E-Health in Nigeria: just pain, no gain?

On Thursday 26 January, I was at an e-health symposium organised by Northwestern University in collaboration with MediFix and iDEA Hub. The symposium’s focus was The Pains and Gains of e-Health in Nigeria. At the end of the symposium, I came away thinking that for those venturing into the e-health market in Nigeria it has been mainly pain and hardly any gain.

One reason for this may be that healthcare is a public service, which is for the Government to provide. Healthcare systems around the world strive for universal health coverage (UHC), which means providing the population with access to the full range of quality health services, from health promotion to medical treatment, rehabilitation, and palliative care, without them paying over the odds. However, as the Nigerian Government has one of the lowest levels of health expenditure in Africa, it is left to the private sector to improve UHC. The small problem is though, private players need to recoup their investment. So how do e-health startups provide wide access to affordable quality healthcare, and make profit? Apparently with great pain.

Here are some of the key takeaways for e-health providers from the symposium and some of my observations on them.

1. The target market of e-health solutions extends beyond hospitals and patients. E-health startups in Nigeria seem to hold a very narrow view of what e-health is. Therefore the target market is defined too narrowly, so everyone is looking to provide the same product. The potential customers of e-health solutions are healthcare providers (HCP) including individuals and hospitals, the Government, healthcare insurers and patients. UHC cannot be achieved if there are no products built for the Government, healthcare insurers and individual HCPs.

2. Think outside the box when deciding on the service offering. Since the target market is wider, so should the solutions on offer. It is true that the service offering of e-health startups has evolved beyond the provision of basic health information to consumers. There are many startups today trying to do something different in the space, such as e-consultations (Kangpe and Mobidoc), clinical reference information and e-learning (Medenhanz), blood centre services (Lifebank), and medication supply (Drugstoc and Medsaf). However, the general feeling is that there is just so much more that can be done. Here are some of the e-health services on offer around the world, which Nigerian e-health startups should consider providing.

HCPs Patients Government Insurers
Registration Electronic Health Records (EHR) Data and statistics Data and statistics
e-Prescription Health Information Public health information Health management
Computerised order entry Analytics Emergency response Online claims management
Supply chain and inventory control e-Ambulance Disaster response
Patient management Appointments scheduling
EHR Homecare services
Homecare services
Resource management

3. The user experience is key. Yes, this old chestnut. The Nigerian population is very diverse in culture and language, at least half the population is living on less than $1.25, and roughly 40% of population is illiterate. Startups that are building a product for Nigerian patients, must bear these facts in mind and give due consideration to the usability of the product.

Do not presume that a product which is successful in Lagos would be successful in Kano. Forget about building a mobile app, if the aim is to achieve wide penetration, because smartphone penetration is low. According to the GSM Association, roughly 17% of all mobile connections are via a smartphone and only 11% of the population has a 3G or 4G connection. Furthermore, the public perception is that the cost of data is high, so apps do not have high usage. Instead, for informational products, consider delivering the message via interactive voice response (IVR) because many people cannot read.

Providers that are set on building an app must consult with key stakeholders to find out what they expect and require the app to do. This is something that I often advise clients to do because building a product that does not meet the users’ requirements is one of the main reasons that IT projects fail. A well known example is the NHS patient records project, which failed spectacularly for this reason, among others. The project was terminated at a cost of £10 billion to British taxpayers.

4. Build credibility. Like in any other industry, e-health providers must address the main concerns users have which may hinder use of their product. Two such concerns which were mentioned during the symposium were the credibility and completeness of health information and e-diagnosis, and privacy and security of digitised patient records.

Privacy and security is more of a concern to HCPs than patients. While it is true that Nigerians are becoming more aware of the importance of keeping their personal data private and secure, a large section of the population lives below the poverty line and/or is illiterate. In a toss-up between keeping their data private and secure and staying alive, I think they would choose to stay alive.

However, credibility and completeness of health information and diagnosis is a real concern for patients. Many patients prefer to use foreign applications and websites for these services because instinctively they trust them more. The question was raised whether this and other e-health products should be regulated.

In my opinion, a distinction should be drawn between medical services and devices, for which regulation already exists, and health information and products. A product that involves diagnosis, treatment, mitigation or prevention of any disease, disorder, or abnormal physical state is regulated by the National Agency for Food and Drug Administration and Control. There are softer measures that may be implemented to increase consumer trust in Nigerian e-health products. For example, the Medical and Dental Council of Nigeria can make available a searchable database of medical practitioners so that the public can confirm the persons providing advice or responsible for content on e-health sites are registered medical practitioners. Also, the Government could sponsor an accreditation scheme similar to URAC, a US not-for-profit dedicated to promoting continuous improvement in the quality and efficiency of healthcare management. WebMD has been accredited by URAC since 2001. This is just one of the ways it gained consumer trust.

5. Localise the content. Though our official language is English, there are over 500 local languages. Hausa, Igbo, Yoruba, Fula, Kanuri, Ijaw, Ibibio and Tiv are some of the most widely spoken languages in Nigeria and in which e-health providers can supply content or user instructions. In Cameroon, Dr Susan Aweh gained notoriety for providing health information in pidgin English through videos that she posts on YouTube.

E-health providers should translate their content to a local language. However if  receiving content from third party contributors or content providers, and they are not providing the translations, ensure that they grant the right to undertake the translation before translation begins, otherwise this may lead to a copyright infringement claim. The same applies if adapting text into IVR.

6. If the aim is to reach as many patients as possible, the best way may be through the telcos. With 83 million unique subscribers, telecommunications companies are able to reach approximately 45% of the population through their networks, so they are generally considered to be the quickest route to achieving wide product penetration. However, consider this.

Since many Nigerians do not access the internet via a smartphone or 3G or 4G connections. Again do not waste time building a native app, unless smartphone users are the target market. Build a mobile browser version of the solution, which can be accessed using a slower 2G connection.

E-health providers should not expect any telco to subsidise their business. Building and maintaining a network is expensive. E-health solutions need to pay their way. Any provider looking for sponsorship should try the Government or an NGO, because it is  unlikely to get that from a telco.

Only value added services (VAS) providers – holders of a VAS licence issued by the Nigerian Communications Commission – can transact directly with a telco. This means that proceeds from an e-health solution will be split three ways. The telcos traditionally retain upwards of 60% of the revenue derived from VAS, leaving the e-health provider and the VAS provider to share the remainder. Therefore, e-health provider must think very carefully about price. Some e-health providers use the  amount that they want to take home as revenue as a starting point and simply add on the VAS provider and telco’s percentages. This simply will not do as this could make the solution prohibitively expensive. It may be better to collect small amounts from a large number of users, rather than large amounts from a small number of users.

A telco may require that the e-health provider supply the solution as a white label product. This means that while the provider may obtain the reach, it will not have any brand recognition, unless the provider negotiates an agreement that the solution be co-branded.

Finally, a telco may insist on exclusivity, so that the e-health provider is unable to offer the same solution to other telcos. This would mean that the provider will only  have access to a fraction of those 83 million unique subscribers. Such a scenario should be built into the provider’s business plan.

7. Do not underestimate the obstacles to scalability in e-health. Although the Nigerian market has its own peculiarities, scaling up e-health businesses has proven to be quite difficult all over the world. This is true even in countries that do not have Nigeria’s power and connectivity problems.

One of the oft-cited reasons for achieving scale in e-health is the fragmented organisation and culture of healthcare, which hinders standardisation and interoperability. Interoperability is the ability of two or more systems or components to exchange information and to use the information that has been exchanged. Interoperability in e-health is a complex issue that cuts across the legal, organisational, semantic and technical, and which can be a topic of a very long article on its own.

To achieve interoperability, there must be a legal framework and wider policies in place which allow for and encourage the exchange of information between e-health providers. Sadly, the Nigerian legal framework is lacking in many respects.

For example, the National Health Act 2014 permits HCPs to disclose patient healthcare records to other HCPs and third parties in the interest of the patient. There is also a duty of HCPs to disseminate information on the organisation of their health services. However, this is only at facility level, which means there is no clear obligation to provide information to another HCP operating in another facility or a third party in the interests of interoperability.

Nigerian e-health providers do not have the benefit of certain legal protections available in other jurisdictions. For example, under EU law, if a user or their authorised representative reproduces or translates a software’s source code, and the reproduction or translation of the code is indispensable to obtain interoperability information, there is no copyright infringement. This permits software providers to decompile software belonging to a third party, where that party does not make available interoperability information for its software. Also where a software provider refuses without justification to supply interoperability information, which is indispensable for the technical development of competitor products on a neighbouring market, this has been held in certain circumstances to constitute a breach of EU competition law.

Besides the legal, the adoption of uniform medical coding standards and terminology such as the International Classification of Disease, the Logical Observation Identifiers Names and Codes and Systematized Nomenclature of Medicine, would facilitate semantic interoperability of e-health solutions. Under the National Health ICT Strategic Framework 2015-2020, the Government envisages introducing these standards after it has built a Health Information Exchange using various existing health solutions in Nigeria. However, given the slow pace at which the Government implements projects and the rate of development of private e-health solutions, it may be preferable to set these standards now, before our interoperability problem worsens. However, e-health providers can play a proactive role in this. Through associations and networks, they can agree standards to be adopted for solutions. This way e-health providers drive the standardisation process rather than wait on the Government.

In conclusion, it would take a concerted effort from both Government and the private sector to make e-health viable on a national scale. It is unlikely that any one solution would be able to meet or contribute to all the requirements of UHC – providing wide and affordable access to a full range of quality health services – and turn a profit, so startups must find a niche and stick to it. There is no doubt that turning a profit and increasing that profit will involve considerable pain. However, I see e-health in Nigeria like the telecommunications industry. For those that dare to venture and do so wisely and resolutely, there is much to gain.

Leave a Reply