Ebenezer Yakubu Dissertation Final Corrected

APPROVAL PAGE This research has been read and approved having met the basic requirements for the award of Masters in Information Management in, Bayero University Kano Nigeria. _______________________ _______________________ Dr. Lami Umar Abdullahi Date (Supervisor) _______________________ _______________________ Dr. K. D. Abbas Date (Head of Department) _______________________ _______________________ External Examiner Date iii

Table of Contents Tittle page - - - - - - - - - i Declaration - - - - - - - - - - ii Approval Page- - - - - - - - - iii Dedication - - - - - - - - - iv Acknowledgement - - - - - - - - v Table Of Content - - - - - - - - vi Abstract - - - - - - - - - vii CHAPTER ONE INTRODUCTION 1.1 Background to the Study - - - - - - 1 1.2 Brief Historical Background of JUTH - - - - 4 1.3. Statement of the Problem - - - - - - 5 1.4. Research Questions - - - - - - - 6 1.5. Research Objectives - - - - - - - 6 1.6. Significance of the Study- - - - - - - 7 1.7. Scope of the Study - - - - - - - 8 1.8 Limitation of the Study - - - - - - - 8 1.9 Definition of Terms - - - - - - - 9 CHAPTER TWO Review of Related Literature 2.1 Introduction - - - - - - - - - 11 2.0. The Concept of Health Informatics - - - - - - 12 2.3 Benefits of having Health Informatics Infrastructures in health care - 14 vi

ABSTRACT Health Informatics has proven to be useful in data gathering, as well as the administration of healthcare services, and has the potential of improving the quality and reliability of healthcare data and services at all levels hence the need to have adequate infrastructure. The research work assessed the availability and use of health informatics infrastructure for service delivery in Jos University Teaching Hospital. The objectives of the study were to determine the health informatics infrastructure available in the health institution, ascertain the types used for delivery and also identify the challenges associated with their use. Using a quantitative approach a cross- sectional descriptive survey was adopted for the study. From a population 1335, a sample size of 308 participants were selected using stratified sampling techniques. Data were analyzed using descriptive survey design. Findings revealed that health informatics infrastructures such as computers, intercom and video/teleconferencing were present in JUTH but some of the equipment were not used for service delivery as a result of cost and frequent breakdown of equipment as well as obsolete equipment, poor internet connection, poor knowledge as well as security and privacy issues. The study further established a relationship between availability and use because it is the available infrastructure that is found to be mostly utilized for service delivery. The study recommended for an independent agency to be set up by the government that will shoulder the responsibility of providing adequate health informatics infrastructure at all levels of care, health managers, professionals and the general public should seize the advantage of using health informatics for quality health care delivery. In the other hand, government and hospital management should prioritized provision and maintenance of health informatics infrastructure as well as training of staff on use. ix

System (NHMIS) by all the governments of the Federation to be used as a management tool for informed decision making at all levels which will eventually lead to improved healthcare (Adeleke, Erinle et al. 2015). Nigerian government has also developed the Health ICT Strategic Framework (2015-2020). The framework is designed to form a roadmap for actions and for strategic application of ICT to help achieve universal health coverage (UHC) and other goals and priorities, which will ultimately create a harmonized and favourable environment for a sustainable application of ICT in the health sector, Adewole (2015) The Nigeria Health ICT Strategic Framework has Infrastructure as one of its critical component; the document refers to Infrastructure as the physical facilities and related assets that form the foundation for Health ICT implementations which will eventually build an effective and efficient health informatics system especially in tertiary health institutions. According to the National Health Policy (2014), adequate ICT tools should be provided to all the health care facilities in the country, particularly to teaching hospitals. The core purpose of this study is to assess the availability of health informatics infrastructure in tertiary health institutions as well as their status in terms of use by focusing on ICT assets and the connectivity of IT systems for health in the face of unreliable connectivity and poor implementation of policies in Nigeria. The goal of this research was to produce an outcome that can be generalized and applied to other tertiary health institutions and can also serve as a barometer in measuring the quality of services available the facilities and other levels of health care delivery in the country. xii

Furthermore, with the passing and the enactment of The National Health Bill (2014) and formulation of the National Health ICT Strategic Framework (2015-2020) which “ is meant to guide the deliberate and judicious use of ICT within the health system to enable the delivery of quality, affordable and equitable health services to all citizens” this study will assess the availability, and use of health informatics infrastructure in Jos University Teaching Hospital Jos, Plateau state Nigeria. 1.4 Research Questions 1. What types of Health Informatics Infrastructure are available for service delivery in Jos university teaching hospitals? 2. What health informatics infrastructure are used for service delivery in the health institutions under study. 3. What are the challenges associated with the use of health informatics in the health institution under study? 1.5 Research Objectives The main purpose of this study is to examine the deployment of Health Informatics Infrastructure (ICT) and their current status in terms of functionality Jos university teaching hospital The specific objectives of the study are to; 1. Determine the health informatics infrastructure available for service delivery in Jos University Teaching Hospital (JUTH). xv

Infrastructure: The Underlying foundation, facilities or basic framework in a system or an organization. Jos University Teaching Hospital : A tertiary health institution located in Jos, Plateau state Nigeria. CHAPTER TWO REVIEW OF RELATED LITERATURE 2.1 Introduction Health informatics is all about using computers to enhance the way health information is processed. The astronomical growth and new trends in Information Communication Technology (ICT) and the role it plays in health care service delivery in the healthcare domain during the last quarter of the 20th century have dramatically changed medical practice resulting in the reconstruction of the traditional boundaries of medicine and its organizational structures in the developed world (Ojo 2006, Commonwealth Health Ministers Meeting 2008). This uptake of ICT has made it impossible for workers who specialized in certain medical areas to work without the aid of informatics applications (Lun 2002).This advancements have created an information age that heralds a strong knowledge evident in the nature of interaction between healthcare professionals in their daily professional activities (Ojo2006, Chandrasekhar and Gosh at Africa (HELINA), held at Ile Ife in Nigeria in 1993, elaborated the importance of informatics applications in the African healthcare sectors. (Mandil et al 1993). Furthermore, International development agencies argue that ICT is the only catalyst to accelerate African socioeconomic development to bridge the digital divide between Africa and the industrialized world especially in the health sector leading to efficiency and effectiveness, Soriyan et al (2001) xviii

terms of its radical effect on care processes and its vital importance to health care delivery. The major purpose of Health Informatics therefore, is to increase the understanding of medicine and medical practice by using real-world medical data. In the subject of healthcare, health informatics is adjudged to be a blend of information science and computer science. 2.3 Benefits of having Health Informatics Infrastructures in health care Health informatics helps doctors and other health care workers with their decisions and actions, and improves patient outcomes by making better use of information—making more efficient the way patient data and medical knowledge is captured, processed, communicated, and applied. These challenges have become more important since the internet made access to medical information easier for patients, (Sullivan & Wyatt 2006). ICT has been identified by many scholars as the main infrastructure in health informatics and it has marked a great turnaround in the health sector. According to Adeleke et al. (2014), ICT has become the cornerstone upon which efficient and effective healthcare delivery thrives. Evidently, computer and telecommunication technology plays a critical role in the transformation of healthcare services. ICT has proven to be useful in data gathering, as well as the administration of healthcare services, and has the potential of improving the quality and reliability of healthcare data and services. Information sharing and transfer within healthcare providers have become possible through dedicated communication lines enabled by ICT. Consequently, electronic medical records and knowledge-based healthcare services are achievable with the use of ICT. Clinical research, health information and related resources are made readily available through the Internet, which has become a viable and reliable means of communication, training and education. One can also purchase healthcare products using the available online stores. This xxi

revolution created an information age that heralds a strong knowledge evident in the nature of interaction between healthcare professionals in their daily professional activities (Ojo 2006, Chandrasekhar and Gosh 2001). Health informatics has a number of long-term benefits in terms of research and healthcare delivery that can be used to create a sustainable health care system solutions are required to manage the massive amounts of data created by medical equipment and healthcare systems, allowing for effective storage and retrieval in real-time data analysis and decision-making. Organizations with expertise utilizing and enhancing their health IT infrastructure for research have shared their lessons learned in these areas, adding value to organizations with similar goals but less experience or resources, (Danciu I, Cowan JD, Basford M, et al. 2014). It has been established that investing in health informatics infrastructure will enable the demand and use of electronic health data for research which is beneficial to researchers by providing them with the necessary tools and expertise. It is also evident that patients benefit from health informatics by providing clinical trial participation opportunities, to clinicians by enabling more rapid translation of research into practice, and to population health analysts by facilitating patient cohort views. In order to reduce project-specific IT costs, using health IT to assist research necessitates greater flexibility, increasing use of standards, and reusable ways for getting, preparing, and evaluating data. (Masys DR, Harris PA, Fearn PA, et al.2012). It is a common knowledge that ICT has changed organizational structures and healthcare delivery within the developed countries of Western Europe, America and Australia. It means that it could equally apply to Nigeria. Information systems and health informatics have become crucial to health institutions (Al-Shorbaiji 2002) initiating improvements in the way organizations are managed (Muid 1994). Nowadays, shared care delivery by professionals of xxii

different specialties or even self-care by patients themselves in their homes is replacing the traditional doctor-patient care setup (Grimson 2001). In addition, interactions between external and internal factors that involve professionals like managerial procedures also bring organizational change (Slappendale 1996). The role of information technology in ensuring good quality data in any healthcare organization would be to facilitate the proper functioning of the necessary system required to run the data system. Another role would be to ensure the accessibility and free flow of information across the different health organization. This is a crucial role of information technology in health informatics (Takvorian, 2007). Other benefits of having a robust health informatics infrastructure in any health facility especially in Nigeria can be cost effective approach that will ensure proper service delivery, which can aid in beneficiary’s behavioral change through the use of ICTs. This is true because presently most Nigerian teaching hospitals have to generate money by billing patients for the services rendered to them, so as to augment the money received from the government to run the hospital and pay staff salaries. Meanwhile, it is believed that if the use of ICT is adopted the cost of running the hospital on the long run will be reduced and the health care delivery system may be as efficient and effective as it is in the developed world (NHS, 1998). Though one may argue that ICT has no direct impact on certain prominent health issues in the country such as malnutrition and diarrhea, however, ICT can directly influence some areas such as disease control and management. ICT‘s impact on health outcomes is always indirect. In addition, telemedicine reduces diagnostics and data collection costs, thereby improving the professionals’ efficiency. 2.4 Availability of Informatics infrastructure in Nigerian health institutions from a historical perspective xxiii

A major milestone for the globalization of health informatics in general was the first IFIP-IMIA world congress on health informatics in developing countries in Mexico in 1982 (M. Korpela, 2013). This was where the introductory proceedings addressed the fundamental issue “as to whether developing countries can afford to spend scarce resources on informatics while many millions of people have no access to the most primitive forms of Primary Health Care” and after that several developments followed. According to Idowu, (2003), Health informatics in Nigeria started in the late 80s when a collaborative research project between the Computing Centre of the University of Kuopio, Finland and Obafemi Awolowo University, and Obafemi Awolowo University teaching Hospital (OAUTHC), Nigeria, was initiated and this initiative was part of INDEHELA (a long term research project on Informatics Development for Health in Africa). The collaborative project produced a very rudimentary hospital information system based on the Veterans Administration’s (VA) Admission Discharge Transfer, running on a stand-alone PC, which was in use at OAUTHC in 1990 (Daini et al, (1992). The group then organized the first International Working conference on Health Informatics in Africa which was held April 19-23, 1993 at Ile-Ife, Nigeria (HELINA, 1993). In the late 1990s, the Finnish / Nigerian research team decided to expand their rudimentary hospital information system with the aim of developing a comprehensive system suitable for use in all Nigerian teaching hospitals and medical centers. The plan then was that by 2001 all the teaching hospitals in Nigeria would have Health Informatics units which could make use of standardized software. In reality, though some hospitals have computer or IT units, these serve primarily to support word processing for administrative and clerical purposes. There were other efforts made towards developing a informatics infrastructure such as ‘Made in Nigeria Primary xxiv

Healthcare and Hospital Information System’ (MINPHIS) in 2004 only five teaching hospitals and medical centers use the system as of 2007. One of the reasons for this limited use is the cost of purchasing the commercial software system. Idowu, Adagunodo et al. (2004) reported that, another system was developed at the Department of Computer Science & Engineering, Obafemi Awolowo University, Nigeria. The system was designed for referral of patients from one hospital to another such that patient’s case file, referral note and medical examination result that were transferred manually from one hospital to another could be transferred over a computer network. It can be seen clearly from the above that most of the intervention and the infrastructure suffered setback because they were designed to address a particular health informatics need which brought about the question of interoperability in terms of scale up. Nigeria is currently witnessing continuing advocacy and increase in number of individuals yearning for computerization of health information and healthcare processes. On the other hand, the Government is evolving plans and strategies for the adoption and implementation of health information technology (Adeleke, Erinle et al. 2015). In response to the yearnings and to improve the use of ICT in healthcare delivery in the country, the Nigerian Government in 2014 developed a 5-year Strategic plan on health with health information system taking a strategic position. The goal is to provide an effective National Health Management Information System (NHMIS) by all governments of the Federation to be used as a management tool for informed decision making at all levels and for improved service delivery for healthcare (Adeleke, Erinle, et al.2015). However the policy only provide for inter-sectoral structure for collection, collation, analysis, storage, dissemination and use of health-related data and not service delivery at the facility level. xxv

The Government recognized the need to have a harmonized health information management through Health Information Technology (HIT). It was on this premise that the first National Conference on HIT was organized by the Federal Ministry of Health (FMoH) between November 2 and 4 2011. The focus of the conference was to have one harmonized health data management system and the specific objectives were to compile a list of health information system applications in use in the country, to review the interoperability of the existing systems, to review the Health Information Technology components of the country’s eHealth strategies and to propose strategies for the establishments of interoperability standards and capacity building. Subsequently, the National Council on Health in August 2013 approved the deployment of EHRs in all thirty six states of the federation, including the Federal Capital Territory (Adeleke, Erinle et al. 2015). In another development, the government rolled out plans to ensure Universal Health Coverage for all citizens by the year 2020 through leverage on the vast potentials of ICT, the FMoH through her National Health ICT Strategic Framework (2015-2020) intends to scale-up of ICT infrastructure in all health facilities across the country to ensure they are in step with Health ICT and health system priorities (FMoH 2016). This singular efforts is designed to address the lingering challenge of inadequate health informatics infrastructure in Nigerian tertiary health facilities which will enable the healthcare industry transition by developing incentive mechanism for Health ICT infrastructure and use them to improve patient processes and outcomes and ultimately assist in achieving universal health coverage (UHC. Quite a number of studies in the literature have evaluated the availability and use of Health informatics infrastructure in Nigerian tertiary health institutions, notably, Idowu et al (2003) identified health informatics infrastructures such as mobile phones, personal computers, non- xxvi

hospital Internet facilities in four Nigerian teaching hospitals namely; Obafemi Awolowo University Teaching Hospital IleIfe, Ladoke Akintola University Teaching Hospital Ogbomoso, Lagos State University Teaching Hospital and University College Hospital Ibadan. The health Informatics Infrastructures that were readily available are mobile phones which were much utilized by almost all the health professionals in the teaching hospital essentially for communication consulting and generally for improving health care services. However, there was lack of Internet connectivity which grossly impact on effective delivery of services in the surveyed hospitals. On their own part, Adeyemi and Ayegboyin (2004), in a survey involving four general hospitals, 10 primary health-care centers, and six private hospitals in Nigeria reported that none of the 6 institutions had e-mail access or a Web site and only very few of the workers possessed personal computers or had any measurable computer skills. On the contrary, Olatokun & Adeboyejo (2009) reported a 100% Internet usage by (Nurses and Pharmacist), 98.1 % (Medical doctors) and 96.2% (Nurses/ Midwives) at the University College Hospital (UCH) Ibadan. This clearly shows that Internet facilities are becoming entrenched and indispensable in the hospital environment especially in tertiary health institutions in contrast with what is obtained in primary health-care centers. 2.5 Use of Health Informatics Infrastructure in Nigerian Health Institutions The telecommunications sector in Nigeria has undergone significant growth, as of February 2023, the Nigerian Communications Commission (NCC) put telephone density in the country at 119.01 per cent, where telecom operators have connected 325 million lines. Of the 325 million lines, 227 million are active. The demand for improved and additional infrastructure will continue to grow as more telecoms operators deploy new technology and expand their current operations. It has been proven also that health systems in developing nations including Nigeria xxvii

seek to leverage these network infrastructural developments to achieve better healthcare for citizens and to improve the working conditions for public servants and the provision of quality health care services in a country has been shown to be guided by the level of access and use of ICTs by medical personnel in the country (Awopetu et al., 2014:69).The potential of ICTs to improve health has therefore, been recognized by both the public and private sectors with evidence of success of ICT for health initiatives in Nigeria and globally, however, scale-up and sustainability have proven to be challenging, though the ICT sector has evolved faster than the policies that guide the use of health informatics, presenting significant challenges to projects moving towards institutionalization, (Nigeria National Information and Communication Technology (ICT Policy, 2012). Use of computers in healthcare settings provides opportunities for individuals, medical professionals and healthcare providers to obtain information on different aspects of diseases, communicate with other healthcare professionals and patients via videoconferencing, offer access to Medline, medical/nursing journals, textbooks and the latest information on breakthroughs in health (Gour & Srivastava, 2010 cited in Dery et al., 2016). Health Informatics has enabled healthcare providers to deliver better healthcare at a reduced cost and also contribute to quality improvement in services. These systems collectively drive eHealth and provide lifesaving data and information for clinical and non-clinical use (Dery et al., 2016). Electronic medical records, which has been defined by the World Health Organization as the cost-effective and secure use of ICT in support of health and health-related fields, including healthcare services, health surveillance, health literacy and health education, knowledge and research (USA Department of Health and Human Services, 2011) holds the key to improving healthcare delivery (Dery et al., 2016). xxviii

Whereas the use of health informatics infrastructure for service delivery in the developed countries has been widely explored with most developed countries making great advances (Howitt et al., 2012), developing countries on the other hand are seeing a proliferation of eHealth pilots but few full scale implementations (Lewis et al., 2014). Several studies conducted in Nigeria have revealed utilization pattern of use of health informatics infrastructure among health professionals. These include a study that reported utilization of desktop computer, ICT enabled television, and laptop computer and smart phone for patients care among nurses with greater percentage of the nurses making use of desktop computer for keeping record of disease surveillance and smart phones for patients care follow-up, emergency response system, and patient’s appointment reminder (Adesuyi, Abolarinwa, Maitanmi and Ajao, 2020); a single- facility study of the Federal Medical Centre (FMC) Yenagoa in Bayelsa State, Nigeria that reported 47% of the respondents to have utilized computer for health care delivery, 21.4% for internet connectivity, and 39.9% for telephone (Ceo, In, Yi, Pa, Dambo, & Ma, 2018); Utilization of Mobile Technology for Knowledge Update among Nurses in Primary and Secondary Healthcare Settings in Osun State, Nigeria that showed an average ( 48.0%) level of knowledge, 100%, 72.3% adoption of mobile technology, particularly mobile phone and laptop PC respectively for knowledge update (35.8%) (Abubakar, Garba & Balarabe, 2015) and use and gratification of ICTs by health care personnel in Nigerian South- South tertiary hospitals that reported 77%, 89% of the participants to have utilized telephone and computer respectively for health care (Udousoro, 2014). Similarly, Adeleke et al. (2015) found that participants in their study are considerably knowledgeable and skilled especially in the use of electronic mail (52%) and the Internet (47%) mostly through self-efforts which saw majority of respondents reported to have used computer (94%) and the Internet (95%) for more than three years. The study notes that xxix

major factors that contributed to the way the healthcare professionals utilized computer and the internet were profession, age, sex and possession of a laptop computer (p =.000). Following the push for health informatics in health care delivery, quite a number of tertiary health facilities hospitals have subsequently been provided with various infrastructure, such as the computers and Internet. The government has harnessed the opportunities of ICT in health care delivery by providing relevant infrastructure and upgrading of equipment in teaching hospitals across the country. This demonstrates the commitment of the government towards overhauling the entire health sector by equipping teaching hospitals with state-of–-the-art medical equipment (Nwoko, 2011). This is done in order to respond to the perennial need for health informatics infrastructure among health workers. According to the National Health Policy (2014), adequate ICT tools should be provided to all the health care facilities in the country, particularly to teaching hospitals. In order to achieve this, the Nigerian government has agreed to create a special fund, referred to as the Basic Health Care Provision Fund, for the provision of ICT tools to all the teaching hospitals in the country. The National Health Bill (2014) indicates that 50% and 15% of the fund respectively is to be allocated to the provision and maintenance of ICT facilities in the hospitals. In May 2014, an online inventory data collection form28 was circulated to key stakeholders and known Health Informatics implementing agencies to catalogue initiatives in Nigeria. A desk review of several databases was conducted in parallel to the request for submissions. A total of 84 unique ICT for health initiatives in Nigeria were identified and also raised as a major concerned with the physical infrastructure (e.g., connectivity, electricity, hardware, directory services) and software components (e.g., electronic health records (EHRs)/electronic medical xxx

records (EMRs), health information datasets) that contribute to the Health Informatics enabling environment, (GSMA mHealth Country Feasibility Report: Nigeria, 2014). Although the public and private sectors are taking steps to improve infrastructure related to health informatics, the findings revealed an existence of a digital divide between rural and urban areas. Contributing to the divide are prohibitive costs to both consumers and corporations looking to provide and expand services. The inadequate infrastructure for power and connectivity are crucial barriers to ICT for health implementations. The survey identified mechanisms to improve and maintain facilities, basic health equipment, and power and Internet/broadband connectivity. It is now clear that a sustainable health financing mechanisms should be established and a sub-set flagged for the improvement and maintenance of facilities, power, Internet and other infrastructure for health informatics. The report identified the need for a coordinated Health ICT strategy for the country. The strategy will enable Nigeria to leverage current and future ICT investments to build an integrated national health informatics infrastructure and help enable Universal Health Coverage (UHC) by 2020. The United Nations policy review assessment for ICTS for health enabling environment 2014 too revealed that the Nigeria ICT for health enabling environment is transitioning from experimentation and early adoption into developing and building up, existing implementations, but in order for the sector to continue to flourish, investments must be made to improve infrastructure especially to less economically developed regions. Sustainable financing mechanisms need to be identified, and the private sector can and should be engaged in this endeavor. As progress continues, efforts should be made to ensure the systematic alignment of health Informatics with health sector strategies and priorities. xxxi

As previously reported the Health ICT Strategic Framework (2015-2020) was designed to respond and created opportunities for Government of Nigeria’s commitment to ICT. An assessment of the enabling environment for Health ICT was conducted in 2014 which will facilitate the availability of health informatics infrastructure in the country. The Infrastructure component of the strategic framework contained the following specific recommendations; • Reinforce existing strategies for ongoing funding and investment in power provision, acquisition, installation and maintenance at all health facilities throughout the country, including exploring mechanisms (i.e. regulatory) for promoting distribution of alternate power • Define minimum infrastructure and computing requirements for each type of health facility and health administrative office and link to accreditation and assessment • Develop and introduce a basic ICT and related equipment package for health facilities based on prioritized services and application needs that encourages local ownership and capacity building • Strengthen local and regional support programs, such as the Rural Information Technology Centers, to ensure ongoing support for infrastructure development and maintenance • Install and maintain Internet and/or broadband connectivity for all tertiary and secondary along with prioritized primary health facilities as well as State and LGA level health administrative offices • Develop incentive mechanism for Health ICT infrastructure improvement. xxxii

Based on the Theory of Change, the recommendations are connected along a logical pathway of activities with short- and long-term impact. The activities reflect a five-year process, separated into three phases, to support the attainment of UHC. Set-up and preparation will take place in year 1. During years 2 and 3, activities that reflect Deploy, Maintain and Support to help meet the vision will be carried out. The final two years (years 4 and 5) will be focused on Consolidate and Continuous Review activities and reviews of progress. The documents concluded that “ As time advances, there will be opportunities to assess the status of progress and revisit the action plan.” Revisiting the action plan will be important to ensure the continued alignment of the activities with achieving UHC. 2.6 Challenges of Health Informatics Infrastructure in Nigerian Health Facilities It is a known fact that health informatics can be inappropriately applied, have functional errors, be unreliable, user-unfriendly, ill-functioning or in or the environment may appropriately prepared to accommodate health informatics within the clinical setting which will negatively affect processes and decisions of the health care providers. Ammenwerth and Shaw (2005) assert that health care informatics depend heavily on stable ICT infrastructure they pointed out that repeated crashes of information’s systems and networks show how dramatic these infrastructure affects patients care processes thereby leading to clinical errors. Other studies have shown that despite the immense benefits of health informatics as a means of delivering quality health care services, the potential have not been fully harnessed by health professionals especially in developing countries. This is due to problems of access (slow or unreliable Internet connectivity), high subscription cost of information materials; lack of awareness of what is available; lack of relevance of available information (i.e. not meeting xxxiii

professionals’ needs in terms of scope, style, or format); lack of time and incentives to access information; and lack of interpretation skills (Gatero, 2011). Additionally, government institutions appear to be slow in implementing reforms on health informatics and other appropriate ICTs which are required to improve healthcare delivery (Akanbi, Ocheke et al. 2012, Akor and John-Mensah 2016). Government policy and strategy; lack of ICT infrastructure; lack of basic ICT skills/knowledge; poor internet connectivity; financial issues/constraints; and inadequate electric power supply were identified as the major challenges that hinder the successful implementation which was also corroborated by Martinez, Villarroel et al. (2005), Ward, Jaana et al. (2006), and Ouma and Herselman (2009). Unfortunately, the funding needed to tackle this challenge is currently inadequate (Ejughemre 2014). It has been reported that the low speed and expensive internet bandwidth in most sub-urban parts of Nigeria (Osuagwu, Okide et al. 2013) will be a barrier to the availability of Health Informatics in Nigerian because for example, a high bandwidth is required for assessing the EHR (National Research Council 2000). The lack of affordable connectivity and bandwidth has also been described as the primary obstacle to several of the most promising health applications in tertiary health facilities which including telemedicine and other real-time diagnostic support and training initiatives (Blantz 2010). 2.7 Summary of the Review This chapter commenced with an introduction and definitions Health Informatics, its relevance in health care and how progress in technological development and globalization has pushed for an increased demand for data and information in the health sector. Health informatics was also xxxiv

shown to be a catalyst for Africa’s socio-economic development and a yard stick for measuring quality of health care. The Chapter went further to x-ray the benefits of health informatics in the health care which include speedy decisions and actions, efficiency, effectiveness, and sustainable health care system solution, research and development as well as cost reduction as well as how infrastructure is the drivers for the deployment of health informatics. Additionally, Internet connectivity, electricity, hardware, directory services and software components (e.g., electronic health records (EHRs)/electronic medical records (EMRs), health information datasets) were identified as infrastructure for health informatics especially in resource constrain setting such as Nigeria. A background of Health Informatics from a historical perspective in Nigeria was also discussed in the chapter, from the 80’s in OAUTH to development of NHIMS and the organization of health information technology conference as well as the Nigerian Health ICT strategic framework (2015-2020). The Chapter continued with a description of the types of health informatics infrastructure and ICTs for health landscape in Nigeria. This includes the various policies designed for ICT deployment, telecommunication density, and the recommendation of the health ICT strategic framework (2015-2020) on ICT infrastructure for health and how it intends to scale up the uptake of health informatics across the country based on the theory of change. Challenges associated with the effective availability and use of health Informatics were also discussed. Factors such as poor power supply, cost of equipment poor broadband network, and poor implementation of policy by government among others were identified in this chapter. xxxv

CHAPTER THREE RESEARCH METHODOLOGY 3.1 Introduction: Research methodology describes and justifies the overall approach that will be adopted in the research process, from the theoretical foundation to the strategies that will be used in the collection and analysis of the data. It is a system of explicit rules and procedures in which research is based and against which claims of knowledge are evaluated (Ojo, 2009). It explains and justifies the research strategy chosen. Research design issues, which include the methods, tools, procedure and data analysis techniques, are addressed. Therefore this section focuses on the research techniques that were adopted and used for the study with the aim of achieving the research objectives 3.2. Research Design The research design adopted for a study contains important assumptions about the way in which a researcher views the world (Saunders, Lewis, & Thornhill, 2009). These assumptions will underpin the research strategy and the methods chosen as part of that strategy. The research xxxvi

philosophy reflects how a researcher considers or thinks about the effects of the approach taken in the development of knowledge; informally, it is the way we go about doing research (Saunders et al, 2009). The study uses a cross-sectional descriptive survey approach with the application of quantitative research methods. This was employed to investigate the availability and use of health informatics among health workers in Jos University Teaching Hospital. xxxvii

3.3. Preliminary Study A preliminary study was carried out on Jos University Teaching Hospital to have an understanding of the staff composition of the staff in the facility this was achieved by taking a tour of the health institution and obtaining the breakdown of the different categories of health professionals from the office of the head of establishment who is the custodian of personnel information. 3.4 Population of the Study Any group of people or observation , which includes all the possible members to that category is called population. “A population is usually defined as „all the members of any well-defined class of people, events or objects . It represents a census or complete enumeration method in which all ‟ the units are reached. The merit of such a concept is that results obtained are representative, accurate and reliable and hence question of error becomes almost insignificant” Pandey (2005). According to John W. Best (2007), “A population is any group of individuals who have one or more characteristics in common that are of interest to the researcher. The population may be all the individuals of a particular type or a more restricted part of that group”. The study location is Jos University Teaching Hospital in Plateau state, the population in this study consisted mainly of various hospital staff who are directly involved with the creation, storage, management, appraisal, disposal and use of health information by the use of health informatics infrastructure in the facility. These health workers are 1335 in number in the facility. 3.5 Sampling Technique and Sample Size Sampling is the process by which a relatively small number of individuals or measures of individuals, objects or events is chosen and analyzed in order to find out something about the entire population from which it was chosen. Sampling procedures provides generalizations on the basis of relatively small preparations of the population. xxxviii

Kulbir Singh Sindhu (2005), states that sampling is the process of drawing a sample from the population. For this purpose, the population is divided into a number of parts called sampling units. In the opinion of .Fred N. Kerlinger (2007) ‘‘Sampling is taking any portion of a population or universe as representative of that population or universe” The study used both the probability and nonprobability sampling techniques for data collection. For probability sampling technique, the stratified random sampling method was used for the different categories of health workers, and for the non-probability sampling technique, convenient sampling method was used to administer the questionnaires among the health workers within the various departments because of their homogeneity. Stratified random sampling is a form of random sampling in which the population is divided into two or more groups/strata according to one or more common attributes while convenience sampling is a non- probability sampling method where data is collected from an easily accessible and available group of people. The individuals in the sample are selected not because they are most representative of the entire population, but because they are most easily accessible to the researcher, (Lavrakas, 2008). Therefore, the total number of health workers in JUTH is 1335. A sample size of 308 was selected for the study based on Krejcie and Morgan (1970) recommendation on selection of population sample to participate in the study. In applying the stratified sampling technique, the health professionals in JUTH were proportionately stratified using the formula below: Formula: Prop. Sample (Prop s) = X÷N x Ps Where: Props = Proportional sample size X =Population of health workers in the tertiary health institution N =Total population health in the three selected tertiary health institutions (1335), Ps =Population sample size for the study (308) xxxix

S/no. Category Of Health worker No. health workers Sample size 1 Doctor 457 107 2 Nurse 529 112 3 Pharmacy 30 7 4 Lab. Scientist 165 38 5 ICT workers 7 2 6 Medical social workers 16 4 7 Radiologists 20 5 8 Health Info. Managers 84 19 9 Physiotherapist 19 4 Total 1335 308 Table 1 Total Number of health workers and sample size 3.6 Respondent Group and Justification for their Selection In this study, the hospital workers that were included are the medical doctors, nurses, pharmacists, physiotherapists, radiologists, medical laboratory scientists, ICT staff, and health information managers represents the end user of the health informatics infrastructure the health facility and that will provide the right information and answer to the research questions in the study. In addition, only health workers who have consented or agreed to participate in the study were included. However, health workers who do not consent or disagreed to participate in the study were excluded. The probability method was considered more appropriate because it gives every member of the population equal chance of being selected and also, opinion of different groups of health workers was required for the study. xl

3.7 Data Collection Instrument The study used primary data collection methods. The main instrument of data collection was questionnaires supplemented by observations. These instruments were used for assessing the availability and use of health informatics infrastructure in JUTH , which were personally administered by the researcher and filled by respondents in their various work stations during working hours. 3.8 Administration of Research Instrument Questionnaires are one of the research instruments commonly used to gather primary data. This data collection instrument according to Onyango (2002) consists of a set of questions for submission to a number of persons or respondents in order to gather data. Generally, they are categorized as closed or structured questionnaires and open or unstructured questionnaires. In a closed or structured questionnaires, the respondents are provided with alternatives from which to select one or more than one answer depending on the structure of the question. Open ended or unstructured questionnaires are designed to allow free responses from participants rather than on confining them to specific alternatives. In this study, closed ended (structured) questionnaire was used. The questionnaires were administered to Doctors, Nurses, Pharmacists, Medical Laboratory Scientists, Radiologist Physiotherapist, ICT staff and Health information Managers. Personal Observation was also used to gather data for this study. This is because through this type of data gathering method, a researcher will be in a position to obtain first hand and direct experiences on how things are done and by the same token being in a position of checking and validating facts presented in the responses from the interviews. Observations made for this study xli

were at the Accident and Emergency (A&E) Department and the Medical Records Unit. The study used a non-participatory obtrusive observation and observed how records were created upon arrival of patients at the A&E department. The observations made within the same department were on how admission or discharges for patients in relation to their medical records take place. Observations were also in Pharmacy unit on how drugs are dispensed and billed. Through observation, the researcher was able to experience how laboratory and radiology results were processed and transferred to the clinicians. Observations were also made in ICT units to have a clear picture of the infrastructure available and this helped in the elimination of bias from respondents. Due to time constraints observations could not be made in all the departments and units covered by the study. 3.9 Data Analysis According to Cresswell (2003), data analysis is the act of converting data with the intention of taking out useful information and facilitating conclusions. The analysis is therefore made to provide answers to the research question. The analysis from questionnaires for a study on the deployment and status of health informatics infrastructure in three tertiary health institutions in plateau state was interpreted, where each question was discussed and findings from the sample analyzed using Microsoft Excel (2007) for a visual presentation of the research results. Methods used to interpret findings of the research study included pie charts, bars and table and graphs. xlii

CHAPTER FOUR DATA PRESENTATION ANALYSIS AND DISCUSSION OF THE FINDINGS 4.1 Introduction This chapter presents findings of the study that was conducted to examine the availability and Use of Health Informatics infrastructure for service delivery in Jos University Teaching Hospital (JUTH). The results of the data collected were presented, analyzed, discussed and reported under the following headings: 4.2 Response Rate 4.3 Types of Health Informatics Infrastructure Available 4.4 Types of health informatics Infrastructure used for service delivery 4.5 Challenges Associated with the Use of Health Informatics Infrastructure 4.2 Response Rate Out of a total of three hundred and eight (308) questionnaires that were distributed to the various health professionals at Jos University Teaching Hospital, two hundred and ninety three (293) were filled out and returned, giving a response rate of 95%. As a result, the data analysis on questionnaires administered is based on those questionnaires filled out and returned by the respondents in various departments and units at JUTH. The observations made by the researcher were also incorporated into the findings. xliii

Table 4.1 presents the survey response rates from the various health workers in the hospital Source: Field work 2023 Table 4.1 shows that the respondents constitute majorly of clinical staff of JUTH who are directly engaged in service delivery as follows: 104 (35.4%) were Doctors, while 113(38.6%) are Nurses, Pharmacists and Medical laboratory were 34 (11.6%) and 7 (2.4%). The other set of respondents were the non-clinical staff, comprising of 15 (5.1%) health information managers and other health professionals were 20 (6.8%). 35.49% 38.57% 11.60% 2.39% 5.12% 6.83% Responses Doctors Nurses Lab Scientists Pharmacists HIM Others Figure1. Showing distribution of respondents by their profession xliv Table 4.1: Response Rate Category of health worker Freque ncy percent ages Doctors 104 35.50% Nurses 113 38.60% Lab Scientists 34 11.60% Pharmacists 7 2.40% HIM 15 5.10% Others 20 6.80% Total 293 100.00 %

4.3 Types of Health Informatics Infrastructure Available The first objective of the study was to determine the types of health informatics infrastructure available for service delivery in Jos University Teaching Hospital (JUTH. Table 4.2 presents the results. Table 4.2: Types of Health Informatics Available Type of Health Informatics Available Not Available Total Computer/Laptop device 200(68.0% ) 93(32.0%) 293(100% Intercom 185(63.1%) 108(36.9%) 293(100% Video/teleconference facility 173(59.0%) 120(41.0%) 293(100% Telemedicine Facility 97(33.0) 196(67.0%) 293(100% Clinical Decision support system 87(29.6%) 206(70.05%) 293(100% Internet 108(36.8%) 185(63.2%) 293(100% LCD/LED Screens 157(53.5%) 136(46.5%) 293(100% Source: field work 2023 Figure 2 200 185 173 97 87 10 8 15 7 93 108 120 196 206 185 136 29 3 29 3 29 3 29 3 29 3 29 3 29 3 availability Of Health Informatics In JUTH Available Not Availabe Total xlv

Table 4.2 present responses from different categories of health workers regarding the availability of health informatics infrastructure in the health facility. The raw data obtained from a total of 293 health workers in JUTH 68.0% of them reported the availability of desktop or laptop computer device, 63.1% the availability of intercom, 59.0% that of video/teleconferencing facility, and 53.5% reported that the availability of LCD/LED screens for service delivery in the facility. Conversely, only 33.0% reported the availability of telemedicine service, 29.6 % reported the availability of a clinical decision support system (CDS) while 36.6% respondents reported the availability of internet service as shown in figure 2 4.4 Types of health informatics Infrastructure used for service delivery in JUTH The second objective of is study intended to ascertain the types of health informatics infrastructure in use for service delivery in JUTH. Table 4.3 presents the results. Table 4.3: Types of Used in JUTH Type of Health Informatics used In Use Not In Use Total Computer/Laptop device 225(76.8%) 68(21.2%) 293(100%) Intercom 180(61.4%) 113(38.6%) 293(100%) Video/teleconference facility 119(40.6%) 174(59.6%) 293(100%) Telemedicine Facility 83(28.3%) 210(71.7%) 293(100%) Clinical Decision support system 54(18.4%) 239(81.6%) 293(100%) Internet 97(33.0%0 196(67.0%) 293(100%) LCD/LED Screens 104(35.5%) 189(64.5) 293(100%) Source: Field work 2023 Table 4.3 shows that 76.8% and 61.6% of the respondents agreed that they use computer/laptop device and intercom respectively for service delivery while 40.6% stated that they use video/teleconferencing facility. The table also shows that 71.7% and 81.6% stated that they are not using telemedicine facility and Clinical decision support system respectively while 67.0% xlvi

stated that they are not using the internet. A total of 64.5% of the respondents also reported that they don’t use LCD/LED screens. It was also observed that the health workers themselves purchased most of the computer/laptop devices used for service delivery. Figure 3 shows the types of health informatics infrastructure used for service delivery in JUTH Figure 3 Computer/Laptop device Intercom Video/teleconference facility Telemedicine Facility Clinical Decision support system Internet LCD/LED Screens 0 50 100 150 200 250 300 350 225 180 119 83 54 97 104 68 113 174 210 239 196 189 293 293 293 293 293 293 293 Use Of Health Informatics In Juth In Use Not In Use Total 4.5 Challenges Associated with the Use of Health Informatics Infrastructure in JUTH The third objective of the study was to identify the challenges associated with the use of health informatics infrastructure. In order to ascertain this, the respondents were asked to tick either Yes or No. Table 4.4 presents the results. xlvii

Table 4.4: Challenges Associated with the use of Health Informatics Infrastructure Challenges Yes No Total Poor Power supply 58(19.8%) 235(80.2%) 293(100%) Lack of training 108(36.8%) 185(63.2%) 293(100%) Poor knowledge 158(54.0%) 135(46.0%) 293(100%) Lack of physical access 125(42.7%) 168(57.3%) 293(100%) Breakdown of equipment 197(67.2%) 96(67.2%) 293(100%) Cost of equipment 231(78.8%) 62(21.2%) 293(100%) Security and privacy issues 189(64.5%) 104(35.5%) 293(100%) Poor Internet connectivity 268(91.5%) 25(8.5%) 293(100%) Obsolete equipment 179(61.1%) 114(38.9%) 293(100%) Source: Field Work 2023 From the data obtained from the 293 respondents as presented in Table 4.4, 91.5% identified poor internet connectivity, 78.8% mentioned cost of equipment while 67.2% and 64.5% of the respondents respectively mentioned breakdown of equipment and security and privacy issues as the major challenges associated with the use of health informatics in the healthy facility. Additionally 61.1% also identified obsolete equipment and one of the major challenges. 54.0% of the respondents identified poor knowledge as an impediment faced in the effective use of health informatics in the health facility. However, 80.0% and 63.2% of the respondents did not see poor power supply and lack of training respectively as a challenge also 57.3% affirm that lack of physical access is not a challenge associated with the use of healthy informatics infrastructure in JUTH xlviii

Figure 4 shows the breakdown of the challenges faced by health professionals in JUTH in the use of health informatics infrastructure for service delivery. Figure 4 Poor Power supp ly Lack of training Poor knowled ge Lack of phys ical access Breakdow n of equip ment Cost of equipment Security a nd pr ivacy issues Poor I nt ernet connectivity Obsole te equipment 0 50 100 150 200 250 300 350 58 108 158 125 197 231 189 268 179 293 293 293 293 293 293 293 293 293 Challenges Of Health Informatics In Juth Yes No Total 4.6 Discussion of the Findings This study has clearly demonstrated the place of health informatics infrastructure from the perspective of health professionals in Jos University Teaching Hospital based on availability and use for service delivery. The results from this study are discussed below in line with the research objectives: (a) Determine the health informatics infrastructure available for service delivery in Jos University Teaching Hospital (JUTH). The first objective of this study was to determine the health informatics infrastructure available for service delivery in JUTH. The result of the analysis revealed high availability of computers devices (desktop or laptop) which is used EMR, service billing, drugs dispensing, discharge and bookings, tomography, magnetic resonance imaging and other clerical and accounting services. xlix

Intercom and mobile phone was also available and used for communication among health workers and not to consult patients off site. Video/teleconferencing facilities were mostly used for training and workshops. LCD/LED screens are usually used alongside the video/teleconferencing facilities. The study result further revealed low availability of telemedicine, which was recently lunched at the time of conducting this research in the facility. Clinical decision support system and internet were the least available infrastructure in facility. To buttress this finding, Idowu et al, (2003), reported that ICT capabilities (computers, mobile phones etc) were available in Nigerian teaching hospitals but not much internet connectivity was available, The implication is that when some health informatics infrastructures (internet for example) are not available, there will be inefficiency, which was the case of Jos University Teaching Hospital where some basic ICT capabilities (internet) were reported not sufficiently available in the hospital and the available ones were in poor working condition. Consequently, the insufficient availability of ICT facilities in JUTH also affects the primary goal of the institution, which is provision of quality timely healthcare services to the public. (b) Ascertain the types of the health informatics infrastructure used in the health institutions under study. The second objective was to ascertain the types of health informatics infrastructure used in JUTH. Results of the findings revealed that a highest utilization of computer/laptop devices where some even used their personal devices to provide services to their clients. More than half of the respondents reported to be using intercom while less than half are using video/teleconferencing facilities as well as LCD/LED screens. l

The result also revealed low utilization of telemedicine, clinical decision support system, and the internet. This is clearly connected with their availability because the health workers can only work with what is provided to them. (c) Identify the challenges associated with the use of health informatics infrastructure in the health institution . The third objective was to identify challenges associated with the use of health informatics infrastructure. The challenges revealed by the findings include poor internet connectivity which was not sufficient initially, followed by cost of equipment as the most pressing. Additionally, breakdown and obsolete equipment, security and privacy issues as well as poor knowledge of the availability and sometimes poor knowledge of the use the available health informatics infrastructure were identified as other challenges. It was also revealed that lack of training and poor power supply was not identified as a major challenge associated with the use of health informatics in JUTH. From the above findings, a significant number of respondents indicated that ICT facilities were frequently utilized at different stages of patients care in JUTH. In addition, it was found that lack of internet connection hinder sharing of patient’s health records between departments and health professionals in the hospital. The implication of this finding is that effective and efficient utilization of health informatics infrastructure cannot be achieved in JUTH. li

CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATION 5.1 Introduction The basis for this study was to carry out an assessment on the availability and use of health informatics infrastructure for service delivery in JUTH. An investigation was conducted through the use of questionnaires administered on a selected group of respondents categorized under different health professionals. Some observations relevant to research question were also made. This chapter gives a summary, makes conclusions and recommendations of the study. 5.2 Summary of the Study The study was conducted in Jos University Teaching Hospital JUTH to assess the availability and use of health informatics infrastructure for service delivery. Chapter one dealt with the background to the study where the field of health informatics was clearly presented as defined by different scholars and the role of ICT as the backbone of health informatics. The Chapter went further with the statement of the problem, research questions and objectives, significance of the study as well as the scope and limitation of the study Chapter two reviewed related literature under the concept of health informatics, benefits of health informatics infrastructure in health care, the availability of health informatics infrastructure in Nigerian health institutions from a historical perspective and also discussed the use of health informatics infrastructure in Nigerian hospitals as well challenges associated with their use. Chapter three discussed the methodology used for the study, where the researcher adopted a quantitative research method, research design was a cross-sectional descriptive survey. Chapter four showed data presentation, analysis and discussion of the findings while chapter five showed the summary, conclusion and recommendations. lii

5.3 Summary of the Findings This study found that Health Informatics Infrastructure are available and play a pivotal role in enhancing quality and effective healthcare delivery in Jos University Teaching Hospital. There is no doubt that health informatics is significant in the health institution in areas such reducing patient waiting time, reducing some clinical challenges and errors as well. Findings on the availability of health informatics in Jos University Teaching Hospital showed that majority of the respondents agreed that health informatics infrastructure were available in the hospital. Some of the infrastructures available in JUTH include computers/laptop devices, intercom, mobile phones, video/teleconferencing facilities and LCD/LED screens. However, the findings revealed low availability of telemedicine, clinical decision support system and internet which are available only in few specialized clinics such Infectious disease units which is funded by donor agencies such as USAID and CDC. The types of the health informatics infrastructure used for service delivery in the health institution were ascertained in the study and the findings aligned with their availability. Findings in the study showed a significant use of computer/Laptop devices, intercom, video/teleconferencing, and LCD/LED screens. This further revealed low utilization of health informatics infrastructure which low availability was reported such as telemedicine, clinical decision support system and the internet. This is a clear indication that the availability will infrastructure enhances utilization. Data obtained during the study also indicates that health informatics infrastructure were present in JUTH but some of the equipment were not used for service delivery as a result of high cost and frequent breakdown of equipment as well as obsolete equipment, in addition, poor internet connection in the hospital to enhance effective communication using these gadgets, poor liii

knowledge as well as security and privacy issues were also identified as part of the challenges associated with the use of health informatics in the JUTH. In the same vein only few of the respondents identified lack of training and poor power supply as a major challenge. 5.4 Conclusion The study revealed that health informatics infrastructure are available in JUTH and is used based on circumstances upon which a medical practitioner attended to a patient. The available health informatics infrastructure were found to be mostly computer/laptop devices used for storing Electronic medical records (EMR), there were also intercom services to enhance communication among care givers, video/teleconferencing facility which is mostly used for zoom meeting, trainings and technical support from experts outside the facility. This study revealed that there is no effective communication between health professionals and patients. Also, there is no effective collaboration among health professionals, as well as poor referrals in Jos University Teaching Hospital due to lack of internet connectivity to enhance efficient utilization of e-health facilities. Finding also revealed that the availability of the health informatics infrastructure will increase their use and that will help to achieve quality healthcare services. Despite the formulation of Nigeria Health ICT Strategic framework (2015-2020) which was a policy document specifically designed to serve as road map on the application of ICT in Nigerian hospital that will provide a lunch pad for gradual provision of Health informatics infrastructure in Nigerian hospitals across level. There still exists an infrastructural gap in the field of health informatics in JUTH. liv

5.5 Recommendation Effective and efficient healthcare in developing countries remains a dream that must be realized, therefore Nigerian government and health administrator’s needs to improve the healthcare delivery services to accelerate universal health coverage which will help get people out of poverty. This can be achieved by building health informatics infrastructures across health institution at all levels if these recommendations are followed. In order to mitigate and tackle some of the problems of poor availability of health informatics infrastructure for service delivery, the Nigerian government should establish an agency, different from the ministry of health and if provided with sufficient finances, the agency will administer and spear-head the provision of the required health informatics infrastructure and train personnel in government tertiary hospitals, and the knowledge and skills will be cascaded to different levels of health care, from state hospitals to Primary health care which are predominantly located in rural areas and it will enhance efficient healthcare service delivery to citizens. It is a known fact that healthcare must be safe, effective, timely, efficient, equitable, affordable and people-centered and this can only be achieved through availability proper and effective utilization of health informatics infrastructures. Since level of use is clearly linked to availability and health workers only make use of the technology at their disposal, the government, hospital management, health professionals, and the public should take advantage of the prospects provided by health informatics infrastructure usage for quality healthcare delivery as long as they are available. The study revealed that stable power supply, ICT training, among health professionals and having physical access alone cannot enhance effective utilization of health informatics infrastructure, rather, the equipment needs to be available in the hospital, up to date, and in proper working condition, networked via intranet and internet. This will address other challenges including referrals, collaboration and communication and effectiveness in JUTH. lv

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APPENDIX Questionnaire: For Health Workers Purpose: The purpose of this questionnaire is to gather information regarding the availability of health informatics infrastructure used for service delivery in JOS University Teaching Hospital (JUTH) in Plateau state. The study is purely for academic purposes in fulfillment of the requirements for the award of Masters in Information Management. Information gathered will be treated in strictest confidence. Instructions: Please respond to the questions in this questionnaire as honestly as possible. If space provided is not sufficient please use a separate piece of paper for additional details. Thank you. Category of health workers ---------------------------------------------------- Tick as applicable Section 1 Availability Health Informatics infrastructure Types of Health Informatics Available Not Available Computer/Laptop device Intercom Electronic Med. Record Video/teleconference facility Telemedicine Facility Clinical Decision support system Internet LCD/LED Screens lix

SECTION TWO Type Health Informatics used Types of Health Informatics In use Not in use Computer/Laptop device Intercom Electronic Med. Record Video/teleconference facility Telemedicine Facility Decision support system Internet LCD/LED Screens Section 3 Challenges associated with the use of Health Informatics Challenges Yes No Poor Power supply Lack of training Poor knowledge Lack of physical access Breakdown of equipment Cost of equipment Security and privacy issues Poor Internet connectivity Obsolete equipment lx

APPENDIX Acronyms AHIMA - American Health Management Information Association AMIA - The American Medical Informatics Association HER - Electronic Health Record EMR - Electronic Medical Record FMoH - Federal Ministry of Health FG - Federal Government HIT - Health Information Technology ICT - Information and Communication Technology IFIP - International Federation for Information Processing IMIA - The International Medical Informatics Association II - Information Infrastructure IT - Information Technology JUTH - Jos University Teaching Hospital LGA - Local Government Area NHIS - National Health Insurance Scheme SHONET - State Hospital Network SMH - State Ministry of Health WHO - World Health Organization UHC - Universal Health Coverage lxi