Equipping Laboratories for Stronger health systems

By Emmanuel Uko

The journey of supporting and augmenting laboratories in Africa has only started, and evidently, the gap is huge. At the WHO Polio lab in Maiduguri, Borno State, eHA identified cases of damaged, obsolete and inadequate equipment and swung in to supply the needs with support from the World Health Organization (WHO).

As we walked into the office of Professor Marycelin Baba, the Director of the Laboratory, Professor of Medical Virology and lecturer with the University of Maiduguri, we could tell how busy the facility had become on a daily basis. Samples from patients were brought in  on a queue for processing. “Our work here is becoming satisfying”, Prof told us expressively, “especially with partnership from the World Health Organization (WHO) and eHealth Africa (eHA). They have provided various major equipment that enable the center to remain functional”, she said, her passion unwavering for 32 years in the profession.

The lab in Maiduguri, was set up by  Global Polio Laboratory Network (GPLN), to distinguish poliovirus as a cause of acute flaccid paralysis (AFP) from AFP caused by other diseases. It serves the northern part of Nigeria while the one earlier established in Ibadan, Oyo State, serves the southern part of the country. 

Prof. Marycelin Mandu Baba, Director, WHO Polio Laboratory in Maiduguri, is happy to have participated in the polio eradication process in Nigeria.

Photo Credit: eHA

The WHO Polio Laboratory in Maiduguri, like many other labs in developing countries, often  grapples with acute shortage of equipment, reagents, machines, power supply and human resource, which affect its productivity. Research has shown that the number of optimally functional laboratories accredited to international standards were 380, as of 2014; 91% of these were in South Africa. This means that 12 out of 49 countries in the region had one or more laboratories accredited to international quality standards; 37 had none. However, the Global Polio Laboratory Network consists of 146 WHO-accredited polio laboratories, in 92 countries, across the six WHO regions of the world.

Nigeria has 2 of those 146 WHO-accredited polio laboratories. eHA currently provides support to 7 laboratories: 2 in Nigeria, one each in Uganda, Kenya, Ethiopia, Egypt and the Democratic Republic of Congo. The organization is strategizing to commence support to laboratories in Cameroon, Côte d'Ivoire, Ghana, South Africa, Senegal and Central African Republic. This support will improve laboratory and diagnostic services for Africa’s teeming population. “We continue to carry out needs audits and take steps to offer solutions where we identify gaps,”  said eHealth Africa’s Project Manager, Tolulope Oginni. eHA has supported the lab with digitized biosafety cabinets for tissue culture, a Polymerase Chain Reaction (PCR) Workstation, a PCR thermomixer, multi-channel and single-channel pipettes of varied volumes for serology.

Dr Muhammad Talle of the WHO Polio Laboratory in Maiduguri showcases how the new PCR thermomixer donated by eHA works.

Photo Credit: eHA

Dr. Muhammad Talle remains hopeful that the lab will continue to deliver appropriate services according to approved standards.

Photo Credit: eHA

“eHA has brought us relief”, said the Assistant Director for Lab Technical Operations, Dr Bamidele Oderinde, who came in later to the conversation. “The new machines help to reduce technical problems and the functionality complaints we have. We have upgraded our operations, research capabilities and training standards for our students”.

Professor Baba remains keen on contributing her quota towards the eradication of viral diseases, through differential diagnosis of acute flaccid paralysis. According to her, the newly equipped lab benefits people beyond Borno State and extends to other parts of Nigeria. Supporting this lab and other laboratories is part of eHA’s service areas, to build and operate effective laboratories in-country across the globe, and develop the tools and technology needed for effective dissemination and use of public health-related information.

The Director, Prof. Marycelin Baba (3rd right), with eHA delegates and other staff of the laboratory, during eHA’s visit to the lab.

Photo Credit: eHA

Renewable Energy for Improved Healthcare Delivery in Nigeria

By Juliana Okoro

Access to energy is a prerequisite for quality health care and it is fundamental to the achievement of universal health care coverage and the Sustainable Development Goals. Yet, about one in four health facilities in Sub-Saharan Africa lack access to electricity, and three in four facilities lack reliable power. The lack of sufficient and reliable power is jeopardizing the well-being of hundreds of millions of people, especially women and children, who often bear the brunt of inadequate primary healthcare services. According to Dr Julie Yemi-Jonathan. O, Country Manager, We Care Solar, “without a reliable source of electricity, nighttime deliveries are most of the time, attended in near darkness, cancelled or conducted by flashlight, and the outcomes are often tragic.”

Off-grid renewable energy solutions present a key opportunity to provide clean, reliable and cost-effective electricity to rural health centers, which can dramatically transform the quality of healthcare services provided to rural communities.

Harnessing the enormous potential of renewable energy to improve energy access for primary healthcare facilities requires combined action from the health and energy sectors. To this end, the Nigeria Energy Conference, which took place between 20 - 22 September 2022, brought together key energy and health sector stakeholders, including policy-makers, practitioners, financial institutions, development partners, and NGOs that can play a role in enhancing electricity access for primary healthcare facilities.

During a panel session at the conference, eHealth Africa facilitated a discussion about sustainable energy for improved healthcare delivery in Nigeria. The panelists discussed what needs to be done to ensure that Primary Health Centers (PHCs) have access to energy for better health outcomes. Acknowledging the challenges most PHCs face, the panelists elaborated more on how the lack of electricity in primary health centres has led to more medical emergencies and increased mortality rates.

The panel discussion sparked the much-needed, cross-sector thinking around how to deliver energy to health facilities, especially in resource-constrained environments. A resounding takeaway was that distributed solar power and energy-efficient devices hold great potential for creating stronger and more resilient health systems in Africa and beyond.

We Care Solar's deployment of solar suitcases to Primary healthcare centers has had a tremendous impact on reducing child mortality and maternal mortality rates. According to the company’s representative on the panel, “a lot of our health facilities do not have access to a reliable power supply. We have seen cases where surgeries are turned down because of a lack of power. Sometimes surgical operations are suddenly interrupted, leading to the death of the patient, due to power failure”. This she said, “prompted We Care Solar to develop the Solar Suitcase”. 

Another speaker, Mohammed Bello, a project manager at eHealth Africa, identified solar energy as the reliable solution to these challenges. He highlighted some projects implemented by eHealth Africa with support from partners and stakeholders to ensure health facilities across the country have access to a reliable power supply. According to him, eHealth Africa is working with the Nigerian Energy sector and Integration Consulting firm, which are critical players on issues concerning energy.

The panel speakers and moderator after the session hosted by eHealth Africa at the Nigeria Energy Conference 2022

Key lessons from the panel session hosted by eHealth Africa at the Nigeria Energy Conference 2022:

• There is a dire need to increase renewable energy access in primary health centres, especially those in remote areas.

• The use of solar panels as an alternative source of electricity in primary health centers will help mitigate the energy challenges faced by primary health centers.

• Health facilities should be a top priority in electrification plans for both national governments and development partners. Off-grid renewables offer rapidly deployable, reliable, cost-effective solutions.

• In order to address the energy access needs of healthcare facilities, the energy and health sectors must work together. This should happen at all levels, from strategy and planning to policies, budgeting, procurement and implementation.

• Innovation has to be encouraged and promoted, as in the case of the solar-powered suitcases by We Care Solar. Also, in the design of robust, low maintenance, efficient, user-friendly medical devices suited for remote off-grid areas.

• Energy-efficient medical devices, combined with off-grid renewable energy and telecommunications, can expand the services offered by primary health centres in under-served communities. This also reduces the need for patients to travel to larger, more distant facilities.

• There are funding opportunities from donors as long as the organization involved can provide evidence of work done in this field.

How eHealth Africa is implementing the Geolocation Health Facilities Database Initiative (GHFDi) Project in the Republic of Togo

By Friday Daniel, Chinedu Anarado and Munachi Okoro

The public health space has relied on platforms from multilateral agencies and nonprofits to plan interventions. Platforms such as the Humanitarian OpenStreetMap, the WHO Integrated Supportive Supervision (ISS), and electronic surveillance (e-SURV) database, GRID3, and the Global Health mapping platforms were some of the only sources of information on health facility data. But these data sources can be inadequate, rarely reflect the realities on the ground and do not have the imprimatur of relevant government authorities. Equally, Ministries of Health in most WHO countries lack the capacity to curate and manage their health facility data, leaving a critical information gap in the health planning process. 

The WHO conceived the Geolocated Health Facility Data initiative (GHFDi) project as a public good to enhance access to information on the status, location and functionality of health facilities across participating WHO member countries. The overall idea is to deepen capacities in each country to manage this data, ensure its openness and availability in planning public health interventions. 

The GHFD project requires participating countries to grow their capacity to curate and manage their health facility data. But first, an assessment of the existing health facility list or registry is essential. This is expected to provide insight into the efforts required to achieve an ideal scenario which is a database of health facility information, with name, location, unique identifier, geographic coordinates and hosted in an open source platform. Countries may then choose to share this information with a global database managed by the WHO, and then invest in an ongoing process to grow their capacity to ensure the information is updated periodically. 

eHealth Africa is one of the implementing partners of the AFRO region responsible for implementing this project in the Republic of Togo. On the 9th of August 2022, an introductory meeting was held at the headquarters of the Ministry of Health in Togo. This meeting was organized by eHealth Africa in partnership with the Ministry of Health and the WHO country office. 

It brought together various stakeholders responsible for establishing and updating the health facilities database in Togo, including the Ministry of Health (MSPAUS), the National Institute of Statistics and Studies and Demographics (INSEED), as well as the delegate ministry in charge of Territorial Development.

Landscape assessment and data collection session during the workshop in Togo

With an introduction by Dr. Ouedraogo Romain Hilaire, health systems coordinator at the WHO country office, Mr. Compaore Fabris, eHealth Africa representative in Togo and Chinedu Anarado, program manager, eHealth Africa, discussed with the participants on how GHFD seeks to strengthen the capacities of the Ministry of Health to guarantee the availability, quality, accessibility and use of a health facilities master list (HFML) in countries. 

This capacity building should enable the Republic of Togo to have a standardized database open to the public. Participants discussed the seven strategic pathways through which the GHFD initiative will strengthen the Ministry of Health, including governance and policies, partnerships and collaboration, technical capacities, innovation, financial sustainability, communication and advocacy, interoperability, and data management.This introductory meeting led to the conclusion and agreement to hold a participatory landscape analysis workshop on August 30th and September 2nd.

At the end of this workshop, it was discovered that Togo has a unit in charge of the health services mapping, who oversees the health facilities master list (HFML). The Ministry of Health in Togo appreciates the initiative and sees it as an opportunity to strengthen the government's efforts to ensure universal access to care.

Group photograph of the workshop participants

eHealth Africa has since implemented a landscape assessment and is currently developing a report and cost work plan that will itemize the efforts required to bring Togo to the ideal scenario. 

To learn more about the GHFD initiative: https://www.who.int/data/GIS/GHFD 

How a Global Health Facility Database can improve the timely delivery of health services

By Chinedu Anarado

The COVID-19 pandemic amplified gaps in global capacity to respond to public health events of such dimension and scale. The world was slow to respond, and when it did, wealth inequalities ensured that some countries had access to life-saving support before others. Poorer countries largely bore the burden of COVID-19 as they grappled with huge infrastructure gaps while trying to ensure their people were safe from COVID-19. At the same time, global health strategists did not have access to the information they needed to deploy appropriate interventions to support developing countries. 

Bamali Nuhu Hospital, Kano Municipal, Kano, Nigeria

The impact of this scenario was predictable. Vulnerable populations were more affected, while those living far from health facilities required more effort to get vaccinated. In Africa, the average readiness rate for vaccine rollout was 40 percent. These issues highlighted the pressing need for improved data that can provide relevant insights into the location of health infrastructures and the distribution of healthcare services. The world needed definitive answers to a straightforward question: where are the health facilities?

Quality data about the location and status of health infrastructures at the local, national and international levels could have improved global efforts to contain COVID-19. With reliable information on health facilities, Governments can improve their vaccine logistics, distribute personal protective equipment (PPE), and expedite vaccine and therapeutics rollout. It became evident that if we want to rapidly reach the needed populations with the necessary support, we must understand their accessibility to health facilities. 

In December of 2021, the World Health Organization (WHO) launched a global campaign to improve access and visibility of health facilities among member states. This global initiative is being implemented across WHO regional offices in Africa (AFRO), South East Asia (SEARO), Eastern Mediterranean (EMRO), and the Western Pacific (WPRO) regions. The goal is to help countries collate and validate their health facility master list and contribute this information to a global database of health facilities. 

“In this age of information, member states need updated database tools to reach the World Health Organization’s triple billion targets for healthier populations, universal health coverage (UHC), and health emergencies protection.”

— Steve Macfeely, Director, Data and Analytics ,World Health Organization

Republic of Tanzania’s Health Facility Registry

We can achieve these challenging targets with robust and authoritative data collection, integrated into a collaborative system that allows citizens and municipalities to identify the locations and services provided by health facilities in their vicinity.

This Global Health Facilities Database (GHFD) will serve as a central repository, providing information such as the health facility’s name, location, and type while assigning a unique identifier to each. In addition to improving aspects of primary care, this data can improve response time, identify gaps in quality, and support advanced health emergency efforts, such as the COVID-19 response.

The public health space has relied on platforms from multilateral agencies and nonprofits to plan interventions. Platforms such as the Humanitarian OpenStreetMap, the WHO ISS, and e-SURV database, GRID3, and the Global Health sites mapping project were some of the only sources of information on health facility data. But these data sources can be inadequate and often do not reflect the realities on the ground. Hence, the WHO has conceived the Global Health Facility Database (GHFD) project as a public good to enhance information access on the location and status of health facilities across all WHO member countries. 

The GHFD project will require participating countries to update their health facility data, participate in an assessment of the existing health facility list or registry, sign an MoU with WHO to share that information with a global database managed by the WHO GIS office, and receive capacity support to ensure the information is updated periodically. A standard health facility list should bear information on the status, location, and capacity. 

Each facility in each country will come with a unique identifier on the GFHD database. Thirty-two countries in Africa are participating in the project’s first phase, which will run for five years. eHealth Africa is implementing this project in five countries: Cameroon, Chad, the Gambia, Seychelles, and Togo. For eHA, this is one of the ways we support the strengthening of health systems and ensure that we can improve access to care for vulnerable populations.

“Supporting WHO member states with establishing and maintaining a master list of health facilities and combining them into a standardized health facility registry will not only strengthen national healthcare delivery systems but also provide a critical resource needed to respond to any public health emergency of international concern (PHEIC).”

— Vince Seaman, Senior Program Manager, Polio, The Bill and Melinda Gates Foundation

We believe that the time has come to support establishing and maintaining a master list of health facilities in each WHO member state and the creation of a global health facility database (GHFD). The availability, quality, and accessibility of the master list of health facilities and the Global health facilities database will transform our capacity to deliver interventions and ensure that wastage of health consumables such as vaccines reduces and health support is prompt and timely. 

Five crucial points for a successful data collection exercise

Insights from the Kano State Primary Health Care Monitoring and Evaluation systems assessment

By Chinedu Anarado

Are you planning a data collection exercise? If yes, you will be best served with some of our field experience implementing various data collection activities. eHealth Africa has more than a decade of experience collecting large-scale data, including qualitative and quantitative data. These span geographic information system data, vaccination and vaccinator tracking data, implementation of health systems improvement, and reproductive health services surveys. At every point in a calendar year, eHealth Africa team members are in a remote community interacting with locals and trying to understand the reason for some challenges preventing effective public healthcare service delivery.  

We recently concluded data collection efforts in Kano state to assess the challenges to data use in decision making within the monitoring and evaluation (M&E) framework of the Kano State Primary Healthcare Management Board (KSPHCMB). Leveraging support from Technical Advice Connect (TAConnect), eHA designed a mixed study to help us identify the quality of data, their collection process, and how best to encourage empirical decision making and improve the quality of healthcare services delivery. From a sampling population of over 1000 persons within the state primary healthcare (PHC) M&E system, including data generators and data users, we sampled 596 respondents for our quantitative questionnaire and 21 respondents for our qualitative tool. Their responses are now guiding our analysis and findings. Here are five big lessons we learned while delivering this effort. 

1. Stakeholder engagement is the key to success , and no stakeholder is more important than the other. Any person’s response could be the insight that unlocks the issues you are trying to solve. But they can make or break your ability to reach all your respondents and access all the communities from where you require information. Our approach was first to map out all the stakeholders and their interests in the project. Next, we agreed on a means of communication and what information was important to them before we reached out. Adequate and open communication is the key to successful stakeholder engagement. We ensure we address all their concerns, make them a part of the project, and, where permissible, include them in helping you to get access to the communities you need to study. Ensure to share your collection tools with stakeholders for their input where necessary. Overall, mainstream stakeholder engagement throughout your collection phases if you want to be successful in data collection.

2. Failing to plan is planning to fail. A field plan helps you understand how much time you need to start and end every data collection effort. Because we have a lot of experience implementing data collection, we can estimate the time required to conclude an exercise accurately. To do this, we establish certain parameters such as the number of data collectors available, how many questionnaires are to be administered, the coverage area, and how long it will take to administer a questionnaire to one respondent. With these figures, draw up a field collection plan to estimate the quantity of data one enumerator can collect in a day. This information is vital if you plan to pay data collectors based on performance or measure their effectiveness. Ensure to include a couple more days for mop-up and recollection. This will help address unforeseen delays and disruptions. eHA has designed a tool, Planfeld, that automates planning for field logistics in public health. Planfeld improves efficiency, reduces your turnaround time, and saves valuable resources. It ensures you do not miss any planned collection location since it allows you to input your planned coverage areas. Planfeld uses the data portal, published by eHA, with over 350,000 points of interest and more than 451,000 settlements across Nigeria and it is interoperable with any geodatabase

3. Test your tools. Our best practice at eHA is finding an equivalent to the sample population outside the study area and administering the proposed instrument. In this study, we leveraged the Jigawa State primary healthcare management officials to pilot our tools. The essence of this exercise is to give us real-time information on the issues we could encounter in the field and plan for them. Field testing will also highlight any problem with your survey tools and allow you to correct such problems before you begin data collection. For example, in the Kano State M&E assessment, we discovered challenges regarding the page-to-page transition. We spent the next couple of days reviewing the open data kit forms. We resolved this issue before commencing data collection in the field. Pilot testing is also the platform to test to see if your collection estimates and timelines are realistic. It is best practice to use pilot testing to simulate if your collection plan is workable.

4. Establish and implement quality checks. For example, collection teams must record the geo-coordinates of the collection locations. It is essential to check the time to complete a single form. These are some ideas that could signal the quality of data collection—for instance, spending five minutes on a form that should take 20 minutes to complete signals that an enumerator is doing something wrong. In a GIS collection project, an enumerator collected several points from one location. Our quality checking standards flagged this, and we immediately rectified it. Quality checks ensure you do not return to the field to implement recollection when you have finished data collection because of quality issues.

5. Engage and train experienced data collectors. Over the years, eHA has built up a cadre of enumerators who understand the job and our quality standards. This lessens the time we spend training them. It has also helped us to reduce field errors and ensure the correct information is collected. Pre-collection training is still important, though, and it is an opportunity to introduce new tools, collection modalities, and quality standards to your enumerators. Training also allows you to address respondents' psychography, social and cultural norms. For instance, do not send male enumerators to interview female respondents in a conservative society. If this must happen, it must be in public and under the supervision of another adult.

An assessment is only as good as the data supporting it. If you collect poor-quality information, the analysis will be flawed. Thus, it is vital to align some of your collection approaches, like the outline above.

Taking A Bite Out of Malnutrition

By Hafsat Jaafar

In less than a decade, the number of acutely malnourished children receiving treatment globally has quintupled: increasing from just over one million in 2011 to over 14 million in 2020. Nigeria has the second-highest number of under-five child undernutrition in the world, with about 2 million children suffering from severe acute malnutrition. A major challenge directly impeding child nutrition is the reduced access and utilization of maternal and youth-friendly sexual and reproductive health services. 

In 2016, the United Nations (UN) declared the Decade of Action on Nutrition and stakeholders have made more efforts to contribute to Nutrition improvement globally.  The World Bank is taking a double-pronged approach to address malnutrition through the Accelerating Nutrition Results in Nigeria (ANRiN) project. ANRiN focuses on reaching pregnant women, adolescent girls, and children under the age of 5 years. The project aims to abate the surging rate of malnutrition through appropriate maternal care, counseling,  infant and young child feeding, healthy sanitation behaviors, prevention and, when necessary, appropriate treatment of diarrhea, and ensuring adequate intake of essential vitamins and minerals through food fortification and supplementation.

eHealth Africa as a lead consortium member has begun the implementation of the ANRiN project in 12 LGAs of Kaduna State; Kaduna South, Chikun, Kajuru, Kagarko, Jaba, Zangon Kataf, Jema’a, Sanga, Kaduna North, and Ikara. The eHA- ANRiN team delivers the Basic Package of Nutrition Services (BPNS) and Adolescent Health Services (AHS) to beneficiaries of the project. This includes; behavior change communication to improve infant and young child feeding behaviors, namely early and exclusive breastfeeding (0-6 months) and appropriate complementary feeding (6-23 months); micronutrient powders to children 6-23 months to improve the quality of food provided for complementary feeding; iron/folic acid supplementation for pregnant women with counseling to improve compliance; intermittent preventive treatment for malaria to pregnant women; zinc and ORS for treatment of diarrhea in children 6-59 months; vitamin A supplementation twice a year for children 6-59 months; deworming twice a year for children 12-59 months; and counseling and provision of commodities to married adolescents in Kaduna for increasing birth spacing.

eHealth Africa among winners in 2021 edition of the Wiki Loves Africa Photo Contest

By Oladipo Olurishe

2nd Place Winner Wiki Loves Africa Photo Contest 2021

Our submission to the Wiki Loves Africa 2021 Photographic Competition came 2nd place out of over 8000 entries.

Wiki In Africa, the international organizers of the Wiki Loves Africa challenges the global photographic community each year to respond to a call for photographs of life in Africa along a specific theme. This year, the competition called for photographers to contribute images that visually interrogated the theme of Health + Wellness within the African context but looking at the positive aspects within that sector of African life.

The image which emerged as a global winner was shot at the Kano head office of eHealth Africa during a Malaria Microscopy Training conducted by our Laboratory team. The image was uploaded by Dr. Nirmal Ravi who leads the team and was present during the session.

Need for Stable and Sustainable Energy for better Healthcare Delivery in Nigeria: A case study of Kano and Osun State Health facilities

By Mohammed Bello

A recent publication by International Renewable Energy Agency (IRENA) stated that around a billion people today rely on health facilities without electricity supply. While most large hospitals may have round-the-clock access to power, electrification rates drop significantly for rural clinics. In the absence of reliable power, many of the basic life-saving interventions cannot be undertaken safely or at all.

Also, a recent study analyzing over 121,000 health facilities, in 46 low and middle-income countries, found that almost 60% of them lacked access to reliable electricity. Even facilities with electricity access can often suffer from an unreliable supply – negatively affecting the ability of medical professionals in rural communities to deliver modern health services.

Renewable energy is at the forefront of solving this issue. Off-grid (stand-alone and mini-grid) renewable energy solutions represent a cost-effective, rapidly deployable, and reliable option to electrify healthcare centers, transforming lives whilst bolstering global efforts to achieve Sustainable Development Goal 3 – good health and wellbeing.

Lack of sufficient and reliable power is jeopardizing the well-being of millions of people, especially women and children, who often bear the brunt of inadequate primary healthcare services. In fact, worldwide, more than 289,000 women die every year from pregnancy- and childbirth-related complications, many of which could be averted with the provision of better lighting and other electricity-dependent medical services (Sustainable Energy For All, 2019).

Like the pilot Energy survey from 10 selected health facilities across seven (7) Local Government Areas (LGAs) of Kano state in August 2020, the expanded phase was also carried out by the Nigerian Energy Support Programme (NESP), a technical assistance programme co-funded by the European Union and the German Government and implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH in collaboration with the Federal Ministry of Power (FMP), in partnership with eHealth Africa. It was conducted in close cooperation with geospatial data experts from INTEGRATION Environment & Energy GmbH (INTee) and Reiner Lemoine Institut (RLI) in Germany. This is part of the effort of the NigeriaSE4ALL Initiative to offer the most up-to-date, ground-truth, electrification data available in Nigeria.

The expanded survey was also carried out using a remote interview method for conducting interviews with the health facility in-charges in selected health facilities across 43 out of 44 LGAs of Kano, and 27 out of 30 LGAs of Osun state.

The findings from the result of the earlier concluded pilot survey necessitated the expansion in the scope of the survey, to gather sufficient information that would help provide a bigger picture of the energy needs, current situation, and guidance for the planning of possible implementation of suitable energy solutions for communities. The expanded scope covered a total of 291 health facilities - 173 health facilities in Kano state and 118 health facilities in Osun state.

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Helpdesk Agents administering questionnaires remotely to Health Facility In-charges in Kano and Osun State

The methodology used in collecting the data is through remote administration of survey questionnaires via phone calls, to ensure adherence to and support the COVID-19 response efforts in Nigeria and minimize the risk of infection through physical contact.

The primary aim is to assess energy gaps and identify the potentials for connection to an off-grid power source (renewable energy) and at the same time, determine the readiness for Covid-19 response at the Primary Health facility level.

The diagram below presents a summary of the implementation approach adopted for the survey.

Figure: Summary of the implementation approach adopted for the survey.

• The following four major data sources were utilized; 

  • list of health facilities extracted from the eHA data portal, 

  • Grid Clusters (potential location for off-grid infrastructure),

  • Senatorial administrative boundary

  • Contact list for Health Facility representatives

Health facility data and senatorial administrative boundaries were downloaded from the eHA Data portal/ GRID3 as shapefile format, power grid location was downloaded from Nigeria SE4ALL Webmap; in Geojson format, containing the KEDCO - Grid Data MV Lines (2016) and Osun state MV power lines. 

Finally, a structured survey was designed to capture the energy required capabilities and capacity of the health facilities.

Fig 2. Map showing the distribution of Primary health facilities in Osun state(Left) and Kano state(Right)

Activities

Remote administration of questionnaires to the health facilities in-charges via phone calls to identify the following:

• the health centers’ current electricity supply status

• general services provided by the health centers, 

• their current ability to cope with the COVID-19 response

• available infrastructure at the health center that would impact considerations around power requirements

Key Findings

• The survey findings indicate that all infrastructures do not meet up the minimal requirement stated by NPHCDA and some health services needed to be upgraded

• Power shortages affect the functionality of many types of equipment at the health centers across all assessed facilities thereby, affecting the output and overall performance of the facilities in terms of service delivery.

Benefits of the survey

The outcome of the survey provides visibility on areas and health facilities that require urgent intervention, such as the provision of PPEs to the health facilities and other equipment/infrastructures. Also, the data collected were subsequently published with updated health facilities infrastructure and services information on the eHA data portal for public access and to all for non-commercial use.

Finally, the survey makes readily available information relating to health facilities and the preventive measures taken during the COVID-19 crisis.

Future Survey Use Case Potential:

The remote survey showcased the capacity to effectively gather information on energy sources and requirements whilst supporting efforts in preventing the spread of the COVID-19 virus, without requiring a face-to-face engagement. 

Considering the necessity for energy supply, especially at health facilities, these surveys present a clear understanding of current energy systems that may not be sustainable and the need to consider alternative sustainable energy systems that would have minimal impact on climate change and make lives better.

Ultimately, surveys can be conducted nationwide to establish a baseline for the energy requirements of Primary Healthcare facilities.

It is evident that the functionality and efficiency of the Nigerian health systems especially in rural settings, can not be optimized with the use of on-grid electricity, some components of which are affected by unstable weather due to climate change. As such, harnessing renewable energy will be an alternative way of addressing the persistent power challenges in the health sector.

The Program Partners

Remote Data Collection as a First Step for Developing a Digital Information System to Guarantee the Supply of Quality-Assured Blood to the South African Population

By Dr. Alexander Pinz

The project    

The provision of safe and high-quality blood and blood products is a significant challenge for blood establishments in times of crisis. Depending on the crisis at stake, blood demand may suddenly explode, e.g. with mass casualty events; or there will be shortages in blood supply because of infectious diseases (epidemics, pandemics), and environmental catastrophes (e.g. floods, droughts). In these situations, it is important that blood establishments can rely on adequate information and emergency plans, enabling them to ensure the continuous supply of blood and blood products to both the entire population, and the persons severely hit by the crisis. However, currently, blood establishments are rarely included in national or regional emergency management plans. They often lack adequate information technology, enabling them to foresee slowly emerging crises or to react appropriately to catastrophic events that suddenly happen. According to the participants in the CoordinatedBlood-Workshop, which took place in Berlin in September 2018, these challenges apply to the South African blood supply system, too.

To better prepare blood establishments for crises, the BISKIT-consortium—comprising eHealth & Information Systems Africa, the Paul-Ehrlich-Institut (German Federal Institute for Vaccines and Biomedicines), and the Working Group Inter-disciplinary Security Research (Free University Berlin), the European Research Center for Information Systems (University of Münster), and the Chair for Software & Digital Business (Technical University of Darmstadt)—has started the project Blood Information System for Crisis Intervention and Management, funded by the German Federal Ministry of Education and Research. The aim of this research project is to improve the supply of safe and quality-assured blood and blood products before, during, and after a crisis to the South African population. To achieve this objective, the consortium is going to 

• develop an information-system including a user-interface (demonstrator) for data-based decision-making, 

• develop crisis management plans and recommendations for crisis communication, and

• organize and implement capacity building training on the use of the demonstrator.

The challenge

To accomplish these objectives, we need an enormous amount of data. First, we have to map the South African blood transfusion as well as crisis management systems, including their major stakeholders. Second, we have to visualize the entire blood supply chain from vein to vein. Thus, we have to assess every single process step such as donor recruitment, donation, processing, and testing, transportation, and storage, as well as issuing of blood products. Also, we need GIS data on the locations of the relevant facilities like blood establishments, mobile clinics, hospitals, etc. Finally, we need quantitative data on the duration of each process step, the number of donors/donations, number of products, etc. However, due to the COVID-19 pandemic, we are not allowed to fly to South Africa to start our data collection process. So what can we do?

The solution

We exploited the digital tools available to us to start a virtual data collection process. Thus, we use video conference systems to implement key-informant interviews with relevant stakeholders of the South African blood transfusion and crisis management system. We store the data in a CKAN-portal that only members of the BISKIT consortium can access. To make the information obtained via these interviews available to the entire consortium, we transcribe the interviews with artificial intelligence software. We then analyze the anonymized transcripts with cloud-based as well as standard qualitative analysis software.

Having, so far, conducted 20 key informant interviews with persons responsible for different parts in the blood supply chain, and the crisis management system, we have t great insights into how the South African blood transfusion and crisis management systems work. We can use these insights to map the relevant actors and processes of the respective systems. In addition, we now have a notion of the different data available for upload. With this information, we start modeling the blood supply chain from a logistical perspective, and, thus, get the project started.

The world saw more video calls this year due to the COVID-19 pandemic.

Sure, virtual data collection differs from data collection on-site. The social aspects of collaboration are missing. Nevertheless, in the interviews, we created a good atmosphere with the project partners in South Africa. Using video calls enabled us to at least see each other and get the relationship-building process started. This adaptation to the travel restrictions resulting from the COVID-19 pandemic has shown us we can collect data with digital technology. This approach enables us to better focus on the travels that are relevant for project success. It helps us to reduce our carbon footprint of development cooperation work. However, we are also looking forward to getting to know our project partners in person. Because in the end, this will further improve the quality of the data we can collect, and, thus, contribute to the aim of increasing the resilience of the South African blood supply system by using digital technology.

Dr. Alexander Pinz is the Project Manager for the Blood Information System for Crisis Intervention and Management (BISKIT) project at Paul-Ehrlich-Institut (PEI). PEI is the leading organization within the BISKIT consortium and responsible for coordinating the project implementation.

Supporting Vaccine Logistics and Maintaining the Cold Chain in Northern Nigeria

By Sadiq Haruna Hassan

A child in Kano State getting vaccinated

Every year, Nigeria spends millions of dollars to procure vaccines. The amount has grown from over US$ 302 million in 2015 to an estimated US$ 426.3 million in 2020. 1 Once the vaccines have been procured, a major challenge is maintaining the cold chain in transit to and on-site at last-mile health facilities. The cold chain is the system of storing and transporting vaccines at recommended temperatures—ideally between 2°C and 8°C—from the point of manufacture to the health facilities where they are used.2 If the cold chain is broken at any point between manufacture and usage, it could result in:3

• Loss of vaccine potency

• High vaccine wastage rates

• Loss of funds spent on procuring vaccines

• Need for re-immunization

To maintain the cold chain, health facility workers, and cold chain officers at local government and state levels in Nigeria must monitor and track the performance of cold chain equipment (CCE) regularly. Health workers record data on daily temperatures of CCE and the functionality of the equipment at health facilities across the country ( i.e. whether the equipment is working or not) using paper-based charts and forms, and cold chain officers visit health facilities routinely to collect this data.

A vaccinator in Kogi State shows us the vaccine to be used in her House-to-House Immunization Plus Days visit

As a result of insecurity, the location of the health facilities, and now, the COVID-19 pandemic, conducting this process in Northern Nigeria has been challenging. 

Vaccine Direct Delivery is a third-party logistics (3PL) service offered by eHealth Africa to the Sokoto and Zamfara State Primary Health Care Management Boards. Through this service, eHA picks up the required amount of vaccines from the state cold stores, transports them at the appropriate temperatures, and delivers directly to health facilities that are equipped with functional CCEs, ensuring that the cold chain is maintained and that the vaccines remain potent even in transit. In addition, using the VARO application, eHA helps decision-makers and key stakeholders to remotely monitor the performance of CCEs at 393 apex health facilities in both states.

A Health Delivery Officer in Zamfara State downloads the temperature records of Cold Chain Equipment

In Kano state where VDD is not operational, the apex health facilities, LG, zonal, and state cold stores keep track of CCE performance using LoMIS Stock, a solution developed by eHealth Africa. The solution allows health workers to send reports about vaccine stock data including vaccine utilization, wastage, and cold chain equipment functionality, using their mobile phones. These reports can be accessed in near-real-time by cold chain officers and decision-makers so that the faulty cold chain equipment can be fixed and back-up protocol for maintaining the cold chain can be followed.

Vaccines save lives. At eHA, our goal is to provide our partners with accurate data and technological tools so that they can better reach underserved populations with potent life-saving vaccines.

VDD’s inroads against Vaccine Shortages in Zamfara State

By Sadiq Haruna

Even though the federal government of Nigeria, adopted the Push-Plus system of vaccine delivery in 2013, Zamfara State experienced challenges with vaccine supply and availability at the health facility level. This led to large numbers of newborns and infants being completely unvaccinated or not completing the full vaccination course. eHealth Africa began providing third-party logistics (3PL) services to the Zamfara State Primary Health Care Management Board through the Vaccine Direct Delivery project in 2019. Through the service, vaccines are delivered directly to all the government health facilities and 14 local government cold stores in the state.

See the numbers so far:

Using Geospatial Technology to Improve Vaccination Coverage Rates: A Case Study of Ganjuwa LGA, Bauchi State

By Fatima Mohammed

In May 2012, Nigeria and 193 other member states of the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP), a strategy to launch the “Decade of Vaccines” during which millions of deaths would be prevented through more equitable access to vaccines, by 2020. Two important targets of this plan were that all 194 countries should attain a national coverage of 90% and 80% in every district or equivalent administrative unit, for all vaccines.

Since the launch of the plan, the National Program on Immunization (NPI) led by the National Primary Health Care Development Agency (NPHCDA), has made great efforts to increase the immunization coverage rate in Nigeria. Immunization is a top priority for decision-makers and they have collaborated with partner organizations to develop strategies to strengthen the delivery and demand for Routine Immunization (RI) and Supplementary Immunization Activities (SIAs). As a result, more children have been vaccinated than ever before1. However, Nigeria is still ranked as one of the countries with the lowest immunization coverage rates globally2. Several factors such as the insurgency in the Northeast, and cultural perceptions and beliefs leading to non-compliance and drop-out rates, have contributed to this but a major challenge has been the lack of an accurate denominator.

A child getting vaccinated during a vaccination campaign in Kogi State

What is a denominator?

A denominator usually refers to the total estimated number of eligible individuals in a population or the total estimated number of people in a target population3, 4. When delivering immunization services, health personnel develop micro plans to ensure that immunization services reach every community5. Micro-plans are used to identify priority communities, determine denominators/ eligible individuals, identify barriers and develop work plans for deploying solutions to those barriers6. Denominators are essential during the microplanning process to make sure that eligible people are not left out.  If health workers and administrators are unaware of a community’s existence, that community may be left out of micro-plans, denying eligible children the vaccines that they need. This will, in turn, reduce herd immunity in the state and eventually in the country, even though high immunization coverage rates are recorded.

An ongoing microplanning activity

For the past decade, eHealth Africa has worked with partners to support the National Program on Immunization and increasing the capacity of health systems to deliver quality health services, especially in underserved communities. eHA designs and deploys data-driven solutions and interventions that leverage Geographic Information Systems (GIS) technology, to identify and map settlements within the remotest communities, so that health workers can develop accurate, comprehensive micro-plans, to better plan and monitor health interventions.

A Data Collector collecting settlement data in Bauchi State

Through the Vaccinator Tracking Systems (VTS) project, we track the movement of vaccinators during SIAs to identify missed settlements and ensure that these settlements and their target population are reached, achieving a wider immunization coverage. Having mapped all the 36 states of Nigeria through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) project, we provide up to date maps to states based on an accurate database of settlements and communities in  Nigeria, enabling our partner states to plan more efficiently. 

Case Study: Ganjuwa Local Government Area in Bauchi State

The Bauchi state master list of settlements contains 1,134 settlements for Ganjuwa Local Government Area (LGA). The planning for all interventions and projects in the state is based on this number. However, the eHealth Africa geodatabase has a list of 2,817 settlements for the same LGA, implying that almost 60% of the settlements in the LGA are left out during the microplanning process and consequently, during polio campaigns. Whenever eHA conducted the vaccinator tracking exercise based on the list on our geodatabase, the LGA perpetually fell below the target coverage rates.

To address this, eHA planned and conducted a “Hamlet Buster” activity to identify and rename the missed settlements in Ganjuwa LGA, in December 2019. The LGA had 2,051 machine-named settlements according to our geodatabase, the highest ever recorded in Nigeria.  Machine-named settlements occur when geospatial data collection tools pick up on features that are indicative of hamlet areas or small settlement areas. During a hamlet buster activity, field data collectors trace and visit these settlements using their geocoordinates, determine their name and accurate boundaries, and update them on the geodatabase. 

At the end of the hamlet buster activity in Ganjuwa, 1984 0f 2051 machine-named settlements were visited and renamed. This data will help to achieve the following in Bauchi State:

• Improve healthcare provision planning and Monitoring by updating the existing micro plans

• Harmonize the LGA/State master list of settlements with eHA’s geodatabase list

• Create more accurate health facility catchment area maps and targets for Routine Immunization and other interventions

“This work will help the state to achieve great milestones in health delivery because the data will not only be used for immunization but for other programs. It will make our planning for future activities easier and more realistic. The state is very grateful to eHealth Africa for this because we now have an authentic microplan. eHealth Africa also helped us to transit from paper-based to digital micro plans.”

— Bakoji Ahmed State Immunization Officer, Bauchi State.

Strengthening the Malaria Continuum of Care through Data Collection and Research

By Les de Wit and Emerald Awa-Agwu

In 2018, there were approximately 258 million cases of Malaria worldwide and 93% of these cases occurred in Africa. Pregnant women and children have been the focus of most Malaria eradication projects and this has led to a remarkable decrease in the prevalence and incidence of the disease in this population1. However, among young people and non-pregnant adults, the number of new cases is on the rise.1 and very little is known about the attitudes and health-seeking behavior of this group around Malaria.2

Patients at Nuhu Bamalli Maternity Hospital

To answer the questions about the knowledge, attitude and behavior patterns of young people and to inform Malaria strategy and program development to eliminate the disease, data was needed. 

With our expertise in data collection, eHealth Africa teamed up with Restless Development, a youth-led development organization, whose mission is to place young people at the forefront of change and development and CUAMM, an Italian non-governmental organization. This key goal of the project was to support the implementation of the Fighting Malaria Improving Health Project, funded by Comic Relief and GSK.

How did we do this?

eHA developed the digital survey tool, set up mobile devices for data collection and provided data visualization and analysis, as well as related training. The survey was created using an open-source tool often utilized in low resource settings, Open Data Kit (ODK). 

Following the creation of the electronic survey, tablets were installed with an ODK app and configured to download the survey form. Data was collected from 5,000 individuals between the ages of 15 - 24 in three chiefdoms within the Port Loko district of Sierra Leone. Chiefdoms are the third and lowest administrative levels of governance in Sierra Leone. eHA trained a team of young people to conduct the survey and send reports electronically. Data collection could take place in the absence of an internet connection because of ODK’s ability to store data offline and then, synchronize to the server periodically when an internet connection became available.

eHA has developed an ODK companion tool, Gather, which allows for secure turnkey integration with various data sharing solutions. Using Gather, the collected data was able to be viewed online in an open-source visualization service, Kibana. The Gather and Kibana connection allowed representation of data in near real-time - as soon as the survey responses were synced from the mobile tablets the survey results would appear live in Kibana which had been configured with a number of data monitoring dashboards to provide aggregated views of response data.

At the conclusion of the two data collection periods, the results were automatically compared within Kibana and workshops were held in Lunsar in conjunction with all stakeholders to review and discuss survey findings.

A refresher training on ODK for researchers in Lunsar, Sierra Leone

Overall, the insights gained from these projects supported learning around how action research can help young people to take a leadership role in identifying the underlying causes of public health issues in communities.

eHealth Africa in the Fight against Malaria

Malaria is a public health issue that eHealth Africa is extremely passionate about. We have collaborated with several partners to identify challenges within the continuum of care and to provide the decision-makers and program planners with solutions that are appropriate for their contexts and with data that paints a true picture of the situation so that they can make informed decisions. 

A data collector in Kaduna State, Nigeria

Recently, we supported Malaria Consortium to map nine hard-to-reach local government areas of Kaduna State and eleven hard-to-reach local government areas of Kano State. We leveraged our expertise in Geographic Information Systems to collect geospatial data relating to settlement names and locations, and the nearest functional primary and secondary health facilities to the settlements over a period of two weeks.

Also, last year, eHealth Africa partnered with Case Western Reserve University, Hemex Health and the University of Nebraska Medical Center (UNMC) to design the Sickle and Malaria Accurate Remote Testing (SMART), an integrated point of care platform that diagnoses, tracks and monitors sickle cell disease and malaria in low-resource settings. The solution won the Vodafone Wireless Initiative Project Prize. 

eHA also worked with THINKMD and the Kano State Primary Health Care Management Board (KSPHCMB) to implement a 2-month study among community health workers (CHWs) in five LGAs to determine if the MEDSINC, a digital clinical assessment platform could improve adherence to the Integrated Management of Childhood Illnesses (IMCI) clinical guidelines. 

As always, our goal is to support our partners with technological solutions that can improve health delivery and increase access to quality health services for underserved populations.

LOMIS Stock Goes National!

By Joshua Ozugbakun and Emerald Awa-Agwu

How can accurate, real-time health inventory data will improve access to essential medicines and save lives?

With over 23,640 health facilities alone in Nigeria (as at 2005), collecting, managing and keeping track of health commodity stock data can be cumbersome. For the Nigeria Centre for Disease Control and Prevention (NCDC), the agency that is tasked with ensuring that pharmaceutical and health commodities are available in all the 36 states of Nigeria and the Federal Capital Territory, Abuja, this is a major challenge. To effectively prevent, treat and control diseases, medical supplies, and essential medicines must be available at all health facilities, treatment centers, and laboratories at all times. If the NCDC is unable to keep track of its own stock inventory data, its ability to deliver on its mandate will be hindered.

Prior to now, NCDC used to stock, track delivery, and management of pharmaceutical products using paper-based documentation. This method was not only error-prone but made it difficult to access and analyze information about pharmaceutical commodities stock and allocation across the 36 states in Nigeria and Abuja (FCT). This led to delays in the decision-making process to replenish commodities and in turn, stockouts at health facilities and treatment centers. 

The resultant effects of these delays and stockouts are poor health outcomes like high mortality and morbidity rates, low life expectancies, and distrust in the health system. There are already several unpleasant stories of people who had diseases that were not detected or treated adequately because the medical supplies and essential medicines were unavailable, and the statistics only worsen as one goes from urban to rural areas.

Health workers in Chiranchi Primary Health Center using LoMIS Stock to take health stock inventory

The LoMIS Stock mobile application

To address this challenge, NCDC partnered with eHealth Africa to automate its supply chain processes for the distribution of pharmaceutical and laboratory commodities. eHA introduced and scaled up LoMIS Stock, a solution that has been used by the Kano State Primary Health Care Management Board (KSPHCMB) to manage the supply and availability of vaccines and health commodities at last-mile health facilities, since 2014 with great success.

The tool allows health workers to submit reports relating to vaccine stock availability and utilization, alongside other details as required by various users, thus ensuring that near-real-time data relating to vaccine and pharmaceutical stock inventory can be accessed by decision-makers and health program planners for evidence-based planning and action. For example, NCDC’s ability to monitor the real-time stock levels of antiviral medications like Rivabirin at health facilities will ensure that response campaigns are executed in a seamless manner and that Nigeria is better able to respond to outbreaks of viral hemorrhagic diseases.

Since October 2019, eHealth Africa’s Technical team has been working with NCDC’s Supply Chain Unit to configure/customize the tool whilst entering data on its National Stockpile onto the system. Currently, over 300 commodities have been entered onto the system and we expect more commodities to be added in the course of this year. This will ensure that the distribution of these commodities is faster and more efficient and that the agency’s operational processes are targeted and data-driven. 

eHA and NCDC are employing a staggered approach to ensure that the tool is rolled out and adopted by the State Ministries of Health, treatment centers and NCDC-affiliated laboratories across 36 states and FCT of Nigeria by June 2020.  The potential for transforming health service delivery and health information management in Nigeria through technology is limitless.

Ensuring RI quality through Monitoring and Supportive Supervision

By Fatima Adamu

A comprehensive Routine Immunization (RI) program is critical to ensure health security for any population. RI helps to prevent and eradicate diseases, support surveillance, and strengthen preparedness and response to health emergencies. Every year, the Federal Government of Nigeria spends millions of U.S. dollars on the national immunization program. As of 2015, the estimated total expenditure on vaccination was US$302,103,133.

A mother and child at the Immunization Clinic at Nuhu Bamalli Hospital, Kano State

With so much money being spent, decision-makers at various levels need to ensure that they are getting value for money. Various partners, including eHealth Africa, support the government in various capacities to strengthen the capacity of Nigeria’s health system to provide quality immunization services and thus, reach all eligible children. eHealth Africa has been working with the Kano State Primary Health Care Management Board (KSPHCMB) to answer the following questions:

• What resources (infrastructure, human resources for health) are available and what is the status of these resources?

• What is the level of knowledge of the health workforce?

• What is the quality of services provided at the facility level? Do the services provided conform with set standard operating procedures?

• What challenges prevent health workers from providing immunization at the highest quality?

These questions represent the gaps that existed in Kano State’s RI program before 2014 when the Kano Connect project was launched. KSPHCMB was riddled with poor reporting, communication, and data management systems, making it difficult for them to have a clear picture of what was taking place at the facility level.  The Kano Connect platform embedded supportive supervision to increase accountability and RI service quality. 

A Routine Immunization session at Nuhu Bamalli Hospital

Supportive Supervision and Monitoring in RI

Supportive supervision fosters program improvement by imparting knowledge and skills to health workers through a hands-on approach. During supportive supervision visits or activities, supervisors go to the health facility to observe and assess the services provided by health workers using checklists or set indicators. Based on the results of their observation, they can correct errors and note any challenges with supply and resources. It also allows supervisors to measure and monitor trends in vaccination coverage and other immunization systems indicators like safety and vaccine management by reviewing reports and data.

In Kano State, the Kano Connect project/platform provided mobile phones, Closed User Group (CUG) platform, airtime and internet access to Kano state health workers across the three levels (state, zonal, and LGA) in the state, to enable them to send RI Supportive Supervision reports through their mobile phones and communicate with their colleagues for free. The Kano connect platform allows RISS officers to send action points from supportive supervision visits as well as the geo-coordinates of the health facilities.

A RISS Program Officer conducting a supportive supervision visit to Dala Maternal and Child Health Clinic

The RISS reports are submitted near-real-time (as soon as the sessions are conducted) as soon as sessions are conducted by both the RISS officer. This helps the state to monitor and track all RISS reports across the three levels.

Additionally, through the use of our designated Kano Connect online dashboard, managers are able to visualize the RISS data for action. Similarly, LGA level staff in the routine immunization system are also able to see both their individual performance and the data collected.  By visualizing more granular-level information, the data becomes more useful for decision-making within the sector which drives solutions towards improving RI coverage rates across the state.

The Kano Connect dashboard

Kano Connect has supported the Kano state government to verify locations of over 1,000 RI health facilities across the state using our expertise in Geographic Information Systems. This has led to an evidence-based geolocation update of the database and has helped to aid planning to reach all eligible children in the state. Additionally, the platform has made HWs more accountable in conducting RI sessions as planned and provided a system for managers to track action points in the state.

Since the uptake on the use of the Kano Connect dashboard in 2016,  the RISS submissions at the state, zonal and LGA levels have reached 98%, 100%, and 96% respectively; this has improved data quality of routine immunization supportive supervision in Kano State.

Finally, in the last five years, the Kano Connect platform has provided an accountability path for the entire RI program in Kano by improving data quality and frequency and by highlighting key gaps and action points for tracking and follow up. The continuous real-time effect of the Kano Connect platform helps managers to correctly identify issues and act promptly which in turn helps to increase the RI coverage among target populations of children across Kano State. Supportive supervision as a strategy in the delivery of public health services promotes quality at all levels of the health system through the development of professional competence among the health workforce.

Supporting Access to Immunization through Supplementary Immunization Activities

By Abubakar Shehu and Emerald Awa- Agwu

Supplementary Immunization Activities (SIAs) are one of the four strategies put forward by the Global Polio Eradication Initiative (GPEI) in 1988. In Nigeria, SIAs include Immunization Plus Days (IPDs), Outbreak Responses (OBRs) and other immunization outreaches conducted by the Nigerian government and its polio eradication partners. The aim of SIAs is to interrupt the transmission of the poliovirus by immunizing all children under five years of age with two doses of oral polio vaccine irrespective of their previous immunization status—unimmunized, partially covered or fully immunized.

A child receiving the Oral Polio Vaccine

SIAs are intended to complement Routine Immunization. However, in some areas, they represent the major strategy for catching unimmunized children and ensuring that they are vaccinated against polio and other vaccine-preventable diseases. Access to routine immunization services may be hindered for a variety of reasons including:

• Challenges with cold chain equipment leading to vaccine damage and loss of potency, and eventually, unavailability of vaccines. Caregivers are often reluctant to return to health facilities where vaccines were unavailable. This results in missed opportunities to commence or complete the vaccination course.

• Security challenges that make health facilities hard to reach by caregivers who bring children for immunization.

• Access-related challenges such as caregivers having to travel long distances to the health facility or being unable to afford the cost of transportation

• Wrong myths or perceptions about vaccinations such as loss of fertility as a result of vaccination.

SIAs take immunization services directly to children at their doorsteps, thereby bridging any gaps that may result from an inability to access vaccines at the health facilities. By achieving a vaccination coverage of at least 80% (that is, by vaccinating at least 80% of the targeted children with a potent vaccine), herd immunity can be achieved and the poliovirus can be deprived of the susceptible hosts which it needs to survive.

Through Supplementary Immunization Activities, children who were missed by routine immunization services can be reached with life-saving vaccines

Prior to 2012, Nigeria had been conducting SIAs but was still recording cases of wild poliovirus (WPV). After a holistic examination of the immunization program, it was discovered that there was a huge disparity between the actual versus reported immunization coverage. Reports from independent monitoring and supervision groups showed that the actual vaccination coverage of the SIAs was much lower than the reported coverage. There were many missed settlements and an even larger number of missed children. It was discovered that some vaccination teams never visited the communities, instead, they would discard the vaccines and record false information in the tally sheets to account for the empty vials. Not only was this frustrating the polio eradication efforts, but it was also causing the health system huge losses as a result of the wasted vaccines.

It became imperative to develop a methodology to improve vaccination coverage and ensure that the vaccination teams visited all the target settlements during SIAs. This led to the development and deployment of the Vaccination Tracking System (VTS) in 2012.

VTS provides healthcare administrators and partners in the polio eradication space with daily insight into the activities of vaccination teams during SIAs by collecting passive tracks of the vaccination teams using Geographic Information Systems (GIS technology-enabled android phones and uploading them onto a dashboard for visualization. This provides stakeholders with near-live data about the geo-coverage of the vaccination campaign. The system also identifies missed settlements on a daily basis so that immediate action can be taken and the settlements can be included in the ongoing campaign. Another benefit of the VTS is that it increases the accountability of vaccination teams because the vaccinators know that they are under constant supervision. This greatly reduces the risk of data falsification.

The VTS dashboard provides decision-makers with near-real-time data about the progress of immunization campaigns and outreaches

So far, VTS has been used to track 82 supplementary immunization activities in 30 states of Nigeria. A significant proportion of these states have seen an exponential increase in the vaccination geo-coverage rates from the first campaign tracked to the last tracked campaign.

Increase in vaccination coverage rates

VTS makes sure that eligible children who, for any reason, are unable to receive their vaccinations through the routine immunization sessions at the health facilities, have a second chance to be protected against vaccine-preventable diseases like Polio and Meningitis.

Innovations in Newborn Sickle Cell Screening

By ZIllah Waminaje

In Africa, 50% to 90% of children who have sickle cell die before their fifth birthday1. To improve their chances of survival, health systems must integrate Newborn Screening (NBS) for Sickle Cell Disease (SCD) with comprehensive treatment and management plans.

For almost five decades, newborn screening for SCD has been conducted using conventional procedures such as electrophoretic techniques, isoelectric focusing (IEF), high-performance liquid chromatography (HPLC) and DNA analysis, which require specialized laboratories with stable electricity, long sample processing times, expensive equipment and reagents, and highly skilled personnel. These methods, while ideal and feasible for developed countries, are inappropriate for low-resource settings like sub-Saharan Africa where 70% of SCD sufferers reside.

Screening with Sickle SCAN Device

Sickle SCAN is an innovative, cost-effective point-of-care (POC) device that has been developed by Biomedics Inc. to address the challenges of SCD diagnostics in low-resource settings. It is a simple rapid point-of-care test kit that can detect the presence of Hemoglobin A, S, and C and yield results within 5 minutes using blood from a heel/ finger prick or vein. In addition to newborn screening, the Sickle SCAN device can be used for premarital/preconception genetic counseling, blood donor screening, and general screening.

Sickle SCAN

Several features make the Sickle SCAN ideal for low-resource settings and large-scale mass screening programs. The first is that it does not require specialized technical knowledge to administer or read the test results. Anyone can be trained to use the device. The device does not require any special equipment or electricity and thus, eliminates the time, resources and logistics needed to transport samples to a laboratory. Finally, the short result turnaround time allows for the prompt identification of SC-positive babies so that early treatment can commence and survival rates can improve.

Since December 2018, eHealth Africa has partnered with Sickle Cell Well Africa Foundation (SCWAF), Pro-Health International and the Presidential Committee on the North- East Initiative (PCNI) to hold Sickle Cell awareness and testing outreaches in Adamawa, Bauchi, and Gombe states. Over 1000 people in all three states were screened using Sickle SCAN rapid diagnostic test kits. Patients who tested positive for sickle cell disease were immediately given routine medication and referred to sickle cell clinics.

Sickle Cell Outreach in Hong LGA, Adamawa

Since healthcare in many African countries is community-based, rapid POC test kits like the Sickle SCAN can be easily integrated into existing health programs like routine immunization at primary health care centers or health insurance schemes to facilitate universal screening and ensure sustainability. This will ensure that relevant data on SCD births, morbidity and mortality rates and long term outcomes are captured.

Sickle Cell Awareness and Testing Outreach in Toro LGA, Bauchi

eHealth Africa continues to work with partners to address health inequalities by ensuring equal access to quality and effective diagnostic tools to achieve universal health coverage.

How eHealth Africa supports Universal Health Coverage across Africa

By Emerald Awa- Agwu

April 7 is World Health Day and this year, the World Health Organization (WHO) is focusing on Universal Health Coverage (UHC).

WHO: Universal Health Coverage - What does it mean?

Good health is crucial for developing economies and reducing poverty. Governments and decision-makers need to strengthen health systems so that people can get the healthcare and services that they need to maintain and improve their health, and stay productive.  However, improving access to health services is incomplete if people plunge further into poverty because of the cost of health care. WHO estimates that over 800 million people spend at least 10% of their household budget on health care which is indicative of catastrophic health expenditure (CHE).  CHE can mean that households have to cut down on or forfeit necessities such as food and clothing, education for their children or even sell household goods.

One of the targets of Sustainable Development Goal 3—Ensure healthy lives and promote wellbeing for all at all ages— is to achieve universal health coverage by 2030. Therefore, achieving UHC has become a major goal for health system reforms in many countries, especially in Africa.

Through our projects and solutions, eHealth Africa supports countries across Africa to strengthen the six pillars of universal health coverage.

1. Health Financing for Universal Health Coverage

WHO recommends that no less than 15% of national budgets should be allocated to health. We believe that accurate and up to date data, can ensure that available health funds are better allocated. In Nigeria,  we worked with several partners to map and collect geospatial data through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program. Data relating to over 22 points of interest categories including health facilities, was collected across 25 states and the Federal Capital Territory in Nigeria. This data helps decision-makers to distribute resources and plan interventions that target the people who need it most.

2. Essential Medicines and Health products

Vaccines are some of the most essential health commodities

Countries decide what medicines and health commodities are essential based on the illnesses suffered by the majority or significant sections of their population. They must also ensure that quality, safe and effective medicines, vaccines, diagnostics, and other medical devices are readily available and affordable.

When essential medicines and health products are procured, it is important to maintain proper records and to ensure that health facilities do not run out of stock. eHealth Africa created Logistics Management Information System (LoMIS), a suite of mobile and web applications, LoMIS Stock and LoMIS Deliver that address challenges in the supply of essential medicines and health products such as vaccines and drugs. In Kano State, health workers at the facility level use the LoMIS Stock mobile application to send weekly reports on the vaccine stock levels, essential drug stock levels and the status of cold chain equipment. Supervisors can view the reports in near real-time through the LoMIS Stock Dashboard and plan deliveries of medicines and health products to prevent stockouts of vaccines and essential drugs, using LoMIS Deliver. LoMIS Deliver reduces errors by automating the process of ledger entry to capture the number of vaccines on-hand at the facility and the quantity delivered.

3. Health systems governance

Health system governance according to the WHO is governance undertaken with the aim of protecting and promoting the health of the people. It involves ensuring that a strategic policy framework exists and providing oversight to ensure its implementation. Relevant policies, regulations, and laws must be put in place to ensure accountability across the health system as a whole (public and private health sector actors alike).  Effective health systems governance can only be achieved with the collaboration of stakeholders and partners who will support the government by providing reliable information to inform policy formulation and amendments. Over the years, we have worked with several partners to provide this support.

4. Health workforce

Health systems can only deliver care through the health workforce

The attainment of UHC is dependent on the availability, accessibility, acceptability, and quality of health workers1. They must not only be equitably distributed and accessible by the population, but they must also possess the required knowledge and skills to deliver quality health care that marries contextual appropriateness with best practices.

Recognizing this, eHA supports the Kano State Primary Health Care Management Board (KSPHCMB) to improve health service delivery by providing health workers in Kano State with access to texts, audio courses, and training modules through an eLearning solution. Through the eLearning web and mobile-enabled platform, health workers can gain useful skills and knowledge on a wide range of topics. Read about the pilot of the eLearning solution here.

In Sierra Leone, we work with the Ministry of Health and Sanitation (MoHS), U.S. Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENET) to implement the Field Epidemiology Training Program (FETP). Through FETP, public health workers at the district and national level gain knowledge about important epidemiological principles and are equipped with skills in case/ outbreak investigations, data analysis, and surveillance. This positions Sierra Leone to meet the Global Health Security Agenda target of having 1 epidemiologist per 200,000 population. In addition, we support Sierra Leone’s MoHS to build additional capacity in frontline Community Health Officers (CHOs), who are based at the Chiefdom level through the management and leadership training program. CHOs are often the first point of contact for primary care for the local population and the MLTP program equips them to provide better health services and improve health outcomes at their facilities.

5. Health Statistics and Information Systems

In line with our strategy, we create tools and solutions that help health systems across Africa to curate and exchange data and information for informed decision making and future planning.  The Electronic Integrated Disease Surveillance and Response (eIDSR) solution has been used in Sierra Leone and Liberia to transform data collection, reporting, analysis, and storage for a more efficient response and surveillance of priority diseases. Its integration with DHIS2, a health information system used in over 45 countries, makes it easy for health system decision makers to visualize data and gain insight into the state of public health. Read more about our other solutions Aether and VaxTrac. In addition, we also support the Nigeria Center for Disease Control and Prevention (NCDC) by creation and maintenance of a data portal which serves as a repository for all datasets that are relevant to detecting, responding and preventing disease outbreaks in Nigeria.

6. Service delivery and safety

Staff at the Kano Lab

The Service delivery and safety pillar encompasses a large spectrum of issues including patient safety and risk management, quality systems and control, Infection prevention and control, and innovations in service delivery. With our experience working to respond to polio and ebola virus emergencies across Africa, we support health systems to mount prevention and control programs at the national and facility level. We are also committed to creating new technologies and solutions that can help health providers to develop better models of healthcare. We also construct health facilities ranging from clinics to laboratory and diagnostic facilities that utilize state of the art technology to correctly diagnose diseases such as Sickle Cell Disease, Meningitis, and Malaria.

Our Sokoto Meningitis Lab has been at the forefront of meningitis testing and surveillance in Northern Nigeria, offering reliable and prompt diagnoses to support the prevention of future outbreaks.

eHealth Africa continues to work with governments, communities and health workers so that everyone can obtain the quality health care, in a prompt manner and from health workers and facilities within their communities, thus achieving universal health coverage.

eHealth Africa supports data collection on the prevalence of Hepatitis B in three districts in Sierra Leone

By Uche Ajene

eHealth Africa (eHA) is supporting data collection on the prevalence of Hepatitis B in the Bo and Bombali districts, and Western Urban area in Sierra Leone, through its Hepatitis B Sero Survey project. U.S. Centers for Disease Control and Prevention (CDC) is funding this project.

A Sero Survey is a test of blood serum from a group of individuals to determine seroprevalence.

The African Regional Committee of the World Health Organization in 2014, endorsed a resolution to reduce chronic Hepatitis B virus (HBV) infection prevalence to <2% in children less than 5 years of age in all member states by 2020. In Sierra Leone, there is no accurate data on Hepatitis B Virus (HBV) infection among children and women of childbearing age. Hence the need for a survey to determine the prevalence of HBV infection among infants, children and women of childbearing age in order to inform the HBV vaccination policy of Sierra Leone.

In 2007, the country introduced the Hepatitis B vaccine as a component of the pentavalent vaccine provided at 6, 10 and 14 weeks of age. However, a birth dose of Hepatitis B vaccine recommended by WHO to prevent mother - to - child HBV transmission is not yet included in the routine immunization schedule.

The Hepatitis B community serosurvey conducted in the 3 districts, targeted some 2,544 infants aged 4- 24 months and their biological mothers to evaluate the risk of mother to child transmission and subsequent need for a Hepatitis B vaccine birth dose; and also 2,332 children aged 5- 9 years to assess the impact of childhood pentavalent vaccine on the prevalence of Hepatitis B virus infection among children.

Prior to collecting data, a five- day classroom and practical field training was conducted to:

• build the knowledge of the surveyors

• identify households

• counsel families ahead of the survey

• conduct a rapid diagnostic test on Hepatitis B and  the processing and tracking of venous blood specimen

As part of the training, a practical field exercise was also conducted to pretest participants’ knowledge on the classroom training.

eHA is a technology-driven organization. In a drive to discourage potential errors via paper-based methods and to present an automated approach to health data collection, eHA also trained supervisors and phlebotomists on the use of the Open Data Kit (ODK) tool. eHA provided the phones and data for the survey and installed the ODK  app (which is used for data collection in the field), the age= app for age calculation, and the  ODK dashboard. With ODK, data collection is done easily, and survey activities monitored in near real time.

A total of 3,934 forms were submitted via the ODK tool of which 3,158 (80%) of households visited were willing to participate in the survey. Out of the 2,232 households selected for children aged 2 months - 24 months, 1,704 children were enrolled which is 76% and 1,604 biological mothers of these children were also enrolled.

For the 5-9 year-olds, out of the 2,250 households selected, 80% participated with 1,811 enrolled. For children with vaccination cards, 1,186 were enrolled and 401 for the 5- 9 year- olds. A total of 551 serum samples were collected during the 6-week community serosurvey.  

eHA continues to work with the CDC and other partners with a view to increasing the early detection and reporting of government-identified priority diseases, especially when very little is known about HBV prevalence in Sierra Leone.

Benefits of a Direct Delivery Model

By Adamu Lawan and Emerald Awa- Agwu

eHealth Africa's third- party logistics service, VDD ensures that vaccines are delivered to last mile health facilities in a timely manner

Vaccination is one of public health’s most cost-effective interventions. According to the World Health Organization1, it prevents between 2 million to 3 million deaths every year. Even though there has been great progress towards achieving universal coverage, there are still 20 million unvaccinated and under-vaccinated children worldwide. To reach these children and to meet global disease elimination targets, all countries must provide an uninterrupted supply of potent vaccines to the most hard-to-reach and conflict-affected areas.

Nigeria has experienced challenges in maintaining functional vaccine cold chains and supply chains, leading to low vaccination coverage rates. Nigeria’s cold chain system consists of five levels: a national cold store which stores all vaccines in the country and supplies six zonal cold stores located in each of Nigeria’s six geopolitical zones. The zonal stores supply vaccines to the state cold stores, which in turn supply the LGA cold stores. The primary health care facilities staff have to visit the LGA cold stores to collect their vaccines on a weekly or daily basis depending on the status of their cold chain equipment.

This system was inefficient and time- consuming because health workers from over 9,000 health facilities in Nigeria often had to leave work to collect vaccines when they could be treating patients instead. In addition, the system was fraught with high operational costs and poor vaccine stock visibility, especially in transit.

To alleviate this problem, the Nigerian government adopted a direct delivery model called Push Plus in 2013, to transform its supply chain at the state level. A direct delivery model is one which delivers vaccines and dry goods directly from the state cold store to the last mile health facilities according to customized schedules, bypassing the LGA warehouses completely and preventing stock-outs.

The benefits of this model have been enormous. The direct delivery model has freed up an additional 1- 6 hours each week for health workers to attend to patients—time previously spent by health workers in transit to obtain vaccines. In addition, vaccine availability at the last mile health facilities has improved. By increasing the number of health facilities that have functional cold chain equipment, health posts and smaller health facilities can receive vaccines from closer health facilities instead of going to the LGA cold store every day. This has led to a massive drop in the stock-out rate. In Kano state, vaccine stock-out rates dropped from 93% to 3% and in Lagos State, from 43% to none. Not surprisingly, the immunization coverage of Lagos State increased from 57% to 88%. WHO2 lists vaccine shortages and stock-outs as a major cause of missed opportunities to vaccinate.

Nigeria is projected to spend about US$ 450 million by 2020 on vaccines, By increasing vaccine accountability and visibility, the direct delivery model has also reduced the amount of money that could be lost due to wastage and pilfering of vaccines.

eHealth Africa implemented Vaccine Direct Delivery, a third-party logistics service based on the direct delivery model in Kano State from 2014 to 2016 and currently implements it in Bauchi and Sokoto states. We work with the state primary healthcare development agencies to ensure that vaccines and dry goods are delivered safely and in a timely manner to health facilities. Using our LoMIS Deliver solution, eHA plans, schedules, and routes deliveries to enable health delivery officers choose the correct quantity of vaccines and dry goods from the state cold stores and deliver them to health facilities equipped with cold chain equipment. The process of determining what quantities to deliver at the health facility is fully automated to avoid manual errors. The project also incorporates reverse logistics—returning balance stock or waste, if any to the state cold store. VDD provides governments and other stakeholders with accurate, near real-time data for decision making and forecasting.

Through VDD, over 28 million doses of vaccines have been delivered to health facilities in Kano, Bauchi and Sokoto State from 2014 to date, reaching over 13 million children under the age of one. eHealth Africa continues to support governments across Africa with system-level approaches to transforming health service delivery.