Post-COVID-19 Nigeria needs a robust Health Management Information System to handle high disease burden

Nigeria is among a few countries that conceptualised a health management information system (HMIS) in the early 90s but implementation has been a challenge till date. Besides COVID-19, the country has a huge burden of communicable and non-communicable diseases which require a robust HMIS that enable informed decision-making to ensure effective service delivery.

Till September 15, Nigeria has recorded 56,478 cases while 1,088 people have died due to the COVID-19 pandemic. This amounts to just 273 cases and 5.1 deaths per million population. For a nation of 200 million people with a weak health system, these statistics paint an impressive picture but they might not show the whole picture.

Another particularly important thing to note is that the country is suffering from another health crisis that hardly came in the limelight. As per the World Health Organisation (WHO), Nigeria reported 115,950 cancer cases and 70,328 deaths in 2018. Furthermore, research suggests that cancer deaths in Nigeria and other developing countries may rise by 70% until 2030, the year fixed by the UN to achieve universal health coverage and several other health targets.

At a time when the country has deployed its maximum resources in combating COVID-19, concerns have arisen about the handling of other deadly diseases like cancer, Lassa Fever, Yellow Fever, Monkey Pox, Meningitis, and Diabetes. In a recent report published in the Journal of American Medical Association (JAMA), the researchers have expressed serious concerns on comorbidity in Nigeria as it was discovered that out of 100 patients who recovered from COVID-19, 78 had evidence of previous heart inflammation, and 60 showed ongoing inflammation at the time of observation. The COVID-19 comorbidities were also related to obesity among the recovered patients.

This article attempts to provide a comprehensive picture of the healthcare system, HMIS, and COVID-19 response of Nigeria.

COVID-19 Response

Nigeria’s health sector is weak due to years of poor funding which has resulted in poor services and a huge amount of money being annually spent on medical tourism by the elite. But with international borders closed in the face of this pandemic, it was a moment of truth for Nigeria’s health system.

The East African country reported its first COVID-19 case on February 27. In the initial weeks, scattered cases were reported but the country recorded the first big jump of 168 cases on March 20. Though agencies were already into service to respond to the outbreak, stricter social distancing, contact tracing, testing, and lockdown measures were implemented after a sudden rise in the cases.

The COVID-19 cases in Nigeria peaked on June 15 with 904 new cases while the maximum number of COVID-19 related deaths were reported on June 18 when 45 people died in the country. Thereafter, cases and deaths both declined gradually. As of September 15, Nigeria had reported 56,478 cases and 1,088 deaths due to COVID which is about 273 cases per million population and 5.1 deaths per million population. 

About 42,922 COVID-19 patients were treated in health facilities and discharged. The Nigeria Center for Disease Control (NCDC) led the country’s COVID-19 response and has published guidelines for police, security agencies, and health professionals. Besides, it has also prepared a comprehensive set of guidelines for upcoming elections in the country.

However, the low tally of cases and deaths in Nigeria might not show the real picture. As per the COVID-19 Situation Report of Nigeria on September 8, the country had conducted 430,712 tests and new tests stood at 3,909, which is among the lowest in the world based on tests per million population. Boss Mustapha, who chairs the government’s task force on the disease, has recently said that he and other officials were “disturbed by the low level of sample collection” as people are not subjecting themselves to testing despite increased testing capacity.

But that is not the only reason for the low number of tests as Nigeria has also struggled to build up capacity in the initial months. While testing has been free in state-owned laboratories, these facilities were few and limited largely to major cities. Even today, the NCDC dashboard on COVID-19 lists less than 100 sample collection sites in the whole of Nigeria. The limited number of testing facilities resulted in a long waiting period to get tested and for results. In several media reports, Nigerians have detailed the struggles and long waiting times they faced to get tested which has negatively impacted the confidence of the people.

A patient-centric, integrated health information system can help in quickly identifying communication gaps and support mass dissemination of information on preventive measures as well as important alerts through EHRs and/or automated messages, chatbots, and dashboards. Such a system can also help in identifying and monitor the at-risk populations to reduce deaths due to the outbreak.

Despite the low testing rates, Nigeria’s preparations and its effective handling of the Ebola Viral Disease outbreak in 2015 and subsequent ‘health emergency alerts’ on Ebola in 2019 supposedly helped the country in responding to COVID-19. Those experiences also helped the health ecosystem in the country to interact with African CDC, WHO, and other international bodies in coordinating with COVID-19 Response and cushion its economic and humanitarian shocks. The economic initiatives of the government such as Economic Stimulus Bill 2020, Cash Transfers to vulnerable people, stimulus package by the Central Bank, and food assistance schemes also helped the country to tide over the economic crisis and its subsequent impact on the health sector caused by the pandemic. 

Healthcare System in Nigeria

Nigeria has 40,533 healthcare facilities out of which 85.4% are for primary healthcare, 14.2% for secondary, and 0.4% are tertiary healthcare facilities or national hospitals. The Federal Ministry of Health is the topmost healthcare coordinating authority in the country which is also responsible for medical education and managing/regulating 163 national hospitals that constitute tertiary healthcare facilities (0.4%) in the country. Besides, the national government through National Primary Healthcare Development Agency (NPHDA) also coordinates with the primary healthcare facilities which are run by local governments (774) while secondary healthcare facilities are regulated by the 36 state governments in their respective areas.

Though the public sector plays a dominant role in the healthcare system of Nigeria, the private sector also owns 26.4% healthcare facilities. Besides, Nigeria also has a Public-Private Partnership (PPP) policy document which includes national standards and guidelines for the conduct of PPP healthcare programs and projects in the country.

Despite having several health policies, health strategies, and programs, Nigeria is still suffering from a huge disease load and poor services which results in its citizens spending as much as USD 1 billion on medical tourism. The National Health Policy (NHP2016) acknowledges that Nigeria is saddled with an unbearable burden of Communicable and Non-Communicable Diseases (NCDs). This is coupled with issues such as low levels of health literacy, poor sanitation, and inadequate attention to key social determinants of health. Besides, due to globalization and other factors, the country is experiencing drastic changes in consumption patterns of alcohol, food, and tobacco. Disease patterns are changing with more people affected by cancers, diabetes, hypertension, mental health conditions, road traffic accidents, domestic violence, unsafe sex, and insufficient physical activity. Other threats to the Nigerian populace include food insecurity, floods, Lassa fever, Ebola, Cholera, and Avian Influenza. The Country Cooperation Strategy (CCS) 2014-19 with WHO also mentions a heavy load of these diseases. The Vision 2020 of Nigeria which aimed at making the country among the top 20 economies also has three health-related objectives - guaranteeing the well-being and productivity of the people, optimizing the key sources of economic growth, and fostering sustainable social and economic development. The following are the key initiatives of Nigeria’s healthcare system:

National Health Policy (NHP) 2016

The National Health Policy 2016 is a comprehensive long-term health policy aimed at helping Nigeria achieve Sustainable Development Goals (SDGs) set by the United Nations for the year 2030. The policy has been planned to be implemented in three phases through National Strategic Health Development Plans (NSHDP) i.e., NSHDP 2016-20, 2021-25, and 2026-30.

Besides the experiences of the previous health policies, the NHP 2016 was enriched by National Health Act 2014 and Primary Healthcare Under One Roof (PHCUOR), SDGs, National Strategic Health Development Plan 2010-15, globalization, climate change, and other contemporary issues related to healthcare.

The policy is meant to provide strategic directions to all the possible components of healthcare ecosystems including financing, technology, health information management, pharmaceuticals, supply chains, non-government organizations, diseases (diabetes, cardiovascular diseases, cancer, Sickle Cell Disorder or SCDs, and injuries), mental health, oral health, eye health, nutrition, food safety, water and sanitation; environment, chemical products, and medical waste, gender issues, medical tourism, health system, health service delivery, and health facilities, etc. Besides, it recommends the federal government to allocate 15% of the total budget for healthcare as per the commitments of the Abuja Declaration 2001.

National Health Promotion Policy 2019

The National Health Promotion Policy 2019 came in succession to the National Health Promotion Policy 2006, Strategic Framework for its Implementation (2007), and National Health Policy 2016; and is meant to strengthen the health promotion capacity and national health system in Nigeria. The main guiding principles and values of the policy are – accountability and responsibility, equality, equity, and social inclusion, ethics, professionalism, efficiency, regulation and legislation, community ownership, and multi-dimensional collaboration.

Against the backdrop of each broad objective and action points stipulated in the revised NHPP 2019, the strategic plan will determine how to apply relevant and applicable strategies; define demonstrable performance results and provide a monitoring and evaluation framework for the next five years. It will also facilitate efficiency and harmonization among the frontline, strategic, allied, and collaborative stakeholders as well as the beneficiary Nigerian people.

NHPP aims to bring various federal ministries, state governments, local bodies, research institutions, non-government organizations, professional bodies, private sector, laboratories, and media, etc. to work in cohesion to achieve the goal of universal health coverage and health targets. This also presents an implementation framework to achieve the healthcare objectives through resource pooling and working in cohesion.

National Health Promotion Forum (NHPF)

Constituted under NHP 2016, NHPF is a multi-sectoral technical advisory forum focused on strengthening collaboration on the implementation of the National Health Promotion Policy throughout the country. It also has parallel setups in the provinces, local governments, and wards which are respectively State Health Promotion Forum, LGA Health Promotion Forum, and Ward Health Promotion Committee.

The NHPF’s membership is based on institutional representation by designated focal persons which includes Ministries Departments and Agencies (MDA's), Development and Implementing Partners, Non-Governmental Organizations, Professional Associations, Regulatory bodies, Academic Research and Training Institutions, Media and Telecommunication Organizations, Private Sector, Traditional Institutions, Faith-Based Organizations and Civil Society Organizations working on health-related activities.

National Social Protection Policy

Enacted in 2017, the National Social Protection Policy is aimed to establish a gender-sensitive and age-appropriate framework to ensure a minimum social floor for all Nigerian citizens for a life of dignity. The policy measures include education and health services, social welfare and child protection, social housing, livelihood enhancement and employment, social assistance, traditional family and community support, legislation and regulation, targeting and registration, graduation and exit, coordination and integration, monitoring, and evaluation.

Health Management Information System (HMIS) in Nigeria

As per the Country Cooperation Strategy (CCS) of Nigeria 2014-19, a Health Management Information System (HMIS) was first incepted in Nigeria as early as 1992. Thereafter, it went through improvements in 2006 as per the requirements of the International Health Regulation (IHR) 2005. The CCS states that although the rates of reporting improved in 2012 for some states, systematic routine analysis of submitted health management information data and feedback to health institutions were lacking.

The National HMIS policy provides clear coordination structures with assigned roles and responsibilities at the federal and sub-national levels but the coordinating forum, that is, the Health Data Consultative Committee, is largely nonfunctional in many states. The NHP 2016, has recommended the following provisions for a robust HMIS in the country:

• Strengthen mechanisms to ensure accuracy and timeliness of health data reporting from public and private health facilities
• Build capacity on routine data collection, analysis, and interpretation for decision making,
• Strengthen and integrate existing surveillance systems and registries into the overall health management information system.
• Strengthen data infrastructure, including information communication technology (ICT) at all levels
• Strengthen mechanisms in confidentiality and security in lines with the provisions of the National Health Act 2014
• Establish a national health observatory for appropriate knowledge management

Besides, NHPP 2019 also emphasizes on timely data collection, processing, and their use in decision-making to improve healthcare services for all Nigerians. The policy emphasis on setting up a Routine Reporting System (RRS) to facilitate the timely collection of authentic health data. It also emphasizes on developing health promotion indicators, quarterly monitoring of sectoral health promotion activities from the community to local government to state to the national level, and a comprehensive national survey of health promotion programs conducted every five years using the standardized indicators. The country is presently implementing two key programs in the field of Health ICT (Information and Communication Technology). They are:

• Digital Health Inventory

The Digital Health Inventory is being implemented through the ‘Nigeria Digital Health Landscape (DHL): An Inventory of Digital Health Solutions 2017'. This is a five-year plan and has eight prioritized health areas. They are – maternal, neonatal and child health; essential commodities; nutrition, HIV/AIDS: PMTCT, logistics and supply chain, immunization, tuberculosis, and malaria. It aims to establish an e-health governance structure to aid collaboration and coordination. The National e-Health Project Management Office oversees its day-to-day project management and coordination. As per the assessment in 2017, about 43% of people in Nigeria were using computers, 39.8% smartphones or tablets, 7.98% feature phones, and 9.24% basic phones. The inventory had reportedly captured 150 unique e-health services and applications in 2017. This shows a huge scope of an electronic health information system powered by real-time and geospatial health data in the country. 

• National Health ICT Strategic Framework 2015-2020

This framework was launched to enable and deliver universal health coverage in Nigeria by the year 2020. It incorporates the effort and inputs of over 150 public and private health and technology sector stakeholders and is a three-part document that articulates the collective vision and necessary actions of stakeholders involved in the health system in Nigeria. The framework provides guidelines for budgeting, legal provisions, monitoring, and evaluation (M&E), interoperability, capacity building, and action plan to implement the ICT Health project.

An emergency meeting of the National Council of Health in February 2018 on Lassa Fever, Yellow Fever, Monkey Pox, Meningitis, and other disease outbreaks, had highlighted a couple of deficiencies in the HMIS of Nigeria. Some of the major identified areas of concern were low preparedness (surveillance, laboratory, testing, and collaboration with stakeholders), poor communication between states and federal agencies, poor public education, weak political will, and lack of proper coordination.

Despite several well-drafted policies, HMIS in the country remains weak evident by the fact that the weekly epidemiological reports are not available on the portal of the ministry. There are links to three reports of the portal, the latest epidemiological report is related to October 2, 2015. But, reports are not available against those links. The Nigeria Health ICT Reports are also not available after 2015.

Another problem with Nigeria’s HMIS is low funding that is also the case with the country’s health system. In 2019, Nigeria’s Health Minister Dr. Osagie Ehanire had said that funding for HMIS and related monitoring and evaluation activities has “so far been largely donor-dependent” while also saying that this is not desirable. He also acknowledged that poor data quality and limited use of information remain a major concern.

The Way Ahead

COVID-19 has added to the existing burden of diseases in Nigeria. The top ten fatal diseases in the country are – Lower Respiratory Infection, Neonatal Disorders, HIV/AIDS, Malaria, Diarrheal Diseases, Tuberculosis, Meningitis, Ischemic Heart Diseases, Stroke, and Cirrhosis. As mentioned earlier, a report has recently said that out of 100 patients who recovered from COVID-19 in Nigeria, 78 had evidence of previous heart inflammation, and 60 showed ongoing inflammation at the time of observation. The COVID-19 comorbidities were also related to obesity among the recovered patients.

Another major problem in Nigeria is the resistance of people in engaging with the health system which has lagged through years of poor service delivery thus negatively impacting the confidence of Nigerians. The country needs confidence-boosting measures and a robust communication strategy to instill the trust of its citizens that can be done by deploying an integrated health management information system that not only connects but also engages citizens by keeping them connected through routine updates and useful information.

As several health data and reports on the portal of the Federal Ministry of Health are over 2-3 years old, timely collection of health data and their processing for use in decision-making also seems to be a huge challenge in the country.

Nigeria also needs to improve its adoption of e-health technologies. Although it’s commendable that the country managed to quickly set up an online dashboard and chatbots for providing COVID-19 information, the room for further improvement was huge. The country hasn’t yet developed a contact-tracing app despite struggling to effectively trace contacts of infected individuals.

Besides, the chatbot developed to disseminate COVID-19 information could be counterproductive if not updated timely. On one hand, Boss Mustapha, Chairman of Presidential Task Force on COVID-19 has said that people are not subjecting themselves for testing and as a result, Nigeria’s testing capacity isn’t being utilized fully. The chatbot, on the other hand, recommends people to self-isolate if any individual has recent travel history to any foreign country or has been in contact with a confirmed case of COVID-19. It recommends contacting authorities only when one starts to feel unwell with known COVID-19 symptoms.

Given the heavy load of communicable and non-communicable diseases in the country along with a weak health system, it’s critical for Nigeria to transform its health data collection, processing, and dissemination to ensure informed decision-making and efficient resource allocation. The country needs a robust HMIS which is operational through real-time geospatial data. This will go a long way in handling the present disease load and also develop a pandemic resilient health management information system in the country. 

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.