Assessing the Enabling Environment for ICTs for Health in Nigeria: A Review of Policies

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Assessing the Enabling Environment for ICTs for Health in Nigeria: A Review of Policies Prepared by the United Nations Foundation in Support of ICT4SOML

SEPTEMBER 2014

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Table of Contents Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . 4 List Of Acronyms And Abbreviations. . . . . . . . . . . 5 Important Definitions. . . . . . . . . . . . . . . . . . . . . . . 6 List of Figures and Tables. . . . . . . . . . . . . . . . . . . . 7 Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . 8

Summary of Recommendations and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 31 Strategy and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 31 Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 32 Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 32

background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Saving One Million Lives . . . . . . . . . . . . . . . . . . . . . . . . . 9

Appendix 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

report objectives . . . . . . . . . . . . . . . . . . . . . . . . . 12

full list of documents reviewed . . . . . . . . . . . 34

how to read this report . . . . . . . . . . . . . . . . . . . 12

Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 literature search . . . . . . . . . . . . . . . . . . . . . . . . 14 key informant interviews . . . . . . . . . . . . . . . . . . 14

Nigeria ICT for Health Enabling Environment . . . . . . . . . . . . . . . . . . . . . 15 Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 16 Strategy and Investment . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 19 Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 21 Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 23

summary of findings . . . . . . . . . . . . . . . . . . . . . . 23

Global Benchmarks for Comparison and Lessons . . . . . . . . . . . . . . . . . . . 28 Leadership and Governance . . . . . . . . . . . . . . . . . . . . . . . 28 Strategy and Investment . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Legislation, Policy and Compliance . . . . . . . . . . . . . . . . . . 29 Standards and Interoperability . . . . . . . . . . . . . . . . . . . . . 29 Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Services and Applications . . . . . . . . . . . . . . . . . . . . . . . . . 30

Appendix 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 list of key informant organizations . . . . . . . . 35

Acknowledgements The United Nations Foundation would like to sincerely thank the Saving One Million Lives (SOML) Secretariat, the Federal Ministry of Health and the Federal Ministry of Communications Technology for their leadership and support in the strategic application of technology to save lives – especially those of women and children. The contributions made throughout the landscape and inventory processes, including establishing contacts between the Information and Communication Technology for Saving One Million Lives (ICT4SOML) team and industry stakeholders, have been invaluable. We would like to thank, in particular, Dr. Kelechi Ohiri and Seyi Ibidapo of the SOML office. We would also like to thank all partners and key informants who contributed to the landscape and inventory for ICT4SOML. The resulting outputs, including this report, would not have been possible without the input of all key health and ICT stakeholders in Nigeria. A special thanks is due to Dr. Funke Fashewe of the Clinton Health Access Initiative, Dr. Dauda Suleiman of Futures Group, Dr. Farouk Jega of Pathfinder International, Dr. Ahmad Abdulwahab of PRRINN and Mr. Felix Uduh of the National Primary Health Care Development Agency. In closing, we would specifically like to acknowledge United Nations Foundation staff and consultants who contributed to the authorship, design and implementation of this report. Thanks are due to Dr. Patricia Mechael, Dr. Ime Asangansi, Jonathan Payne, Avrille Hanzel and Nadi Nina Kaonga, as well as consultants from Health Systems Consult Limited: Alozie Ananaba, Nkata Chuku, Uche Nwachukwu and Bamidele Aderibigbe.

ICT4SOML LEAD

COORDINATING PARTNER

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List Of Acronyms And Abbreviations ANC

Antenatal Care

ARV

Antiretroviral

eHealth

Electronic Health

EHR

Electronic Health Record

EMR

Electronic Medical Record

FCT

Federal Capital Territory

FMCT

Federal Ministry of Communication Technology

FMOH

Federal Ministry of Health

GSMA

Groupe Speciale Mobile Association

HIS

Health Information System

HIV/AIDS

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

ICT

Information and Communication Technology

ICT4SOML

Information and Communication Technology for Saving One Million Lives

ITU

International Telecommunications Union

JSI

John Snow, Inc.

LGA

Local Government Authority

LMIC

Low- and Middle-Income Country

MCH

Maternal and Child Health

MDG

Millennium Development Goal

mHealth

Mobile Health

MNCH

Maternal, Newborn and Child Health

NACA

National Agency for the Control of AIDS

NAFDAC

National Agency for Food and Drug Administration and Control

NCC

Nigeria Communications Commission

NCH

National Council on Health

NHIS

National Health Insurance Scheme

NHMIS

National Health Management Information System

NIGCOMSAT

Nigerian Communications Satellite

NIMR

National Institute of Medical Research

NIPOST

Nigerian Postal Service

NIPRD

National Institute for Pharmaceutical Research and Development

NITDA

National Information Technology Development Agency

NPHCDA

National Primary Health Care Development Agency

ORS

Oral Rehydration Salts

OSSAP

Office of Special Assistant to the President

PATH

Program for Appropriate Technology in Health

PHC

Primary Health Care

SHC

Secondary Health Care

SMS

Short Message Service

SOML

Saving One Million Lives

SURE-P

Subsidy Reinvestment and Empowerment Programme

UN

United Nations

USPF

Universal Services Provision Fund

WHO

World Health Organization

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Important Definitions Electronic health (eHealth) refers to the use of information and communication technology (ICT) in support of health and health-related fields, including health care services; health surveillance; health literature; and health education, knowledge, and research. The definition introduces a range of services such as electronic health records to ensure continuity of patient care across time, mobile health (mHealth) services, telehealth, health research, consumer health informatics to support individuals in health decision making, and eLearning by health workers. In practical terms, eHealth is a means of ensuring that correct health information is provided in a timely and secure manner via electronic means for the purpose of improving the quality and efficiency of health care delivery and prevention programs. mHealth services, in particular, focus on the application of mobile and other wireless technologies for health systems strengthening. An eHealth Strategy can serve as an umbrella for planning and coordinating different national eHealth efforts while considering fundamental elements in terms of regulatory, governance, standards, human capacity, financing and policy contexts. A good National eHealth Strategy presents a set of interventions that the health sector plans to use to facilitate the efficient and effective delivery of services. Without an overarching national level strategy, ICT initiatives are left at the hands of individual organizations without coordination and a guarantee that they are in the best interest of clients. A national level eHealth strategy with sector-wide participation and ownership is an effort to fill this gap. Frameworks serve as guides, rules or well-defined approaches towards addressing a particular matter. An eHealth framework is specifically concerned with applying ICT in a health system. Different frameworks exist and can range from being general, and providing comprehensive approaches to governing the regulatory environment and guiding implementations within that context, to being specific, and focusing on a particular aspect of eHealth, such as data standards. A health information system (HIS) is a system that collects, transmits, stores and manages health-related data. The data can be patient-specific (or row-level data) or aggregate. Reports can typically be generated from an HIS. If a system is primarily being used to inform and support health management practices, the system is referred to as a health management information system. An architecture is a conceptual framework that is used to inform data collection, transmission, storage and sharing. Architectures show the integration of many components into a whole, as well as the interoperability that enables these components work together. Interoperability is the ability of an application or platform to establish a data exchange with another application or platform. For interoperability to occur, both services must use the same standards [for communication]. Standards serve as rules or guidelines that ensure consistency in the context in which they are applied. Standards can exist around data, processes and systems. The standards development process is variable (e.g., government-mandated versus stakeholder-based). As such, it is possible for multiple standards to exist and formal-alignment among the different standards. A policy refers to a course or principle of action adopted or proposed by an organization or individual while strategy refers to the method or plan chosen to bring about this desired course or principle of action. While compliance has multiple meanings, the report primarily uses it to mean adherence (to policy and legislation).

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List of Figures and Tables Figures figure 1. current status of the nigeria ict for health enabling environment according to the who-itu stages/extent of development . . 15 figure 2. timeline of national policies and strategies . . . . . . . . . . . . . . . . 20

Tables table 1. soml program areas and targets . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 table 2. components of the ict for health enabling environment . . . . . . 13 table 3. summary of information on key roles of fmoh departments and agencies within the context of ict for health . . . . . . . 17 table 4. summary of information on key roles of fmct departments and agencies within the context of ict for health . . . . . . . 18 table 5. summary of enabling environment, highlighting strengths, gaps and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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Executive Summary Committed to reducing maternal and child mortality, the Federal Government of Nigeria is implementing the Saving One Million Lives (SOML) initiative. The initiative will scale up primary health care services and will focus on ten program areas, including maternal and child health, routine immunization, essential medicines, nutrition, malaria, elimination of motherto-child transmission [of HIV/AIDS], private sector engagement, quality improvement, fiscal space analysis and data management. The federal government has recognized the opportunity that information and communication technologies (ICT) present to help accelerate the achievement of SOML’s goals. Consequently, the Federal Ministry of Health with support from the United Nations Foundation, along with GSMA, the Government of Norway and other partners, have launched ICT4SOML – Information and Communication Technology for Saving One Million Lives. Through ICT4SOML, ICT for health tools that address SOML’s program areas will be scaled up and the ICT for health enabling environment in Nigeria will be strengthened. In order to understand the current state of affairs of the enabling environment, a comprehensive two-phase baseline assessment was designed. The initial assessment includes a landscape and inventory analysis and the policy review. The findings of the initial assessment will help ensure that activities within ICT4SOML are informed and contextualized to the Nigerian environment. This report, in particular, presents the findings from the policy review. This review has been structured around the eHealth enabling environment framework from the World Health Organization and International Telecommunication’s National eHealth Strategy Toolkit. The seven core components of the framework are leadership and governance; strategy and investment; legislation, policy and compliance; standards and interoperability; workforce; infrastructure, and services and applications. Through this framework, the strengths and gaps in the enabling environment for applying ICTs for Health in Nigeria are analyzed and discussed, using information from the following sources: reports on SOML and ICT4SOML activities, including the accompanying inventory report; national policies and strategies; international eHealth policies and strategies and key informant interviews. Recommendations in each of the seven component areas have been outlined, including recommendations based on a review of eHealth policies in similar jurisdictions as well as international best practices. Notable strengths in the existing environment include inter-ministerial involvement in and commitment to ICT for health, acknowledgement of infrastructure and regulatory gaps and numerous on-going implementations. However, a lack of harmonization, no strategic longterm financing mechanisms and an inadequate policy and regulatory environment hinder progress in realizing sustained and effective ICT for health enabling environment. Therefore, it will be important to improve coordination and put appropriate mechanisms in place to foster progress. As an immediate next step, the findings and recommendations in this report will be reviewed by key stakeholders, including policy makers and other stakeholders working on improving Nigeria’s enabling environment. Based on the review and other contextual considerations, a national, overarching framework should be developed. This framework should build upon and capitalize on the policies and strategic drivers already in place to support ICT for health activities. In addition, the framework should provide standards for eHealth implementation, and a proper governance structure to provide an enabling environment for eHealth in Nigeria.

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Introduction background Approximately one million women and children die from preventable causes every year in Nigeria. Of those deaths, roughly 33,000 women die from pregnancy-related causes, and of the 946,000 children who die before their fifth birthday, 241,000 are newborns1. Nigeria is constrained by an inequitable distribution of resources and inadequate health services. Despite efforts to address maternal and child health challenges, Nigeria has among the highest rates of maternal and child mortality in the world2, with 560 maternal deaths per 100,000 live births3 and 125 deaths of children under 5 years of age per every 1,000 live births4. In recognition of the effort to accelerate progress in reducing maternal and child mortality and to meet the health-related Millennium Development Goals (MDGs) 5, the Federal Government of Nigeria has implemented several initiatives to help address some of the health system challenges, including Saving One Million Lives (SOML).

Saving One Million Lives SOML aims to scale up access to essential primary health services and commodities and focuses specifically on the health and wellbeing of Nigeria’s women and children. The vision of the initiative is to create an environment where all women, children and caregivers are equipped with information to be able to mitigate death and have access to quality health services when and where needed. With a focus on improving health outcomes and having significant impact, clear and ambitious targets have been established6. SOML has been divided into ten program areas. Each program area has established targets (refer to Table 1). All targets are aligned with the MDG 2015 timeframe. 1. http://www.countdown2015mnch.org/documents/2012Report/Nigeria_Report_2ed.pdf 2. http://www.unicef.org/nigeria/children_1926.html 3. http://data.worldbank.org/indicator/SH.STA.MMRT 4. http://data.worldbank.org/indicator/SH.DYN.MORT/countries 5. Nigeria Revised National Health Policy (2004). Available from: http://www.gnhc.gov.bt/wp-content/ uploads/2012/04/nationalHpolicy.pdf 6. http://www.soml.org.ng/index.php

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table 1. SOML Program Areas and Targets PROGRAM AREA

TARGETS Reduce maternal mortality ratio from 545/100,000 live births to 250/100,000 live births Reduce the neonatal mortality rate from 40/1,000 live births to 14/1,000 live births

Maternal and Child Health

Increase the proportion of births attended to by a skilled birth attendant from 38.9% in 2008 to 85% Increase the proportion of pregnant women attending 4 or more antenatal care (ANC) visits from 45% in 2008 to 80% Increase the number of upgraded primary healthcare facilities from 1,000 MSS sites in 2012 to 5,000 sites

Routine Immunization

Increase number of infants receiving DPT37/Pentavalent vaccines in target Primary Health Care facilities and communities to 87% Increase percentage of coverage of oral polio vaccine to 87% 80% of under-five diarrhea episodes treated with oral rehydration salt (ORS) and zinc

Essential Medicines

80% of under-five malaria episodes treated with artemisinin-based combination therapy within 24 hours 80% of under-five pneumonia episodes treated with cotrimoxazole or amoxicillin Cure rates: Consistently achieve a cure rate of 75% of children admitted for acute malnutrition from 71.4%

Nutrition

Case fatality rates: Consistently achieve a death rate of less than 10% of children being treated for acute weight-loss Exclusive breast feeding for at least 80% of children under the age of 6 months 100% of children under the age of 5 receiving vitamin A Increase the utilization rates of children under the age of five years sleeping inside the mosquito nets from 29% in 2010 to equal or greater than 80% Increase the utilization rates of pregnant women sleeping inside mosquito nets from 65% in 2010 to at least 80%

Malaria

Increase the uptake of all eligible pregnant women receiving two doses of Intermittent Preventive Treatment from 5% in 2008 to equal or greater than 80% Improve the uptake of prompt diagnosis and treatment of children under the age of five with fever cases or suspected malaria cases using effective antimalarial from 33$ as recorded in 2008 to at least 80%

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Increase access to antiretroviral (ARV) prophylaxis for all HIV positive pregnant women from 22% to 90% Elimination of Motherto-Child Transmission [of HIV/AIDS]

Increase access to ARV prophylaxis for all HIV exposed infants from 8% to 90% Increase access of HIV positive pregnant women to quality infant feeding counselling to 90% Increase access of HIV exposed infants to early infant diagnosis service to 90% To increase the amount of data and information reported and available on private sector clinical services, financing, and operational management for improved health system planning

Private Sector Engagement

Quality Improvement

To implement business models that identify and coordinate private sector providers to achieve increased knowledge, improved quality of services, and economies of scale through shared resources, leading to increased investment-grade enterprises Target(s) Forthcoming Supporting departments within FMOH & NPHCDA in using the report to develop the 2015 health budget

Fiscal Space Analysis

Having 30-40% of donors in the Development Partners Group use tool as basis for aid grants Increase in the Federal Government’s allocation to health

Data Management

Phase 1: Scale-up of SOML in 20 states with the lowest reporting rates (0-25% as of August 2013) by December 2014; 80% reporting in other states. Phase 2: Scale-up in the remaining 17 states by December 2015; 80-100% reporting in all states.

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ICT4SOML The Nigeria Federal Ministry of Health (FMOH) has expressed interest in strategically and systematically using information and communication technology (ICT) to improve maternal and child health8. Accordingly, in support of the Nigeria FMOH, the United Nations (UN) Foundation, Government of Norway, GSMA and other key partners in Nigeria are working together to leverage ICTs for health (or electronic health, otherwise called eHealth). An initial focus has been placed on the SOML initiative through an effort entitled “ICT4SOML”. ICT4SOML has two main goals9: 1. To support the scale-up of high priority ICT for health projects through working groups targeting specific SOML program areas 2. To strengthen the ICT for health enabling environment in Nigeria through the development of a national framework that addresses gaps in the enabling environment

7. Diphtheria, Pertussis and Tetanus 8. GSMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/ mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014 9. ICT4SOML Highlight Report. Available from: http://hingx.org/Share/Attachment/1569/ICT4SOML_Highlight%20 Report_v4.pdf

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report objectives The primary purpose of this report is to provide policy makers and other key stakeholders with an understanding of the current ICT for health enabling environment in Nigeria as it relates to legislation, policy and compliance.

A two-phase assessment of ICT for health in Nigeria was conducted to facilitate the design of ICT4SOML, to inform policy and enabling environment strengthening activities. Phase 1, which consisted of a landscape analysis, inventory and policy review, will help ensure that all activities within ICT4SOML are informed and contextualized to the Nigerian environment10. This report presents the findings from the policy review of Phase 1 and is a complement to the previously published Landscape and Inventory review. The primary purpose of this report is to provide policy makers and other key stakeholders with an understanding of the current ICT for health enabling environment in Nigeria as it relates to legislation, policy and compliance. The report identifies gaps in the ICT for health enabling environment, especially those gaps which are on the critical path to scaling up high priority ICT for health interventions, and provides recommendations to ameliorate these gaps. Understanding the current state of affairs can better shape the ICT4SOML goals and define the magnitude of strategic investment needed to achieve the goals. The findings of this report, in conjunction with the landscape and inventory report, are intended to support policymakers and other key stakeholders in refining the broader ICT4SOML and SOML goals and to develop addressing gaps and enriching the enabling environment. Cultivating a strong ICT for health enabling environment enables a high performance health system that supports both near-term SOML goals and sets the foundation for long-term sustainability and improved health outcomes.

how to read this report The “National eHealth Strategy Toolkit” by the World Health Organization (WHO) and International Telecommunications Union (ITU) forms the framework for this report. The toolkit describes seven components in a national electronic health (eHealth) environment11 (refer to Table 2). 10. Ibid. 11. WHO-ITU National eHealth Strategy Toolkit (2012). Available from: http://www.itu.int/ pub/D-STR-E_HEALTH.05-2012

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table 2. Components of the ICT for Health Enabling Environment COMPONENT

DESCRIPTION

Leadership and governance

Oversee and coordinate eHealth activities at the national level, ensuring alignment with national health goals and priorities

Strategy and Investment

Responsible for planning and engaging all stakeholders involved in ICT for health activities and aligning and procuring financing for ICT for health

Legislation, policy and compliance

Covers national policies and legislation for ICT for health in terms of development, alignment and regular review

Workforce

Empower health workforce to use ICT for health through education and training programs

Standards and interoperability

Introduce standards and ensure their use for enhanced interoperability and integration

Infrastructure

Refers to the physical infrastructure, services and applications that form the foundation for ICT for health implementations

Services and applications

Devices and tools utilized by end users to collect, transmit, access and maintain health information

As adapted from the 2012 WHO-ITU eHealth Strategy Toolkit12, Table 4 This report focuses on legislation, policy and compliance; standards and interoperability; leadership and governance; strategy and investment; and workforce. The concurrently published report, “Assessing the Enabling Environment for ICTs for Health in Nigeria: A Landscape and Inventory”, focused on infrastructure and services and applications and is a complement to this report. Together, the two reports will provide a complete picture of the current ICT for health enabling environment in Nigeria. Following the methodology section, the report has been divided into three sections: • Nigeria ICT for Health Enabling Environment: Using the WHO-ITU framework, this section provides information on each of the components for enabling environment. Each component has its own stand-alone section that contains an overview and analysis for that component. Therefore, readers can focus on specific components by reading the accompanying section. For example, readers interested in standards information can read the “Standards and Interoperability” section only. • Global Benchmarks for Comparison and Lessons: This section provides an overview of global trends and focus areas. In addition, the policies of selected countries have been used to highlight different approaches, common themes and options for Nigeria to address gaps in her enabling environment. For consistency, the WHO-ITU framework has been loosely applied to this section. • Gaps and Recommendations: The gaps identified through the assessment of the ‘Nigeria ICT for Health Enabling Environment’ are featured in this section. Recommendations are provided for each identified gap. In efforts to help inform the development of the National ICT for Health Framework, special attention has been made on legislation, policy and compliance and standards and interoperability.

12. Ibid.

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Methodology The potential of ICTs to improve health has been recognized by both the public and private sectors with evidence of success of ICT for health initiatives in Nigeria and globally.

The source documents and information featured in this report were obtained through a search of the literature and key informant interviews. Guiding questions used to inform the search and interviews were derived in accordance with the WHO-ITU framework13. The questions covered the structure, interaction and role of entities in the health system, service delivery, health care financing system and basic funding mechanisms and health system challenges – keeping in mind that relevance to ICT4SOML was a priority. After analysis, gaps were identified and recommendations formulated.

literature search Source documents were obtained through desk research and key informants. For the Nigeria-specific documents, literature searches included “Nigeria” as a key word. Key informants, including representatives from the FMOH and UN Foundation, were specifically asked to provide recommendations on policy guidelines to review. Global benchmark countries were first identified by key informants with extensive technical expertise in the global ICT for health sector. Countries were selected based on their relevancy to informing identified gaps in Nigeria’s enabling environment and strength of their enabling environment. To identify how Nigeria compared to countries with a similar contexts and to learn from approaches in these comparable countries, a few countries were included for their similarity to Nigeria on geography, socioeconomic status and health indicators. [See appendix for full list of source documents.]

key informant interviews Key stakeholders within the ICT and health sectors in Nigeria who were deemed as being most relevant to SOML and ICT4SOML success were selected for informant interviews. [See appendix for complete list of key informants.] Interviews were conducted with the key stakeholders in May 2014. Interviews lasted no longer than one hour. In addition to exploring the structure, interaction and role of entities in the health system, service delivery, health care financing and funding mechanisms and health system challenges, cross-sector engagement was also examined. Transcripts of the interviews were analyzed for important themes and trends. Informants were also asked to provide recommendations on relevant policies, reports and other documents to review. 13. Ibid.

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Nigeria ICT for Health Enabling Environment The potential of ICTs to improve health has been recognized by both the public and private sectors with evidence of success of ICT for health initiatives in Nigeria and globally, but scale-up and sustainability have proven to be challenging. The ICT sector has evolved faster than the policies that guide the use of ICTs for health, presenting significant challenges to projects moving towards institutionalization14. The WHO-ITU Toolkit describes a framework for stages of development of the national ICT for health enabling environment (see appendix for a description of the stages). For the purposes of this report, Nigeria is considered to be transitioning from ‘experimentation and early adoption’ to ‘developing and building up’15. Countries at the developing and building up stage are directed (a) to strengthen existing systems, (b) to ensure that guidelines and policies are in place and enforced, and (c) to establish funding and planning mechanisms for full transition of the enabling environment and long-term success.

figure 1. C  urrent Status of the Nigeria ICT for Health Enabling Environment According to the WHO-ITU Stages/Extent of Development

Current Status of Nigeria ICT

ESTABLISHED ICT ENVIRONMENT

Desired Trajectory of Nigeria ICT

MAINSTREAMING SCALE UP DEVELOPING & BUILDING UP

II.

EMERGING ENABLING ENVIRONMENT FOR eHEALTH

III.

I.

ESTABLISHED ENABLING ENVIRONMENT FOR eHEALTH

EARLY ADOPTION

EXPERIMENTATION

EMERGING ICT ENVIRONMENT

For more information on the stages/extent of development, please refer to the WHO-ITU eHealth Strategy Toolkit.16 14. Nigeria National Information and Communication Technology (ICT) Policy [Draft] (2012). Available from: http://www.researchictafrica.net/countries/nigeria/Nigeria_National_ICT_Policy_(draft)_2012.pdf 15. WHO-ITU National eHealth Strategy Toolkit (2012). Available from: http://www.itu.int/pub/D-STR-E_HEALTH.05-2012 16. WHO-ITU National eHealth Strategy Toolkit (2012). Available from: http://www.itu.int/pub/D-STR-E_HEALTH.05-2012 [see Table 2]

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A summary table outlining the findings from the review of the enabling environment can be found at the end of this section. In addition, more detailed information on each of the components of the enabling environment explored below are located in the appendix.

Leadership and Governance Understanding organizational arrangements by identifying the key stakeholders and how they interact with one another and external actors is important for assessing and strategically supporting the implementation of programs. Given the multidisciplinary nature of digital health, the FMOH and Federal Ministry of Communication Technology (FMCT) each play important roles in its governance. The Nigerian health care system is divided into primary, secondary and tertiary levels. Local government areas (LGAs) are responsible for primary health care; States oversee secondary care facilities, and the federal government is responsible for tertiary health care. In addition, the federal government, through the FMOH, provides high-level health sector leadership and is responsible for the overall strategic oversight for healthcare in the country. The FMOH, which is headed by the President-appointed Honorable Minister of Health, has ten departments and six agencies through which it carries out its functions. The departments and agencies all play different roles in ICT for health leadership, the most relevant, along with two special presidential programs, have been outlined in Table 3.

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table 3. Summary of Information on Key Roles of FMOH Departments and Agencies within the Context of ICT for Health DEPARTMENT/AGENCY

KEY ROLE

Department of Health Planning, Research and Statistics (DPRS)

Leadership for national health information systems

Department of Hospital Services

Provides governance for tertiary health centers and hospital information systems

Department of Public Health

Oversees epidemiology and surveillance information systems

Department of Food and Drugs

Oversees the National Products Supply Chain Management Programme (NPSCMP) which has a technical working group responsible for harmonizing and supporting an electronic logistic management information system

National Primary Health Care Development Agency (NPHCDA)

Provides oversight for primary health care policy and Midwives Services Scheme; has its M&E and ICT units

National Agency for Food and Drug Administration and Control (NAFDAC)

Provides oversight for food and drugs; has a mandate for the National Mobile-based Authentication Service; oversees drug and medicines database

National Health Insurance Scheme (NHIS)

Oversees health financing; e-NHIS database involving clients, health maintenance organization, providers and insurance companies

National Agency for the Control of AIDS (NACA)

Provides national leadership for HIV/AIDS activities, including monitoring and evaluation and health information systems strengthening

National Institute of Medical Research (NIMR)

Oversees medical research and uses a medical research information system

National Institute for Pharmaceutical Research and Development (NIPRD)

Leadership for pharmaceutical research, and national database for locally sourced drugs and biological products

Subsidy Reinvestment and Empowerment Program – Maternal and Child Health (SURE-P MCH)

Chairs the ICTs for supply chain and mobile conditional cash transfer (mCCT) working groups

Office of Special Assistant to the President on the Millennium Development Goals (OSSAP-MDG)

Provides leadership/governance for MDGs, MDGs tracking and the MDGs information system

Established in 2011, the FMCT oversees ICT-related policy formation, implementation monitoring and evaluation, as well as the supervision and oversight of most government ICT-related projects and initiatives. The FMCT seeks to improve infrastructure, optimize use of existing resources and build capacity. Similar to the FMOH, the FMCT exerts its operations through its departments and agencies. Table 4 provides a summary of those entities.

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table 4. Summary of Information on Key Roles of FMCT Departments and Agencies within the Context of ICT for Health DEPARTMENT/AGENCY

KEY ROLE

Department of e-Government

Leads the formulation and supervises the implementation of the National ICT Policy; coordinates and supervises ICT programs across all ministries

Galaxy Backbone

Falls under the auspices of e-Government and is meant to enhance ICT infrastructure to improve the efficiency and effectiveness of government operations through a common services platform, offshore VSAT hubs, data center, metro fiber backbone and multiple redundant Internet gateways

National Information Technology Development Agency (NITDA)

Oversees the National IT Policy and enacts services through the NITDA Act (2007); tasked to enter into strategic alliances with the private sector and international organizations

Department of Planning, Research and Statistics

Responsible for coordinating policies in conjunction with the e-Government; involved in reviewing and updating master plan and road maps in ICT sector

Universal Services Provision Fund (USPF)

Tasked to enhance accessibility and availability of telecommunications and ICT infrastructure and services throughout Nigeria

Nigerian Communications Commission (NCC)

Responsible for creating enabling environment for competition among industry operators and maintain accountability of these organizations to ensure efficient distribution of quality and affordable services

Nigerian Communication Satellite (NIGCOMSAT)

Manages commercial viability of the Nigeria Communication Satellite and intentions to support a national telemedicine initiative

Beyond the departments and agencies listed under the FMOH and FMCT, there is the National Council on Health (NCH) and the National Planning Commission17. The NCH serves as an advisory board on health issues and will become the highest policy-making body for healthcare in the country upon passage of the pending National Health Bill. In 2013, the NCH issued a mandate for the routine reporting of data from all primary health facilities into the national data warehouse administered by the FMOH Department of Health Planning, Research and Statistics (DPRS). The National Planning Commission, which reports directly to the President, is responsible for setting national priorities and goals and engendering consensus across government agencies. In part due to the number of relevant government departments and agencies, health ICT leadership is decentralized and often roles are not clearly defined. Competing programs and priorities within government further complicate the development of a coordinated cross-ministerial health ICT strategy, which contributes to lack of transparency, fragmentation, market risk, and high costs. The establishment of an inter-ministerial governing body for ICT for health with representation from all levels of the health system would provide a platform for sustained strategic alignment of health ICT activities. Such a platform would also serve to improve cross-sector communication and collaboration by facilitating shared learning, promoting transparency and partnerships, and encouraging adoption of best practices.

17. http://www.nationalplanning.gov.ng/?view=featured

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18   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Strategy and Investment Strategy, or the deliberate application of ICTs in alignment with national health goals, and its drivers informs how investments can be made to best support the application of ICT for health and, subsequently, to enable the achievement of national health goals. There is currently no formal eHealth strategy or framework in Nigeria. However, as part of ICT4SOML, there is a plan to support the development of a National eHealth Framework focused initially on maternal and child health use cases. The framework will coordinate and strategically direct the activities of the leadership and stakeholders as they work to address health system challenges through the strategic application of ICTs within the health system. Key strategic drivers of ICT for health include political will and commitment, and health system needs and opportunities. From the perspective of the Nigerian government, ICTs are an important enabler to achieve its strategic goals and vision for a healthy nation, as illustrated in the Vision 2020, the drive to meet the MDGs, the National Health Strategic Development Plan, and the push for Universal Health Coverage in Nigeria. These strategic visions are key strategic drivers within the health system that underpin the application of ICTs. In addition, the government and its partners have announced a vision to improve ICT infrastructure (e.g. the National Broadband Plan) and build capacity in the use of ICTs as part of efforts to catapult Nigeria to the league of top 20 economies by 2020. Over time, the ICT sector has shown sustained growth with technology becoming more affordable and the general population having taken advantage of this, as evidenced by the continuous increase in the mobile phone penetration.

Key strategic drivers of ICT for health include political will and commitment, and health system needs and opportunities.

The burden of financing health care services is borne by individual households who typically pay out-of-pocket for their health care18. Despite primary health care (PHC) facilities constituting the majority of health care facilities in Nigeria and having a central role in maternal and child health, many are underfunded, understaffed, lacking essential equipment and drugs, and poorly managed19. Two funding schemes have been proposed—NHIS and the National Health Bill—to help address shortages in funding and could serve as long-term funding mechanisms for ICT for health. The National Health Bill, in particular, will be most relevant to ICT4SOML, given its focus at the PHC level. Other funding sources should be advocated for, identified and explored to establish a portfolio of short- and long-term financing opportunities. The resulting variety of funding sources, mechanisms and incentives should be aligned with the health system and ICT for health priorities and needs. The work being done through ICT4SOML can and should take the key drivers under consideration, along with serving as an advocacy tool for identifying sustainable financing mechanisms for ICT for health20. The drivers can be used to help inform the framework; potentially viable sources of funding (and funding considerations) should also be included in the framework. The resulting framework can then serve as a foundation for an overarching national eHealth policy and accompanying strategy.

Legislation, Policy and Compliance Legislation, policy and compliance addresses the legal and regulatory measures, public policy, and observance of rules and regulations related to ICT for health. There are numerous existing policies and strategies that describe activities related to ICT for health in Nigeria, some of which have been enacted and others that have not yet been signed off by the relevant ministry or included in the Gazette of the Federal Republic of Nigeria. Twelve national

18. GSMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/ mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014 19. http://www.who.int/pmnch/countries/nigeria-plan-chapter-3.pdf 20. Sustainable Financing for Mobile Health (mHealth): Options and opportunities for mHealth financial models in low and middle-income countries (2013). Available from: http://mhealthalliance.org/images/content/sustainable_financing_for_mhealth_report.pdf

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policies and strategies (drafts and fully endorsed documents) have been identified for their direct applicability to the ICT for health enabling environment. The earliest and most broadly encompassing of these documents is the National Health Policy of 2004. As time has progressed, the relevant documents become more specifically geared towards ICT for health (refer to Figure 2). To illustrate this point, the most recent documents, which are still being drafted, directly address ICT for health. In addition, a ministerial committee housed within the FMCT has been working towards harmonizing ICT policy across the different sectors.

figure 2: Timeline of National Policies and Strategies

National Health Policy

2004

National Human Resources for Health Strategic Plan

2005

2006

2007

2008

FMOH Integrated Disease Surveillance and Response Policy Strategies for Strengthening the Secondary Health Care Delivery Service

2009

Nigeria Global Health Initiative Strategy

2010

2011

National Strategic Health Development Plan Framework

FCT eHealth Policy and Policy Implementation Strategies

2012

National ICT Policy Draft

2013

2014

Health Information System Policy and Strategic Plan: 2014-2018 (draft, not yet endorsed) National eHealth Policy Draft

For more information on each of the documents, please refer to the appendix.

A ministerial committee housed within the FMCT has been working towards harmonizing ICT policy across the different sectors.

There are several gaps that should be addressed to strengthen current and inform future policies and plans with respect to use of ICTs to improve health system performance: multi-regulation, mal-alignment, stakeholder engagement and legal framework. While the FMCT has been tasked with harmonizing ICT policies across sectors, multi-regulation still poses a problem in the ICT for health environment. For example, not all policies are in alignment with the national health plans or existing policies and do not build upon previous, related policies. In addition, most policies do not have accompanying strategic documents to guide planning and implementation. Furthermore, there is no clear guidance on how to formally engage stakeholders and ensure that all tools can integrate with the key tools and systems currently being used by the government in the health domain. In addition, without an appropriate legal framework, the government is unable to properly enforce compliance to policy and regulations, and as such, activities to address the gaps may yield limited success. It is recommended that a national eHealth policy be developed that builds off existing momentum and policy precedent, while simultaneously addressing the above gaps. Such an informed policy would setup an enabling environment for the coordinated, systematic and strategic scale-up of ICT solutions for health. The policy must also setup systems for sustained accountability and compliance, policy revisions, reviews of ICT for health implementations, guidelines for stakeholder engagement, and a legal framework addressing patient safety and privacy21.

21. Patient Privacy in a Mobile World: A Framework to Address Privacy Law Issues in Mobile Health (2013). Available from: http://www.trust.org/contentAsset/raw-data/03172beb-0f11-438e-94be-e02978de3036/file

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20   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Standards and Interoperability Adoption of health informatics standards is a prerequisite for interoperability of health information systems. Setting standards and technical guidelines for collection, storage and exchange of health information facilitates access to accurate data in a timely, secure fashion, enabling continuity of care across place, provider, and encounter and leading to a health system that can monitor itself and continuously improve. The Federal Government of Nigeria has recognized the importance of standards and interoperability and has mandated their use in several policies, including the National Health Policy, Strengthening Secondary Health Care Service Delivery, the Integrated Disease Surveillance and Response Policy, the National Strategic Health Development Plan Framework, the Nigeria Global Health Initiative Strategy, the National ICT Policy, and the FMCT eHealth Policy. Despite this, the application of standards and interoperability best practices in Nigeria faces many challenges, including limited uptake of health informatics standards, limited capacity and awareness, lack of engagement in international standards development processes, limited coordination and alignment across public and private actors, and inadequate governance structures.

Adoption of health informatics standards is a prerequisite for interoperability of health information systems.

No national body has been appointed with developing endorsing specific health informatics standards within Nigeria22. Nigeria generally does not participate in international health informatics standards development activities, such as those led by the International Organization for Standardization Technical Committee on Health Informatics, Health Level 7, or Integrating the Health Enterprise. Nigeria also lacks national guidelines and requirements for privacy, security, and auditing of health information, which results in each department and agency being responsible for their own, often conflicting, policies. Officially appointing a transparent body to administer and develop health informatics standards for Nigeria would go a long way to addressing the poor uptake23, and there are some signs of a growing appetite for this. In late 2013, the National Council for Health approved a resolution that appointed the FMOH Department of Health Planning Research and Statistics as the official administrator of the 250-indicator primary health center report, which all 37,000 health facilities in the country are required to submit into the National Health Management Information System (NHMIS) each month. But this does not go far enough. A national body would govern reporting indicators, clinical documentation requirements, interoperability and integration requirements, architectural guidelines, as well as privacy, security, and auditing requirements.

Workforce The ICT for health workforce consists of health workers who are trained to use ICT systems and ICT workers who are skilled at building, implementing, maintaining, and scaling up these systems along with the infrastructure required to support them. The federal government is committed to capacity building within the ICT and related sectors, but ICT skills training in the health sector, in particular, is lacking. One of the more significant challenges has been recruiting ICT-trained individuals out of the more lucrative private sector. It will be crucial to provide training on basic ICT skills to ensure technical literacy24, and ensure that supervisors and decision-makers are aware of end-user needs. However, it appears that such capacity building has not yet taken place; there is no plan or strategy.

Appropriate incentives should be identified and used in conjunction with training and implementation.

A plan and partnerships should be identified to help carry out capacity building as a part of SURE-P and other programs. Best practices and lessons learned can and should be documented and used to help develop a coordinated plan or strategy that will meet 22. The Standards Organization of Nigeria was established in 1971 to administer and serve as technical lead for standards development activities in-country for industry, but health was excluded from its mandate. 23. The State of Standards and Interoperability for mHealth (2013). Available from: http://www.mhealthalliance.org/images/content/state_of_standards_report_2013.pdf 24. http://nphcda.org/making-a-difference-with-the-midwives-services-scheme/

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capacity-building needs among intended end-users in the health system. A means to carry out capacity building is through formal institutions (i.e., schools, continued education). Institutional capacity training for trainers and trainees, alike, should be strengthened. Core competencies should be established and integrated into a training curricula. Also, appropriate incentives should be identified and used in conjunction with training and implementation.

Infrastructure The telecommunications sector in Nigeria has undergone significant growth.

Infrastructure is concerned with the physical infrastructure (e.g., connectivity, electricity, hardware, directory services) and software components (e.g., electronic health records (EHRs)/electronic medical records (EMRs), health information datasets) that contribute to the ICT for health enabling environment. The telecommunications sector in Nigeria has undergone significant growth25. Over 62% of the population has access to a mobile phone26 and there are over 173 million mobile phone subscriptions27. While, broadband subscriptions remain low, forecasting indicates that such services will become more affordable. Through the Galaxy Backbone initiative, a national fiber optic backbone (for broadband) will be present in even the most rural areas of the country28. However, the capacity for software development remains limited. Furthermore, with limited financing for the health system, maintaining the health infrastructure (i.e. facilities, medical equipment) has been a challenge. Additionally, traditional grid electricity supplies are not fully reliable. [Please refer to the report, “Assessing the Enabling Environment for ICTs for Health in Nigeria: A Landscape and Inventory”, for more details on infrastructure in Nigeria.] Although the public and private sectors are taking steps to improve infrastructure related to ICT for health, a digital divide exists between rural and urban areas. There are high costs to both consumers and corporations; to consumers the costs are in obtaining services and for corporations, expanding services is costly. Incentives should be identified to promote expansion of affordable services to rural areas. Also, sustainable health financing mechanisms should be established and a sub-set flagged for the improvement and maintenance of facilities, power, Internet and other infrastructure.

Services and Applications The ICT for health enabling environment is ‘developing and building up’. However, obstacles remain to further accelerate progress and transition to the next stage of evolution.

Services and applications refer to the actual ICT tools and systems used in the delivery and administration of health, consisting of individual electronic health information, health care communications and collaboration, healthcare service delivery, health information and knowledge and healthcare management and administration. Projects in Nigeria span all of the aforementioned uses. Specific examples of types of tools include hospital-based EHRs, decision-support tools, disease surveillance tools, patient monitoring and care and distance learning applications. The concurrently published report, “Assessing the Enabling Environment for ICTs for Health in Nigeria: A Landscape and Inventory”, described 84 ICT for health projects at varying levels of scale and technological maturity. Most eHealth services in Nigeria are SMS-based, data applications, pre-loaded applications or accessible through web-based portals. The majority of services have been directed towards maternal and child health. Furthermore, there is a precedent for national coverage – as 22 of the initiatives reported nationwide coverage. Moreover, most states have more than 20 on-going ICT for health implementations. It is important to note that fragmentation is an issue and rigorous evaluations have only been conducted on a small number of projects. Despite FMCT attempts to harmonize ICT policy and initiatives, the current lack of harmonization across projects translates to a lost opportunity for capturing data in national 25. GSMA mHealth Country Feasibility Report: Nigeria (2014). Available from: http://www.gsma.com/ mobilefordevelopment/gsma-country-feasibility-report-nigeria-2014 26. Ibid. 27. http://www.ncc.gov.ng/index.php?option=com_content&view=article&id=125:art-statistics-subscriber-data&catid=65:cat-web-statistics&Itemid=73 28. http://www.researchictafrica.net/publications/Evidence_for_ICT_Policy_Action/Policy_Paper_6_-_Understanding_what_is_happening_in_ICT_in_Nigeria.pdf

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22   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

information systems to further enhance decision-making. In addition, the fragmentation underlines the inability to systematically and securely share health information amongst providers and facilities for such activities as referrals and longitudinal patient care. Minimal reporting and interoperability requirements, along with secure and integrated reporting and project portals, should be established.

summary of findings The ICT for health enabling environment is well on its way to ‘developing and building up’ from ‘experimentation and early adoption’. The awareness, interest and commitment to ICT for health is present in both the public and private sector, as evidenced by growing government leadership, multiple policies addressing elements of ICT for health, and the numerous services and applications already being implemented in the country. However, many obstacles remain to further accelerate progress and transition the health ICT system to ‘scale-up and mainstreaming’, the next stage of evolution identified in the WHOITU eHealth Strategy Toolkit. There is no unifying ICT for health strategic framework and no platform exists to support sustained dialogue and collaboration across public and private sectors. Existing implementations and policies are fragmented. In the private sector, there has been significant growth in ICT services offered, but in order for the sector to continue to flourish, investments must be made to improve infrastructure especially to less economically developed regions. Sustainable financing mechanisms need to be identified, and the private sector can and should be engaged in this endeavor. As progress continues, efforts should be made to ensure the systematic alignment of ICT for health with health sector strategies and priorities.

It is recommended that a national eHealth policy be developed that builds off existing momentum and policies.

The following table outlines the findings from the review of the Nigeria ICT for health enabling environment. Strengths, gaps and recommendations to address those gaps are included. Additional information on the gaps identified through this analysis, along with recommendations, are discussed in more detail in the final section of this report.

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table 5. Summary of Enabling Environment, Highlighting Strengths, Gaps and Recommendations 1. LEADERSHIP AND GOVERNANCE STRENGTHS

GAPS

RECOMMENDATIONS

• Uses a multidisciplinary approach involving the health and ICT sectors with key leadership roles played by the FMOH and FMCT, respectively

Coordination:

Coordination:

• Leadership is decentralized

• Establish an overarching, interministerial governing body for ICT for Health

• Agencies and departments under each ministry are engaged in providing leadership and infrastructure for ICT for Health • Other key stakeholders are involved, including other government bodies, private sector and NGOs

• Roles not clearly delineated • Individualized strategic approaches and initiatives Communication:

--Should also have representation and coordination at subnational level

• Marked overlap and duplication of efforts (fragmentation and duplication)

• Develop a strategic framework for leadership, coordination and implementation

• Multiple stakeholders involved but no clear consistent mode of engagement and communication

• Clearly define roles and responsibilities Communication: • Interface for cross-sector communication and collaboration • Need to engage all key stakeholders for enhancing partnerships and cooperative design

2A. STRATEGY AND FINANCING: LONG-TERM PLANNING (STRATEGY) STRENGTHS

GAPS

RECOMMENDATIONS

Key strategic drivers in place to support ICT for Health, include

• Lack of overarching national eHealth strategy or framework

• Through ICT4SOML, development of a National eHealth Framework will be supported

• Political will and commitment: Government goals and plans for health system (MDGs; SOML; National Health Strategic Development Plan; Universal Health Coverage; SURE-P MCH; Midwives Service Scheme) • Health system needs and opportunities to apply ICT for Health to help realize health system goals --Improvements in infrastructure (galaxy backbone) --Availability of ICT (i.e., mobile phone penetration) --Capacity-building (SURE-P MCH; Midwives Service Scheme)

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24   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

--Framework can encompass identified key drivers --Can build upon framework to develop policy and strategy

2B. STRATEGY AND FINANCING: INVESTMENTS (FINANCING) STRENGTHS

GAPS

RECOMMENDATIONS

• Recognition of health system financing challenges have prompted proposal of two funding schemes that could serve as long-term financing options for ICT for Health: NHIS and National Health Bill

• Existing financing mechanisms in place not adequate

• Identify variety of funding sources, mechanisms and incentives (include engagement with the private sector – PPPs)

--Out-of-pocket --PHC facilities are underfunded, understaffed and poorly equipped • Need for clear financial management structure

--Align the sources with the health system and ICT for Health priorities and needs • Establish clear management and accountability structure for ICT for Health funds • Advocacy for funding ICT for Health projects, and in alignment with national eHealth strategy

3. LEGISLATION, POLICY AND COMPLIANCE STRENGTHS

GAPS

RECOMMENDATIONS

• Numerous existing policies describe activities within ICT for Health

• Lack of national, overarching eHealth policy

• Development of an overarching eHealth policy (that would build upon a strategic framework and have an accompanying plan) that would help foster enabling environment

--Acknowledge barriers and gaps in the existing environment (see all other categories) • Ministerial committee (at the FMCT) on ICT policy harmonization across sectors exists

• Multi-regulation in the ICT environment despite the harmonization committee • Not all policies have accompanying strategic documents for implementation and planning purposes --Existing policies are not in alignment and/or do not build upon previous related policies • Lack of a legal framework guiding ICT for Health activities

• Need for enhanced accountability, coordination and compliance across all stakeholders involved in ICT for Health activities --Should include mechanism for regular policy reviews and updates

• Unclear of how to formally engage key stakeholders

• Development of legal framework to guide ICT for Health activities, especially as they relate to data safety and security

• Key software currently being used by the government in the health domain has not been explicitly outlined

• Identify clear guidelines for engaging key stakeholders (directly relates to leadership and governance)

• Need for regular review of national inventory

• Further develop nationally used software into interoperable systems that meet appropriate standards and promote integration with government and non-government ICT for Health initiatives • Identify mechanism for regular review of ICT for Health initiatives

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4. STANDARDS AND INTEROPERABILITY STRENGTHS

GAPS

RECOMMENDATIONS

• Recognition of need for secure and safe mechanisms to transmit and store data

• Unclear which national body is responsible for governing standards within health (namely ICT for Health)

• Identify national body to be responsible for governing health standards (include this in leadership and governance)

• Absent uniform standards or clinical documentation requirements

• Develop and enforce uniform standards and clinical documentation requirements (that include data safety mechanisms and build upon international best practices)

• Several policies have mandates for standardizing data and/ or interfacing with the NHMIS: National Health Policy, Strengthening Secondary Health Care Service Delivery, Integrated Disease Surveillance and Response Policy, National Strategic Health Development Plan Framework, Nigeria Global Health Initiative Strategy, National ICT Policy and FCT eHealth Policy

• Discordant software solutions and reporting used across ICT for Health projects • Lack of minimal data safety requirements for ICT for Health initiatives • No accountability mechanisms in place

• Establish minimum reporting, interoperability and integration requirements for software solutions used in Nigeria ICT for Health projects • Establish and enforce data safety requirements --Identify which governing body would be responsible for enforcement • Develop appropriate legal framework and ICT for Health guidelines (directly links to legislation, policy and compliance)

5. WORKFORCE STRENGTHS

GAPS

RECOMMENDATIONS

• Expressed commitment from government to support capacity building (i.e., SURE-P)

• Capacity-building within identified initiatives not yet carried out

• Identify a plan and partnerships to carry out capacity-building as part of SURE-P

• Health workforce has variable experience and capacity to use ICT for Health • No national plan or strategy established to meet capacitybuilding needs

--Document best practices and lessons learnt • Strengthen institutional capacity training for trainers and trainees --Establish core competencies --Identify appropriate incentives structure --Integrate competencies into training curricula • Establish coordinated plan or strategy to meet capacitybuilding needs

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26   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

6. INFRASTRUCTURE STRENGTHS

GAPS

RECOMMENDATIONS

• National broadband plan in development

• Digital divide between rural and urban areas

• Identify incentives for expanding affordable services to rural areas

• Telecommunication corporations, which have been experiencing strong growth, are expanding coverage, even to rural areas

--High costs to both consumers and corporations expanding services • Inadequate infrastructure for power, Internet, etc.

• Establish sustainable financing mechanisms to improve and maintain facilities, power, Internet, etc.

7. SERVICES AND APPLICATIONS STRENGTHS

GAPS

RECOMMENDATIONS

• Numerous projects ongoing throughout the country (refer to inventory)

• Lack of harmonization across projects translating to lost opportunity for synergies and capturing data in national information systems

• Establish minimal reporting and interoperability requirements (see standards and interoperability above)

• Inability to systematically and securely share health information amongst providers and facilities

• Develop secure and integrated portals

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Global Benchmarks for Comparison and Lessons A recent review of ICT for health tools for frontline health workers, as part of the United Nations Commodities Commission29, indicates that governments in Sub-Saharan Africa, including Nigeria, are interested in developing an enabling environment for such tools and their implementation. In particular, they are invested in equipping their workforce with the right ICT for health tools, skills and knowledge and having mechanisms in place for standards and interoperability through setting up national health information systems. To contextualize and provide information on how Nigeria’s enabling environment, (especially as it relates to policy) compares with other settings, the environments of several countries were selected for qualitative review. Much can be learned from countries that have already developed comprehensive eHealth strategies and are working towards improving their enabling environments. Countries were selected for one of two reasons: (1) their approach and structure has been recognized as exemplary by technical experts and/or (2) their approach and structure is relevant to informing gaps within the Nigerian environment. The selected countries and regions are the United Kingdom, the Philippines, the European Union, South Africa, Ghana, Kenya and Rwanda. The most relevant approaches have been outlined in the context of the WHO-ITU framework and the gaps in the Nigerian environment.

Leadership and Governance

All of the benchmark countries have clearly outlined governance structures for ICT for health.

All of the benchmark countries have clearly outlined governance structures for ICT for health. The core component of the governance structure was a national steering committee comprised of executive level decision makers within the Ministries of Health and/or ICT. The actionable activities were typically overseen and carried out by a secretariat that also reported to the steering committee. In the Philippines, the Department of Health and Department of Science and Technology signed a memorandum of understanding to form a national steering committee and several subsidiary technical working groups. Supplemental bodies were formed around data and software compliance, with a representative from the Department of Health30. In both Kenya and Rwanda, a national eHealth Secretariat was formed31. In Rwanda, a National eHealth Coordinator was appointed to drive the ICT for health agenda32. The secretariats were led by a separate eHealth entity that reported to the working groups and steering committee. Responsibilities of the secretariats varied, but generally included overseeing and coordinating the implementation and operations of an eHealth strategy across multiple sectors. At a larger scale, the European Union (EU) established the eHealth Network, which is responsible for the alignment and interoperability of eHealth services across the EU and directed the European Commission on future Health ICT policy actions33. In Nigeria, the government-led technical working groups and the ICT4SOML Steering Committee are in accordance with best practices. The Nigerian approach would be further strengthened with a nationally appointed ICT for Health coordination platform, perhaps situated within the National Council for Health.

29. mHealth Support Tools for Improving the Performance of Frontline Health Workers: An Inventory and Analytical Review (2014). Available from: http://www.mhealthalliance.org/images/content/publications/1822-Inventoryand-Landscape-Report-v6-JH-screen-spreads.pdf 30. Philippines eHealth Strategic Framework and Plan: 2014-2020 (2014). Available from: http://uhmis.doh.gov.ph/ images/pdf/Philippines_eHealthStrategicFrameworkPlan_April152014_Release03_OK.pdf 31. Kenya National e-Health Strategy: 2011-2017 (2011). Available from: http://www.isfteh.org/files/media/kenya_national_ehealth_strategy_2011-2017.pdf 32. Rwanda National E-Health Strategic Plan: 2009-2013 (2009). Available from: http://www.isfteh.org/files/media/rwanda_national_ehealth_strategy_2009-2013.pdf 33. http://www.ehealth-strategies.eu/report/ehealth_strategies_final_report_web.pdf

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Strategy and Investment Establishing sustainable sources of funding to support ICT for health activities is a challenge faced by even high-income regions, in part because ICT investments may not always contribute directly to the bottom line34. In the LMIC benchmark countries, a variety of strategies are used to finance eHealth, but most are not long-term options. For example, Rwanda’s eHealth activities are funded by the government and outside donors via results-based financing on a project-by-project basis. Historically, the external funders in Rwanda have supported funding for the developing of information systems, and by extension, eHealth35. Ghana relies heavily on external funding given the unpredictability of health funding by the government36. In South Africa, local governments use funds from their annual health budget allocations received from the national government to support ICT for health activities and services37, which naturally leads to regional funding disparities for ICT for health. While details were not provided, the Philippines looked to establish a national eHealth fund in 2013, thus earmarking specific funds for eHealth38.

Legislation, Policy and Compliance The benchmark countries selected for review all have eHealth policies and/or strategies. The policies are relatively comprehensive and cover the vision and goals of implementing ICT for health within the health ecosystem. Governance, financing, data security, interoperability and infrastructure comprise some of the more common themes tackled in the policies. Special attention should be called to the Philippines for the relevance of its strategy to the forthcoming Nigeria eHealth framework. The Philippines utilized the WHO-ITU National eHealth Strategy Toolkit to structure and guide the development of the country’s strategic framework and plan. The resulting document contains a detailed and thorough approach to implementing eHealth in an efficient and coordinated manner. The plan covers all of the core components of an enabling environment and initial mechanisms for addressing gaps39.

Standards and Interoperability In Kenya, the development and setting of common standards will be a joint effort of the National eHealth Secretariat and National eHealth Working Group. A common architecture will also be developed in accordance with international best practices. Similarly, in the Philippines and Rwanda, a national eHealth architecture and standards are under development largely influenced by the architectures developed under the Open Health Information Exchange (OpenHIE)40 initiative. Ghana has no operational eHealth architecture and ICT for health implementations are fragmented and are not necessarily built on recognized standards. Furthermore, international data standards are discordant with the government’s standards (mandated through the National Health Insurance Scheme). Therefore, the strategy provides standards, for disease classification, diagnosis and treatment, and procedures for interoperability. South Africa has an established committee—the Private Healthcare Information Standards Committee—that oversees and ensures compliance to eHealth standards. In Scotland, a national standards development framework and national technical architecture have been developed. For interoperability across Europe, the eHealth Network will explore and adapt existing European and international standards to develop more specific eHealth standards for use across the continent. Interoperability testing will also be conducted.

34. Ibid. 35. Rwanda National E-Health Strategic Plan: 2009-2013 (2009). Available from: http://www.isfteh.org/files/media/rwanda_national_ehealth_strategy_2009-2013.pdf 36. Ghana National e-Health Strategy. Available from: http://www.nita.gov.gh/system/files/Ghana_E-Health_Strategy.pdf 37. eHealth Strategy South Africa (2012). Available from: http://www.isfteh.org/media/ south_africa_national_ehealth_strategy_2012_2016 38. Philippines eHealth Strategic Framework and Plan: 2014-2020 (2014). Available from: http://uhmis.doh.gov.ph/ images/pdf/Philippines_eHealthStrategicFrameworkPlan_April152014_Release03_OK.pdf 39. Ibid. 40. Refer to ohie.org for additional information on the Open Health Information Exchange initiative.

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Workforce

Lessons can be drawn from international implementations to help inform strategies within Nigeria.

The lack of ICT skills training of health care workers had been recognized as a weakness in the enabling environment in Kenya. Phase 1 of their eHealth strategy implementation included capacity building to support the implementation. The other benchmark countries acknowledged that basic ICT skills were a necessity among health care workers and other end-users and were a key investment. Capacity to support the development of the tools was needed as well. To address any potential gaps in ICT skills of health care workers, the health care workers in Rwanda will undergo training. Ghana planned to strengthen the general human resource capacity for eHealth, including both the health care workforce and ICT. South Africa established a local chapter of the international Future eHealth Leaders initiative to build a network for skills training.

Infrastructure Infrastructure development and investment was variable across the global benchmark countries. As such, infrastructure component priorities and needs differ. In the high income countries, where infrastructure was generally more advanced than that of LMICs, the focus of strategies and policies was on establishing and strengthening connected systems (e.g., interoperability, networking facilities, patient health information system) and ‘enablers’ (e.g., broadband, information exchanges)41,42. The strategies of the Philippines and South Africa indicated that the infrastructure priorities included connected systems. In addition in South Africa, improving network connectivity was also a priority. The Department of Communications, which had an eConnectivity Forum, was responsible for providing infrastructure for ICTs43. The policies and strategies of the other LMICs outlined the need to address and improve the basic infrastructure of the health system in addition to basic ICT infrastructure.

Services and Applications A wide variety of services and applications were being implemented in the global benchmark countries44. According to the policies and strategies, governments were interested in investing in services and applications that were: (1) in alignment with the overall health sector needs, (2) proven to improve efficiencies, (3) cost-effective, (4) readily scalable, and (5) integrated with other services.

41. eHealth Strategies Report: European countries on their journey towards national eHealth infrastructures (2011). Available from: http://www.ehealth-strategies.eu/report/ehealth_strategies_final_report_web.pdf 42. Scotland eHealth Strategy: 2011-2017 (2011): http://www.isfteh.org/files/media/scotland_ehealth_ strategy_2011-2017.pdf 43. eHealth Strategy South Africa (2012). Available from: http://www.isfteh.org/media/ south_africa_national_ehealth_strategy_2012_2016 44. Please refer to the following databases for country-specific inventories of eHealth tools: http://www.mobileworldlive.com/mhealth-tracker, http://healthmarketinnovations.org/ and http://www.mhealthworkinggroup.org/ resources.

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30   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Summary of Recommendations and Conclusion This section summarizes the recommendations for the Nigeria enabling environment for ICT for health, outlined based on the seven components of the WHO-ITU framework.

Leadership and Governance In order to strengthen leadership and governance for ICT for health, coordination and communication must be strengthened. Gaps identified in relation to coordination include decentralized leadership, poorly delineated roles and responsibilities and individualized strategic approaches and initiatives. In order to address these gaps, an overarching, inter-ministerial governing body for ICT for health should be established. The governing body should have clearly defined roles and responsibilities and include representation from all levels of government – Federal, State and LGAs. Coordination of efforts should be realized across these levels, as well. In addition, a strategic framework for leadership, coordination and implementation should be developed to guide the establishment of these processes and ensuing activities. Communication challenges identified underlined fragmentation and duplication of efforts in the ICT for health environment. There are multiple stakeholders involved but no clear and consistent mode of engagement and communication. An interface for cross-sector communication and collaboration should be established. It will be important to engage all key stakeholders to enhance partnerships and ensure cooperation and coordination.

Strategy and Financing While there is no overarching national eHealth strategy or framework in place, work is being done through ICT4SOML and partners to develop a National eHealth Framework. The framework will encompass the numerous strategic drivers that are already in place (e.g., political will and commitment, health system needs and opportunities). Such a framework could be built upon to develop an informed and comprehensive National eHealth Policy and accompanying strategy. To further enhance the enabling environment for ICT for health, sustainable funding must be identified. Furthermore, a clear financial management structure for ICT for health activities must be developed. It will be important for the leadership to prioritize the identification of viable funding sources, mechanisms and incentives. The sources and proposed mechanisms and incentives should be aligned with the health system and ICT for health priorities and needs. Clear management and accountability structures must also be in place. Advocating for funding will be important, along with engaging the private sector.

Legislation, Policy and Compliance As noted earlier, there is no national, overarching eHealth policy. There are numerous existing policies that cover activities within ICT for health. However, the policies are not harmonized. Multi-regulation is a challenge in the ICT [for health] environment despite regulation efforts by the FMCT harmonization committee. Further undermining progress is the lack of accompanying strategic documents for implementation and planning purposes and lack of alignment with or building-upon pre-existing related policies. Accompanying these challenges is the lack of a legal framework to provide further guidance for ICT for health activities. A legal framework should be developed to help guide ICT for health activities, especially as they relate to data safety and security. As mentioned earlier, an overarching national eHealth policy should also be developed.

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Beyond these frameworks and policies, there is a need for enhanced accountability, coordination and compliance across all of the stakeholders involved. There is robust engagement of multiple stakeholders in ICT for health implementations. A systematic way to engage the stakeholders has not yet been identified but will need to be done. With multiple stakeholders, there are multiple tools and implementations. Key software being used by the government in the health domain has not been explicitly outlined. It will be important to further develop the nationally used and endorsed software into evidence-based interoperable systems that meet appropriate standards and promote the integration of government and non-government ICT for health initiatives. To address duplication of efforts and enhance compliance, a mechanism for the regular review and updates of policies and on-going implementations should be identified.

Standards and Interoperability Minimal reporting and interoperability requirements should be established and enforced.

In the health ecosystem, uniform standards and clinical documentation requirements are absent. Within ICT for health, in particular, there are discordant software solutions and varied reporting structures used across projects. Furthermore, there is a lack of minimal data safety requirements for such software and tools used in ICT for health initiatives. With a lack of accountability mechanisms in place, including no clear responsible governing body, it will be important to identify a national body that will be responsible for governing health standards and patient and data safety. The governing body would oversee the development of uniform standards and clinical documentation requirements, building upon international best practices. It would also be responsible for enforcing compliance to the standards and ensure that minimal requirements are met. In conjunction, minimum reporting, interoperability and integration requirements for software solutions used in Nigeria ICT for health projects should be established. Data safety would need to be addressed, as well. Requirements should be identified and enforced. The legal framework should take data safety into account.

Workforce The health workforce in Nigeria has variable experience and capacity to use ICT for health. No capacity-building to address this challenge has been carried out. Additionally, there is no national plan or strategy established to meet capacity-building needs. Addressing capacity-building may be able to change the health workforce culture and enhance the use and adoption of ICT for health tools in Nigeria. As part of SURE-P, capacity-building in the use of ICTs will be supported. A plan and partnerships to carry out these activities should be identified; best practices and lessons learned should be documented, as well. Learnings from this initial activity can be used to inform a coordinated plan or strategy to meet capacity-building needs throughout the various potential end-user groups. For health care workers, capacity building can be conducted through formal institutions (e.g., training schools, continued medical education required courses). Core competencies and incentives should be identified and integrated into existing training curricula.

Infrastructure A digital divide exists between the rural and urban areas. Contributing to the divide are prohibitive costs to both consumers and corporations looking to provide and expand services. The inadequate infrastructure for power and connectivity are crucial barriers to ICT for health implementations. Appropriate incentives for expanding affordable services to rural areas should be identified, along with sustainable financing mechanisms to improve and maintain facilities, basic health equipment, power and Internet/broadband connectivity.

Services and Applications The fragmentation and duplication of ICT for health activities presents a lost opportunity for synergistic collaboration and the capture of data in national information systems.

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32   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Furthermore, the disconnect leads to an inability to systematically and securely share health information amongst providers and facilities for enhanced care and improved decision-making. Therefore, minimal reporting and interoperability requirements should be established and enforced, and secure and integrated data portals that allow for the linking of data into national health information systems should be developed.

conclusion The Nigeria ICT for health enabling environment is transitioning from experimentation and early adoption into developing and building up. While challenges exist in each of the core component areas, it will be of utmost importance to address the gaps around legislation, policy and compliance; standards and interoperability; strategies and investment and infrastructure. A most crucial next step will be to use the findings to inform the development of the National ICT for Health Framework. Such a framework will help strengthen initiatives, like ICT4SOML, and lead to greater impact.

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Appendix 1 full list of documents reviewed DOCUMENT TITLE

TYPE OF DOCUMENT

RELEVANT SECTION

ICT4SOML Highlights Report

Report

Background

ICT4SOML Aide Memoire

Informal Report

Background

ICT4SOML Situational Analysis

Report

Background

WHO-ITU National eHealth Strategy Toolkit

Guidelines

Entire Document

National Health Policy

Policy

Nigeria Policies

National Human Resources for Health

Policy

Nigeria Policies

FMOH Integrated Disease Surveillance and Response Policy

Policy

Nigeria Policies

National Strategic Health Development Plan Framework

Framework

Nigeria Policies

Nigeria Global Health Initiative Strategy

Strategy

Nigeria Policies

Nigeria ICT Policy

Policy

Nigeria Policies

FMOH Equipment Policy

Policy

Nigeria Policies

FMOH Guidelines on Medical Equipment

Guidelines

Nigeria Policies

FCT eHealth Policy Draft

Policy

Nigeria Policies

mHealth Support Tools for Frontline Health Workers

Report

Global Benchmark Policies

UK/Scotland

Strategy/Report

Global Benchmark Policies

Philippines

Strategy

Global Benchmark Policies

European Union eHealth Strategies Report

Report

Global Benchmark Policies

South Africa eHealth Strategy

Strategy

Global Benchmark Policies

Ghana eHealth Strategy

Strategy

Global Benchmark Policies

Kenya eHealth Strategy

Strategy

Global Benchmark Policies

Rwanda eHealth Strategy

Strategy

Global Benchmark Policies

GSMA mHealth Feasibility Report: Nigeria

Report

Other Relevant Documents

Trustlaw Report on Privacy and Security

Report

Other Relevant Documents

Standards and Interoperability

Report

Other Relevant Documents

Sustainable Financing

Report

Other Relevant Documents

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34   ASSESSING THE ENABLING ENVIRONMENT FOR ICTS FOR HEALTH IN NIGERIA

Appendix 2 list of key informant organizations • Clinton Health Access Initiative • Health Information Systems Program • The Nigerian Federal Ministry of Health • Pathfinder International • Futures Group • National Agency for the Control of AIDS • Society for Family Health • Saving One Million Lives • SURE-P MCH • National Primary Health Care Development Agency • JSI Deliver • PRINN-MNCH • Centers for Disease Control • National Agency for Food and drug Administration and Control • PATH • Nigerian Communications Commission • Federal Ministry of Communications Technology

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  UNITED NATIONS FOUNDATION IN SUPPORT OF ICT4SOM   35

PHOTO CREDITS FRONT COVER: United Nations Foundation INSIDE FRONT COVER: Photographer: Emeka Chukwu, Event: client tracking, Venue: Kobi PHC, AMAC Abuja PAGE 9: United Nations Foundation PAGE 12: United Nations Foundation PAGE 14: United Nations Foundation PAGE 16: United Nations Foundation PAGE 23: Photographer: Jimmy Daniels, Organization: Instrat, Event: Midwives training, Venue: Kano PAGE 27: United Nations Foundation PAGE 33: United Nations Foundation PAGE 37: United Nations Foundation

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  UNITED NATIONS FOUNDATION IN SUPPORT OF ICT4SOM   37

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