A more sustainable approach for Nigeria’s digital health ecosystem

In Nigeria's digital health sector, Agbons Oaiya has seen the same cycle repeat for more than a decade:

A funder with the best intentions works with an implementing partner to design and introduce a new health information system. The system aims to improve data collection and use for a specific health area such as HIV/AIDS. While the system's technology may function properly, poor design limits its usefulness and slows its uptake. When the funding comes to an end, the information system dies out.

Agbons observed that these efforts hadn't adequately considered the long term—not the people and processes responsible for maintaining the system, nor its integration into the country’s health infrastructure.

For the last three years, Agbons has served as the Nigeria country coordinator for PATH’s digital health interventions in Nigeria, which are funded and supported by the US Centers for Disease Control and Prevention’s (CDC’s) Technical Assistance Platform (TAP) and the United States President’s Emergency Plan for AIDS Relief.

In this role, he has used his deep experience in information technology management and digital health to help his country carve a different path—one where HIV/AIDS information systems are integrated, scalable, sustainable, and backed by effective policies and leadership.

In this article, Agbons reflects on the challenges Nigeria has faced with its HIV/AIDS data systems, and how CDC TAP’s approach to strengthening digital health leadership and governance is laying the foundation for improved data use and health service delivery for all Nigerians.

In Nigeria, the goal is to have an AIDS-free nation by 2030. Collecting data, synthesizing data, and using data for decision-making has been an important part of working toward this ambitious goal, and there has been considerable investment to achieve this.

At one point, we had more than 10 electronic medical record (EMR) systems, which made it impossible to accurately track all HIV/AIDS patients; presently, we now have consolidated to three major EMRs. However, when you have a multi-donor environment and each donor has its own priorities, without strong digital health policies, leadership, and governance, everyone brings their own new digital system with its own goals. Also historically the various government agencies and departments that work on public health have often faced challenges in collaborating effectively.

Now, we have a new minister of health who is doing a lot to strengthen and optimize digital health, and helping to bring agencies together to better collaborate on information systems.

There also has been the challenge of digital health skills and capacity in the government. Without effectively building the technical capacity, you have this challenge of transferring health information systems to the government because people may not know how to use them effectively.

In Nigeria, CDC TAP’s goal is to provide high-quality digital health and public health informatics support to the Government of Nigeria through a CDC in-country mechanism. We are ensuring that every digital health activity we design with our government partners includes a thorough process of in-country capacity-building, incorporates a robust governance framework, and builds in local ownership.

Strong, committed leaders can move forward digital transformation efforts and encourage the use of data to make better decisions about care and resource allocation throughout the health system. A digital health governance framework details the governing bodies at all levels of the health system with clear lines of authority, roles, and responsibilities. It shows who is responsible for ensuring that all digital health systems and tools in the country are built to be scalable and interoperable.

Strong governance drives the design of these information systems and their interconnectivity with other systems. It drives ownership of health information system, data use, and sustainability. Governance for me is the most important piece.

The strength of the governance structure and the level of involvement of government leaders tell you at the beginning if something will work or not.

Since PATH started working in Nigeria through CDC TAP in 2021, we have worked across several areas to improve the digital health ecosystem in Nigeria, including EMR optimization and integration to support creation of a centralized health database, and improving the interoperability of existing health information systems.

Specific to governance, we have supported the establishment of a national governance structure for health information systems. This multilayer governance structure includes a technical committee and a management team that oversees the sustainability of health information systems.

We also have worked to strengthen capacity around public health informatics and leadership. This has included supporting the government to carry out the Informatics-Savvy Health Organizations (ISHO) assessment so they can understand and articulate our national gaps and plan on how to address these informatics gaps, including identifying what resources are needed.

We have also guided the Government of Nigeria and champions within the HIV/AIDS program in the Initiative for Leadership Enhancement and Development program. This program supports public health informatics leaders to develop long-term visions and strategies to address the identified health information systems gaps following the ISHO assessment, as well as itemizing actionable steps to advance data-driven decision-making.

Data are meaningless unless they are connected and can be analyzed along with other related health information and utilized for decision-making. There has been a lot of investment in data systems in the HIV/AIDS space, which has been useful for decision-making. However, the case is different beyond the HIV/AIDS sector.

We need to see how we can have these systems, like the EMR, expanded to collect data about other diseases such as malaria, tuberculosis, and noncommunicable diseases. Having EMRs focusing on just one disease area limits the usability of data. Comprehensive health records are essential for improving the overall quality of care.

But, in addition to investment in digital health, we need expanded investments in other aspects of the health system so we can truly achieve interoperability amongst digital health systems. You have all this data, but if you don’t focus on other components, such as human resources for health and health financing, it will be difficult to improve health care quality. We need to invest in these critical pillars and see how we can make Nigeria’s health system work for all citizens.