The sector-based and national levels in this analysis concentrate of some external sources of challenges for conceptualizing and operationalizing digital health technologies in PHC delivery. This section of the report contains discussions that help understanding of findings from research participants at these two levels. Accordingly, the author explores themes identified from the interview data to structure the discussion in order to ascertain if findings corroborate claims existing in related academic research studies.

5.2.1 Partnership with Private- and Public-sector Institutions

Focus group discussions on digital health business models and relevant models for utilizing Private-Public Partnerships (PPP) to scale-up DH investments highlighted the huge benefits of increasing investments (in the areas of operational capital, HR, and infrastructure) to advance digital health services in Nigeria. WHO global survey conducted in different African countries to collect data on eHealth and financial investments for digital health showed that external donors provide about 72 percent of the total funding for DH technologies/services (Lah et al., 2020). This situation raises concern on the issue of sustainability.

On this backdrop, the participants analysed various business models designed to engage business partners and foster steady inflow of funds for implementing digital health strategies. An effective framework for achieving these purposes is signing of a legally-binding agreement through Memorandum of Understanding (MoU) with stakeholders in the DH ecosystem. The critical role of key ICT and non-ICT partners in providing adequate funding for digital health implementation in Nigeria was also emphasized. But governments’ commitment to building result-oriented partnerships with private- and public-sector institutions is central to DH advancement. Collaborations with national economic experts widen opportunities for joint negotiations on the cost of acquiring and deploying DH technologies for PHC services and more. Research correspondents agreed that partnership with private/public institutions significantly increases the governments’ bargaining power and reduces cost of digital health solutions in Nigeria. These benefits highlight the need for multi-sectorial approach to digital health interventions. According to USAID (2020), key players in Nigeria’s DH ecosystem (mainly WHO, FMoH, European Union and others) should be engaged through appropriate agreements to consistently provide financial and technical support to improve local capacities for sustainable DH services—and good health outcomes. Research respondents however stressed that the Nigerian government should take complete ownership and financial control of DH initiatives/programs to reduce or eliminate chances of project failures. Additionally, performance of PPP and DH technologies (that is, ROI for digital health investments) should be appraised through the responsiveness of health systems thinking, the number of lives saved, total comorbidities averted, and overall impact on population health outcomes—not only from financial standpoints (Olu et al., 2016).

5.2.2 Implementing Digital Health

Focus group discussions on this module were categorized into three sub-sessions vis-a-vis: (a) Implementing DH (b) Governance and Strategy, and (c) Stakeholders. In the first session, research participants emphasized on the need to conduct proper assessment of system readiness before implementing digital health initiatives. It is also important to find out modalities for developing business requirements and identifying pain-points. Some of the analysed tools for assessing digital health readiness are:

• Health Information System Interoperability Maturity Toolkit
• The DHA, and
• Global Digital Health Index.

In the discussion about the basic principles for developing digital health globally and in Nigeria, the participants agreed that health systems and DH facilitators should:

(a) Focus on designing user-centred systems

(b) Ensure that everyone understands the existing DH ecosystem in Nigeria

(c) Always design for scale

(d) Concentrate on building for sustainability

(e) Be data-driven

(f) Integrate open standards, open data, open source and open innovation

(g) Reuse and improve existing digital health systems

(h) Address privacy and security issues

(i) Use a collaborative and concerted approach.

DH implementation at the national level indicates both strengths and weaknesses. For example, the key strengths include: (i) strong commitment from the federal government (ii) substantial access to infrastructure, and (iii) robust consultations with stakeholders. Some of the challenges are: (i) inadequate regulation of activities among competitors in the DH ecosystem (ii) poor financing (iii) donor chaos (iv) implementation of multiple strategies and (v) slow-paced transfer of skills from partners to local personnel coordinating DH deployment/services.

During discussions on governance and strategy, the research participants agreed that information systems are a combination of people and technology. Thus, IT-related projects in healthcare delivery should always involve a multidisciplinary team of professionals who have the capacity to manage every aspect of development, deployment, operations, and governance for favourable outcomes (Labrique et al., 2018). An analysis of the DH strategy and governance in Kenya and Uganda showed that the health policy in Kenya (projected between 2014-2030) is based on a participatory approach. Likewise, the Ugandan model depends on TWGs that formulate, implement and monitor performance of national health informatics policies—with assistance from health informatics professionals, DH groups, and communities of practice.

Another area of discussion was stakeholder engagement. During the sessions, participants agreed that digital health projects are not monolithic. Therefore, there is need for the Nigerian health sector to collaborate and coordinate DH activities with key ICT and non-ICT organizations as well as other relevant stakeholders. The participants emphasized on the importance of good corporate governance and inter-sectoral efforts in scaling-up DH interventions. But there are questions on the sustainability of DH projects in Nigeria (Etiaba et al., 2020). How effective is the partnership between private/public sector institutions and the government? Are their robust frameworks for engaging stakeholders in the areas of funding and sustainability? Is the quality of DH service up to standard? Are some responsive governance mechanisms guiding protocols for implementing or deploying DH programs? To successfully diffuse innovative healthcare management strategies, including DH technologies in the delivery of PHC in Nigeria, the process has to be encompassing enough to accommodate various interdependent health systems. Thus, it is imperative for stakeholders in the DH ecosystem—especially digital health facilitators—to understand existing systems, as well as the cultural, structural and political economy of beneficiaries (that is, communities) prior to designing contextual DH solutions (Onwujekwe et al., 2019; Ebenson & Allsop., 2020).

5.2.3 Digital Health Architecture Design

The DH architectural design comprises of digital health business model, information channels and technical architecture. Using a blueprint from the Canadian Electronic Health Records (EHR) to explain enterprise architecture, the research participants identified these as basic requirements for DH architectural designs: (a) business (b) data (c) application, and (d) technology infrastructure. As shown in Figure 2, most skills and ideas can be transferred from other sectors to the health sector. But it is quite difficult to transfer business ideas from other sectors to the health sector. The success rate is very minimal, thus, there is need to adopt a holistic approach to this research on “Innovative Health Management Strategies for Enhancing PHC Delivery in Nigeria” (Ritchie & Spencer., 2002).

Figure 5.2: National digital health architecture, information infrastructure and system model

Source: FMoH (2019)

The enterprise architecture in Figure 2 illustrates architecture definition, enterprise vision and the related enterprise-level programs. Major components in the architecture level are (a) architecture definition (b) segment vision, and (c) segment-level programs or initiatives. The focus group used a new-user demo in the form of a pictogram to analyse the linkage between digital health architecture, information systems, and ICT infrastructure. Basically, the digital health infostructure was defined as various purpose-specific digital software applications connected to an internet technology platform to facilitate easy flow of information (including exchange of patients’ data) in a secure and safe manner. DH infostructure is widely used by patients, health providers, health administrators, healthcare organizations, governments etc (Mitchell & Kan., 2019). The digital health infostructure supports a wide range of public health and care services by collecting, storing and retrieving data from different sources that are easily shared to facilitate coordination of health systems’ planning and decision-making at all levels. The flow of information therefore enables interoperability of DH applications as well as consolidates information from all sources in a shared health record to improve health outcomes (Graef & Valcke., 2014).

Business architecture is focused on translating strategy into digitally enabled activities that enhance chances of achieving business objectives. Some basic inputs to business architecture are: (a) clinical guidelines (b) digital health strategy (c) digital health implementation manual, and (d) digital health platform manual. A manual in this context refers to a handbook (Klein et al., 1995).

Data architecture refers to the framework showing the logical and physical data assets of organizations—including their data management resources (Barros & Julio., 2011). In essence, data architecture explains how an organization generates, collects and utilize information across multiple applications on digital health platforms (DHPs). During focus group discussions, participants agreed that DHPs have an impact on the application architecture, and in turn, applications running in a platform-based system need DHP common services. In other words, DHPs are linked with digital health applications implemented by health providers and utilized by patients in different geographical locations. DH applications therefore facilitate interoperability; this enables apps to disseminate useful information as well as enhance clinical and administrative workflow even though they are not directly integrated with each other (Fahmy et al., 2021).

Further discussions among research participants highlighted the need for Nigeria to introduce a use-case while operationalizing digital health architecture designs. The purpose is to reduce systemic challenges related to investments in interoperability and the sustainability of DHP interventions. The use-case strategy will also improve awareness across all 36 states in the country, especially those with innovative leadership and strong commitment to achieving UHC and SDGs. Participants emphasized on collaborations between the government and private-sector organizations as a crucial factor because the health system needs an effective framework to consistently engage stakeholders—especially for funding and sustainability. However, a major digital health consideration should be how to measure the scope of DH for state governments in order to ascertain the extent of infostructure architecture design based on available resources and duration or timeline for implementing DH projects/solutions (Zrenner et al., 2019).

5.2.4 Interoperability and Governance Model

Participants agreed that development in ICT and digital health systems has constantly improved global. However, these hi-tech infosystems integrated in healthcare delivery have often resulted pushed several systems to virtual silos. In other words, lack of interoperability forestalls optimal utilization of some health innovations over time, thereby rendering them obsolete and irrelevant. The challenge of funding and sustainability therefore underscores the need to establish TWGs with the training and expertise to make critical decisions about interoperability standards. The roles of TWGs in the DH ecosystem are indispensable. For example, they set goals and standards for DH services and interoperability. They also develop standard terminologies, set modalities for data exchange, as well as build frameworks for documenting standards. In Nigeria, health administrators use the OpenHIE to establish and promote the interoperability of global health infosystems (Gregor et al., 2007; Goffey et al., 2014).

Fundamentally, OpenHIE provides guide on how to utilize free, standard-based methodologies and reference technologies, thereby empowering developers to easily link systems, so both DH facilitators, health providers and care users can gain from their interoperability. In the context of this academic inquiry, interoperability is best understood as the capacity of systems, devices and apps to exchange information with each other using a familiar language. This functionality enables DH applications to engage in multifaceted communication activities using standards such as DICOM, WISN, LOINC, SNOMED, HL7, ICD-10 etc (Genovese et al., 2022).

The interoperability and governance model also requires a standardized vocabulary, which is considered a primary enabler facilitator of semantic interoperability that allows data to retain its meaning or value regardless of the collector’s identity, time of access, and when it was collated—including the kind of system used to capture it (Goffey et al., 2014). Integrating a standardized vocabulary is necessary to ensure data standards are reliable. Data standards in this context help to eliminate inconsistency in definitions, naming conventions, and element values. Members of the focus group emphasized on the complexity of information ecosystem and the challenges of deploying health information applications. However, they agreed that DH architecture can transform PHC delivery in Nigeria if human and material capacity is developed and utilized to enhance interoperability. For a better understanding of a use-case solution to complex DH systems, the participants analysed Eritrea’s National Health Management Information System (NHMIS) and how the framework helped to operationalize interoperability. Findings showed that the case-study model involved a decentralized and highly integrated infosystem with the capacity to gather data on vaccine stocks and enable the Eritrean Ministry of Health (MoH) to identify health facilities with stock-out challenges in a timely manner (Gregor et al., 2007; Zrenner et al., 2019).

Nigeria needs a DH architecture that should not only be affordable and accessible, but interoperable and easily implemented across the 36 states. Notwithstanding, some of the diverse challenges to existing health innovation programs include:

• Limited local capacity.
• Lack of an effective governance structure to facilitate development, endorsement, and publication of national data standards.
• Limited knowledge of country-specific requirements for Low- and Middle-Income Countries (LMICs), and lack of well-guided directions on how to implement DH interventions in accordance with international data standards for LMICs.
• Poor knowledge of best practices, including proven strategies for leveraging terminology services to share information/data in ways that drive context-specific health system solutions.

The research participants reached a consensus on the need to establish and regulate OpenHIE standards in Nigeria. Further, health administrators and key stakeholders in the Nigerian DH ecosystem should collaborate towards the standardization and harmonization of data dictionary in order to benefit from the global DH architecture. Importantly, the state governments have a responsibility to comply with international governance policies in directing interoperability and DH architecture. To ease adoption and implementation challenges, it is also necessary for DH facilitators and health administrators in Nigeria to use the systems approach in all interoperability policy dialogues thereby fostering inter-sectoral collaboration between International Standard Organizations and the Ministry of Health (MoH).