Iebdem LinComm Care

In many low and middle income countries, primary health care exists largely at the community level or in rural communities, where in most countries, the majority of the population live. In Nigeria for example, over half of the population (about 132 million or approx. 60%) live in the rural communities. In additional to their existence mainly at the rural or community areas, the structure of the primary care system in LMICs comprises of several types, including community health centres, faith-based maternity centres, private clinics, community pharmacies that prescribe and treat patients, community maternity centres, informal but recognised traditional maternity homes, community nursing houses, etc. Each of these health care facilities provide several types of care including check-up, treatment for communicable and non-communicable diseases, children immunisation, etc. A key feature is that they provide care independent of each other. There is no transferability of care. Each patient visit to different facilities means opening new health care record, thereby limiting the extent of treatment and management of care at the primary health care level.

In Nigeria, as in most counties in LMICs, transferability of care amongst health care providers is non-existent. Patient identification systems (PIS) are largely rudimentary and where they exist, are rarely shared amongst providers, as each provider (private or public) maintains own, non-interoperable patient records. This severely constrains the extent to which patients seek health care at multiple or new providers, decreasing access to and continuity of care. Also, patient treatment and disease management is poor within healthcare facilities. 

Enabling information to flow between care providers within and beyond organisational boundaries, and between care providers and patients, is a key means by which we will achieve a safe, convenient and personalised health and care service.

The solution relates to using PIS to enhance transferability of care amongst formal and informal providers in primary health care setting.  For the specific case of Nigeria, with possible scale-up to other countries in LMICs, the Federal Government of Nigeria, through the National Identity Management Commission, recently implemented the harmonisation and integration policy. The policy links the major digital identification database systems in the country, such the Banking Verification Number, phone SIM number, National Identification Card, and Voters’ card into a single and unique National Identification Number (NIN). The NIN serves as a cross sector foundational identification platform, offering a unique identity for use of citizens. The take-up rate has reached over 70% in the rural areas on the country. The unified NIN has the potential to improve access to and more efficient delivery of a range of services in both the government and private sectors, especially the primary health care sector. A digital PIS will enable patient health care information to flow between care providers within and beyond organisational boundaries, and between care providers and patients.

The digital PIS solution is expected to serve the health care providers and their patients in the rural communities of Ekiti state, Nigeria. The pilot study we conducted showed that an improved digital patient identification system provides a key means by which to achieve a safe, convenient, and personalised health care in the primary health care setting, thereby reducing mortality in several disease areas (e.g. maternal mortality amongst women), thereby improving the quality of life of patients.

The IPPA team are well positioned to deliver the digital PIS solution. Firstly, we have an ongoing collaborative and partnership agreements with the Ekiti State government and other stakeholders such as local health based NGOs, NIMC, and ICT providers for future implementation and scale-up. Secondly, we have a multidisciplinary team of experts in both health care, IT, health economics, sociology, etc.  Also, we have a monitoring and evaluation team for continuous monitoring of progress and ensuring that the objectives are realised. 

Raise funds for scaling up to the rest of Ekiti state. It is currently limited to Ikere community. Also, scaling up will require resources to secure the PID devices from the manufacturers and linked to the national ID network maintained by the NIMC.  The fund from Challenge will help us overcome these barriers. 

The digital PIS solution is innovative in several ways. The digital PIS is a form of foundational identification system linking several other services, but also provides the basis for patient identification, verification, and authentication. It provides easy and more efficient access to and usage of health care services in primary health care setting. This differs markedly from the current practice which relies more of paper-work and there is no linkage across health care providers. Therefore, the solution is innovative in the sense that it ensures transferability of care in primary health care setting, something that has hitherto been missing.

An innovative solution to the problem of transferability of care in primary health care setting is expected to increase the access and usage of primary health care services by 40% of the health care providers to be using the solution in the next couple of years in the community of implementation. In the longer term following scaling-up to the rest of Ekiti State, it is expected that up to 80% of the primary health care providers in the state will be using the digital PIS solution for access and usage of care services.

Another goal is to consult on the more efficient collection of primary health care data for monitoring and measurement and evaluation of performance of primary health care.

 There will also be a business expertise to launch the solution for possible scale-up as a program for implementation in rest of the rural communities in Nigeria.

As stated above, we have the expertise to conduct monitoring and evaluation (M&E) of the progress of the solution. This will involve both qualitative and quantitative aspects. The qualitative aspect will involve examining the extent to which the objectives of the solution are being carried out, especially the take-up of the solution by primary health care providers (process evaluation). The quantitative aspect will involve collection of primary health care data for measurement and evaluation of performance of primary health care (impact evaluation).

The solution relates to replacing existing forms of patient identification and authentication amongst rural community health care providers with a new digital identification linked to the NIN. The theory of change (ToC) provides the pathways through which the expected impacts are realised, whilst accounting for potential intended and unintended effects. The pathways include input, activities, outputs, intermediate outcomes, and final outcomes (impact). A diagrammatic representation of the ToC is available upon request. The ToC can be summarised as follows:

• Inputs: the solution (digital PIS) is the main input in the pathway. The solution is one in which existing forms of identification for access and usage of primary health care services are replaced with NIN-based identification system.
• Activities: The solution leads to shifting all existing fragmented paper-based record system (diagnosis, treatment and management of care) to one that are carried out through the NIN based digital ID system across the community primary health care providers. This activity is intended towards achieving the intended outputs.
• Outputs: The outputs expected from the activities include reduced barriers to transferability of health care (e.g., lower search cost of inter-facility usage) and access to safe and convenient medical records. These are intended outputs from the solution. The unintended effects may affect the extent of the impact of the solution on the expected outcomes. These include provider inefficiency potentially arising from network failures and interrupted service.
• Intermediate outcomes: Our ToC identifies two types of outcomes, intermediate outcomes and final outcomes. The intermediate outcomes expected to follow from the solution outputs include easier access to medical services, improved management of care, lower transaction costs, ability of patients and providers to manage care using patient digital IDs, and improved access to data to measure performance of primary health care.
• Final outcomes (Impacts): The final outcomes are the overall impacts expected from the intervention. Both primary and secondary outcomes are identified. The primary impacts include digital ID enhanced improved health care delivery, improved quality of disease management at primary care, and improved health care data. Others include greater efficiency in primary health care service delivery and strengthened patient-provider relationship, etc.
• However, the ToC allows for unintended consequences potentially arising from implementing the solution, such as concerns for privacy and confidentiality issues, and right to consent to using personal information between primary health care providers.
• Also, where community health insurance is present, through the digital PIS solution, the insured group of patients have access to digital payment system for reimbursement that reduced corruption in the reimbursement delivery system.
• However, the extent to which these intermediate outcomes could be achieved may be constrained by unintended effects such as poor interoperability of the PIS solution across access health care providers.
• From the ToC, the process of achieving the impacts may generate spillover effects, which tend to occur at both the patient household and community levels. Paying inadequate attention to this may underestimate the impact of the solution.  

According to our ICT providers, the core infrastructure that powers the digital PIS solution, include;

• (i)The NIMS (backend) Servers which is at the core of the managed services, provides the processing of the enrolment, verification and authentication services over the network of the FEPs.
• (ii)The Network infrastructure provides for two sets of functionality based on the enrolment process, authentication and verification process and the Smart Card personalization process. The enrolment which is done by the FEPs require massive data transmittal in a single and or batched format from the IRCs where enrolments are done to the NIDB Data Centre where the de-duplication is done. It also supports requests for identity verification from several end-user locations on-line as well as support the integrated platform for government agencies, including health care providers that have been harmonized with the NIDB. The network includes dedicated VSAT/WAN, LAN, Internet, connected third party network infrastructure (FEPs have switch platform owners as partners) which link the State Offices of NIMC/IRCs, the NIDB and the end-users.
• (iii)There is strong emphasis on the security design to secure the various components from logical and physical attacks. The security design covers both Server security (including firewall, intrusion prevention and detection systems (IDS,IPS, etc), Network security, Enrolment and End-User security(including PKI, encryption, etc).
• Another key component is the Biometric sub-system. This is used for both the enrolment process and the verification/authentication process. Provision is made for incorporation of the SAGEM AFIS as part of the ‘reuse’ policy of the NIMC

The primary care providers are detailed in the pilot to collect data on access and usage of health care services at the primary care level during a 3 month period. 

Diversity- no segment of the community is excluded

Equity - All members of the society or community have equal access and opportunity to use the solution.

Inclusion - Solution will benefit every segment of the community and benefits everyone. 

The digital PIS solution will improve transferability of care in primary health care setting. In Nigeria, as in many LMICs both the public and private sectors provide the primary health care. Whereas health care tends to be officially free with limited profit-objective in public, the private sector is profit oriented. The core objective of our business model is to seek a balance between the public and private objectives towards sustainability of the solution. The model for sustainability is to ensure that all primary care providers are linked on the NIMC digital ID server. For benefit of the population, our business model is to contract the Ekiti state government for continuous support, whereas providers makes small contribution towards continuous operation of the system.

As the pilot study shows, service contracts to State and local governments will sustain the solution.

The Ikere local government funded the pilot study to test the feasibility of the Solution.