Remote Assessment of Energy Gaps in Selected Health Facilities in Kano State: Identifying Potential for Alternative Energy Sources

By Mohammed Bello

In accordance with the standard for operations in most health centers, The World Health Organization (WHO)¹ states that the majority of health centers require energy for water supply, temperature control, lighting, ventilation, and clinical processes. In terms of electricity, Nigeria is ranked by the World Bank as the second country in the world and the first in Sub-Saharan Africa with more of her population not having access to electricity. With a population of about 200 million Nigerians, over 80 million representing 40% of the country’s population, lack access to grid electricity². Presently, power generation, transmission, and distribution rates are not commensurate with the energy demands of the population, giving rise to consumers depending on dirty and outdated energy sources that have adverse health and economic consequences on them and the society at large. Nigeria’s energy demand was estimated to rise to 88,282MW by 2020 from 15,730MW in 2016³ . Despite the country’s current installed generation capacity of 12,522MW, it generates an average of 4,500 MW, which is transmitted through its fragile National Grid and is grossly insufficient to meet the electricity demand of its 190 million population not excluding demands at health facilities.

Sadly, only an estimated 30% of Nigerians are connected to the national grid. This low and erratic power supply affects the community’s primary health centers forcing the management to rely on kerosene lanterns as a source of lighting and petrol generator as their primary source of electricity (UNDP Nigeria., 2015)⁴. As a result, this hinders the efficiency of health services and amenities for optimal operation.

To improve service delivery dependent on energy supply, there is a need to identify the gaps in energy sources of primary health centers in relation to needs/consumption. To this end, a pilot survey was carried out by 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 fürInternationaleZusammenarbeit (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 in line with the objectives of the SE4ALL initiative that are working globally to ensure universal access to modern energy services; doubling the global rate of improvement in energy efficiency, and doubling the share of renewable energy in the global energy mix by 2030 compared to 2010.

Due to the current pandemic (COVID-19) situation of the world and the country Nigeria, the pilot was geared at finding out how effective remote surveys can be applied to gather data required to understand and make decisions on energy challenges at health facilities. It was pertinent to adhere to all precautionary measures to prevent the further spread of the virus during an actual physical face-to-face survey. Hence, this survey employs a remote data collection approach in administering questionnaires, as an alternative to the conventional physical data collection.

Helpdesk Agent administering questionnaires remotely to Health Facility In-charges in Kano State

In this respect, eHealth Africa (eHA), a leader in the use of technology, data-driven approach plus in-country expertise in public health-focused activities in partnership with NESP having expertise in alternative energy research, conducted a Pilot Survey on selected Primary Health Centers in Kano State with the aim of assessing energy gaps and identifying potentials for connecting to an off-grid power source (renewable energy) and at the same time, their readiness for Covid-19 response at the primary facility level. 

For the purpose of this survey, five major sources of data have been employed which include; health facilities extracted from the eHA data portal, Grid Clusters (potential location for off-grid infrastructure), population figures, senatorial administrative locations, and structural survey questionnaires. Health facility data and senatorial administrative boundaries were downloaded in shapefile format from the data portal published by eHealth Africa, grid cluster was provided by NESP  (containing the cluster of buildings), population information was downloaded from VTS portal in raster format. Finally, a structure of the survey was designed to capture the energy required capabilities and capacity of the health facilities.

A four grouped structure survey form was designed. The first group was basic information from the respondent (8 questions), the second group was infrastructure equipment at the health center (6 questions), the third group was about services rendered by the health facilities (5 questions) and the fourth group was on energy sources at the health facility (12 questions).

Figure: 2.1Map showing the distribution of sample clusters and health facilities

A systematic snowball sampling survey technique was used through a phone call to the health facilities. Since the health facilities were predetermined and a focal person was also identified at each of the health facilities, which made the survey straight forward. Also, the collection process was digitized to an ODK web form.

Key Activities

eHA’s Program and GIS team worked with INTee to analyze remotely mapped clusters for suitability with mini-grid. At the initial phase, INTee shortlisted 30 locations for the survey and handed over the longlist to eHA, to come up with a shortlist of 10 health facilities preferably PHCs, using agreed criteria as highlighted below. The LGAs selected fell within the 3 senatorial zones of Kano  (Sumaila, Bagwai, Gabasawa, Kibiya, Karaye, Minjibir, and Tudun Wada).

• Their electrification status (off-grid and on-grid) and already mapped in OpenStreetMap by NESP

• The health center should be close to a settlement

• The health center should be located where there are nearby  buildings

• The locations and health centers should be within Kano state

  After shortlisting the facilities, a list of community leaders and health facilities in charge were generated along with their contacts for the purpose of conducting a remote interview with them. This is aimed at identifying the gaps within the community and the health facility with respect to their electrification status. 

  The survey sought to assess general information on the health center services and equipment,  and how this relates to their power requirements and current electrification status.  Their current ability to cope with the COVID-19 response were also accessed. eHA administered questionnaires to each of the shortlisted health facilities to identify their current energy needs. Daily calls were made from the call helpdesk to administer the questionnaire and individual responses were captured accordingly. The completed questionnaires were then uploaded to the KoBo Toolbox platform for analysis. NESP was responsible for conducting the analysis.

  To ensure a community-based perspective was covered, community leaders where the health centers were located were also interviewed. Questionnaires were also administered in a similar remote fashion. To capture the appropriate responses,  the local language was used to administer these questionnaires, and the feedback generated were also uploaded to the KoBo Toolbox for analysis purposes.

  Key success

  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.

  It also increased the availability of information related to health facilities and the preventive measures taken during the COVID-19 crisis.

  Beyond the energy needs, the analysis from data gathered during the survey showed that available infrastructures at the facilities do not meet up with the minimum requirements stated by NPHCDA. Some gaps in health services provision were identified and needed to be bridged. Furthermore, power shortages at the health centers across all primary health facilities were a common occurrence. All these were achieved via a remote survey which ensures a zero level of risk faced by data collectors.

The Program Partners

Our Path to Polio Eradication in Nigeria

By Uche O. Ajene

The eHealth Africa (eHA) story began when we were founded in 2009 to provide northern Nigeria’s health infrastructure with customized technology solutions for data-driven decision-making to improve public health. In 2012, we joined the Nigerian government, international philanthropy and development partners, regional and national NGOs, and implementing partners in the fight for polio eradication in the country. All partners brought different yet complementary expertise and experience to the fight, from grassroots community organizing to funding to policy advisory; each partner played a critical role in eradicating polio in Nigeria.  

In 2012, we were a very young and focused team. Our expertise was (and remains) providing technology solutions and operational and technical support. We focus on developing user-centric technology-driven solutions to collect, manage, and analyze data that is still being used today to enhance large-scale public health interventions. We also provide operational and technical support to bridge the gap in access to health delivery services. Through the years, we have worked as part of larger consortiums to implement various programs to address polio in Nigeria, from ensuring vaccine delivery to last-mile health facilities to implementing one of the most extensive community-involved disease surveillance programs in the region. 

On June 18, 2020, the World Health Organization (WHO) declared Nigeria polio-free, and here we revisit some of the steps we took on our path to polio eradication.

2012

Nigeria accounted for more than half of polio cases worldwide in 20121. It was an emergency that needed an immediate response.

Walking into the Kano EOC

Enter the Polio Emergency Operations Centers (EOCs)
The EOCs are a linchpin in Nigeria’s fight against polio. In 2012, we built the first of 8 EOCs, which act as command centers for decision-makers, partner organizations, and relevant stakeholders in the health sector to meet, review data, and take prompt actions to mount a coordinated response during emergencies. They are a government-led initiative to improve information sharing and joint programming (planning, implementation, monitoring, and evaluation) for improved polio (now other public health) emergency management. eHA built and currently manages the National EOC in Nigeria’s capital, Abuja, and seven state-level EOCs, located in Bauchi, Borno, Kaduna, Kano, Katsina, Sokoto, and Yobe.

Increasing Accuracy and Accountability through Tracking
Immunization Plus Days (IPDs) are supplementary immunization activities (SIAs), and mass campaigns complement routine immunization. All children under 5 receive two oral polio vaccine (OPV) doses during these campaigns to boost herd immunity. Polio eradication partners introduced Vaccinator Tracking System (VTS) to increase the accountability of vaccinators.

Under the Global Polio Eradication Programme, eHA mapped all 11 of Nigeria’s northern states in 2012. We collected geospatial data relating to points of interest, including settlements' names and locations and habitation status. Using this data, we supported states in developing accurate, comprehensive maps and micro-plans for planning SIAs, including IPDs. During each campaign, VTS uses Geographic Information Systems (GIS) technology to track, collect and store location data to identify missed or partially covered settlements. The data is downloaded, reviewed, and analyzed at the end of each day during the campaign. Decision-makers identify challenges, take evidence-based actions, and ultimately improve vaccination geo-coverage in high-risk states. Since 2012, over 88% of states in Nigeria have used VTS to increase accountability during campaigns.

Assembling Health Camp boxes in our warehouse

2014 - 2016: In all the nooks and crannies
Nigeria employed many strategies and implemented many programs to eradicate polio. Under the guidance of the National Polio Eradication Program, states created and adapted programs to suit their local contexts. Kano state Health Camps, a targeted mop-up campaign, were free health outreach events where members of each community got access to essential health checkups and free medications. They also provided another avenue for immunization against polio.

WHO procured the necessary medicine and equipment and packaged and distributed these essential medicines to health facilities across the state. Health Camps were a massive success; communities needed vital services and medications and attended these outreach events en masse. Using lessons learned from the implementation in Kano state, eHA supported Borno state in running health camps in seven Local Government Areas (LGAs) in 2016.

Child receiving OPV dose during house to house campaign

End Game Strategy
Despite best efforts during supplementary immunization activities, all eligible children did not receive the polio vaccine. In 2016, eHA supported the End Game Strategy (EGS) project in Kano state by tracking down all the missed children during the state’s IPDs so that they could be followed up and immunized before the next immunization campaign round. 

EGS was coordinated by the Kano State EOC, partner agencies (including UNICEF), and the invaluable support of the Kano Emirate council. The project line-listed all the children missed and categorized them based on the following reasons: Noncompliance (NC), child absent (CA), and block rejection (BR). Households reported by the house-to-house teams as having “no eligible children under 5” were tracked and verified to ensure vaccinators missed no children in those households. Working closely with the Kano Emirate council, Polio eradication partners addressed noncompliance and block rejection cases. Vaccinators revisited houses with absent children and vaccinated them immediately after their return from travels. eHA provided logistics support to District Heads, Ward Heads, Ward Focal Persons, Health Educators, and Senior team Supervisors to support the follow-up and vaccination of children missed during IPD campaigns.

2016: A setback

On August 11, 2016, after two years without a case of wild poliovirus, the Nigerian government reported that the disease paralyzed two children in security-challenged Borno state.  The almost decade-long insurgency in Northeast Nigeria presented a challenge for government and health partners. 

Nigerian Polio Eradication partners developed a more context-specific strategy to reach children in all parts of the state. The  Borno State Primary Health Care Development Agency (BSPHCDA), in close collaboration with WHO, the Bill and Melinda Gates Foundation, U.S Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), and other partners, launched a series of strategies to interrupt the transmission of the virus and reach all eligible children under the age of 5 in security-compromised, partially Hard to Reach (HTR) and HTR settlements.  We leveraged our GIS, field operations, and logistics expertise to collect and analyze geospatial data. The data helped real-time program monitoring and decision-making by the state and relevant key stakeholders. 396,607 children have been immunized in security-challenged areas of Borno state. An additional 2,195,369 children have been vaccinated in non-security-challenged areas.

Mapping Nigeria takes you through hills and streams

Our path to polio eradication in Nigeria has helped us live our mission of building stronger health systems and ultimately improving people's lives in our communities. We have traveled rugged terrain, surmounted obstacles, and developed incredible partnerships along the way. It has been challenging and adventure-filled, but each step taken on this path has been ultimately rewarding.

Improving Emergency Response by Upgrading Information Technology Systems to Better Respond to COVID-19

By AbdulHamid Yahaya and Emerald Awa-Agwu

The Kano State Polio Emergency Operations Center

When designing technology and data solutions, we take the unique needs and contexts of our partners into account. We are then able to give them custom solutions that integrate seamlessly with their systems and that can be deployed easily to respond to active and potential public health emergencies. We provide operational support to Nigeria’s Polio Emergency Operations Centers (PEOCs). Initially designed to coordinate the country’s response to Polio, the EOCs now serve as a command center for decision-makers, program planners, and partners in the health space to plan and mount a coordinated response to all public health emergencies and outbreaks.

In Kano State, the EOC has been instrumental for Routine Immunization (RI) and Supplementary Immunization Activities (SIAs). The State Emergency Routine Immunization Coordination Center (SERICC) uses the well-equipped data infrastructure at the EOC to easily visualize health facility immunization data and immunization coverage data from campaigns on a weekly basis in order to monitor thresholds of priority infectious diseases. This helps them proactively identify patterns and trends in disease occurrence and respond more promptly to forestall outbreaks or epidemics.

On April 11, 2020, when Kano State recorded its first COVID-19 case, we quickly needed to upgrade the phone system so that the state EOC could better respond to the outbreak. Kano state needed a call center where community members could report cases and persons of interest could be followed up. While we set up the call center, we needed to switch the Private Branch Exchange (PBX) from Elastix 2.5 to 3CX. A PBX phone system is a private telephone network used within an organization that allows users to communicate internally (within their company) and externally (with the outside world), using different communication channels. It is ideal for call centers because it also allows for more calls than physical phone lines and free calls between users.

The Kano State COVID-19 call center

This became relevant because it shortened our turnaround time so that we could set up any additional support queues and lines faster. The upgrade also supported an unlimited number of agents to be added to the phone system at no additional cost and even allow agents to work remotely. This was vital for the response in Kano State to keep track of the large number of calls that they received and the persons of interest that were identified in a short time. 

The call center agents do not need to be in a physical location to operate the lines which aligned well with the state’s movement restrictions and social distancing guidelines. Our partners and stakeholders were still able to collaborate, discuss, and resolve issues quickly using the 3CX WebMeeting feature for video conferencing calls. The call center logs over 500 calls on a weekly basis.

Because of our experience with Kano state, we were also able to support Nigeria’s COVID-19 response led by the Nigeria Centre for Disease Control and Prevention (NCDC) by developing an automated system for tracking and following up persons of interest who have been exposed to COVID-19 for a period of 14 days. The system can call thousands of contacts on a daily basis to verify whether or not they have developed symptoms.

Members of our Helpdesk team monitoring the PBX system

Thanks to 3CX technology, we currently support more than 3,000 dashboard users across 12 states with the potential for an unlimited number. We believe that technology is the key to developing sustainable and scalable solutions that can strengthen health systems.

Sustaining the Push: Essentials for Attaining a Polio-free Nigeria

By Mustapha Hadi Mustapha and Emerald Awa-Agwu

Children at a school in Kogi State receive the Oral Polio Vaccine during an Immunization Plus Days (IPD) activity

Today, June 19, 2020, the World Health Organization (WHO) declared Nigeria, polio-free.

The first requirement for attaining the polio-free certification—no wild poliovirus transmission for three consecutive years—was attained on August 21, 2019  1.

The Africa Regional Certification Committee’s visit to Borno State in March 2020 as part of the process for certifying Nigeria polio-free

This success is the result of several sustained efforts, including domestic and international financing, the commitment of thousands of health workers and the switch to electronic, technology-driven data collection and management systems which have given decision-makers and polio eradication partners the accurate data needed to develop plans and strategies for reaching every eligible child, even in hard-to-reach and security-challenged areas 2.

“Having achieved the milestones of primary requirements, the ARCC will first review the complete documentation report of the interruption of wild poliovirus type 1 and then proceed to conduct field verification visits to select states in the south of Nigeria. If the ARCC is satisfied with the national documentation and field verification after both visits in December 2019 and March 2020, the WHO African Region could be certified to have eradicated polio by mid-2020.”

— Dr. Fiona Braka, WHO Nigeria Team Lead, Expanded Programme on Immunization (EPI)

eHealth Africa supported these efforts by providing Geographic Information Systems-based solutions and services including the Vaccination Tracking System (VTS). Here is how states benefited :

• eHA supported states to develop a comprehensive, up-to-date list of settlements. 

In 2014 and 2015, eHA mapped the eleven northern states under the Global Polio Eradication Initiative (GPEI). The data proved so useful to decision-makers that eHA received funding from the Bill and Melinda Gates Foundation (BMGF) teamed up with the National Primary Health Care Development Agency (NPHCDA), the UK Department for International Development (DFID), Flowminder, the United Nations Population Fund (UNFPA) and the Center for International Earth Science Information Network (CIESIN) to map the rest of Nigeria during the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) project which lasted from 2017 to 2019. We also frequently execute data collection and campaign activities across the country during which we gather spatial and non-spatial data relating to several points of interest including settlements and health facilities. These data are housed in what we call the eHA Geodatabase (GDB). 

Using the datasets in the GDB, we have helped states in Nigeria to identify previously unknown settlements and update their master list of settlements. eHA developed and provided the states updated LGA and ward level maps. The maps include the geocoordinates, names, and delineated boundaries of known and newly identified settlements. These updated master list of settlements and the new maps allow health planners to develop accurate, comprehensive micro plans for Routine and Supplementary Immunization Activities and reach eligible children in the remotest communities.

The Vaccinator Tracking System dashboard

• eHA built the capacity of health teams at the state and local government levels to visualize and analyze vaccination coverage data for decision making during campaigns.

Through the VTS dashboard decision-makers, partners, and other stakeholders can access near real-time information about ongoing and concluded immunization campaigns such as the immunization coverage and missed settlements. eHA trained health teams at the state and LGA levels to easily access, visualize and analyze the data on the dashboard, and use it to promptly identify and address challenges that may affect the immunization coverage levels in the state. 

The milestones recorded by Nigeria’s Polio Eradication program prove without a doubt, the positive outcomes that are possible when decision-makers use quality data as the basis for planning and implementing projects. eHealth Africa is proud to be a part of Nigeria’s Polio success story. We thank and congratulate our partner organizations and governments at the national and sub-national levels, who were all instrumental in this achievement.

Going forward, we know that a strong immunization program is essential to sustain this success so, we continue to support immunization programs at the state and national levels through projects such as Vaccine Direct Delivery, LoMIS Stock, and Kano Connect.

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.

The Strides of Polio Vaccination in Hard to Reach Areas (HTRs) in Borno State

By John Momoh

As Nigeria marks 3 years and 10 months without a new wild poliovirus case, here is how the program has contributed to the Polio Eradication initiative in Borno State since 2016:

Inaccessibility to some settlements in  North East, Nigeria presents a great challenge to the immunization program in states like Adamawa, Borno, and Yobe states where the ongoing conflict is most severe. Health facilities in these states have been destroyed leading to a reduced number of eligible children being reached with Routine Immunization (RI) services. The mass displacement of people, migration from settlements, and insecurity have all hindered the planning and execution of Supplementary Immunization Activities (SIAs) such as Immunization Plus Days (IPDs) and Outbreak Response (OBR) campaigns in the region.

A child receives his vaccination at a settlement in Maiduguri, Borno state during an IPD campaign

In 2016, after a wild poliovirus outbreak in Borno, the  Borno State Primary Health Care Development Agency (BSPHCDA), in close collaboration with World Health Organization (WHO), the Bill and Melinda Gates Foundation (BMGF), U.S Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), eHealth Africa (eHA), Solina Health and other partners, launched the Reach Every Settlement (RES) and the Reaching Inaccessible Children (RIC) to access under-5 children in partially Hard to Reach (HTR) and HTR settlements respectively in order to interrupt the transmission of the virus.

Polio eradication partners at a working group meeting

eHealth Africa has been supporting the projects by leveraging our expertise in Geographic Information Systems, field operations, and logistics to collect and analyze geospatial data to aid near real-time monitoring of the program and decision-making by the state and relevant key stakeholders.

Pushing the Boundaries of Routine Immunization coverage

By John Momoh & Emerald Awa-Agwu

In 2017, following the results of the 2016-2017 Multiple Indicator Cluster Survey/ National Immunization Coverage Survey (MICS/NICS) Report, which put Nigeria’s routine immunization (RI) coverage rate at 33%,  the National Primary Health Care Development Agency (NPHCDA) declared a state of emergency on RI in Nigeria 1. This led to the establishment of the National Emergency Routine Immunization Coordination Centre (NERRIC) and its state-level counterparts, across the 36 states of the federation. NERICC and SERICC targeted states and local government areas that had low immunization coverage rates with various interventions, aimed at attaining a RI coverage rate of 84% by 2028. The majority of states in this category are in Northern Nigeria 2. 

Many reasons exist for low vaccination coverage rate including non-compliance by households, insufficient vaccines, health workers, and/or health facilities to meet the demand for immunization services. However, what happens when you have all these factors combined with insecurity, displacement of people, and physical destruction of health facilities?

eHA consultant in Magumeri LGA training the LGA RIE team on the use of electronic data collection methods

It’s an Emergency
The insurgency in Northeast Nigeria has been ongoing since 2009 and the current reality is that health workers and households face grave challenges delivering and accessing RI services. There are issues of security to consider as well as the migration/abandonment of settlements which hinder proper planning and execution of routine and supplementary immunization activities (SIAs). This has led to consistently underserved populations and thus, low immunization coverage rates.

eHA consultant in Biu LGA supporting the LGA RI Officer to micro-plan using GIS Maps

The Strategy
To alleviate this, the Borno State Emergency Routine Immunization Coordination Centre, in close collaboration with partners including the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), the Bill & Melinda Gates Foundation (BMGF), eHealth Africa (eHA), Solina Health, and Novel-T launched the Routine Immunization Expansion (RIE) strategy to expand RI activities to security-challenged areas in order to improve the coverage rates. This strategy uses Geographic Information Systems (GIS) solutions as the basis to identify and target settlements for RI sessions and provide proof of visitation, thereby, improving routine immunization coverage.

eHealth Africa's Role
We have leveraged our expertise in data management solutions and Geographic Information Systems (GIS), to provide end-to-end support for the implementation of the RIE strategy in Borno. We provide the RI teams with up-to-date GIS maps and a list of settlements that they use during their microplanning activity to estimate target populations and allocate catchment areas to health facilities across the state. Using these tools and local knowledge, the teams prioritize and plan what areas to reach using criteria like accessibility, habitation status, and the proximity to adjoining settlements. Furthermore, this allows each LGA to estimate the optimal number of teams and days required to cover all their targeted settlements for each round of RIE implementation. This process is critical to the program because it has a direct impact on logistics and finance planning. During RIE field implementation activities, we monitor RI teams’ coverage in security-compromised areas using GPS-enabled Android phones, similar to what occurs in the Vaccinator Tracking System project.

At the end of each round, we develop a post-implementation report and updated map which are shared with the relevant stakeholders for informed decision-making and progress monitoring.

The Progress So Far

As a result of using GIS technology, routine immunization coverage in security-challenged areas in Borno has increased from 12% in April 2019 to 88% in December 2019.

These results show the significant impact that innovative data solutions and GIS technology, combined with contextual insight and partnership can have on health interventions in low-resource settings.

Reducing eHealth Africa’s Carbon Footprint

By Onche Ogbole

At eHealth Africa, we attribute our successes in the interventions and programs we implement to the virtuous cycle that uses data to drive decision-making and execution. As an organization, we also employ the same virtuous cycle in our operations to become more efficient and sustainable. As we work to strengthen health systems and improve the lives of people in the communities we work in, we also have to look at how we operate to ensure that our operations do not burden or negatively impact the communities we live and work in.  As we reviewed how we work, we asked ourselves about our consumption of energy and had to challenge ourselves to become more energy efficient to reduce our carbon footprint while reducing our costs. When we started the journey towards energy efficiency, we knew that we had to do a better job with energy waste as it accounted for approximately 20% of our energy consumption. We knew that our approach had to be multi-pronged to get the results that we wanted for ourselves and needed to reduce our negative impact on the environment. Our approach included implementing policies, educating our people, and using technology and data to improve our systems.

What We Did and How It’s Working

In 2019, we started implementing our plan to be more energy-efficient and ensured that data was the bedrock of our decision-making and optimization. Our plan included: 

• Installing an energy management system (EMS). This smart system has automated the most common way we use energy, switching lights on and off. Now we no longer had to hope that the last person to leave the office remembered to switch off the lights,  it now happens according to a schedule.

• Installing a renewable energy system. Currently, we have installed a 180kw inverter systems at our Kano campus to provide backup to the existing diesel generator, and grid. These energy sources run on a schedule using a cloud-based monitoring, and scheduling system. eHA has generated 127,236.41kWh between January 2019 and March 2020 across most of our locations in Nigeria.

• Installing an Automatic Transfer Switch (ATS) in the Power house. This allows us to automatically select the appropriate available energy sources based on our load demand.

• Using energy-saving appliances looking for the most  eco-friendly options

• Conducted energy audits at our locations across Nigeria to determine load usage and design systems that best matched the usage at each location

• Facilitated environment and energy management training to our colleagues: We educated them about our environmental impact and energy management. This gave a clear perspective on how we can individually continue to reduce our electricity usage. This was complemented by introducing policies that supported better energy consumption. We have since observed an increase in employee awareness and a positive change in employee behavior. By December 2019, we observed a 30% decrease in our energy bills.

• Monitoring, tracking, and measuring daily energy usage. Currently, the engineering team keeps track of the daily energy consumption of all units at the Kano campus. This helps us know which block is consuming more energy and to see how we can immediately address the inefficiencies.

These energy efficiency measures put into place help us to ensure environmental sustainability at eHA. Last year, these measures contributed to the reduction of CO2 emission by 129 tons at the eHA Kano campus and 201.4 tons across all other locations. We will continue to do our part to reduce our carbon footprint and look for innovative and proven solutions to reduce our energy waste.

Partnerships and Networks: Essential for achieving food security

By Chinedu Anarado

By 2030, the United Nations (UN), and its agency, the Food and Agriculture Organization (FAO) hope to have achieved Sustainable Development Goal 2—end extreme hunger in the world. As of 2017, an estimated 821 million people globally are facing extreme hunger. The bulk of this group lives in Sub-Saharan Africa, where 237 million people were undernourished. In Northeast Nigeria alone, 2019 saw an estimated 2.6 million people left severely food insecure due to the insurgency and conflict1.

Climate change, poor farming practices and the nonexistence of sustainable partnerships and support systems all contribute to the growing cases of low crop yield. Most farmers do not have access to the right kind of information, and where they have information, they lack sustainable support to implement them.

During the planting stage

Recognizing this, the UN identifies the need for governments and private actors around the world to ramp up investment through enhanced international partnerships, research and extension services, and technology. This will increase agricultural productivity in developing countries, thus strengthening nutrition and food security systems. 

Here is how eHealth Africa leveraged partnerships and existing structures to drive the introduction and adoption of the Farm Management Tool (FMT) among 25 farmers in Kano State.

• FMT started as Cornbot, a mobile application built in partnership with Dr. Cornelius Adewale, the Bullitt Environmental Dellow at Washington State University. The application was built to aid farmers to identify, detect, manage and control Fall Armyworm (FAW), a major pest of maize and 85 other plant species. It was an entry for the 2018 FAW Tech Prize jointly sponsored by Feed the Future, the United States Agency for International Development (USAID) and the Centre for Agriculture and Biosciences International (CABI). These platforms continue to provide financial support, expert knowledge, and interventions to local farmers around the world.

• Upon winning the Frontier Innovation Award, eHA and WSU utilized the prize money to build FMT. The project was implemented in a three-pathway approach consisting of a mobile application and a web-based dashboard to aggregate data, face to face training sessions and practical hand-holding sessions. To recruit the farmers, eHA and WSU partnered with the Kano State chapter of the National Agriculture Extension and Research Services (NAERLS) to hold a pre-implementation workshop for 40 smallholder farmers. The workshop gleaned useful information that helped the project team to understand the farmers’ current agricultural practices, challenges, and level of knowledge.

A local farmer watches a video about bio-pesticide production using Neem leaves

• After the workshop, 25 farmers were selected to participate in the study. They each earmarked 25 square meters of test farmland to test the efficacy of incorporating four Good Agricultural Practices (GAPs) put forward by FAO, on crop yield. eHA partnered with Gwarmai Consulting, a local consultancy company to provide handholding support to the farmers, from pre-planting to harvest. The farmers learned soil testing, pest scouting, weeding, plant spacing, fertilizer application, and ash application for soils with high alkaline content.

Farmers at the Pre-Implementation Workshop

The results were impressive. In comparison to the Kano State average Maize yield of 2,750 kg/hectare, test farms recorded a 116% increase. Test farms also had a 195% increase compared with the national average of 2,020 kg/hectare.

In addition, the farmers acknowledged the value of the new information and committed to imbibe them and share with other farmers within their networks. It is often said that information is power. However, the information will never produce the desired effect without platforms and networks to get it across to those who need it. The success of the Farm Management Tool is an example of how Nigeria can reverse food insecurity if the right partnerships and platforms are leveraged to get much-needed information and skills across to local farmers.

Improving Emergency Response by Strengthening Humanitarian Supply Chain and Logistics: Warehousing

By Emerald Awa-Agwu and Mohammed-Faosy Adeniran

In the last five years, the world has seen a progressive rise in public health emergencies, leading to an increased need for humanitarian aid and relief 1.

During humanitarian response activities, large quantities of supplies including food and non-food items, essential medicines and even, human resources need to be deployed to the areas affected by the crises, within the shortest possible time. Sound logistics and warehousing infrastructure becomes imperative, as it could reduce the lead time and cost of transporting essential supplies to these areas; thus alleviating the disaster2.

Over the years, supply chain professionals have had to strategize to develop resilient, context-appropriate approaches to respond to a wide spectrum of crises in different geographical locations. Warehousing is an essential portion of these approaches as they can greatly enhance a health system’s capacity to be prepared for emergencies by storing needed supplies in central locations so that they can be distributed more promptly, in case of an emergency. During an emergency, they help to shorten the time spent getting aid to the affected people and thus reduce negative outcomes such as hunger, injury and/or death.

Here are some examples of how warehousing and logistics are being used to improve emergency response:

The Ebola Virus Disease (EVD) Outbreak in Democratic Republic of Congo (DRC)

The EVD outbreak in DRC started in August 2018 and for the response program led by the World Health Organization (WHO), the major challenge was getting medical and non-medical supplies to the DRC’s conflict-affected Northeastern region. To address this challenge, the WHO set up secondary hubs in Beni and Butembo towns (within the affected area), and five other district warehouses to receive supplies from the main warehouse hubs in Kinshasa (the capital city of DRC) and in Goma, the capital of North Kivu province. 

The complex logistics of Ebola response. Photo credit: World Health Organization

Through these hubs, the WHO has coordinated the storage and distribution of 17 million gloves, over 2 million surgical masks, 909 thousand gowns and over 200 thousand doses of Ebola vaccine, to enhance the Ebola response operations. The combined volume of these supplies is equivalent to two Olympic-sized swimming pools but it has been worth it. More than 1000 people have survived EVD in DRC and over 257,000 have been vaccinated.

Natural disasters in China

China is one of the most disaster-prone countries in the world. Between 2006 and 2010, the country recorded 90,000 deaths and economic losses worth more than 160 billion dollars as a result of natural disasters 3. In line with their 2015 Guidance on Strengthening the Construction of Natural Disasters Relief Supplies Reserve System, victims must receive basic relief items within 12 hours after the disaster breaks out. 

To achieve this, the Chinese government set up 24 relief supplies warehouses in cities around the country, while local authorities at the county to province-level were expected to replicate similar warehouses, especially in hazard-prone locations, taking the population distribution to account 4.

The Conflict in Northeast Nigeria

Since 2014, Northeast Nigeria has been plagued with insurgent activities, heightening the food and nutrition insecurity of vulnerable populations, and leading to the displacement of 1.92 million people. Another 7.7 million people in Borno, Adamawa, and Yobe states require humanitarian assistance. The World Food Programme (WFP) has supported national and state emergency efforts in Nigeria since 2015, by providing food and cash aid to 1.2 million internally-displaced people on a monthly basis.

Laborers loading food items in the Kano warehouse managed by eHA

During an emergency, the ultimate goal is to contain the emergency within the shortest possible time so that the loss of lives and property, as well as the disruption of economic activities, can be minimized. In such scenarios, both supply-side actors (health system administrators and providers) and demand-side stakeholders (affected populations and members of the general public) need to have the commodities that they need to respond to the emergency and to recover from the emergency, respectively. 

Tracking Unknown Settlements in Anambra State, Nigeria

Since 2012, eHealth Africa has been part of national and global polio eradication efforts. For the most part, our interventions and support have been deployed in Northern Nigeria. However, when two cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) were reported in Anambra state early this year, our field operations team was deployed to conduct Vaccination tracking and hamlet buster activities for the first time in eastern Nigeria.

The exercise was conducted in nine high-risk Local Government Areas of Anambra State and the data obtained from the exercise, including habitation status, geocoordinates, and settlement names, were used to develop comprehensive microplans for an upcoming Outbreak Response (OBR) activity in the state. 

We appreciate the members of our Field Operations team who work long hours, travel to distant locations and brave difficult terrain to help us reach every last child with lifesaving vaccination services.

Click the slide show to see how the trip went.

You never know what will happen on the field, so we take everything we need

Field Officers getting ready for deployment

Sometimes the road is dusty

Sometimes, there is insane traffic

But we always move together

The terrain is never easy, so, no mode of transportation is off limits

Even canoes

It’s grueling work- The PFOs need to train LGA ward focal persons and supervisors before the commencement of the campaign

But there’s always time for a selfie

Building Local Capacity and Infrastructure for Disease Surveillance in Africa

By Chinedu Anarado

Nigeria is the only country in Africa where polio is still endemic, however, the continent is still at risk of polio returning due to low immunity levels and weak surveillance systems.  Since 2016, the AVADAR project has been implemented in 8 countries across West and Central Africa to improve the quality and sensitivity of Acute Flaccid Paralysis (AFP) surveillance by health workers and key informants within health facilities and local communities, using mobile phones and an SMS based software application. eHealth Africa trained a total of 7,847 community informants to identify and report suspected cases of AFP, which is the defining symptom of Polio.

The AVADAR mobile application

The project increased the rate of AFP detection and reporting and put the implementing countries in a better position to meet the World Health Organization’s targets for AFP surveillance. In the Democratic Republic of Congo (DRC), for example, a total of 499 true AFP cases have been reported by community informants through AVADAR, a significant improvement over traditional paper-based surveillance systems which yielded 38 cases in the same period.

The Challenge

Our goal was to model a system that would enable health systems in the implementing countries to find, report and investigate AFP cases, and that would be sustainable in the long run. It became imperative for the health systems in these countries to take ownership of and lead the implementation and expansion of the AVADAR model, and possibly replicate it for the surveillance, reporting, and investigation of other diseases of public health concern. However, without the requisite skills, most countries will fail at effectively managing the system including reporting and managing the investigation of cases, and tracking and resolving technical issues.

The Strategy

Relying on our experience with the execution of AVADAR, where some informants were groomed to take on more roles on the project, we worked with the WHO to identify champion informants who had distinguished themselves through their timeliness on the system and technical aptitude with the AVADAR devices. Some of these informants were trained to serve as investigators—who track and review reported AFP cases to confirm if they are true or not—or as technical officers, who resolve technical issues and ensure that their fellow informants are able to continue reporting suspected AFP cases.

The technical officers were grouped into two categories: first-level and second-level technical support officers. The first-level technical officers serve as the first point of contact when an informant has technical challenges with his/her device. When they are unable to resolve these issues, they escalate the challenge to the second-level technical support officers, who are usually WHO staff or investigators within the country ministries of health, with superior technical skills. The second level support officers ensure that all issues are resolved and the AVADAR system can continue to work as expected.

The Success

So far, a total of 217 first level and 57 second-level informants have been trained across all the six countries eHA supported in 2019, as well as Liberia. eHA has now ended operations in four of these six countries— Chad, the Democratic Republic of Congo, Sierra Leone, and South Sudan and the trainees are now managing the network. The technical officers were trained using a two-step approach: theory-based training that took place in a classroom setting, and field practical sessions, giving trainees the opportunity to investigate and resolve real-life technical issues in the field. eHA continues to provide support in Cameroon and Niger, leading refresher training sessions for technical support officers, and resolving advanced technical issues in the two countries.

Some AVADAR informants are also going beyond polio to detect and report other priority diseases such as Measles, Yellow Fever, and Diarrhea in their communities using AVADAR. The flexibility of the AVADAR system and its potential to be used for reporting and detecting other priority diseases leaves no doubt that these countries are better equipped to prevent future outbreaks and protect their populations.

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.

Announcing the eHealth Africa Academy in Kano

With over a decade of experience developing and deploying digital solutions across Africa and some of the most experienced tech professionals in our team, eHealth Africa is committed to sharing knowledge and empowering the next generation to solve local problems using technology and data. We are announcing the launch of eHealth Africa Academy in Nigeria. The first cohort of the Academy, which will run from February 29, 2020, to April 25, 2020, and will focus on teaching participants basic web development skills in HTML, JavaScript, and CSS, and how to apply these skills to start a career in web design. '

The academy will use a combination of in-person workshops and online courses to cover the curriculum within the two-month period. eHealth Africa invites participants with basic computer knowledge to apply to join the Academy. The costs of the program are being covered by the organization and will be free for the participants, however, interested participants must have access to a laptop and internet, and must be able to attend the in-person workshops in Kano during the course of the program. 

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.

Is geospatial data the key to leaving no one behind?

By Jennifer Bencivenga

At its best, the 2016 Paris climate agreement is a fledgling roadmap to fundamentally changing the way humans interact with their environment; at its worst, it’s the grandest of empty gestures.

Whichever the case, global recognition of the climate crisis is certainly a step in the right direction, providing the basis for more ambitious future commitments. However, for communities already experiencing the often catastrophic consequences of a warming Earth, large-scale action and incremental progress offers little in the way of relief — their priority, simply put, is survival.

Small island developing states are quite literally on the frontlines of climate change, facing effects such as rising sea levels, climbing temperatures, and extreme weather events disproportionate to the rest of the world. Though scattered across the Caribbean, Pacific, Indian, and Atlantic oceans, they share similar… Continue reading the rest of the article on Devex

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.