It has been nearly four decades since the outbreak of Nigeria’s first HIV/AIDS case. Since then, the government of Nigeria, with support from international partners such as PEPFAR, has been actively involved in the fight against HIV/AIDS to attain epidemic control and achieve an AIDS-free Nigeria, with zero new infections, zero discrimination and stigma and zero AIDS-related deaths. ¹¹ Recently, the Nigerian government has taken significant steps towards optimising the management of patient health information, elevating data quality, and fostering a more efficient and coordinated approach to healthcare services, particularly within the realm of HIV/AIDS programme management. To support this paradigm shift, PEPFAR, through its agency partners; CDC, USAID and DoD, and in-country technical partner, APIN Public Health Initiative/Public Health Information Surveillance, Systems and Solutions (APIN/PHIS3), partnered with the government of Nigeria in institutionalising relevant eHealth technologies in alignment with the recommended National Health Information Architecture. As of December 2023, EMRs have been deployed across a total of 2,439 health facilities in all states in Nigeria, including the Federal Capital Territory, Abuja. In addition, a central repository of de-identified patient-level data aggregated from these service delivery points, called the National Data Repository (NDR), has also been deployed with over 1.9 million patients actively in treatment as of the same date. ¹² Apart from implementing these eHealth technologies, a series of multifaceted and phased capacity-building sessions was also conducted to drive ownership and sustainability post-donor support.

Some of these learning and development workshops were designed to align with the various administrative structures of the government, emphasising broad health informatics-related activities such as strategy development. Other sessions delved into the practical implementation of these strategies by building capacity for the relevant actions and procedures needed to translate these strategic goals into actionable activities. Additionally, some workshops focused on the effective utilisation of institutionalised digital tools within the context of HIV/AIDS care. Nevertheless, challenges were encountered in establishing the crucial link between formulating a robust national digital health vision, creating comprehensive cross-cutting strategies that spanned all disease and health areas, and effectively translating these long-term and medium-term strategies into operational actions to foster the growth of the digital landscape in Nigeria.

The Intergovernmental Learning Exchange to Advance Data-Driven Decision Making, which is commonly referred to as I-LEAD, is a programme that aims to empower diverse country-level leaders beyond decision-making and policy formulation capacities, managers and technical experts in the public health informatics space. The programme supports these nationally diverse stakeholders in envisioning the digital health landscape, formulating effective strategies to realise their vision, and successfully implementing and sustaining these strategies for impact.

To ensure effective planning, implementation, and sustainability of national digital health solutions and their impact on ensuring the delivery of care, PHI professionals in leadership and managerial capacities should cultivate proficiency across four fundamental dimensions: Vision, Strategy, Operations, and Tactics (VSOT). ¹³ TThe VSOT framework was not developed as part of this study; rather, the framework represents a core PHI leadership construct underpinning the design and delivery of the I-LEAD programme, and another complementing programme called Growing Expertise in E-Health Knowledge and Skills (GEEKS).

The I-LEAD programme primarily focuses on strengthening competencies related to vision and strategy, while completion of I-LEAD is complemented by the GEEKS programme, which addresses the remaining two dimensions: operations and tactics. Together, the synergy of combining these learning programmes, I-LEAD and GEEKS, results in a collective strengthening of the proficiency of a diverse spectrum of PHI stakeholders. The combined approach, which addresses all four VSOT framework dimensions, guarantees that national entities, including PHI leaders and decision-makers or policy formulators, managers, and technical experts, who are essential in conceiving the digital health landscape and developing strategies to realise it, are better prepared to realise their vision, and effectively execute and maintain these strategies.

The I-LEAD programme is conducted on a per-demand basis through the PEPFAR partner – CDC headquarters, and the frequency depends on the requests received from countries that are expected to commit to the programme requirements. One crucial commitment involves following through with the roadmap as an integral part of the post I-LEAD phase. Nigeria, through the FMoH&SW/NASCP and its PEPFAR partners, expressed their interest in attending the 2023 edition, which also included representation from other countries in the eastern African region.

To ensure Nigeria’s active involvement in the I-LEAD programme, a core technical team was established, comprising representatives from the FMoH&SW/NASCP, APIN/PHIS3, and the Technical Assistance Platform (TAP) - a CDC-supported project driven by PATH that aims to assist Nigeria in harnessing and implementing sustainable digital health technologies. This core team had two primary responsibilities, with the first securing Nigeria’s participation in the I-LEAD event. The core team collaborated with the I-LEAD organisers, notably staff from the CDC headquarters in Atlanta, to provide orientation on the prerequisites and processes for attending the I-LEAD event. This orientation also covered Nigeria’s commitment post I-LEAD. The second core team’s responsibility was to coordinate the Nigerian delegates attending the event in completing the I-LEAD preparatory activities. One such activity was leveraging an evidence-based method, the Informatics-Savvy Health Organisation (ISHO) assessment framework, to identify national HIS challenges to bring to the event.

The technical core team purposefully identified and selected 17 delegates to represent Nigeria in the I-LEAD programme. The number of delegates was informed by the scope and structure of the HIV/AIDS programme in Nigeria, and the need to ensure a balanced representation across key institutions involved in national HIS governance, planning and implementation. The Nigerian delegation included government representatives from the FMoH&SW/NASCP, FMoWA, and NMoD, as well as individuals from various inter-agency organisations such as the CDC, DoD, USAID, APIN/PHIS3, Palladium Group/Data.Fi, and PATH.

With support from the I-LEAD organisers and the core technical team, the delegates underwent a comprehensive orientation that covered various aspects of the I-LEAD process in optimising country HIS ecosystems. This included a detailed explanation of the prerequisites for participation and a thorough understanding of Nigeria’s commitment to the post I-LEAD activities. In addition, the delegates were trained to enhance their capacities in utilising the ISHO framework in assessing national informatics systems readiness, identifying HIS gaps across key health system domains impacting healthcare service delivery, and using those insights to inform strategic planning activities and health system strengthening initiatives. Notably, identifying these national HIS gaps must be done empirically through the conduct of an ISHO assessment. This is a fundamental requirement for participating in the I-LEAD programme.

ISHO stands for Informatics-Savvy Health Organisation. ^{14, 15} The ISHO toolkit was originally developed by the Public Health Informatics Institute (PHII) to guide governments, agencies, or any organisation in assessing their informatics readiness and capabilities, to develop e-Health strategies, information systems, electronic health information exchanges, and ensure the availability of an informatics-savvy workforce to achieve a digital public health future. ¹⁴ The ISHO toolkits consist of two types of tools: above-site and site-level. Both tools achieve their goal by assessing informatics capabilities across three strategic pillars. The first pillar, “Vision, Policy, and Governance”, focuses on the existing digital health governing structures, delving into the implementation status of current digital health policies, strategies, and costed plans. The second is “Skilled Workforce”, which examines the structures that ensure the continuous supply and availability of informatics-savvy health workers. The last pillar is “Effective Information Systems”, which evaluates the technological aspects of the current information technology capabilities. ^{15– 21}

Using the above-site ISHO tool, the Nigerian delegates conducted an expedited ISHO assessment at the national level in Nigeria. Each delegate, representing key government ministries including the FMoH&SW and NASCP, the FMoWA, the NMoD, and implementing partners supporting the Nigerian government HIV/AIDS response, played a key role in conducting the assessment. The goal of the evaluation was to determine national HIS strengths, as well as identify informatics challenges, towards establishing a national baseline. Furthermore, completing this stage is a prerequisite for taking part in a Bring Your Own Difficult Decision (BYODD) session during the I-LEAD event. This interactive session provides the platform where critical HIS challenges in participating countries are collectively addressed with support from global public health informatics experts.

The completed above-site ISHO tools were collated, after which the Nigerian delegates convened multiple times to collectively review and analyse each completed above-site tool. Responses from each completed above-site tool were aggregated in a structured format to identify recurring patterns across the different evaluated domains, synthesise emergent themes and collectively shortlist the HIS challenges for presentation in the I-LEAD’s BYODD session.

The national HIS gaps identified after conducting the expedited above-site ISHO assessment were further shortlisted. This was done after several consultative meetings with the government of Nigeria and health informatics Subject Matter Experts (SME) internally and externally, from the CDC headquarters. A selection criterion was developed, and factors such as implementation impact in the digital health space, required resources such as Human Resources for Health (HRH) and cost of implementation, as well as the anticipated timelines, were used to rank and prioritise HIS challenges.

Several health informatics challenges were identified following the analysis of the expedited above-site ISHO assessment and presented in Figure 2. Issues around HIS governance and coordination were a notable challenge. Others revolved around data security, systems interoperability, EMR centralisation and strategies for improvement of data quality, data management and use, sustainability, and funding.

Further discussions were held amongst the delegates attending the I-LEAD and health informatics SME from the government of Nigeria and PEPFAR to distil the identified gaps into five that would be addressed at the I-LEAD event. The foremost informatics gap centred on (1) governance, while others revolved around (2) information system interoperability, (3) data security, (4) EMR centralisation to address the availability of 3 fully established EMRs in Nigeria, and (5) securing digital health funding.

The Nigerian delegate’s capacity was built across various aspects in envisioning, conceptualising, and developing country-level informatics strategies using multiple evidence-based problem-solving methodologies. With respect to the BYODD sessions, these comprised numerous iterative sessions with SMEs. During these sessions, HIS challenges specific to Nigeria were presented and rigorously examined, drawing on different problem-solving methodologies and other country experiences, all tailored to the unique local context. The Nigerian HIS challenges were subsequently addressed and redefined, with five proposed solutions presented in Table 1. Of the five proposed solutions, four were HIS governance-related. These were proposed due to the peculiarities of our multi-stakeholder environment, ensuring coordination and focused intervention to achieve considerable impact with modest resource requirements through efficient implementation planning.

The first HIS governance streamlined activity focused on improving data quality through the harmonisation of value data sets across all EMRs in the country.

The second activity identified from the broader HIS governance challenges focused on the existing Nigerian digital health strategy, specifically, on its implementation and role in supporting interoperability across key information systems to optimise healthcare service delivery. These included activities related to operationalising and monitoring the rollout of the revised strategy. Addressing digital health data standards challenges through technical assistance for the Nigerian digital health standards subcommittee and conducting a security vulnerability and risk assessment on health information systems involved in HIV/AIDS, EMRs, and NDR systems were the third and fourth streamlined activities. The fifth and last activity was on knowledge transfer to promote ownership and sustainability post-donor support. This focused on decentralising the knowledge gained from the I-LEAD, harnessing the fullness of the VSOT framework by conducting a progressive GEEKS event. A detailed roadmap outlining the various tasks across the streamlined activities presented in Table 1 was developed and is provided in Appendix I.

Finally, as part of the Nigerian government’s commitment to the I-LEAD programme, two activities were prioritised for implementation. These included improving data quality through harmonisation of value data sets and decentralising I-LEAD learning and building the capacity of PHI technical groups by convening a tier 1 and 2 GEEKS training.

The findings and interventions outlined in this report bear significant implications for policy and practice in Nigeria’s healthcare landscape. Firstly, the identification of national health informatics challenges, particularly in governance, interoperability, data security, EMR centralisation, and funding, emphasised the necessity for a thorough and well-coordinated digital health strategy. This will guide policymakers to prioritise establishing, implementing, and monitoring robust governance frameworks to facilitate the smooth integration of various digital health initiatives in Nigeria.

Furthermore, the commitment to address these challenges through the I-LEAD programme signifies a shift towards evidence-based policymaking. The I-LEAD programme incorporated BYODD sessions, which harnessed the expertise of global PHI experts to refine and streamline Nigeria’s HIS challenges into actionable activities with the broadest impact across multiple health domains.

Finally, the emphasis on improving data exchange between EMRs as part of the post I-LEAD phase demonstrates the Nigerian government’s commitment to building a skilled workforce and ensuring the integrity and confidentiality of health data. This phase opens the path for better data-driven decision-making and more efficient healthcare operations. Policymakers can utilise this model to shape future initiatives, creating a robust and responsive digital health ecosystem and acting as a model for other countries facing similar difficulties.