations, entrepreneurs in the health sector, innovators, manufacturers, academicians and health research institutions should be a priority for the government and foreign or local investors. As of 2018, according to NDHS data, the doctor-patient ratio in Nigeria was 1:2500 and recurring economic setbacks have continued to limit citizens’ access to quality health care. Therefore, revitalization of the health sector through increased budgetary allocations and creation of a conducive environment for disruptive innovation will certainly expand economic development options.
- CATCHMENT AREAS FOR EACH PHC SYSTEM
There is a small window of opportunity for the Nigerian PHC system to become leaders within the current model of continuity of care. The PHC system can achieve this status by establishing its role as an innovator in disease prevention, treatment and management. The leadership status will not only ease jobs performed by health professionals but increases the performance-based rating in terms of value created for care users and stakeholders in the health innovation ecosystem.
According to the guidelines for PHC administration in Nigeria, each LGA should have various management committees entrusted with the responsibility of planning, managing, monitoring and evaluating PHC services. The committees have a mandate to ensure that individuals and households in remote villages and urban slums assume responsibility for their own health and that of the community. The individuals and families are therefore expected to develop capacity to make meaningful contributions to community development projects.
Committees at the PHC levels from bottom to the top are as follows:
- Committee Members: Depending on their education level and social influence, this group comprises of community leaders, influential personalities in the area, religious groups, women organizations, as well as non-governmental agencies (NGOs), where present.
- Local Government PHC Management Committee
- PHC Technical Committee
- Ward Development Committee
- Village Development Committee
Due to its proximity to high population segments, the health centre has the highest number of facilities and is purposefully structured to delivery health services to the largest number of care users in many developing countries. PHC systems therefore serve as an interface connecting the health sector and communities. There are three types of health centres in Nigeria. The smallest unit is commonly referred to as “the health post,” which is often established at a location donated by the community and run by a voluntary health worker (VHW).
Type 1 Health Centre (Basic Health Clinic)
The basic health clinic is usually a small health facility with limited resources. It has a quite few numbers of staff, no in-patient facilities, and is run by a community health extension worker.
“The basic health clinic provides additional educative and preventive health services” (HW 1)
“Our facility is very small. We need more space to accommodate the influx of residents seeking health services” (HW 3)
Workers in this category are trained to treat simple ailments and short illnesses on out-patient basis. More serious cases are referred to Primary Health Centres or Comprehensive Health Centres.
Type 2 Health Centre (Primary Health Centre)
In comparison to the basic health clinic, the PHC centres have more workers and facilities–about ten or more in-patient beds mostly used for maternity cases. Extra beds may be available for temporary admission when there are acute cases or other health emergencies. The PHC centres are administered by a community health officer or a qualified and practically experienced nurse capable of initiating disease control measures, as well as providing health education and other basic health services.
“Nigerian PHC centres provide services ranging from initial management of pregnancy complications to the diagnosis and treatment of common ailments…Unfortunately, not all PHC centres are well-equipped with both human and material resources needed for efficient handling of such services” (HW 9)
Type 3 Health Centre (Comprehensive Health Centre)
In comparison to other health centre units, the comprehensive health centre is largest with about 30 hospital beds for maternity (10), paediatric (10) and about 10 extra beds for male and female adults who might need in-patient health services. This category of PHC centres is usually manned by a doctor. Services include training of village health workers, disease control and field activities, as well as sensitization and preventive health services.
“Our facility is in dire need of more toilets to cope with the increasing number of clients visiting every day” (N 4)
“I’m impressed with the quality of services being provided” (N 7)
4.4.3 STEPS IN IMPLEMENTING PHC
The notable steps in implementing PHC services in Nigeria are as follows:
(a) Baseline Survey: This refers to office and field activities conducted to identify major administrative and healthcare problems of a particular community or cluster of communities within a given geographical location. It is also known as community diagnosis.
(b) Situation Analysis: This activity aims at determining the ability of health services to properly address health problems. Emphasis is also on how to maximize existing health resources and available basic infrastructure (such as electricity, good roads, water supply, ICT and other health innovations) to provide basic care.
“Our health facility runs with 20 staff, and we have critical infrastructure that enables us to provide 24-hour care to about 25,000 people in the catchment area” (D 8)
(c) Zoning: This involves activities aimed at dividing LGAs into wards in order to equitably assign funds and well-trained health teams to each zone or ward.
“The quality of health services in our facility has significantly improved in recent months following increased access to more funds. Our health centre has not recorded a single maternal or infant death in the last 5 months” (N 6)
(d) Registration: Health workers take count of individuals and households within communities to enable them to create home-based records for every family. It is important to note that registration of households facilitates referral and follow-up on cases.
More than 800 women visited our facility in Onitsha for antenatal care (ANC) services in October 2021 alone. We record between 150 to 200 deliveries monthly” (N 1)
(e) Upgrading: This activity involves renovating existing health facilities and providing adequate drugs, medical equipment and other infrastructure necessary to perform comprehensive PHC functions.
“It is very sad that our PHC has no ambulance for emergencies. We also need a labour room and incubator to properly take care of women and children considering the number of deliveries being recorded” (N 1).
(f) Monitoring: and Evaluation: The focus is on consistent examination of health-related activities at the home, clinic, community and local government levels in order to ascertain performance (results). For example, monitoring and evaluation helps PHC systems to assess family planning and usage acceptance, immunization coverage, use of Oral Rehydration Therapy (ORT), and growth chart for children below 5 years old.
“Children under five years in Anambra State are accessing free medical services, with about 100 children accessing nutrition services weekly” (HA 3}
Some international donor agencies and global health organizations are providing technical support for health development projects implemented in Anambra State and across Nigeria. For example, “Save the Children International” is solely funded by Bill and Melinda Gates Foundation to support efforts from the Nigerian government to strengthen its health system and increase access to healthcare.
- PHC FINANCING IN NIGERIA
PHC systems cannot be effective and efficient if not adequately funded. Considering the issues of corruption and fund misappropriation in Nigeria, the PHC system has remained relatively dysfunctional despite the large portion of finance allocated to the health care sector annually. Health financing in this context refers to the existing payment model that determines how care users pay for health services received from healthcare organizations/facilities.
“There is a positive relationship between health and economic growth” (HW 2)
“Ill-health is a major cause of poverty in Nigeria” (D 5)
Research respondents agreed that establishing a strong healthcare infrastructure is foundational to economic development. According to HW8, Nigerian policymakers need to earmark sufficient amounts of money to improve capacity of the PHC system and empower health professionals to achieve desired levels of health, and ultimately, economic growth.
“Source of funding for PHC systems is categorized into three—public, quasi-public and private sources” (HA 6)
PHC financing approach varies among countries. Depending on the chosen method of raising fund for the PHC system in any particular country, the relative weight might fall more or totally on the government, citizens or both. Health care in Nigeria is funded through donor funding, out-of-pocket payments, tax revenues, exemptions/deferrals, health insurance (social and community-based insurance), and healthcare subsidies.
“Over the years, our health system has been rated poorly in terms of healthcare funding” (D 7)
“The burden of health financing in Nigeria is very high on households” (HA 2)
There are many objectives for healthcare funding. Among the major objectives are:
(a) The need for health care systems to have adequate fund for infrastructure/facilities development.
(b) To ensure there are quality care options available for individuals and households—depending on their economic status.
(c) To help care users make the right choice care when purchasing cost-effective health solutions/interventions.
(d) Assist health providers with financial incentives needed to ensure that all individuals have access to effective health services.
(e) For equitable and efficient distribution of health resources, as well as to ensure that essential healthcare goods and services are adequately utilized according to needs.
Generally, a huge chunk of money expended by Nigerian health sector comes from the three tiers of government—federal, state, and LGAs. Additional financial support comes from care users, public fund generated from various forms of taxation, public/private health insurance institutions, private-sector organizations, donors, hedge funds etc. To achieve national health objectives such as the UN’s Health for All initiative, every country has to choose one or more methods of healthcare financing in addition to establishing a robust organizational delivery structure for health services. Nigeria has explored several options such as the National Health Bill, the National Health policy, Health Financing policy, and the National Strategic Health Development Plan (widely known as the National Health Plan since the National Assembly passed the bill in March 2014).
“In line with the UN-led global health objectives, Nigeria’s national health policy framework aims at strengthening the national health system such that it can provide effective efficient, quality, accessible and affordable health services capable of improving the overall health status of Nigerians” (HA 5)
In addition, the National Primary Health Care Development Agency (NPHCDA) launched in 1992 is responsible for providing appropriate policy direction, mobilizing resource for the PHC, providing technical support, and overseeing supervision of the implementation process at all levels of government. But despite these efforts, Nigeria’s health sector has performed below expectations partly because health expenditure is relatively low, even when compared with other African countries. The Nigerian government should therefore do more in promoting industrial development and human capital development to provide relevant manpower needed to enhance local capabilities in the production of medical equipment, spare parts, and drugs to improve supplies and maintain capabilities. This will drastically reduce cost and improve efficiency in the Nigerian health system.
“A policy action that can transform the Nigerian health system is banning political office holders and the wealthy class from financing overseas medical treatment with public fund” (HA 4)
It must be noted, too, that Nigerians need a change of attitude and behaviour towards health workers in PHC centres notwithstanding the performance lapses experienced in the past. The government should also increase budgetary allocation to the health sector, reduce financing burden on care users, invest in workers’ training, and implement programs that would motivate health workers to provide high-quality care more efficiently.
4.4.4 RELATIONSHIP BETWEEN THE 3 TIERS OF GOVERNMENT IN PHC
Nigeria’s three-tiered government—Federal, State and Local—share responsibilities for providing basic health services to individuals and households in both rural and urban areas. The three tiers if government also implement and monitor health development programs/policies in Nigeria. However, the apex government (federal) has the obligation to provide policy guidance, planning and technical assistance.
“It is the responsibility of the federal government to establish health management information systems” (HA 8)
“The federal government has a mandate to provide technologies used in disease surveillance, drug regulation, vaccine management and training of health professionals” (HA 2)
Notwithstanding the enormity of administrative duties outlined by research respondents (HA8 and HA2), the apex authority shares responsibility for managing health facilities and programs with the State Ministries of Health (SMoH), State Hospital Management Boards, and LGAs.
The LGAs also add efficiency in the care delivery process by training midwives and Community Health Extension Workers (CHEWs). Remarkably, the LGAs provide technical assistance to the PHC system.
“Despite persistent efforts from the federal, state and local governments, the inadequacy of public health system remains an embarrassing stain on ‘the giant of Africa’” (HW 9)
“The failure of Nigerian government to resuscitate its health care sector has given increasing prominence to the private health sector, donor agencies, and international development partners” (HA 4)
In response to the pitiable weaknesses of Nigeria’s PHC structure, the author recognizes the fact that LGAs have limited sources of revenue and cannot address PHC issues alone. For this reason, the apex government created the National Primary Health Care Development Agency (NPHCDA) to provide and sustain federal assistance—financial and technical—to the LGAs. The NPHCDA is responsible for developing, monitoring, evaluating and revising PHC policies. The health development agency also collaborates with both state and local government actors to implement PHC policies, often with support from local and international partners.
Revenue collection and administration is highly centralized in Nigeria. According to the revenue sharing formula, the apex government (FG) collects most of the national revenues—mainly from oil and gas—on behalf of the three-tiered government. Federal revenues are pooled into either (a) an excess crude account (b) a federation account (c) a value added tax (VAT) pool (d) or a ‘Treasury Single Account’ (TSA). The pooled revenues are later divided among federal, state and local governments. Using the existing revenue sharing formula, 20.6% and 35% of fund in the federation account and VAT pool respectively are allocated to the LGAs. Though the LGAs also have their own internal sources of revenues, the amount makes up very small proportion of fund channelled to the federal and state governments.
“Although states in Nigeria allocate reasonable funds to their health sector, there is evidence of erratic release of the earmarked budgets” (HA 10)
Figure 4.10: Percentage of Budgetary Allocations for PHC Activities in Nigeria
Source: Bill & Melinda Gates Foundation (2016)
4.4.5 THE LEGALITY OF IMMUNIZATION IN NIGERIA
The population in Nigeria is unevenly distributed. In 2006 for example, the average population density was approximated at 250 people per square kilometres/ Anambra, Abia, Imo, Lagos and Akwa Ibom were the most densely populated states. According to NPI data, most of the densely populated states are located in the south-east region. Notably, Kano has an average density of 445 persons per square kilometre, a statistical figure which makes it the most densely populated state in the northern part Nigeria.
Nigeria is rated among the ten (10) countries with incompletely immunized children. Mortality rate of children under the age of 5 remains high in sub-Saharan Africa (including Nigeria) despite global decline.
“More than one-quarter of these deaths are preventable through interventions such as immunization” (D 8)
Research data shows there are various individual-, community- and state-level factors responsible for the slow implementation/growth of immunization programmes. According to the 2018 NHDS survey, over three-quarter of children below 5 (about 76%) are not completely immunized. Out of this number, nearly 85% have mothers aged between 15 and 25 years. Also, 95% of those young mothers are illiterates who do not understand the benefits of immunization—a reason why their children are not fully immunized. The disparity in mothers’ age, economic status and literacy levels indicates that most Nigerian children are dying from vaccine-preventable diseases due to ignorance, poverty, cultural beliefs and religious orientations. The sad reality is quite disheartening because Nigeria’s Expanded Programme on Immunization (EPI) was launched in 1979 to achieve “Health for All” in line with the Global Immunization Vision and Strategy outlined and sponsored by the World Health Organization (WHO) and United Nations Children’s Education Fund (UNICEF).
“For children whose mothers attended antenatal clinic, there is a significant reduction in chances of not being fully immunized” (N 2)
“The EPI was launched with a vision to improve the Nigerian health system and save lives of children below the age of 5 by eradicating six killer diseases—namely polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever” (D 8)
The EPI project is expected to strengthen immunization activities, expand coverage areas, accelerate disease control and introduce new vaccines, as well as relevant health technologies. Evidence-based studies show that vaccination and immunization make up two of the most important public health interventions, and both constitute a cost-effective strategy explored by global health systems to lower morbidity and mortality rates caused by infectious diseases (Braun et al., 2013; Adeloye et al., 2017).
“Immunization and vaccination save more than 2 million deaths each year worldwide” (N 3)
But research data supports claims among health professionals that vaccine-preventable diseases remain the most common cause of childhood mortality in Nigeria with an estimated three million deaths per year globally.
- Individual-level factors
Under individual-level factors mitigating against the success of immunization programmes in Nigeria, research data shows that mother’s age, wealth index, marital status, education, occupation, sex of child, and birth order are some of the determinant factors. Other variables include the mother’s exposure to social media and antenatal care.
“The size of child at birth and place of delivery are also considerable factors at the individual level” (N 4)
According to a combined survey from WHO and UNICEF, the National Programme on Immunization (NPI) is performing below expectations due to many factors including ethnicity and religious beliefs. Education was categorized as no education, primary and secondary or higher whereas wealth index was measured with ownership of household items (e.g. radio, television, car) and dwelling features such as reliable water source, toilet facilities, and type of roofing or floor. Marital status was grouped into married and never married. Likewise, occupation was grouped into working and not working. Size of child at birth was categorized into three; large, average and small. Exposure to mass media refers to the frequency of access to newspaper, radio and television. Those who had access to any of the three outlets (for any number of times in a week) were defined as exposed and others were considered never exposed. Based on principal components analysis, these measurement criteria have been used by the World Bank to categorize households into poverty levels. For easy interpretation and clarity, the author rearranged criteria and separated findings into three—poor, middle and affluent. Importantly, data on antenatal care was sieved according to women who visited the clinic at least once during pregnancy and those who never attended. Lastly, place of delivery was dichotomized into health facility (that is, for women who gave birth in public/private hospitals) and home for those who delivered in other places.
- Community-level factors
Factors analysed at the community level include the following: place of residence, type of building, ease of accessing health facilities, ethnicity responsiveness, diversity inclusion index, and the socio-economic status of community. Individuals and household under are thus separated based on whether they are unemployed, uneducated, or poor Accordingly, place of residence was categorized as urban and rural whereas ease of access to health facilities was weighed in terms of distance and availability of affordable means of transportation.
“Community-level performance of the Nigerian health system is best understood in terms of having a problem before getting to health facilities and leaving with solution” (HW 9)
Although research data points towards religion and culture as a major setback to the immunization agenda, respondents (HW2, HW4, HW7, HA1 and HA9) agreed that the legal side of immunization has been ignored by many scholars.
“Nigeria as a multi-ethnic nation is divided along ethnic lines, and religious bias has been a sensitive issue in almost every sphere of our national life—including the academic domain” (HA 9)
- State-level factors
At state level, the main criteria for measuring factors affecting immunization goals in Nigeria is the socioeconomic characteristics of individuals/households residing in the same state. Other characteristics identified include occupation, wealth and education. In line with the method of principal components, scores were dichotomized as follows: least disadvantaged, most disadvantaged, and advantaged.
According to the WHO and UNICEF data, most children from poor families (approximately 95%) and nearly 90% of children aged below 5 whose mothers never had access to mass media did not receive full immunization. Others whose mothers did not register for antenatal clinic (92%) and mothers who delivered somewhere else—outside the health facility (89%)—did not receive full immunization/vaccines. Overall, children born in remote villages (85%) and those whose mothers had problems accessing health facilities (72%) did not receive full immunization. Therefore 9 out of every 10 children living in poor (economically disadvantaged) communities/states were not fully immunized.
Figure 4.11: WHO & UNICEF estimates of immunization coverage in Nigeria
BCG
Source: WHO/UNICEF (2019)
DTP1
Source: WHO/UNICEF (2019)
DTP3
Source: WHO/UNICEF (2019)
Pol3
Source: WHO/UNICEF (2019)
MCV1
Source: WHO/UNICEF (2019)
HepB3
Source: WHO/UNICEF (2019)
PcV3
Source: WHO/UNICEF (2019)
Hib3
Source: WHO/UNICEF (2019)
According to the National Programme on Immunization (NPI), Nigeria conducts routine immunization of children with the following vaccines.
• BCG (Bacilli Calmette Guerin)—at birth or as soon as possible after birth
• OPV (Oral Polio Vaccine)—at birth and at 6, 10, and 14 weeks of age
• DPT (Diphtheria, pertussis, tetanus)—at 6, 10, and 14 weeks of age
• Hepatitis B—at birth, 6 and 14 weeks
• Measles—at 9 months of age
• Yellow Fever—at 9 months of age
• Vitamin A—at 9 months and 15 months of age
- Immunization and the Law
Data-based findings from this study show that individual characteristics as well as community and state factors are major determinants of the variations in incomplete immunization status of Nigerian children. Further, interview results corroborate claims that the poorer a household becomes, the higher the chances of children from such families being incompletely immunized. This assertion therefore implies that poverty (lack of money) is a trigger for poor health-seeking behaviour, which results in double loss (deprivations) for the children. First, the disadvantaged children are denied of nutritious food that could naturally fortify their immune system levels. Secondly, the children are deprived of disease prevention and control benefits of full immunization.
“It is not against the law to be immunized in Nigeria. But neither does the law make it mandatory for anyone to be immunized or vaccinated” (D 7)
From the legal angle, individuals and households have a right to accept or reject immunization programmes and their health benefits. A major factor contributing to the overall low immunization uptake in Nigeria is systemic failure due to negligence of developmental policies in the areas of education, technology, health innovation, economic growth, standard of living, quality of life, national unity etc. Misconception about the relevance of immunization is evident in the fact that most Nigerians, especially the poorly educated households, have an opinion that once any child receives polio vaccine, he or she is totally protected against all childhood diseases. In Muslim-majority areas of the country, many families also reject routine immunization exercises out fear that vaccines sponsored by developed countries (specifically the United States) are for depopulation purposes. In some cases, people’s hostile attitude to PHC workers is a matter of trust in their knowledge about healthcare and the vaccines. Although the political angle—lack of political will to achieve uniform health outcomes with a nationwide immunization policy and too much centralization of the immunization programme—worsens Nigeria’s healthcare problem, immunization is voluntary, not mandatory for everyone no matter their education, religion, gender, location or socio-economic status.
“Health providers in Nigeria should collaborate with community leaders to organize awareness programmes on regular basis at the community level. The overall goals of immunization cannot be achieved without proper enlightenment among individuals and households” (N 5)
“At the moment, mandatory vaccinations in Nigeria are illegal. I am not aware of any law that mandates Nigerians to take vaccines” (D 8)
“Mandatory vaccination cannot be enforced with oral proclamation. It must be based on public health and safety laws otherwise any action from state functionaries—based on oral proclamation—should be considered as violations of citizens’ right to privacy, freedom, personal life, and religious life” (D 6)
4.5.1 CHALLENGES OF HEALTH INNOVATION IN NIGERIA
All over the African continent, telehealth is undergoing serious transformation and radically changing health care services in both rural and urban areas. In 2015, Africa’s telemedicine market experienced substantial growth valued at US$18 billion per year, and financial projection for fiscal year 2021 showed earnings above US$40 billion.
“Disruptive innovation is therefore changing the healthcare space in Africa” (N 4)
And research data shows telehealth has been a lifesaver for urban and rural dwellers in Nigeria despite the slow adoption process. Interestingly, some systemic challenges limiting growth of the promising industry, including the COVID-19 pandemic and its heavy burden on global healthcare organizations, have popularized telehealth. But there are still some high-impact setbacks that need strategic solutions as telemedicine gains wide acceptance in Nigeria.
Figure 4.12: The Telehealth Concept
Source: The Author (2021)
The following are some of the challenges to health innovation in Nigeria:
- Education: A major barrier to the successful utilization of health innovation (e.g. telemedicine) and proven health management ideas in Nigeria is illiteracy. The level of literacy among patients is a determinant factor on their acceptance or rejection of health innovation. Even in states like Anambra and Lagos, where there are all-inclusive health insurance schemes implemented to reduce cost of care and increase access to quality care, a large number of the uneducated population are yet to maximize the opportunities due to ignorance. The illiteracy level in Nigeria is still above 60% of the entire population and this is a setback to the efficiency and effectiveness of health management strategies.
- Experience of health providers: Some of the health providers in Nigeria (including a large number of trained medical practitioners) are not tech-savvy enough to effectively utilize health innovations. Health providers in the digital age require certain level of experience in multimedia tools to enable them to engage in result-oriented and patient-centred telehealth services. There is need for periodic and continual training of health/medical practitioners on the innovative health management practices and efficient use of technology in all states/localities across Nigeria.
- Poor telecom network services: Telehealth providers rely on strong internet networks for optimal performance. Thus, the relevance of internet providers and/or telecom giants (such as MTN, Globacom, 9Mobile, Airtel etc) to the improvement of health care delivery in Nigeria cannot be overemphasized. But the lingering issue of network failures has negatively affected use of health innovations in the country. For example, challenges from non-delivery of SMS and repeated dropped calls have adversely affected businesses and relationships, and in some circumstances, resulted in loss of human lives. Additionally, the frustrating experience from fluctuating telephone calls and charges incurred from undelivered (or returned SMS) are some of the problems Nigeria Communication Commission (NCC) is trying to solve with guidelines and sanctions.
- Financial support: Stakeholders in the Nigerian health innovation ecosystem (such as federal health ministries, state health commissions, PHC administrators, private/public healthcare organizations, innovators, tech start-ups etc) lack adequate financial resources from the apex government—and are therefore unable to maximize benefits of innovation in healthcare. Telehealth is a capital-intensive industry that requires full financial/technical support from donor agencies, foreign investors and government agencies. Although the COVID-19 pandemic has stirred interest in telemedicine, various tiers of government buying into telehealth, authorizing favourable policies and increasing spending on health innovations can only guarantee sustainability and continuity by forging a strong partnership between the private and public sectors (Garagiola et al., 2020).
- Unstable power supply: Most health technologies are satellite-, solar- or electricity-powered 24/7. And as telemedicine gains wide acceptance among policymakers and care users in different geographical locations, m-Health platforms should be appropriately designed, implemented, supported and sustained by all stakeholders—especially the government, health providers and patients. In Nigeria, health practitioners are concerned about the future of telemedicine because of the rising cost of fuel/diesel and intermittent power supply. These challenges constantly hamper the functional levels of health consultants and telemedicine systems thereby increasing cost of health services—and the chain effect is a reduction in the percentage of accessibility to quality health care in Nigeria.
4.5.2 KEY FINDINGS FROM SURVEY RESPONDENTS
According to the open-ended interview questions and responses from survey participants, here is a summary of some important factors affecting the telehealth business model, health innovation, and healthcare management in Nigeria.
- Device Sharing and Community Cooperation
About 60% of the research participants agreed that community cooperation is an important factor in the implementation of innovative health management strategies. The Device Sharing and Community Cooperation Model focuses on low- and middle-income owners in rural and semi-urban areas. Individuals and households form cooperatives in their locations in order to ease the financial stress of acquiring telehealth systems. To achieve this objective, members of community cooperatives usually contribute an agreed monthly amount that entitle each individual and household to share a set of mobile/telehealth systems with others.
- Personalized Health Training
About 40% of the research participants agreed that personalised health coaching services enhance diffusion of health technologies (such as mobile/telehealth systems). Also, regular training of health providers on the importance and use of health innovations is as important as the professional health coaching service offered to care users for the purpose of creating awareness needed to diffuse health innovations.
“Health coaching is equally useful to individuals/households in rural and urban areas” (HW 4)
But rural and semi-urban locations in Nigeria have more uneducated population, thus, they are most likely to experience difficulties in accessing m-Health or telemedicine services. The personalized health training/coaching model was propounded by Dr Rushika Fernandopulle (a Boston-based founder of Iora Health company), and it involves deployment of professional health trainers to remote communities and low-income areas where they offer primary care services that patients in such locations would normally not receive from doctors (e.g. medical check-ups, continuous one-on-one communication, follow-up reminders etc). The main value proposition is based on (i) proximity to the care users (ii) continued assistance on the use of telehealth systems (m-Health and RPM devices) and (iii) the empathic care attention offered by health providers.
- Crowdsourcing, Digital Funding and Mobile Money Solutions
About 50% of research respondents acknowledged the importance of maximizing huge opportunities from ICT-related financial innovations (such as mobile payment devices) that are changing the global healthcare space. Considering that a large number of the patient population who are mainly low-income earners make periodic out-of-pocket payments for medical services, and are excluded from the banking/financing sector, many survey respondents suggest that mobile and/or electronic payment (e-payment) platforms are crucial for the successful diffusion of health innovations. But despite the huge potentials of crowdsourcing, digital funding and mobile payments, there is need for cashiers working in departments offering subscription-based health services to utilize user-friendly and simple-to-use digital payment platforms.
“Electronic payment systems (e.g. e-wallets, bitcoins and cryptocurrencies) and other highly sociable peer-to-peer value exchanges are becoming popular among Nigerians—including the low-income and unbanked population” (HA 7)
Digital currencies and e-payments are also gaining wide acceptance in emerging and developing markets across the world. However, disruptive innovation (specifically telehealth and telemedicine) should be profit-oriented and self-sustainable, especially at the initial stage of diffusing health innovations. The government therefore needs collaboration with private- and public-sector stakeholders (such as venture capitalists, microfinance banks, fintech organizations, crowdfunding platforms, community cooperatives, philanthropic organizations etc) to improve value proposition in the fast-growing and digitalized healthcare industry. Digital technology has huge potentials to significantly reduce transaction cost for care users and increase efficiency of service delivery process.
- Disruptive Health Insurance Models
About 40% of the research participants agreed that health organizations can maximize RPM devices and disruptive m-Health models to make health insurance more effective and appealing. Although telehealth transformation has greatly enhanced medical care services in Nigeria, there is need for more efforts toward developing the insurance industry which currently lacks the confidence of many Nigerians.
“It is worth noting that a larger segment of Nigerians in both rural and urban areas do not have any insurance coverage due to ignorance and the high cost of available insurance packages” (HW 3)
Survey correspondents therefore agreed that the government and private/public-sector organizations should partner to develop a simple, efficient and low-cost health insurance plan—and ensure that every Nigerian citizen benefits from the healthcare program.
A relevant and viable example of socially inclusive and sustainable telehealth business model utilizing the m-Health platform is Jack Ma’s ANT Group Company (a large global financial organization second only to VISA). The China-based conglomerate—one of the world’s largest mobiles (digital) payment platform Alipay serving over 1.3 billion users, with more than 80 million merchants and total payment volume (TPV) reaching CN¥118 trillion as at June 2020—is part of Jack Ma’s Alibaba Group Holding Ltd. The Group’s ‘Crowdfunding for Healthcare’ model inaugurated in 2018 is based on a healthcare-coverage product (Xiang Hu Bao) established to provide health insurance and quality medical care to about 70 million people. The health insurance model requires no upfront payment to enrol beneficiaries. Additionally, beneficiaries pay a specified amount of money every month and the fund are used to pay treatment costs for members stricken by diseases (such as cancer) or involved in accidents. Although there is no one-size-fits-all health insurance program, Nigeria should implement similar conventional, online-based projects with country-specific telehealth planning that allows beneficiaries to upload medical documents and pay monthly bills with a simple touch/click on m-Health apps via a tablet or smartphone devices. Yearly ANT financials show double-digit transformation and a significant change in China’s previously underdeveloped insurance market. Therefore, the Nigerian government can expect revolution in its insurance industry by implementing disruptive health insurance models.
- Reliability of Power/Battery Sources
All survey participants agree that Nigeria’s power and gas sector needs total overhauling to reduce cost of energy (fossil fuels) and improve electricity supply to rural and urban areas. Steady and low-cost power supply to healthcare organizations is a necessity for non-stop delivery of health care services across the country. In addition to eliminating risks to patients on life-support devices, constant power supply to urban and remote locations can prolong the battery life of mobile healthcare devices used by care users. Thus, reliability of power supply and telehealth device batteries reduces challenges for patients using m-Health applications 9Cho et al., 2009).
Considering that m-Health platforms run on battery, solar power or generators that consume fossil fuels, the cost and availability of these power sources are a determinant factor on the ease-of-access level. Therefore, emerging and developing markets need disruptive innovation and strategic healthcare management solutions to maximize digital health options. Nigeria does not have steady and reliable sources of power, thus, most health providers and care users in the country are facing challenges of keeping battery levels of telemedicine devices at optimal level. This setback to data collection, storage and dissemination affects telehealth diffusion, and its negative impact on the quality of life is quite enormous. About 70% of research respondents agree that Nigeria has not keyed into advancements in telehealth systems. They also suggested that Nigeria has abundant alternative power/energy supply options that can be explored to enjoy benefits of health innovation opportunities in m-Health and telemedicine. Many of the survey participants acknowledged the relevance of solar power and renewable energy sources as possible solutions to this sustainability and cost problem of the m-Health/Telehealth business model.
4.5.3 ICT USE IN PHC
The Nigeria government is making efforts to explore development opportunities offered by advancement in Information and Communications Technology (ICT). According to HW6, ICT has the potentials of improving the quality of health services, as well as to empowering patients and enhancing the overall performance health systems. ICT is also a necessary infrastructure for achieving equality in the distribution of health care. But technology diffusion in healthcare management requires a multi-stakeholder effort.
“In order to achieve health objectives through technology-driven strategies, Nigeria needs to create an enabling innovative environment, which it currently lacks” (HA 2)
“Efforts to leverage ICT in healthcare delivery should focus on scaling up of specific technological approaches, strengthening the enabling environment, and implementing supportive policies and guidelines” (D 6)
Nigeria needs to lay foundational infrastructure capable of supporting nationally scaled ICT for implementing healthcare policies and improving maternal and child health outcomes. One of the government-led initiatives for these purposes is the National Health Management Information System (NHMIS). Research data shows the national unique identification card system project handled by the National Identity Management Commission (NIMC) is a giant leap in the right direction. But there are vast opportunities in the ICT sector to be leveraged by policymakers and political office holders. Unfortunately, the present landscape of ICT for health efforts in Nigeria is fragmented. Moreover, the ICT sector lacks coordination, and this challenge makes it nearly impossible to leverage prior investments and realize the full potential of internet-based health technologies.
“The current state of ICT in Nigeria is a wake-up call for stakeholders, policymakers, implementers to prioritize interventions that are capable of boosting maternal and child health efforts” (D 1)
Data from the United Nations (UN) and Federal Ministry of Health (FMoH), Nigeria, highlights that maternal and child mortality rates of children under 5 years old remain one of the worst in global ratings. Maternal mortality rate (560/100,000) and under-five mortality (124/1,000) rates per live births in Nigeria are higher than average in West Africa and significantly higher than the global average of 210/100,000 and 48/1,000 live births. The data points to the fact that Nigeria’s PHC system, has a weak structure, with remarkably low coverage of key interventions due to poor use of ICT. There is no specific strategy on developing relevant ICT. Further, efforts in promoting standards for technology diffusion as well as the interoperability of such technologies lack momentum due to systemic challenges—such as ineffective funding mechanisms.
“A large number of health workers are also resistant to change management due to their literacy level, level of awareness, and technology acceptance index” (H W8)
“I must admit that some health workers have attitude problems…I believe they will change someday with the right training—but it’s going to be a slow process. They cannot overnight” (HA 5)
The benefits of training of health workers in the use of ICT for Health cannot be overemphasized. Creating a conducive environment for health innovation in Nigeria starts with human capacity development. Health professions, as enablers and implementers, have a crucial role to play in scaling up and sustaining use of ICT technologies in healthcare.
“Technology adoption is a priority target for health systems that are willing to achieve their health development objectives” (N 4)
“Mobile and electronic health (m- and eHealth) has the capacity to reduce costs of care, increase product and service penetration, as well as improve access to critical care or information anywhere in the world—especially when the right health technology infrastructure has been put in place” (N 9)
“Mobile health comes with an awesome experience. It’s very helpful and easier than carrying papers. It is handy. It also prevents health workers from exposing themselves with books” (HW 1)
“Mobile health is magical. Even when I lost or forgot my book, I can always access my data and write reports anytime because my phone is never far from me” (N 8)
“Smartphones make our work easier because even at night we can just pick it up and peek at the data” (N 1)
“With a smartphone in my hand, I don’t need to drive all the way to my office, write stuff on paper or access office desktop computer. I don’t also need physical interaction with patients in remote villages” (D 8)
“I also use smartphone to monitor and see what my staff are doing at any time” (HA 6)
In Nigeria and different parts of the world, m-Health and eHealth technologies have helped health systems to diagnose and monitor diseases, create and maintain patient registries, manage payments doe care services, provide point-of-care support to health workers, enlighten the public, reduce/eliminate stock-outs, and monitor/evaluate performance of health workers. Although the FMOH has identified the application of ICTs as a key strategy to strengthening Nigeria’s health system—on paper, the author argues that prioritizing strategic application of ICT to support health delivery is an uphill task that should not be taken for granted.
“Policymakers and political office holders should focus on empowering patients, health workers, and the health system” (HA 7)
“Health administrators have a responsibility to build a platform for shared accountability, inclusion, and equity to ensure that care users and health providers can access responsive and safe links to mobile financial services that allow conditional cash transfers” (HA 4)
- Mobile Midwife Nigeria
With a subscriber base of roughly 23 million in 2014, Nigeria became one of the largest and fastest growing telecommunications markets in the world. Internet availability has surged in recent years, and usage is constantly rising; However, internet penetration and broadband subscriptions has been at relatively low levels.
4.13: Mobile Health and eHealth Technologies/Tools Used in Nigeria
Source: WHO (2019)
To improve maternal and child mortality rates, the Mobile Midwife Nigeria, a subscription-based service, aims at providing maternal, newborn and child health (MNCH) information with a sustainable business model. The initiative delivers targeted, time-specific, evidence-based audio messages containing useful health-related information to pregnant women and new parents. Interestingly the MNCH app is programmed for accessibility in multiple languages. This implies that care users can read information on the platform in their chosen local language (Blaya et al., 2010; Bakibinga et al., 2017).
Mobile Midwife Nigeria leverages the Grameen Foundation’s MOTECH “Mobile Midwife” model in Ghana. The m-Health app has, however, been remodelled to provide health services suitable for the Nigerian context. It explores the willingness of clients to use premium services that can be accessed through interactive voice response (IVR) in three languages—English, Hausa, and Pidgin.
Figure 4.14: Functions of m-Health and eHealth Applications Used in Nigeria
Source: WHO (2019)
4.6 CHALLENGES TO BUILDING A SUSTAINABLE HEALTHCARE SYSTEM IN NIGERIA
Health innovations (such as m-Health tools and related systems) are useful for enhancing communication between healthcare professionals. The fact that communication is crucial in management, including health care systems, health service providers need regular exchange of information/ideas to support activities such staff training, patient referrals, and remote diagnoses—especially in cases where there are no physician and expert medical advice is needed.
4.15 The Nigerian Health System Architecture at the PHC Level
Source: Alliance for Health Systems & Policy Research (2020)
Consultation between healthcare professionals therefore involves a complex network of exchange through ICT. Some of the communication activities may require data transfer, real-time location identification, document sharing, text messaging, telephone calls, video conferencing etc—which fall under mobile telemedicine. Two main challenges for technology diffusion in the Nigerian healthcare system are low technology literacy among care users and health workers, and internet/connectivity issues. Other constraints to the growth of Nigeria’s healthcare system include the following:
Inadequate funding: The federal, state and local governments often earmark several millions of naira to the health sector during yearly budgetary allocations. The problem is: Nigeria’s PHC system gets minimal attention in development policies even though it caters for a larger size of the population—with minimal support from the private sector. On the other hand, expenditure from both federal and state governments prioritizes teaching hospitals, federal medical centres and state-owned hospitals.
“At the lowest tier of government, the LGA, financial allocations usually don’t go beyond the payment of salaries, and issues relating to accountability and transparency have been a major threat to the smooth functioning the national public finance system” (HA 1)
“Many rooms and offices used by clinicians in public health facilities have no power sockets and electricity supply is intermittent” (HW 2)
“Due to poor funding, many PHC facilities are not fenced. The few available medical equipment is open to theft…Systems such as desktops and television had to be placed in secure areas of the facilities which were different from the waiting room and clinician rooms” (N 5)
“The federal government should provide extra financial motivation for users and implementers of health technology, as well as adopt performance-based remuneration for creative thinkers among the workforce” (HA 2)
Moreover, any discrepancy in the estimated annual budget to the health sector results in higher out-of-pocket costs for care users. To ensure sustainability of the Nigerian health system, policymakers and health administrators need to involve more private-sector investors in order to establish a cost-effective financing system. In addition to reducing the cost of care, especially at the community level, Evidence-based studies suggest proper training and adequate motivation for healthcare personnel as keys to sustaining preventive and curative services (McCollum et al., 2016; Alloh & Regmi., 2017; Beckman & Gupta., 2018).
“The big data holds key to health innovation and expenditure in this area should be a priority” (D 8)
It is a common fact that care users generate huge amounts of information utilized by healthcare organizations and health providers, including governments and medical research institutions. From X-rays to blood test results, it is arguably true that the possibility of replacing paper with computerized summaries—thanks to ICT—makes healthcare management easier and more efficient. Also, current trends in global healthcare support forecast from health research organizations that the volume and complexity of patient data will increase dramatically in the future because of advancement in health innovation (such AI, genomics, and personalized medicine among others) – especially as health providers collect broad data to gain more insights.
“As sweet as the benefits of health innovation sounds to me, no government and health system can taste it without big spending” (N 2)
Fake drugs: Nigeria has lost many lives to counterfeit or adulterated drugs. The World Health Organization (WHO) in 2006 reported that over 70% of drugs sold in most pharmacies and chemist shops across Nigeria are substandard. The National Agency for Food and Drug Administration and Control (NAFDAC) also buttressed the fact and reality of fake drugs in Nigeria with its pronouncement that an estimated 41% counterfeits are in circulation.
“The economic impact of fake drugs is quite enormous, and this trend requires attention from policymakers” (HA 6)
“The implications of counterfeit drugs are not just a central challenge to the integrity of public health systems around the globe; it is a threat to human existence” (D 4)
The World Health Organization (WHO) clearly defines counterfeit drugs as “medicines that have been deliberately or fraudulently mislabelled with respect to identity of the manufacturer. The fake drugs are also categorized as health products manufactured for sale with incorrect ingredients and/or misleading information on the amounts of active ingredients. Such products may have been manufactured under circumstances that lack quality control.
“In Nigeria, there are many cases of expired drugs being relabelled for sale and some that are released into the market without complete manufacturing information” (D 2)
Most fake drugs are unregistered with the National Agency for Food and Drug Administration and Control (NAFDAC). In recent years, the government has struggled to reduce the production and trafficking of counterfeit drugs. But no remarkable success can be achieved without adequate infrastructure or political will to properly enforce legislation and standards. Unfortunately, little effort has been made to curb to menace of fake drugs since 1990, when a total of 109 children allegedly died after the administration of fake paracetamol. More 14 children were reported to have died after taking chloroquine phosphate injections, and in 1995, 88,000 units of Pasteur Merieux and SmithKline’s Beechammeningitis vaccines manufactured in Nigeria and supplied to Niger during an epidemic resulted in about 2,500 deaths after vaccination.
“In 2004, three Nigerian hospitals reported different cases of adverse reactions from use of contaminated infusions produced by four Nigerian pharmaceutical companies” (D 5)
In November 2008, a total of thirty-four (34) Nigerian children aged below 5 lost their lives and over fifty (50) were hospitalised with severe kidney damage. Investigations revealed they had consumed a fake drug namely “My Pikin” (meaning “my child” in local pidgin). The deadly concoction was sold as a teething mixture containing paracetamol. Such cases are too numerous.
“Drug counterfeiting is not just prevalent in developing countries. It is a global problem” (HA 3).
High out-of-pocket costs: Cash payment accruing from health services rendered to individuals and households are commonly referred to as ‘out-of-pocket expenditures.’ In Nigeria, care users pay for transportation to health facilities, and are further burdened with extra costs of consultation, laboratory tests, and treatments. The total charges often skyrocket for in-patient cases. Research respondents attribute the exploitative healthcare situation to Nigeria’s relatively dysfunctional PHC facilities, lack of essential drugs, inadequate medical equipment, and poorly motivated health personnel who often blame their incompetence on a ‘helpless’ situation caused by uneven allocation of resources.
“Nigeria is a low- and middle-income country with high disease burdens. This challenge has severe consequence on the health expenditure of most households” (N 8).
“Any extra expenses on healthcare services incurred by a household directly threatens the financial capacity of the household to cater for family members providing, or in other words, maintain subsistence” (N 3)
Findings from this study show that, for reasons relating to congestion in secondary and tertiary health institutions (including the highest of the three types of health centres), a large number of care users in Nigeria have no better option than to patronise private-sector care providers, who charge outrageous fees for consultation, diagnosis and treatments.
Poor health infrastructure: Availability of basic infrastructure and medical tools at different levels of health facilities is a necessity for the achievement of WHO’s “Health for All” agenda. But the reality of Nigeria’s unstable economy impedes realization of the global health objective. For example, many health centres in rural communities across Nigeria are bereft of essential drugs, steady electricity supply, basic health infrastructure (e.g. lab equipment, refrigerators, functional means of transportation, digital technologies etc), and modern buildings. Findings from this study indicate that most PHC centres lack pipe-borne water, toilets, and incinerators. Further, some PHC centres are located more than 5 or 15 kilometres away from the communities, thereby making healthcare inaccessible or problematic during emergency situations. The reality is: location of PHC structures and medical professionals is often based on political expediency rather than the perceived need of care recipients.
4.16 Disparity of Human Resource for Health (HRM)
Source: Bill & Melinda Gates (2020)
Apathy towards healthcare development: Most care users in Nigeria, especially in rural communities, are unaware of their responsibility and rights to participate in the formulation and implementation of health policies. It has also been observed that most consumers of healthcare services are ignorant of the available care services—even the free benefits such as health counselling and family planning. Therefore, apathy among care users has negatively affected policy research, as well as population health management outcomes. This highlights the importance of sensitizing various communities to create more awareness and encourage community mobilization and participation in issues concerning health of individuals and households.
On the other hand, as shown in Figure 4.15, poor attraction and retention of health workers is partly a reason for the inequitable distribution of community health workforce at the PHC level. This scenario is responsible for the inequitable distribution of health resources across Nigeria.
Poor remuneration: Poor compensations of health workers—particularly doctors and nurses—has led to the brain drain syndrome (a situation where trained and qualified physicians leave the country in droves for better job opportunities abroad). Moreover, poor performance of health workers has been attributed to inadequate compensation and consequent loss of motivation. Several health personnel engage in strenuous, time-consuming jobs, and in most cases, unsafe work conditions at different facilities—and remuneration is not commensurate with labour exerted.
In the last two decades, several thousands of Nigerian doctors and nurses have migrated to the United Kingdom and other developed countries in search of better work conditions and salaries. The Nigerian government must therefore consider this trend as a threat to the sustainability of healthcare system.
g) Bribery and corruption: Bribery and corruption have adversely affected growth of the Nigerian health sector. Citing documented evidence on the embezzlement of healthcare fund, inflation of budget, fraudulent claims on health insurance fund, and inflated purchase of medical equipment and other infrastructures, Aregheshola (2019) noted that endemic graft in Nigeria also involves bribery of health professionals, policy regulators, and public office holders.
“Corruption is one of the greatest obstacles stopping Nigeria from maximizing its enormous potentials to achieve development objectives” (HA 9)
“Corruption is an anti-social attitude that allows people to gain undue advantages contrary to legal and moral norms…It has eaten deep into the fabric of governance. Corruption has also become a constant phenomenon seen everywhere around us—from government officials to our protectors, police and the army, even the citizens” (HW 4)
Between 1960 and 2012, Nigeria lost an estimated $400 billion to corruption. In the health sector, some corrupt employees are regularly feeding fat on stolen medical supplies while others are inflating cost of care for personal gains. Regular absence from work and use of informal payment methods have also lowered the performance level of Nigerian PHC health system. Research data shows the problem is widespread and systemic in nature. For this reason, bribery and corrupt activities involving government functionaries are nearly impossible to eradicate. For example, Umeokafor (2017) found an outrageous hike of unit price of drugs purchased by Nigeria’s Ministry of Health (MoH) as part of nationwide efforts improve care for HIV/AIDS sufferers. Additionally, a former minister of health, Adenike Grange, and a former federal legislator, Iyabo Obasanjo, were convicted as accomplices to an organized criminal gang who allegedly misappropriated a whopping sum of ₦300 million. The indicted persons were later acquitted without charges despite the implications of their actions on the poor masses and supposed beneficiaries of the ₦300 million. These examples emphasize the need for accountability in the Nigerian health system.
CONCLUSION
It is not the sole responsibility of health administrators and governments to revamp and sustain performance of health systems. Nigeria’s health innovation ecosystem needs collaborative efforts. Accordingly, the crucial roles of academic institutions, innovators, entrepreneurs, private sector companies, civil society, NGOs, researchers, clinicians and individuals in both rural and urban centres cannot be overemphasized—specifically due to their strong relevance in the ongoing evidence-based health system planning. To galvanize Nigerians into action within the overburdened health care system, the government and policymakers should create a platform that would enable domestication of all landmark research findings in the health sector.
Another aspect of the partnership that could strengthen the Nigerian health system is recognition and the provision of full financial/technical support to health agencies and health development programs like the National Health Insurance Scheme (NIHS); Nigerian Institute of Medical Research (NIMR); National Primary Healthcare Development Agency (NPHCDA); Nigeria Centre for Disease Control (NCDC); and National Institute for Pharmaceutical and Development (NIPRID). Further, health systems research and capacity building are equally useful both at the macro-level of policy and planning as well as at the programme and operational levels. Nigeria has abundant potentials from her large population size. The cultural diversity and availability of unique material and non-material resources also indicate that what Nigeria lacks is the optimal ability to plan and/or design a strategic framework to harness and maximize these potentials in all sectors—specifically the health sector—in order the achieve national development goals. A conducive environment for disruptive innovations basically includes: (a) adequate funding of health organizations, research agencies and innovators (b) steady supply of power/energy across rural and urban areas (c) proper training for health workers and care users on the relevance and use of telemedicine (d) strict-but-gradual application diffusion of health technology through strategic care management practices etc (Christensen et al., 2015).
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[1] To achieve continuity of care, PHC systems are expected to plan for health professionals (that is, care teams — including community health workers) to monitor patients outside of the primary care visit. Continued care activities also involve following up on hospitalizations, medication adherence, and scheduling wellness checks.
[2] Capacity-building and support occurs when stakeholders in the health innovation ecosystem chose to invest in training and resources for staff members rather than space or equipment, in order to provide better care and services.
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