|Year : 2020 | Volume
| Issue : 1 | Page : 1-7
Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa
Victor Alangibi Kiri1, Aaron C Ojule2
1 Department of Mathematics, Physics and Electrical Engineering, Faculty of Engineering and Environment, Northumbria University, Newcastle Upon Tyne, United Kingdom; Department of Pharmacy, Faculty of Pharmaceutical Sciences; Department of Chemical Pathology, College of Health Sciences, University of Port Harcourt, Choba, Rivers State, Nigeria
2 Department of Chemical Pathology, College of Health Sciences, University of Port Harcourt, Choba, Rivers State, Nigeria
|Date of Submission||09-Sep-2019|
|Date of Acceptance||07-Nov-2019|
|Date of Web Publication||14-Jan-2020|
Prof. Victor Alangibi Kiri
39 Juniper Close, Guildford, Surrey GU1 1NX
Source of Support: None, Conflict of Interest: None
Pubic health insurance schemes are usually set up by governments to provide cover for their insured populations against healthcare costs. These schemes are usually administered by a government agency and vary both in how they are funded and provide their services. A number of developing countries have introduced such schemes to minimise the impact of financial barriers to healthcare access by their populations. These schemes are expected to bridge the inequality in healthcare. A National Health Insurance Scheme has been in operation in Nigeria since 2005 to provide health cover for government employees and those in private institutions with no less than ten workers. There are similar schemes in a number of countries in sub-Saharan Africa. We conducted a literature review of publications on public health insurance schemes in sub-Saharan Africa to identify the challenges they encounter. We found 76 relevant publications. Although much have been published on these schemes, few have addressed the critical obstacles to effective implementation, management and sustenance in the unique environments we find in sub-Saharan Africa – where poor technological infrastructures, acts of forgery, counterfeiting and other forms of fraud are common. We highlight these challenges, using the scheme in Nigeria for reference. We discuss the potential role of robust electronic medical record (EMR) systems for sustainable schemes in such environments and describe some of the ways robust EMR systems could be used to mitigate the challenges posed by most of the peculiar problems associated with poor infrastructures.
Keywords: Electronic medical record, health management organisation, information technology, public health insurance, universal health coverage
|How to cite this article:|
Kiri VA, Ojule AC. Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa. Niger Postgrad Med J 2020;27:1-7
|How to cite this URL:|
Kiri VA, Ojule AC. Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa. Niger Postgrad Med J [serial online] 2020 [cited 2020 Apr 1];27:1-7. Available from: http://www.npmj.org/text.asp?2020/27/1/1/275807
| Background|| |
Public health insurance is an agreement that covers the whole or part of the medical expenses incurred by the insured on the basis of the collective sharing of the healthcare risks of a large number of persons and the government. In the main, it covers the costs of healthcare, starting from diagnosis to treatment, based on periodic subscription payments called premiums. Most schemes exclude certain pre-existing medical conditions in their contracts. The contract, known as the plan, is usually between an individual or a sponsor (e.g., an employer or organisation) and the government-controlled agency. Each scheme usually involves the payment of premiums upfront to the provider by those who enrol in the scheme. These schemes usually offer a range of benefits, including preventive services through a network of healthcare providers (HCPs) who have agreed to supply these services to the insured. The contract which typically is renewable annually, also contains the list of qualified HCPs such as physicians, health centres for primary care and hospitals for secondary care as well as laboratories and pharmacies, among others. In most settings, the list only contains the network of service providers who have signed contractual agreements with the insurer, to supply services to the insured persons at costs favourable to both parties. Indeed, in most plans, the insured who uses service outside of the network may either have to pay for the full cost of the care received or be required to pay a much higher share of the cost.
The schemes which operate in sub-Saharan Africa face numerous challenges that negatively impact on their effectiveness and threaten their sustainability.,, Although the literature contains descriptions of some of the schemes in the region, and a few have also highlighted some of the problems, there remains a huge gap in our knowledge of these challenges and fewer still have attempted to proffer pragmatic solutions.,,,,, We conducted a literature review on these schemes, including information sourced directly from the national scheme in Nigeria, to identify some of these challenges. We then proposed adoption of electronic medical record (EMR) systems as essential for addressing most of the operational challenges.
| Methods|| |
We searched the PubMed and Embase databases, as well as the Google Scholar. We restricted our search to publications in English but not on coverage period, using the terms health insurance, health coverage, universal coverage, health information, information technology, electronic communication, electronic patient records, electronic medical records and EMR as search strings in a two-stage screening process. Data extraction was conducted using an interpretive approach by the two authors as independent reviewers based on an identical data extraction form to synthesise the different studies, and we used all the 76 publications that were extracted.
We reviewed the resulting material to identify the major challenges faced by public insurance schemes in sub-Saharan Africa, using the fledgling scheme in Nigeria for reference. The Nigerian scheme was a suitable choice mainly because of its large scope and coverage that made it suitable for a comprehensive identification of the main challenges in the subregion.,
We then described the important roles EMR systems play in such schemes in the developed countries and made the case for their involvement in sub-Saharan Africa, with its poor technological infrastructures and peculiar environment where acts of forgery, counterfeiting and other forms of fraud are common. In highlighting some of the unique challenges to effective implementation and maintenance of these schemes in such environments, we also focused on how suitably robust EMR systems could be used to realistically mitigate some of the challenges.
| Results|| |
The Nigerian National Health Insurance Scheme
The National Health Insurance Scheme (NHIS) in Nigeria was started in September 2005 as a vehicle for the ultimate achievement of universal health coverage. It is being operated under two broad categories of schemes with different operational guidelines namely, the formal and informal sector social health insurance schemes.
The formal sector scheme operates as a social health security plan, in which the costs of healthcare for employees in the formal sector are paid for from funds created by pooling the contributions of employees and their employers. This scheme includes the public and organised private sectors as well as the armed forces, police and the other uniformed services. The contributions are earnings related and are payable by either the employers and employees, or the employers alone. It also includes schemes for students in tertiary institutions. The informal sector scheme is barely functional.
Operational structure and processes
The NHIS is overseen by a government agency known by the same name, and virtually all its customers are in the formal sector. The NHIS is supposed to be completely information technology (IT) driven under the management of health maintenance organisations (HMOs) which are limited liability companies that are regulated by the agency. The agency is responsible for the guidelines, registration of the HMOs and HCPs as well as determining the level of capitation and other payments for the services rendered by the HCPs. The enrolment process requires registration with a preferred HMO and a primary HCP that serves as the enrollee's first point of contact (gatekeeper) for any access. The process is supposed to be conducted online, thus making it available for 24 h daily.
The HCPs are classified as primary, secondary or tertiary, according to the types of services they have been registered to provide.,, The scheme usually pays capitation for primary care as well as fee-for-service payment upon referral by the gatekeeper. Contributions to the scheme are earnings related whereby the employer pays 10%, whereas the employees pay 5% from the basic salaries. Referral by the gatekeeper is required which involves the issuance of a pre-authorisation code by the HMO.
Payment for primary care service is covered by the routine capitation paid monthly to the primary HCP. The amount payable depends only on the number of enrollees registered with the HCP, whereas payments to the others are on the basis of fee for service and involve standard billing protocols approved by the NHIS. The HCPs are expected to submit their bills to their respective HMOs on a monthly basis for processing and payment through e-banking.
The main challenges
Over the 14 years of operation, the NHIS has faced several challenges, the most notable of which are (1) a weak national health system, (2) low level of awareness and enrolment, (3) insufficient political will, (4) poor management and (5) poor compliance with its procedures.,,,,,
Weak national health system
We could find no evidence of a formal legal framework on the type of healthcare the different tiers of government should provide their populations. The local governments are currently not involved and the state governments oversee both primary and secondary healthcare with grossly inadequate management and resources.,,,
Low level of awareness and enrolment
Literature suggests that majority of Nigerians are not aware of the services provided by the NHIS, primarily because of poor promotion, underresourcing of the scheme and its deplorable performance record, compounded by the general poor perception of public health insurance schemes.,,,,,,,, At present, most enrolees of the NHIS are employees of the federal government and its various establishments, of which only about 3% have enrolled. The low enrolment may also be related to the inadequate legal framework of the scheme that makes it optional even for the state governments.,
Insufficient political will
In common with many governments in sub-Saharan Africa, there is insufficient political will for the scheme in Nigeria. The Act which established the scheme contains the necessary policy framework for a genuine national health service system, but many of its terms are yet to be implemented.,,
The HMOs are the operational fulcrum of the NHIS, but their performance record is very poor. Their failings include poor coordination, management, incomplete remittance of capitations and delayed settlement of invoices. As a result, there is widespread dissatisfaction among many of the HCPs which, in turn, is leading to poor quality of service and rejection of enrolees.,
Poor compliance and fraudulent practices
Several forms of fraudulent practices have been reported, including collusion with HCPs and illegal usage by non-enrolled patients., These occur primarily because the scheme is not supported by an effective IT system for detecting, monitoring or mitigating violations. The scheme is based on a paper recording and trailing system; patient identification and approval processes are done manually, which invite a number of abuses.
In the rest of this article, we described how the use of suitably designed robust EMRs systems can help significantly minimise most of the handicaps and challenges we have highlighted.
Electronic medical record systems
EMR systems automate the clinical operations of HCPs.,, They enable digital storage of patient records including charts, with facilities for tracking patient demographics, medical histories, medications, test results and other types of patient-specific clinical information, as well as the costs associated with the services provided. It can accurately capture the state of the patient at different stages and facilitate access to the entire patient history at an instant. The system usually involves a single modifiable file that is constantly updated as activities are entered into it and, hence, reduces the chance of data replication. It facilitates efficient extraction of medical information for examination and clinical review and eliminates the logistical issues associated with paper copies of medical records. EMR systems have become a routine feature of the health sector in developed countries, and their uptake in many developing countries is on the increase because they help improve the quality of healthcare. They also provide a platform for a variety of software applications that offer benefits to patients and HCPs. A comprehensive EMR platform may include clinical and pharmaceutical administrative facilities with decision support for physicians and management. EMRs also facilitate increased efficiency, improvements in the accuracy of medical records, pharmacy inventory management and accounting.,,,,,
Virtually, all public health insurance schemes in the developed countries involve EMR systems for their day-to-day management, including registration of customers, interactions between stakeholders and service delivery, to name but a few.,,, However, this is not the situation in many of the poor regions of the world, especially in sub-Saharan Africa where almost every aspect of the management of such schemes is paper based.,, Unfortunately, many HCPs in the region lack the basic infrastructures needed for the effective implementation of EMR systems. Indeed, only a few currently have adequate facilities for information and communication technology – considered as an essential life-saving resource by every HCP in the developed world., Paper-based medical records require a significant amount of physical storage capacity and other resources as well as the problems associated with collation of such information for clinical practice and decision-making at different locations. This is current situation in most countries in sub-Saharan Africa, including Nigeria.
The potential value of electronic medical record systems
An effective EMR system would be sufficiently adaptable for accommodating appropriate software applications which can assist the organisation in its operations and enable it to be able to address many of the operational challenges even in sub-Saharan Africa.
An EMR system can accommodate relevant financial accounting software packages, including those with features for monitoring financial activities in the system. These include specifically developed applications for monitoring transactions and mitigating against the risk of resource misappropriation. These could include provisions for audit trailing to track activities in the organisation and minimise the risks of forgery and false claims.
Improvement of quality of care
It is a standard requirement of EMR systems to facilitate access to patient medical records by physicians and other approved healthcare staff.,,,, Such systems can also facilitate information sharing between the various authorised users, which can be extended to multiple care settings, including all approved internal and external stakeholders.
Appropriate computerised decision support systems with features for improving clinical decision-making can be incorporated. These include granting timely access to patient's current treatments during prescribing to prevent drug–drug interactions and to improve compliance with best practice. The system can also accommodate appropriate disease management tools, including facilities for public health promotion.
The EMR system can be as useful as it is designed to serve, within the limits of current electronic technology. For example, it can accommodate a suitable project portfolio management tool which can facilitate centralised management of the processes involved., The tool can be used to track resource levels, monitor utilisation of services and manage staff-related demands such as workload, stock levels, forecast required staff levels and absenteeism. There are commercial software packages with suitable interfaces for incorporation, and access to such data can be restricted to duly designated staff by the adoption of a secured (password based) facility.
An EMR system with an inventory monitoring provision can enable both the HMOs and HCPs to operate within mutually agreed terms, on the minimum standard of delivery required of the services by the way of performance targets, which each party can monitor independently. The HCPs can also use the system to prepare standard operating procedures and train their staff on such procedures for effective practice and. perhaps, also include provisions for rewarding improvement and mitigating non-compliance. Facilities for prompt identification and resolution of issues can also be incorporated to ensure smooth operation and maintenance of the EMR system itself. Such a monitoring system can also facilitate evaluation of service delivery levels by both the HCPs and HMOs, identify the problem areas and initiate appropriate processes for improvement.
Fraudulent claims and service utility
A robust EMR system can be designed to incorporate fingerprint identification mechanism, similar to the current practice on smartphones. Such a provision can facilitate confirmation of enrollees at the points of service and also serve as an additional means for the required authorisation process. Indeed, a facility for electronic photograph identification can also be incorporated.
It is imperative that service providers are paid on a timely basis, to enable them manage their cash flows effectively and be able to continue to provide their services uninterruptedly. Schemes which operate on paper-based records and paper-based billing systems are associated with costs associated with several forms of expenses, most of which are avoidable with electronic billing., Electronic billing also offers benefits such as faster processing and reimbursements. For example, the average turnaround time for claims ranges from several weeks to months in the NHIS paper-based billing system, which can be substantially reduced under an effective electronic billing system.
We know from experience and the literature that the benefits from EMR systems significantly outweigh the costs associated with their adoption.,,, The electronic billing system can facilitate an efficient transmission of claims to the designated clearing house for processing by the touch of a button – ensuring that the claims are delivered accurately on a timely basis, immediate confirmations are received and real-time status checks can be conducted with timely information on the stage of each claim being processed.
| Discussion|| |
Financial constraints constitute the most critical barrier to healthcare access in most sub-Saharan African countries as most governments in the region rank healthcare low on their priorities.,, Public health insurance schemes have been identified as a viable means for addressing this problem.,,,,,,,,,,,,,, However, there are several stumbling blocks to the achievement of universal health coverage through effective and sustainable public health insurance schemes in the subregion.,,,,,,,,,,,, These schemes operate within an environment of poor resourcing, poor management, high levels of fraudulent practices and poor physical access to healthcare facilities, with much of the cost burdens borne by the insured.,, We choose the scheme in Nigeria to highlight these challenges because most of the problems also apply to the other national schemes in the subregion.,,
The adoption of a mandatory public insurance scheme that is backed by more rigorous regulations has been suggested as a viable solution. The involvement of alternative sources of funding (e.g., public–private partnership) has also been identified as another option for improving the scheme towards the goal of a universal health coverage., However, these suggestions may not be enough to compensate for the impact of the major operational challenges we have highlighted.
Evidence suggests that the current schemes in the subregion are unsustainable and face extremely high risks of failure because of the difficulty in preventing the problems of fraud and other deliberate acts of abuse under their current paper-based operations.,,, We have made the case for the involvement of suitably robust, EMR systems for schemes in the subregion, citing evidence from other regions of the world.,,,,,,,,, Few have identified the potential benefits which large-scale adoption of fully integrated EMR systems could facilitate in this subregion., For example, an EMR system can be designed to meet the objectives of the different stakeholders of the scheme. EMRs with integrated relevant software packages may enable the NHIS, HMOs and HCPs in Nigeria to carry out many of their activities more efficiently, as well as to mitigate against misappropriation of funds, improve quality of care, track staff absenteeism, check compliance with procedures and practices and monitor service delivery, among others.
Indeed, the EMR system has become a tool of necessity for healthcare delivery in the developed countries – facilitating access to standard operating procedures; treatment guidelines and the provision of comprehensive, updated information on prescription drugs, for the minimisation of contraindications, drug–drug interactions and monitoring the health status of patients.,
| Conclusion|| |
This review highlights the gap in literature on the peculiar challenges associated with public health insurance schemes in sub-Saharan Africa and extends our knowledge by describing some of the fundamental problems – issues which are largely ignored, despite proliferation of these schemes in recent years. It describes how some of those associated with the environment of poor infrastructures, inadequate management and high fraudulent activities can be addressed with suitably designed EMR systems, suggesting that such resolutions may enhance the sustainability of these schemes, which are vital to the goal of universal health coverage.
The authors are grateful to the reviewers for their useful suggestions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Organization for Economic Co-operation and Development (OECD). Stat Extracts. OECD's iLibrary. Health, Health Expenditure and Financing, Main Indicators, Health Expenditure since 2000 (Online Statistics). Organization for Economic Co-operation and Development; 2013. Available from: http://stats.oecd.org/
. [Last accessed on 2018 Jun 01].
Schoen C, Osborn R, Squires D, Doty MM, Pierson R, Applebaum S. How health insurance design affects access to care and costs, by income, in eleven countries. Health Aff (Millwood) 2010;29:2323-34.
Olugbenga EO. Workable social health insurance systems in sub-Saharan Africa: Insights from four countries. Afr Dev 2017;42:147-75.
Odeyemi IA, Nixon J. Assessing equity in health care through the national health insurance schemes of Nigeria and Ghana: A review-based comparative analysis. Int J Equity Health 2013;12:9.
Bultman J, Kanywanyi JL, Maarifa H and Mtei G. Tanzania Health Insurance Regulatory Framework Review. Ministry of Health and Social welfare and Social Security Regulatory Authority; 2012.
Mills A, Ataguba JE, Akazili J, Borghi J, Garshong B, Makawia S, et al.
Equity in financing and use of health care in Ghana, South Africa, and Tanzania: Implications for paths to universal coverage. Lancet 2012;380:126-33.
McIntyre D, Garshong B, Mtei G, Meheus F, Thiede M, Akazili J, et al.
Beyond fragmentation and towards universal coverage: Insights from Ghana, South Africa and the united republic of Tanzania. Bull World Health Organ 2008;86:871-6.
World Health Organization. World Health Report, Health System Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010.
NHIS Guideline National Health Insurance scheme. Available from: http://www.nhis.gov.ng/
. [Last accessed on 2018 May 03].
Omoleke II, Taleat BA. Contemporary issues and challenges of health sector in Nigeria. Res J Health Sci 2017;5:210-6.
Akhtar R. Health Care Patterns and Planning in Developing Countries. Westport, Connecticut: Greenwood Press; 1991. p. 264.
Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst 2013;11:1-10. Available from: http://www.health-policy-systems.com/content/11/1/20
. [last accessed 2018 April 13].
Etiaba E, Onwujekwe O, Honda A, Ibe O, Uzochukwu B, Hanson K. Strategic purchasing for universal health coverage: Examining the purchaser-provider relationship within a social health insurance scheme in Nigeria. BMJ Glob Health 2018;3:e000917.
Showers V, Shotick J. The Effects of household characteristics on demand for insurance: A Tobit analysis. J Risk Insur 1994;61:492-502.
Truett DB, Truett LJ. The demand for life insurance in Mexico and the United States: A comparative study. J Risk Insur 1990;57:321-8.
Das M. Perception of customers regarding health insurance benefit of public sector insurance companies-A case study of Karimganj district of Assam. Int J Hum Soc Sci Stud 2018;4:158-72.
Kotoh AM, Aryeetey GC, Van der Geest S. Factors that influence enrolment and retention in Ghana' national health insurance scheme. Int J Health Policy Manag 2018;7:443-54.
Booysen F, Hongoro C. Perceptions of and support for national health insurance in South Africa's public and private healthcare sectors. Pan Afr Med J 2018;30:277.
Boateng D, Awunyor-Vitor D. Health insurance in Ghana: Evaluation of policy holders' perceptions and factors influencing policy renewal in the Volta region. Int J Equity Health 2013;12:50.
Mukangendo M, Nzayirambaho M, Hitimana R, Yamuragiye A. Factors contributing to low adherence to community-based health insurance in rural Nyanza district, Southern Rwanda. J Environ Public Health 2018;2018. p. 9:2624591.
Owusu-Sekyere E, Chiaraah A. Demand for health insurance in Ghana: What factors influence enrollment? Am J Public Health Res 2014;2:27-35.
Fenny AP, Kusi A, Arhinful DK, Asante FA. Factors contributing to low uptake and renewal of health insurance: A qualitative study in Ghana. Glob Health Res Policy 2016;1:18.
Gunter TD, Terry NP. The emergence of national electronic health record architectures in the United States and Australia: Models, costs, and questions. J Med Internet Res 2005;7:e3.
Katurura MC, Cilliers L. Electronic health record system in the public health care sector of South Africa: A systematic literature review. Afr J Prim Health Care Fam Med 2018;10:e1-e8.
Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: An evaluation of information system impact and contingency factors. Int J Med Inform 2014;83:779-96.
Blondeau C. And American Health Information Management Association (AHIMA). Pocket Glossary for Health Information Management and Technology. 3rd
ed. Chicago: American Health Information Management Association; 2012.
Bodenheimer T, Grumbach K. Electronic technology: A spark to revitalize primary care? JAMA 2003;290:259-64.
Blumenthal D, Glaser JP. Information technology comes to medicine. N
Engl J Med 2007;356:2527-34.
Vogel LH, Perreault LE. Management of information in healthcare organizations chapter. In: Shortliffe EH, Cimino JJ, editors. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. 3rd
ed. Springer-Verlag, London; 2006. p. 476-510.
Institute of Medicine, Committee on Improving the Medical Record. The Computer-based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press; 1991.
Were MC, Shen C, Bwana M, Emenyonu N, Musinguzi N, Nkuyahaga F, et al.
Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa. Int J Med Inform 2010;79:90-6.
Cruz-Correia RJ, Vieira-Marques PM, Ferreira AM, Almeida FC, Wyatt JC, Costa-Pereira AM, et al.
Reviewing the integration of patient data: How systems are evolving in practice to meet patient needs. BMC Med Inform Decis Mak 2007;7:14.
McDonald CJ, Tierney WM. Computer-stored medical records. Their future role in medical practice. JAMA 1988;259:3433-40.
Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N
Engl J Med 2011;365:825-33.
Gearing P, Olney CM, Davis K, Lozano D, Smith LB, Friedman B, et al.
Enhancing patient safety through electronic medical record documentation of vital signs. J Healthc Inf Manag 2006;20:40-5.
Branger PJ, van der Wouden JC, Schudel BR, Verboog E, Duisterhout JS, van der Lei J, et al.
Electronic communication between providers of primary and secondary care. BMJ 1992;305:1068-70.
Moorman PW, Branger PJ, van der Kam WJ, van der Lei J. Electronic messaging between primary and secondary care: A four-year case report. J Am Med Inform Assoc 2001;8:372-8.
van der Kam WJ, Moorman PW, Koppejan-Mulder MJ. Effects of electronic communication in general practice. Int J Med Inform 2000;60:59-70.
Project Management Institute. The Standard for Portfolio Management. 4th
ed. PMI Newtown Square, PA; 2017.
Shifrin M, Kurdumova N, Danilovet G, Ershova O, Savin I, Alexandrova I, Sokolova E, Tabasaranskiy T. Electronic Patient Records System as a Monitoring Tool. Stud Health Technol Inform 2015;210:236-8.
Payne TH, tenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010;17:108-11.
Rind DM, Safran C. Real and imagined barriers to an electronic medical record. Proc Annu Symp Comput Appl Med Care 1993:74-8.
Choi JS, Lee WB, Rhee PL. Cost-benefit analysis of electronic medical record system at a tertiary care hospital. Healthc Inform Res 2013;19:205-14.
Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ, et al.
Acost-benefit analysis of electronic medical records in primary care. Am J Med 2003;114:397-403.
Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, et al.
Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood) 2005;24:1103-17.
Barlow S, Johnson J, Steck J. The economic effect of implementing an EMR in an outpatient clinical setting. J Healthc Inf Manag 2004;18:46-51.
Spreeuwers AM, Dinant GJ. Success and Failure in Social Health Insurance in Sub-Saharan Africa: What Lessons can be Learnt? Global Medicine, Official Magazine of IFMSA-NL; 2012.
Carapinha JL, Ross-Degnan D, Desta AT, Wagner AK. Health insurance systems in five Sub-Saharan African countries: Medicine benefits and data for decision making. Health Policy 2011;99:193-202.
Kutzin J. Health financing for universal coverage and health system performance: Concepts and implications for policy. Bull World Health Organ 2013;91:602-11.
Onwujekwe O, Onoka C, Uzochukwu B, Hanson K. Constraints to universal coverage: Inequities in health service use and expenditures for different health conditions and providers. Int J Equity Health 2011;10:50.
Mohammed S, Sambo MN, Dong H. Understanding client satisfaction with a health insurance scheme in Nigeria: Factors and enrollees experiences. Health Res Policy Syst 2011;9:20.
Adeniyi AA, Onajole AT. The national health insurance scheme (NHIS): A survey of knowledge and opinions of Nigerian dentists' in Lagos. Afr J Med Med Sci 2010;39:29-35.
Ibiwoye A, Adeleke IA. Does national health insurance promote access to quality health care? Evidence from Nigeria. Vol. 33. Geneva Papers on risk and Insurance: Issues and Practice; 2008. p. 219-33.
Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E, Baltussen R. Household perceptions and their implications for enrollment in the national health insurance scheme in Ghana. Health Policy Plan 2012;27:222-33.
Uzochukwu BS, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract 2015;18:437-44.
] [Full text]
Boidin B. Extension of health coverage and community based health insurance schemes in Africa: Myths and realities. Bull Soc Pathol Exot 2015;108:63-9.
Degroote, S., Ridde, V. & De Allegri, M. Health Insurance in Sub-Saharan Africa: A Scoping Review of the Methods Used to Evaluate its Impact. Appl Health Econ Health Policy (2019). https://doi.org/10.1007/s40258-019-00499-y
Goudge J, Alaba OA, Govender V, Harris B, Nxumalo N, Chersich MF. Social health insurance contributes to universal coverage in South Africa, but generates inequities: Survey among members of a government employee insurance scheme. Int J Equity Health 2018;17:1.
Passchier RV. Exploring the barriers to implementing national health insurance in South Africa: The people's perspective. S Afr Med J 2017;107:836-8.
van den Heever AM. The role of insurance in the achievement of universal coverage within a developing country context: South Africa as a case study. BMC Public Health 2012;12 Suppl 1:S5.
Gautier L, Ridde V. Health financing policies in sub-Saharan Africa: government ownership or donors' influence? A scoping review of policymaking processes. Glob Health Res Policy 2017;2:23.
Alesane A, Anang BT. Uptake of health insurance by the rural poor in Ghana: Determinants and implications for policy. Pan Afr Med J 2018;31:124.
Olugbenga-Bello AI, Adebimpe WO. Knowledge and attitude of civil servants in osun state, South Western Nigeria towards the national health insurance. Niger J Clin Pract 2010;13:421-6.
] [Full text]
Dhillon RS. A Closer look at the Role of Community-Based Health Insurance in Rwanda's Success. Global Health Check, Oxford: Oxfam International; 2011. Available from: http://www.globalhealthcheck.org/?p=324
. [Last accessed on 2017 Jan 04].
Williams F, Boren SA. The role of electronic medical record in care delivery in developing countries. Int J Inf Manage 2008;28:503-7.
Rotich JK, Hannan TJ, Smith FE, Bii J, Odero WW, Vu N, et al.
Installing and implementing a computer-based patient record system in sub-Saharan Africa: The Mosoriot medical record system. J Am Med Inform Assoc 2003;10:295-303.
Hannan TJ, Rotich JK, Odero WW, Menya D, Esamai F, Einterz RM, et al.
The Mosoriot medical record system: Design and initial implementation of an outpatient electronic record system in rural Kenya. Int J Med Inform 2000;60:21-8.
Kiragga AN, Castelnuovo B, Schaefer P, Muwonge T, Easterbrook PJ. Quality of data collection in a large HIV observational clinic database in sub-Saharan Africa: Implications for clinical research and audit of care. J Int AIDS Soc 2011;14:3.
Castelnuovo B, Kiragga A, Afayo V, Ncube M, Orama R, Magero S, et al.
Implementation of provider-based electronic medical records and improvement of the quality of data in a large HIV program in sub-Saharan Africa. PLoS One 2012;7:e51631.
Waters E, Rafter J, Douglas GP, Bwanali M, Jazayeri D, Fraser HS, et al.
Experience implementing a point-of-care electronic medical record system for primary care in Malawi. Stud Health Technol Inform 2010;160:96-100.
Williams F, Boren SA. The role of the electronic medical record (EMR) in care delivery development in developing countries: A systematic review. Inform Prim Care 2008;16:139-45.
Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW, Szolovits P. Implementing electronic medical record systems in developing countries. Inform Prim Care 2005;13:83-95.
Oluoch T, Santas X, Kwaro D, Were M, Biondich P, Bailey C, et al.
The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review. Int J Med Inform 2012;81:e83-92.
Haskew J, Rø G, Turner K, Kimanga D, Sirengo M, Sharif S, et al.
Implementation of a cloud-based electronic medical record to reduce gaps in the HIV treatment continuum in rural Kenya. PLoS One 2015;10:e0135361.
Yogeswaran P, Wright G. EHR implementation in South Africa: How do we get it right? Stud Health Technol Inform 2010;160:396-400.
Meessen B. The role of digital strategies in financing health care for universal health coverage in low- and middle-income countries. Glob Health Sci Pract 2018;6:S29-S40.
Menendez MD, Alonso J, Rancaño I, Corte JJ, Herranz V, Vazquez F. Impact of computerized physician order entry on medication errors. Rev Calid Asist 2012;27:334-40.
Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients – A systematic review. Int J Med Inform 2008;77:365-76.