The State of the Nigerian EMR Market

EMRs are the building blocks of digital health yet adoption has been slow and challenging. Massive rewards exist for companies that can successfully crack the market.

Photo by National Cancer Institute on Unsplash

I was recently approached by a foreign investor to weigh in on the EMR market in Nigeria. As an entrepreneur that’s been building and writing about health technology in Nigeria for the last 8 years, I usually have a relevant article written by myself or others to share when approached like this. On this occasion, I fell short as I didn’t have anything EMR-specific to send along. So here’s my attempt to provide a brief overview of the EMR space in Nigeria, from my limited perspective.

The Early days and the Public Sector

EHRs began popping up on the radar in the early 2000s. Saboath Technologies a company based in Ibadan founded by Dr Simpa was an early purveyor. Supported at one point by Microsoft, they’d attempted to digitize several public and private sector facilities but never quite got off the ground. In 2005, The Society for telemedicine and eHealth was founded by Dr Adebola. The society aimed to promote the adoption of eHealth and provided training and technical support to policymakers. Around the same period, millions of dollars entered Nigeria via USAID and PEPFAR to fund HIV programs. To deal with the vast number of patients and data points, EHR systems began to be deployed. These were mostly open-source solutions based on systems like OpenMRS.

This progressed slowly into the early to mid-2010s when public sector hospitals began digitising thanks to a number of initiatives. The Universal Service Provision Fund, a fund that was created to “facilitate the widest possible access to affordable telecommunications services for greater social equity and inclusion for the people of Nigeria” was one such initiative. It provided funding to digitise 27 government hospitals via an open competitive bidding process. Another initiative, health in a box coordinated by the Federal Ministry of Health began the digitization of many of its federal medical centres and teaching hospitals. The solution aimed to connect tertiary centres digitally and provide telehealth infrastructure.

State governments in states such as Ondo, Oyo and more also dabbled in hospital/ clinic digitisation. Instrat a for-profit company that’s funded through a mix of donor and government funding successfully deployed EHR solutions across several of these states. In some instances, they leveraged satellite connectivity to enable access and data transfer from remote locations. eclat another for-profit entity also made similar headway in several states. They grew to a point where they became an attractive acquisition target for Interswitch the billion-dollar valued Nigerian fintech company.

Anecdotally however many of these schemes are yet to attain the heights they promised. They have either totally failed, been scaled back significantly or only function partially with constant complaints from users.

Private sector and Startups

While the public sector digitisation was ongoing, private sector clinics and hospitals in the 2000s started to look at digitising. Several software shops buoyed by public adoption began to sell their solutions to private facilities. Anecdotally, local hospitals didn’t initially trust local companies to have the right expertise. Thus stories abound of hospitals buying solutions from far-flung places like India. These imported systems however were built for a different reality and didn’t have the required local support. They ended up being abandoned in failed deployments, leaving behind a trail of frustrated facility owners and managers.

Over time local dedicated EHR companies grew and became more trusted. Some via building their own custom solutions and others via mastering the deployment and customization of open-source EMR software. By 2018 there were at least 14 of them going by Techcabal’s census of the space at the time.

Infographic from Techcabal report on Nigerian health tech startups

Many of these EHR vendors were still however small companies with only a handful of hospital users split between public and private facilities.

Helium health came on the scene first as ‘one medical’ in 2016. It’s since gone on to raise over $12m and rolled up a number of EHR players to become one of the leading providers. On its website, it reports having over 470 customers and 250,000 monthly encounters. Key among this was a deal with the Akwa Ibom state government to digitise over 42 general hospitals and 200 primary healthcare centres. Helium has expanded beyond Nigeria to Kenya and acquired a practice management startup based in the gulf region to expand beyond Africa. In the same vein, Talamus another EHR startup made significant strides since its 2018 launch. It reports working with over 450 facilities and has a presence in Nigeria, Ghana and Zimbabwe. In tandem with the relative success of startups and local companies, Indian IT companies have also set up local operations to provide the local support that was once lacking for Indian software in the earlier days.

Policy and environment

Despite the efforts of many players in the Nigerian EMR space, adoption is still abysmal. This isn’t surprising as the global experience demonstrates that EMR adoption usually struggles in the absence of supporting policy and regulation. In the U.S, the advent of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 which provided several incentives for EMR adoption, saw EMR adoption grow significantly. These incentives were across 3 stages and paid out over $17 billion to facilities that were able to successfully digitise.

One study showed that EMR adoption rose by 11 percentage points thanks largely to the implementation of the HITECH Act.

In Nigeria, the policy and regulatory environment hasn’t been as encouraging. Supported by the UN Foundation and several other bodies, a draft health IT strategy was put out and eventually approved in 2016. This strategy has however now expired with most of its contents yet to be implemented. One strategic area that did see some activity is around the setting and adoption of informatics standards. In 2020, 32 industrial standards for health informatics were adopted to provide technical guidelines for those building health technology solutions.

A more challenging issue beyond policy is the underlying environment of tech illiteracy. Anecdotes abound of healthcare professionals who struggle with navigating basic computer hardware and software. Companies thus often have to provide significant tech literacy training to workers before solutions can successfully go live.

The GSMA’s suggested digital health roadmap for operators is instructive in this regard.

It highlights that digitising health professionals is the foundation on which other digitisation options lie. This roadmap helps inform strategy and potential business models to pursue.

Market dynamics and Business models

Despite the challenges with policy and literacy, the opportunity for EMRs in Nigeria is immense. There are over 39,000 health facilities in the country. A conservative estimate would put the digitisation of these facilities at less than 10%. Meaning there are at least over 30,000 facilities that are potential customers and users of EMR. Accessing this market is however no cakewalk. Barriers to EHR adoption range from high costs to connectivity challenges and ease of use. The business model thus deserves careful attention.

To digitise, facilities require significant investment in infrastructure, hardware, software and connectivity. Directly billing the facility upfront for this would likely prove too expensive for most. Subscription billing over time would be better for the cash flow of facilities and enable them better afford digitisation. Financing and collecting regular payments can however be difficult to administer. The proliferation of various fintech solutions means that this approach is now more viable than its ever been.

While financing may now be a bit easier to set up, convincing the facility to make this ongoing regular investment still represents a barrier. Most facilities are really only interested in making more money. Making the link between digitisation and increasing sales can be a tenuous one for the average facility manager or owner. The simple model for them would be to directly pass on the costs to the patient. They know this to be a difficult proposition as patients are already baulking at the high cost of care. Any increase in prices would deter patients even more so they are reticent to digitize. They would prefer instead to invest in other initiatives that are more likely to lead to an immediate increase in sales.

The other option for EMR vendors is to target bigger customers, the insurers/HMOs. These HMOs might be keen to finance digitisation in order to enable easy auditing and claims submission. Several companies have gone down this route with varying models and success. Curacel and Medismart are examples. The former is now YC-backed and they provide an interface to enable facilities to submit claims to HMOs for a fee. The latter offers a full EMR suite that connects facilities directly to HMOs. The HMOs however are reticent to pay for this as they aren’t incentivised to manage claims in a timely or efficient manner. They prefer the onus for claims submission to remain on the facility seeing as the health insurance regulator doesn’t enforce the timely and proper payment of claims. This insurance-led model as a driver for digitisation has gained ground in other markets but has proven problematic clinically. In this model, the clinician and patient experience are often relegated elevating the risk of the reimbursement-focused EMR becoming a source of dissatisfaction and angst.

In Nigeria, HMOs provide a minority of healthcare payments in any case. Over 70% of healthcare payments come directly from patients’ pockets. Is centring the need of patients the best route to facility digitisation? Is a B2C model viable where the patient pays for an encounter themselves? Helium health and several others have tried this model. It’s still early days so it’s hard to tell the success of this. Anecdotally, however, patients don’t seem to care much about digitisation and may likely opt for a cheaper non-digitised facility over a digitised more expensive alternative. Targeting donors and the government may provide a veritable option for adoption. Public facilities after all make up 73% of health facilities on the national register. Several players already exist in this space but don’t have full penetration yet. This model requires the right institutional setup and sales process to ensure success either in competitive bidding processes or in proposing and pushing through private-public partnerships.

Conclusion

The jury is still out on the best models for promoting EMR adoption and it’s yet unclear how the market will progress. There’s however a massive opportunity and a huge reward awaits whoever is able to successfully crack the market. Nailing the value proposition and making appropriate technical and design decisions are immensely consequential. Factors such as cloud vs on-premise, mobile vs desktop first, SNOMED vs ICD-10 and FHIR vs CCDA are all non-trivial considerations for players in the industry. Furthermore, training users appropriately and selecting appropriate financing options are key factors to consider. Integrated support for hardware, electricity, internet connectivity and ongoing maintenance are also central to ensuring minimal attrition over time. If this all sounds like a complex challenge, that’s because it is. EMRs may be complex but they are the building blocks for a lot of digital health. Growth in adoption will provide a strong foundation for further innovation and success.