EHA Community Health Observatory (ECHO)

eHealth Africa and EHA Clinics collaborated to develop EHA Community Health Observatory (ECHO). ECHO connects data systems from a comprehensive community health platform, molecular and genomics lab network, GIS, community pharmacies, and pharmacy supply chain. By leveraging the established community systems, ECHO will deliver community-level, near real-time visibility of AMR.

David Akpan is a Deputy Director at eHealth Africa with 18 years experience in public health practice. He leads a team of experts to design, implement, and evaluate quality projects.

In Nigeria, the healthcare journey predominantly unfolds within the private sector, significantly bypassing the public primary care system. This shift towards the private sector, which accounts for approximately 60% of healthcare delivery and 84% of primary healthcare expenditures allocated to non-primary healthcare facilities, illuminates a critical issue in the country's health data landscape. Such a dynamic fosters a health information blackout at the community level, rendering early detection and management of outbreaks and antimicrobial resistance (AMR) infections challenging.

This disconnect is particularly acute when considering the common practice of self-treatment through community pharmacies. As a result, valuable health information crucial for understanding and combating AMR remains untapped, allowing AMR infections to circulate undetected within communities. This gap not only hampers effective response mechanisms to AMR but also undermines the overall health security of the population. By focusing on bridging this gap, the EHA Community Health Observatory (ECHO) aims to illuminate the AMR landscape in Nigeria, enhancing early detection and facilitating timely intervention to mitigate the spread and impact of AMR infections locally and globally.

ECHO aims to empower clinicians, including physicians, pharmacists, and community health workers, by providing detailed insights into local antimicrobial resistance (AMR) patterns. This information helps them prescribe the most effective antibiotics, optimize patient treatment, and conserve healthcare resources. Additionally, ECHO offers valuable data to public health programs at local, regional, and national levels, enhancing their understanding of antibiotic usage and AMR trends. ECHO allows for early detection of AMR spread and better preventive strategies.

In ECHO, regulators and policymakers will find a pivotal tool to guide the development of regulations and policies, such as limiting indiscriminate antibiotic use in agriculture and advocating for increased AMR research funding. Academic researchers also benefit from ECHO as a robust platform to test interventions to combat AMR.

At its core, ECHO serves communities by facilitating a coordinated approach among healthcare providers, public health authorities, and policymakers to address AMR effectively. Through active engagement and collaboration with community-based Nigerian healthcare and public health stakeholders, ECHO is being co-designed to meet the real-world needs of these critical groups. This collaborative approach ensures that ECHO is relevant and deeply integrated into the healthcare landscape it seeks to improve.

ECHO's contribution to the public good is multi-faceted, focusing primarily on providing open-access data and resources to combat antimicrobial resistance (AMR). By anonymizing and aggregating data related to AMR prevalence, risk factors, and the efficacy of response interventions, ECHO creates an invaluable open-access platform. This platform will empower researchers, policymakers, and healthcare practitioners worldwide with the necessary information to make evidence-based decisions and craft targeted AMR interventions.

In addition to data, ECHO is committed to offering open-source tools and models, including machine learning algorithms, data integration platforms, and other software resources. These assets will be freely available, allowing other entities to replicate or tailor ECHO's innovative approach to their specific needs, thereby enhancing global collaboration and innovation in the ongoing battle against AMR.

ECHO will contribute to the academic and practical understanding of AMR by publishing peer-reviewed research from analyses conducted using our free-to-use dashboard. These publications will advance the scientific community's knowledge and provide actionable insights for on-the-ground AMR management strategies. Through these efforts, ECHO aspires to serve as a beacon for open, collaborative efforts to mitigate the global threat of antimicrobial resistance, ensuring its outputs are a public good accessible to all under fair, reasonable, and non-discriminatory terms.

ECHO solution enhances the response to antimicrobial resistance (AMR) outbreaks at the community level, particularly benefiting underserved and vulnerable populations who often rely on healthcare services from non-clinical settings and primary care facilities. Our approach is straightforward: we begin with evaluating and refining our initial data collection efforts on AMR, followed by integrating AMR diagnostic and treatment tools (DCTs) into the ECHO framework. Subsequent steps involve:

• Retraining our community health teams (REACH) on the updated system.

• Gathering comprehensive data from various community sources.

• Conducting thorough data analysis alongside predictive modeling.

The tangible impact of ECHO will manifest through several vital outputs, including integrating an AMR data surveillance tool, training community health teams on ECHO's functionalities, developing predictive analytics products, and providing real-time analytics to enable swift AMR outbreak responses. Expected outcomes include:

• A reduced timeframe for detecting AMR infections.

• Enhanced planning and execution of AMR outbreak responses.

• Improved antimicrobial stewardship by data-informed feedback.

Our pathway to impact links activities and outputs to desired outcomes, aiming to provide evidence-backed and effective AMR surveillance and response mechanisms. An upcoming impact evaluation study will further validate ECHO's contribution to AMR surveillance, ensuring our efforts benefit those most needing accessible and quality healthcare solutions.

Over the next year and the subsequent three years, ECHO aims to scale its impact significantly within Nigeria and internationally. In the immediate future, EHA Clinics and the REACH program are charting an expansion into additional Nigerian states, including Lagos, Kebbi, Sokoto, and Edo. This broadening footprint within Nigeria will enable ECHO to gather more data, enhance its predictive modeling, and refine AMR surveillance tools, thereby increasing its capacity to respond to AMR outbreaks.

Looking beyond Nigeria, eHA and EHA Clinics have ambitions to establish a presence in South Africa, introducing the ECHO solution to a new healthcare ecosystem and further broadening its impact on AMR surveillance and response. Leveraging eHealth Africa's extensive operational footprint across 24 countries, ECHO plans to identify and collaborate with community-based partners. These partnerships will facilitate the adoption and integration of ECHO into diverse public and community health landscapes, customizing its deployment to meet local needs and challenges.

Furthermore, within Nigeria, ECHO aims to connect with hundreds of community-based healthcare groups and thousands of community pharmacies. Integrating these entities into the ECHO network will significantly extend our reach, making critical AMR data more accessible and actionable for a broader spectrum of healthcare providers. 

To rigorously measure success against our impact goals, eHA has developed a structured results framework to monitor the ECHO project implementation across all dimensions. Key performance indicators (KPIs) provide a comprehensive overview of the progress and impact of ECHO. These include:

• Number of AMR-related data points integrated into the ECHO system: 

• Patient interactions compliant with antimicrobial guidelines: 

• Number of AMR-related analytics products generated (disaggregated by type, including maps): 

• Percentage of health facilities or responders utilizing ECHO for AMR surveillance and rapid outbreak response: 

Additionally, eHA’s QA team will closely monitor system performance metrics, user feedback, improvements in AMR outbreak response times, and the generation of reliable evidence for AMR outbreak management. 

A baseline on AMR data in Nigeria was established at the project's inception. After 12 months of implementation, we will conduct an outcome harvesting evaluation to gather evidence on the question, 'How can data and analytics reduce the impact of antimicrobial resistance and bacterial infections in low and middle-income communities?' This evaluation will provide crucial insights into ECHO's effectiveness and guide further refinements.

The following are several barriers that could impede our progress, alongside strategies to overcome them:

1. Financial Constraints: To mitigate funding constraints, we intend to pursue grants, forge strategic partnerships, and encourage government ownership of our solutions. EHA Clinics is actively seeking investment from the private sector and applying for research grants to enhance our community presence and technological infrastructure.

2. Technical Challenges: Tailoring our technology to varied settings demands additional expertise and resources. We plan to invest in our research and development capabilities and use technological experts to refine our platform.

3. Policy and Regulatory Hurdles: We may encounter policy gaps or regulatory barriers hindering the implementation of our solution. Our strategy involves engaging with policymakers and advocating for policies and regulatory frameworks supporting our mission.

4. Infrastructure Limitations: In some regions, infrastructure improvements will enable effective data collection and technology deployment. Collaborating with local partners, we aim to identify and navigate infrastructure challenges, utilizing innovative solutions such as mobile data collection to ensure continuity.

5. Cultural and Educational Differences: Variability in cultural beliefs and levels of education could affect community engagement and the adoption of our solution. We plan to undertake culturally sensitive outreach and educational initiatives, working closely with local influencers 

The Trinity Challenge is a strategic move for eHealth Africa and EHA Clinics, propelled by our commitment since 2018 to establish a quality-focused, high-performing primary care network in Nigeria. We recognized early on the pivotal role that a robust primary care system plays in public health issues, outbreak preparedness. Our approach to every antimicrobial prescribed is meticulous, involving tracking, review, and subsequent education on proper antimicrobial stewardship. 

The challenge of antimicrobial resistance (AMR) aligns perfectly with our mission and capabilities, particularly leveraging our comprehensive informatics platform, supply chain, and lab infrastructure. However, scaling our efforts and integrating advanced AMR management strategies across wider communities presents significant challenges. Barriers include the need for enhanced data analytics and predictive modeling capabilities to better understand and anticipate AMR trends, as well as the requirement for additional resources to expand our reach and impact.

The Trinity Challenge offers a unique opportunity for us to overcome these barriers. With its support, we can access cutting-edge research, technologies, and a global network of experts. This collaboration would not only bolster our analytical capabilities but also provide the crucial backing needed to extend our AMR interventions more broadly, making a substantial contribution to global health security.

To enhance and scale the ECHO solution effectively, collaboration with organizations possessing specific expertise in climate data and animal health data integration is paramount. One such organization is the Climate Systems Analysis Group (CSAG), renowned for its leading international climate research and comprehensive skills in both the physical and social dimensions of climate. CSAG's strong track record in engaging with society and supporting responses to climate variability would be invaluable in integrating climate data into the ECHO platform. This integration is crucial for understanding and predicting how climate variability influences antimicrobial resistance patterns.

Additionally, collaboration with organizations specializing in animal health is essential. Integrating animal health data sources is key to adopting a true One Health approach to combating AMR. Organizations with a background in veterinary science, livestock management, and zoonotic diseases could provide the necessary expertise to incorporate these data sources effectively.

Furthermore, eHealth Africa and EHA Clinics would benefit significantly from experts capable of supporting, advising, and validating predictive models that integrate geospatial data and community health. Expertise in data science, epidemiology, and geospatial analysis would enable us to refine our models for predicting AMR spread, enhancing the effectiveness of our interventions.