Realising the benefits of digital health implementation in a middle-income country:
Applying Theory of Change in Nigerian primary care

Student thesis: Doctoral Thesis


Healthcare quality and evidence-based practice remain a grand challenge to be resolved. There remains a “60-30-10 challenge” where only 60% of care conforms to evidence-based guidelines, 30% is of low significance, and 10% is detrimental.
Digital health has been seen as a tool for the transformation of healthcare quality and safety globally. An electronic health record (EHR) system, a form of digital health, can be a solution to paper documentation bottlenecks in health service delivery if it is successfully implemented. This study aimed to establish how the benefits of digital health implementation could be realised in low- and middle-income countries, using the example of Nigerian primary care and the Theory of Change approach.
Theory of Change (ToC) is an outcomes-based approach that starts with the long-term goals and works backwards to the inputs and mediating components required to achieve those goals for complex programmes. ToC was developed to guide a pilot study and identify the preconditions needed to realise its long-term goal in Festac Primary Health Centre (PHC) Lagos, Nigeria. OpenMRS was used as the EHR platform, and forms and concept dictionaries were created to meet the needs of the clinical services. During the implementation study, interviews were conducted with the Festac PHC stakeholders. The interview transcripts were analysed thematically using the Framework method, and a system evaluation was done to test the EHR system’s usability. A workshop for health informatics experts was held. The study used qualitative document analysis to complement the interview and the workshop techniques for triangulation. The pilot study was evaluated using selected success factors related to specific categories.
The ToC approach identified real changes during the pilot study. The EHR adoption and usage data from the system go-live revealed that the number of registered patients and patient registration forms completed on the EHR system was 1790. ANC and immunisation encounter forms (n=198 and n=309) were completed. Vital signs (n=325) and visit notes (n=177) were entered into the EHR. The main technical components of OpenMRS are the database (data concepts mapping, backups, security, etc.) and the EHR software (clinical modules and customisations). The interview data (n=14) showed that the EHR implementation was relevant and identified key themes relating to readiness, expectations and sustainability of the EHR implementation. There was a consensus by the six healthcare professionals (HCPs) who completed the EHR user survey that the system was not difficult to use. The workshop highlighted that data modelling, and interoperability standards are key priorities for maternal and child health data services in LMICs. Findings from the document analysis showed the relevance of the selected grey literature (n=15) in providing contextual information across the study. The study proposed a generic ToC map that LMIC implementers can use to introduce an optimised EHR with the assumptions about sustainability and other relevant factors. The critical success factors were the sustainability, financial and organisational categories. The PHC management and the research team agreed on solid arrangements to sustain the EHR implementation, but there was no guarantee.
This study has presented ToC as a rewarding approach in helping EHR implementers and health stakeholders to question their assumptions. It is apt in framing dialogue with stakeholders and serves as a framework for learning and reflection. Any future LMIC health IT implementation study in primary care can adapt this ToC approach to their contexts with necessary modifications based on inherent characteristics. Further work is needed to explore health data interoperability across public PHCs by designing a national health data model for maternal health services data set based on established data standards and examining the preconditions and drivers for implementing such a model.
Date of AwardApr 2021
Original languageEnglish
SupervisorPhilip Scott (Supervisor) & Alice Good (Supervisor)

Cite this