ALMANACH Nigeria - Impementation and scaling up of a digital Clinical Decision Support System / ICRC Nigeria
Nigeria is one of the countries with the highest mortality for children under five years of age. Due to the violent conflict in the northern part of the country and scarce medical resources, mortality and morbidity for children in the region is significantly worse compared to other parts of the country. Malaria, respiratory diseases, diarrhoea, measles, and the nutrition crisis continue to cause suffering among children and related communities. About 800’000 children under five (17% of population) living in Adamawa State in north-eastern Nigeria are in need of essential health services.
The project’s objective is to enhance health care provision for children under five in resource-constraint settings. By implementation of a novel (hand held) digital health tool, designed to provide clinical decision support for health care providers in Primary Health Care (PHC), the project is aiming to improve health care provider’s adherence to evidence-based clinical guidelines, thus improve quality of care, patient oriented services, and the ultimately strengthen the local health delivery system. In parallel, the automated upload of aggregated data from the clinical consultations enables Public Health decision makers to remotely monitor the epidemiological situation in hard-to-reach areas.
ALMANACH, acronym for ALgorithm for the MANAgement of CHildhood illness, is an innovative, digital Clinical Decision Support System (CDSS) tool that provides real-time diagnostic and therapeutic support to health-care workers consulting children from 2 months to 5 years of age in resource-constraint settings. In 2018, Swiss TPH in project partnership with the International Committee of the Red Cross (ICRC) and cooperation with the Adamawa State Primary Health Care Development Agency (ADSPHCDA, hereafter the Agency) in Nigeria, deployed the CDSS and piloted it in 12 health facilities. Gradually, ALMANACH was scaled to all 397 PHC facilities and 15 outpatient departments of secondary hospitals in Adamawa State. The development and implementation of the digital tool was supplemented by various training courses and by specific supervision measures on site.
In an effectiveness-study performed in 2020, researchers at Swiss TPH in partnership with the ICRC and the Agency evaluated the impact of the CDSS on quality of care and health outcomes in remote PHC clinics in Nigeria. Findings showed that the implementation of ALMANACH (i.e. the development of the algorithms, the training of health care providers, the supportive supervision and use under real-world conditions in clinic) had a strong positive impact on the recovery of sick children, as well as the quality of care they received. The results were published in the peer-reviewed journal BMJ Open. (https://bmjopen.bmj.com/content/12/7/e055315.full)
Primary target groups are children under 5 years old in Adamawa State, Nigeria. Secondary beneficiaries were the primary health care workers who obtained a powerful digital assistant for enhanced diagnoses and evidence-based treatment recommendation for paediatric care.
Swiss TPH's involvement/tasks
Swiss TPH’ role was to provide the conceptual and technical expertise to develop, validate, implement and maintain the ALMANACH CDSS. The tool’s clinical content is based on WHO’s Integrated Management of Childhood Illness (IMCI) guidelines, which were enhanced and further expanded. It is tailored to the local context, which means it includes conditions relevant to the epidemiological profile of the geographic region and takes into account both the Ministry of Health’s clinical guidelines as well as the resources available locally at the PHC facilities in terms of drug supply, equipment and staff.
ALMANACH is an easy-to-use digital tool for Android tablets and smartphones that enables health care providers to better adhere to clinical guidelines and thus better exploits IMCI’s potential. With a stepwise, user-friendly format, the ALMANACH’s algorithms guide healthcare providers (from community health workers in remote, resource scarce locations to hospital doctors) to take a structured clinical history, perform relevant physical examinations and diagnostic tests, and finally provide diagnoses and evidence-based treatment recommendations.
Aggregated clinical data from ALMANACH consultations are uploaded to a Health Management Information System (DHIS2). Review of this data enables healthcare managers to monitor more closely clinical case management, trends of diseases like respiratory conditions as well as other outbreak-prone infectious diseases. An epidemiological bulletin from the health facilities implementing ALMANACH is issued regularly and published on the website of the project partner the Adamawa State Primary Healthcare Development Agency (ADSPHDA).
By the end of 2022, the Nigerian ALMANACH project was handed over to the Adamawa Agency, who since then manage and maintain the CDSS independently. The Agency is planning to extend the thematic scope as well as supporting the replication of ALMANACH in other Nigerian States. To ensure the intervention's sustainability, Swiss TPH's ALMANACH team is providing continued technical support (strategic advice, clinical and IT support) until the end of 2023.
Schmitz T, Beynon F, Musard C, Kwiatkowski M, Landi M et al. Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study. BMJ Open. 2022 Jul 21;12(7):e055315.
Bernasconi A, Crabbé F, Adedeji AM, Bello A, Schmitz T et.al. Results from one-year use of an electronic Clinical Decision Support System in a post-conflict context: An implementation research. PLoS One. 2019 Dec 2;14(12):e0225634.
ALMANACH - A New Digital Tool to Improve the Quality of Children Healthcare (video)