Context & Problem Statement

Across both states, baseline assessments revealed common challenges:

• Heavy reliance on manual data entry, leading to duplicated and inaccurate records.
• Fragmented patient documentation, limiting clinicians’ ability to track history and continuity of care.
• Long patient wait and journey times, particularly in high-volume service points like OPD, ANC, and immunization.
• Stockouts due to poor visibility into inventory levels.
• Limited visibility into HRH performance, absenteeism, and module usage across facilities.
• Poor data flow upward, resulting in underutilized health data for state-level planning.

Digitization was identified as a strategic pathway to address information gaps, strengthen service delivery, and provide real-time operational visibility.

The Intervention: ElephantOS

ElephantOS is a mobile-first, HL7 FHIR-compliant EHR system designed for PHC and district hospitals operating in low-connectivity environments.

Key Capabilities

• Offline-first workflows with automated syncing.
• Under 2-hour onboarding for new users.
• Integrated clinical modules: OPD, ANC, Immunization, FP/Childbirth, Lab, Pharmacy.
• Inventory management including expiry alerts, stock exchange tracking, and automated visibility dashboards.
• Real-time analytics dashboards for LGAs and state stakeholders.
• Role-based access control for secure and auditable user activity.

The system is optimized for speed (<3 minutes per consultation entry) and intuitive use for health workers with varying levels of digital literacy.

Deployment Approach

The deployment followed a structured, repeatable methodology across both states.

Needs Assessment

Detailed assessments were conducted in all 36 facilities, covering:

• Infrastructure (power, devices, solar availability)
• Network coverage (MTN/GLO/Airtel)
• Staffing levels
• Patient load and service patterns
• Workflow mapping for each service area

These assessments guided hardware allocation, training needs, and facility-specific rollout plans.

Train-the-Trainer Model

For each facility:

• A Site Champion was selected to lead internal change management.
• Champions participated in a 2-day technical training covering:
  
  • System navigation
  • Clinical module workflows
  • Troubleshooting and offline workflows
  • Change management principles
• Champions conducted step-down training for all staff before go-live.

This model enabled rapid scaling across multiple LGAs with minimal disruption.

Go-Live & Implementation

Across Bayelsa and Ondo:

• 36 PHCs went live between February and March 2025.
• Elephant teams provided in-person support, workflow adjustment, issue resolution, and refresher training.
• A remote support system (Helpdesk, WhatsApp, and phone) enabled real-time troubleshooting.
• Daily data monitoring allowed proactive intervention for underperforming facilities.
  
  

Impact Summary

Reach

Across both pilots, ElephantOS supported:

• Over 100,000+ patient visits
• 47,000+ immunization interactions
• Over 36,000 children under five
• 8,300 ANC visits
• Nearly 4,000 insured patients tracked
• Over 62,000 clinical consultations
  
  

These numbers demonstrate the scale and consistency of usage across both states.

Improvements in Efficiency

Reduction in Data Entry Time

Digitization led to significant reductions in documentation burden:

Ondo State

• Data-entry time dropped by 50%, from ~22 minutes to ~11 minutes per encounter.
• Largest gains occurred as user proficiency increased month-on-month.

Bayelsa State

• Data-entry time reduced by:
  
  • 30% in OPD
  • 34% in ANC
  • 38% in Immunization
  • 35% in FP/Childbirth
• OS performance improved dramatically over the first 6–8 months, with some services achieving 70–84% reductions by October.
  
  

Reduction in Patient Wait & Journey Times

Ondo State

• Wait time fell by up to 60%, dropping from ~35 minutes to ~14 minutes.
• Patient journey times decreased across OPD, ANC, Immunization, and FP services.
  
  

Bayelsa State

• Wait time decreased by ~40% for most services.
• Journey times improved steadily month-by-month, with immunization visits nearly 30% faster.

These improvements stem from:

• Digital queue management
• Faster data entry
• Immediate patient record retrieval
• Automated clinical workflows
  
  

Improvements in Data Quality

ElephantOS enforced:

• 100% completeness of required fields
• Duplicate record prevention
• Real-time validation and flags
  
  

This improved:

• Accuracy of monthly reports
• Reliability of patient histories
• Timeliness of DHIS2 submissions
• State-level monitoring of service utilization

In both states, OS revealed that paper registers significantly overreported some service points (especially OPD and FP/Childbirth), while underreporting ANC and immunization in non-digitized facilities.

Digital data brought transparency to actual service volumes and trends.

Inventory & Supply Chain Improvement

A major win across both states was the improvement in stock management.

Stockout Reductions

• ANC commodities: 50%+ reduction
• Family Planning commodities: up to 70% reduction
• Immunization commodities: up to 90% reduction (Bayelsa)

ElephantOS enabled:

• Real-time expiry alerts
• Visibility into stock levels per facility
• Automatic prompts for replenishment
• Tracking of commodity movement across facilities

This allowed LGA and state supply chain teams to respond quickly and avoid service delivery disruptions.

HRH Visibility & Workforce Performance

ElephantOS tracked:

• Daily login activity
• Number of service entries per staff member
• Module utilization
• Absenteeism patterns

Key findings:

• 76% of Ondo health workers were active on OS at least 5 days/week.
• Bayelsa recorded 185 trained staff, with an average 49% absenteeism rate for 5-day inactivity periods—highlighting a need for stronger supervision.
• Dashboards allowed LGA teams to identify:
  
  • Underperforming staff
  • Facilities requiring refresher training
  • Modules with inconsistent usage
  • Bottlenecks caused by staffing gaps

This level of visibility was not possible prior to digitization.

Human-Centered Impact

Patient and health worker feedback highlighted:

For Patients

• Faster service delivery
• More reliable follow-up, especially for immunization
• Better continuity of care
• Improved drug availability
• Higher overall satisfaction (80–85%)

For Health Workers

• Reduced workload
• Easier documentation
• Improved data accuracy
• Better access to patient histories
• Increased digital literacy and confidence
  
  

Policy & System-Level Implications

Both states demonstrated that:

• Digitization is operationally feasible across rural/urban PHCs.
• When paired with supervision, ElephantOS can become a core part of routine service delivery.
• Dashboards empower LGA officers, M&E teams, and state leadership to make real-time decisions.
• Embedding EHR usage into PHC operating protocols is essential for sustainability.

The pilots set a precedent for:

• Statewide digital health scale-up strategies
• Integration with DHIS2, BHCPF systems, and supply chain processes
• Stronger governance frameworks for digital compliance
  
  

Key Learnings

What Worked

• Train-the-trainer model accelerated adoption.
• Offline capability eliminated connectivity as a barrier.
• Real-time dashboards strengthened accountability.
• Quick onboarding (<2 hours) facilitated system acceptance.

Challenges

• Variability in staffing levels affected usage consistency.
• Competing programs (e.g., NTD campaigns) temporarily reduced engagement.
• Power reliability influenced performance at some facilities.
• Some service points (FP/Childbirth) required additional change management.
  
  

Conclusion

The CHAI × ElephantOS pilots in Bayelsa and Ondo demonstrate that digital transformation of primary healthcare is both scalable and impactful. With strong partnerships, structured implementation, and continuous support, even resource-constrained settings can rapidly adopt and sustain digital systems that dramatically improve service quality, data integrity, and patient experience.

These deployments represent a major step toward building data-driven, patient-centered, digitally enabled health systems across Nigeria and beyond.

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