Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 1 of 16 ORIGINAL RESEARCH Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Coverage Jameel Ismail Ahmad1, Murtala Jibril2, Barroon Isma’eel Ahmad3, Abdurrahman Suleiman4, Nasir Sani Inuwa5, Abdullahi Garba Ali6, Salihu Ibrahim Ismail7 1. Department of Surgery, Faculty of Clinical Sciences, Bayero University Kano/ Aminu Kano Teaching Hospital, Kano, Nigeria. 2. Department of Pharmacology and Therapeutics, Faculty of Pharmaceutical Sciences, Bayero University, Kano, Nigeria 3. Department of Computer Science, Ahmadu Bello University, Zaria, Nigeria 4. Hubuk Technology, Zoo Road, Kano, Nigeria 5. First Monument City Bank (FCMB), Nigeria. 6. Faculty of Computer Science and Information Technology, Bayero University, Kano, Nigeria. 7. Department of Biochemistry, Federal University Dutse, Jigawa State, Nigeria Corresponding author: Jameel Ismail Ahmad MBBS, FWACS, MBA; Address: Department of Surgery, Faculty of Clinical Sciences, Bayero University Kano, Aminu Kano Teaching Hospital, Kano, Nigeria; Email: iajameel@yahoo.com Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 2 of 16 Abstract Introduction: The COVID-19 pandemic highlighted the need for evolving an integrated healthcare ecosystem that will connect patients to digital and home healthcare to achieve univer- sal health coverage. The survey aims to assess perceptions and preferences about digital and home healthcare services and develop an integrated healthcare ecosystem. Methods: A survey of 254 Nigerians was conducted to assess their awareness, preferences, and willingness to pay for digital and home healthcare services using electronic questionnaires, and the data were analysed using SPSS 16.0. Results: Males constituted 70.9%, and 61.4% were aged ≤35 years. Two-third were clients, and a third were healthcare providers. Although about 71% patronized public hospitals, there was poor satisfaction (31.7%) than those attending private hospitals that were more satisfied. The male gender, private hospital utilization, and age of ≤35 years were associated with the satisfac- tion with OR 1.19 (95% CI 0.69-2.05), OR 1.22 (95% CI 0.73-2.04), and OR 2.41 (95% CI 1.38- 4.20) respectively. Thirty minutes was the acceptable delay in receiving care by most respond- ents. Only 39.4% were aware of digital health, and 52.8% were aware of home healthcare. Male gender was associated with DH awareness, while being a healthcare provider was associated with both DH and home healthcare awareness. The respondents' median amount was willing to pay for DH and HH respondents is $1.64 - $6.56 and $3.28 – $6.56, respectively. Conclusion: In response to the survey result, we designed an integrated hospital, digital, and home healthcare project named eDokta, to leapfrog the attainment of universal health coverage in Nigeria. Keywords: Digital health, home healthcare, universal health coverage, healthcare ecosystem Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 3 of 16 Introduction Nigeria is the most populous country in Af- rica and is poised to become the third most populous in the world by 2050 (1). Poverty, inequality, and poor access to health have kept the citizens' life expectancy low. The Ni- gerian healthcare system is bedeviled with a lack of human resources, infrastructural and system challenges, which threaten the attain- ment of universal health coverage (UHC). To ameliorate that, Nigeria developed a national health Information Communication Technol- ogy (ICT) strategic framework 2015-2020 with the vision: "By 2020 Health ICT will help enable and deliver universal health cov- erage in Nigeria" (2). This strategic frame- work provides for the identification, prioriti- zation, and application of appropriate ICTs that can strengthen the national health sys- tem. Poor implementation of the framework led to poor results by 2020. One of the most essential strategies for improving the provi- sion of quality health care to attain UHC in resource-constrained settings is the effective utilization of digital health (DH). Digital health is defined as a system that connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated and in- teroperable, and digitally-enabled care envi- ronments that strategically leverage digital tools, technologies, and services to transform care delivery (3). It is also defined as the ap- plication of ICT to advance health services delivery." The term DH is also used inter- changeably with eHealth. The World Health Assembly (WHA) recognized the role of DH in healthcare delivery in resolution WHA 58.28 (2005): "eHealth is the cost-effective and secure use of ICT in support of health and health-related fields including healthcare ser- vices, health surveillance, health literature, and health education, knowledge and re- search. mHealth is a subset of eHealth and in- volves providing health services and infor- mation via mobile technologies such as mo- bile phones, tablet computers, and personal digital assistants. DH is a tool for the achievement of Goal 3 of the Sustainable De- velopment Goals by 2030, which is to "En- sure healthy lives and promote well-being for all at all ages," particularly its article 8 to "Achieve universal health coverage (UHC)" in ensuring people access quality healthcare without falling into financial catastrophes (4,5). The role of DH cut across healthcare financing, health service delivery, human re- sources training, health system support, and health information system. Despite these po- tentials, DH implementation has taken a slow course, especially in many African countries. Some of the challenges hampering its scale- up in many developing countries are issues bordering on usability, technology integra- tion and interoperability, data security, and privacy, reliability, network access, afforda- bility, acceptability, illiteracy, funding, trained human capacity, policy, and regula- tion (6,7). The application of DH in Africa has gained momentum over the past decade, essentially due to the digital revolution brought about by the increasing penetration of mobile technology and internet use, which stood at 80.8% and 25.1% as of 2018. This is further enhanced by the proliferation of af- fordable smartphones, particularly from China (5). These factors have afforded a great opportunity, which could improve the Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 4 of 16 smooth launching of various DH platforms, but there is a need to understand enablers for their effective utilization. A feasibility sur- vey was conducted to develop a sustainable DH platform that will facilitate the attain- ment of SDGs. The objectives of the study are to assess the respondents' perceptions about conventional hospital-based care; set awareness and preferences of DH and home healthcare; determine the willingness to pay for DH and HH services; and then develop an integrated healthcare ecosystem that will in- corporate hospital-based, digital and home healthcare services to achieve UHC. Methods An online survey to assess the awareness, preferences, and willingness to pay for Nige- rians' DH and home healthcare services was conducted in December 2019 electronically using google forms. (8) The data was auto- matically received, and a Microsoft Excel spreadsheet version of the data was gener- ated. The data was then transferred and ana- lysed using Statistical Product and Service Solutions (SPSS) 16.0. Basic information, perceptions, and awareness of hospital based, digital, and home healthcare and their associ- ation to age, sex, status, and hospital being utilized was analyzed. Results Two hundred and fifty-four (254) respond- ents electronically filled the online question- naire representing a response rate of 84.7%. The respondents include those living in all 36 states and the capital of Nigeria. However, 69.7% were living in Kano state. Males con- stituted 70.9%, while 61.4% and 38.6% were aged ≤35 years and >35 years, respectively. The respondents include civil servants (40.2%), medical doctors (31.5%), trad- ers/businesspersons (8.3%) and 11.4% were unemployed. Others include other health workers, bankers, engineers, and software developers. Healthcare providers constituted 36.2%, while clients were 63.8%. (Table 1) Table 1: Respondents’ baseline characteristics Over-all Percentage % (N=254) Age (years) ≤35 61.4(156) >35 38.6(98) Sex Female 29.1(74) Male 70.9(180) Status Clients 63.8(162) Providers 36.2(92) Hospital being utilised Private 28.7(73) Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 5 of 16 Public hospitals were the most utilized by 71.3% of the respondents. The level of satis- faction is better with the private hospitals as 60.3% of the respondents were satisfied in contrast to only 31.7% who were satisfied with the public hospitals. Younger age ≤35 years, male gender, and private hospital pat- ronage were associated with reasonable satis- faction with OR 1.22 (95% CI 0.73-2.04), OR 1.19 (95% CI 0.69-2.05), and OR 2.41 (95% CI 1.38-4.20) respectively. Only a quarter of the respondents considered lack of trained staff, while delay in receiving care and poor staff attitude featured prominently by 74% and 63% of the respondents. Lack of feed- back from hospitals and health workers and lack of quality branded drugs are reasons for dissatisfaction by nearly a third of the re- spondents. Thirty minutes was the acceptable delay in receiving care when sought for by 80% of the respondents. The DH awareness of the respondents was relatively low (39.4%) and male gender and being a healthcare provider associated with the awareness OR 1.40 (95% CI 0.80-2.47) and OR 1.40 (95% CI 0.83-2.36) (Table 2). Vir- tual booking for medical consultation, health education, and remote patient monitoring was the commonest DH services needed (Figure 1). Nearly two-thirds of the respond- ents preferred online DH services over mo- bile DH services, and 90.9% use Android phones, while 8.3% use iOS phones. More than half (52.8%) of the respondents were aware of home healthcare services which were significantly associated with respond- ents' status as healthcare providers, OR 3.25 (95% CI 1.90-5.60) (Table 3). Approxi- mately three-quarters (74.8%) of respondents believe it was operational, and 93.3% were willing to utilize the services. The Home Healthcare (HH) services needed include home consultation (81.3%), home delivery of purchased drugs (66.3%), and simple investi- gations (64.7%). Other services include sam- ple collection and delivery of results and nursing care. Public 71.3(181) Type of phone used iOS 8.3(21) Others 0.8(2) Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 6 of 16 Figure 1: Preferred digital health services by the respondents Table 2: Awareness of digital health and home healthcare Digital health Home healthcare Awar e n=10 0 Una- ware n=154 OR (95% CI) p-value Awar e n=13 4 Una- ware n=120 OR (95% CI) p- val ue Age (years) ≤35 57 99 0.74 (0.44-1.23) 0.291 78 78 0.75 (0.45-1.25) 0.3 02 >35 43 55 56 42 Sex Male 75 105 1.40 (0.80-2.47) 0.261 94 86 0.93 (0.54-1.60) 0.8 90 Female 25 49 40 34 Status Provider 41 51 1.40 (0.80-2.47) 0.230 65 27 3.25 (1.90-5.60) 0.0 00 Client 59 103 69 93 Hospital patronized Private 25 48 0.74 (0.42-1.30) 0.322 26 47 0.37 (0.21-0.66) 0.0 01 Public 75 106 108 73 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% Booking for medical consultation Digital medical Consultation Digital Health Education Remote patients monitoring Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 7 of 16 There is a remarkable willingness to pay for the DH and HH services. The median amounts the respondents were willing to pay for the digital booking for consultation, digi- tal booking and physical consultation, digital booking and virtual consultation, and digital health education were $3.28 ($4.92), $6.56 ($6.56), $6.56 ($13.12) and $1.64 ($5.90) re- spectively. The median amounts (and inter- quartile range) the respondents were willing to pay for a home consultation, simple inves- tigations, sample collection/results delivery, nursing care, and pharmaceuticals delivery were $6.56 ($13.12), $3.28 ($4.92), $3.28 ($4.92), $6.56 ($6.56) and $4.92 ($6.56) re- spectively. (Table 3). Table 3: Willingness to pay for digital and home healthcare services in USD Digital Health Services Booking Booking and physical con- sultation Booking and re- mote consulta- tion Health education Median (Inter- quartile range) $ 3.28 (4.92) 6.56 (6.56) 6.56 (13.12) 1.64 (5.90) Mean (SD)/$ 5.75 (±7.12) 8.98 (±9.06) 8.62 (±8.82) 5.60 (±21.90) Home health services Consulta- tion Basic Investi- gations Sample taking and results deliv- ery Nursing care Pharmaceuti- cals delivery Median (Inter- quartile range) $ 6.56 (13.12) 3.28 (4.92) 3.28 (4.92) 6.56 (6.56) 4.92 (6.56) Mean (SD)/$ 9.58 (±9.83) 6.76 (±32.05) 5.61 (±5.14) 8.64 (±12.03) 7.58 (±10.60) Those younger than ≤35 years were more to pay a higher amount for digital booking, dig- ital booking and physical consultation and health education with OR:1.39, OR:1.05, and OR:1.38, respectively. At the same time, those patronizing private hospitals were more willing to pay for the digital booking and health education. Females and those patron- izing private hospitals were more willing to pay higher for all types of home healthcare services. At the same time, those older than 35 years were more willing to pay higher amounts for a home consultation, sample col- lection and results of delivery, nursing care, and pharmaceutical products. Compared with the clients' willingness to pay for the services, healthcare providers were more willing to pay higher for all digital and home healthcare Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 8 of 16 services. (Table 4). The healthcare providers' willingness to pay higher was more when the services involve consultation such as digital booking and physical consultation, digital booking and remote consultation and home consultation with OR 2.31 (95% CI 1.36- 3.91), OR 2.21 (95% CI 1.30-3.78 ) and OR 2.29 (95% CI 1.36-3.89) respectively. Table 4: Respondents willingness to pay higher than medium (WTPH) and willingness to pay the medium and lower (WTPL) between healthcare providers and clients Digital health services Booking Booking and physical con- sultation Booking and remote consul- tation Health education WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) Pro- vid- ers 39(53) 1.51 (0.89- 2.57) 46(46) 2.31 (1.36-3.91) 43(49) 2.21 (1.30-3.78) 43(49) 1.07 (0.64- 1.79) Cli- ents 53(109) 1.00 49(113) 1.00 46(116) 1.00 73(89) 1.00 Home healthcare services Consultation Basic Investiga- tions Sample taking and results delivery Nursing care Pharmaceuticals delivery WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) WTPH (WTPL) OR (95% CI) Pro- vid- ers 54(38) 2.29 (1.36- 3.89) 46(46) 1.95 (1.15- 3.28) 54(38) 1.49 (0.89- 2.50) 41(51) 1.44 (0.86- 2.43) 52(40) 1.12 (0.67- 1.88) Cli- ents 62(100) 1.00 55(107) 1.00 79(83) 1.00 58(104) 1.00 87(75) 1.00 Discussion The Nigerian healthcare industry is pluralis- tically shared by the public and private sec- tors. Although the public sector owns about 66% of the health facilities in Nigeria, the pri- vate sector accounts for 70-75% of the total health expenditure (9). The public healthcare system is organized into primary comprising of primary healthcare services at the rural and community level, secondary consisting of general and specialist hospitals, and tertiary healthcare having the teaching hospitals and specialized medical centers. The private hos- pitals and clinics contribute significantly to Nigeria's healthcare delivery all over the country (10). The healthcare budget is abys- mally low as only 3.6% of Nigeria's GDP was Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 9 of 16 spent on health, which translates to $14.6 bil- lion in 2016. There is a considerable healthcare infrastructural gap and a massive brain drain of healthcare workers (11). It is estimated that about 3,000 new medical doc- tors are registered in Nigeria annually. Cur- rently, nearly 2,000 doctors migrate from Ni- geria to other countries yearly, leaving a net of 1000 doctors and further widening doctors' deficit to about 260,000. Nigerians spend an average of $1 billion on medical tourism an- nually abroad. Nigeria has five hospital beds per 10,000 population (9,12). Public hospi- tals' patronage remains high, with 71% of the respondents despite its poor satisfaction level (32%) when compared to private hospitals likely due to affordability factors. There is a higher satisfaction level (60%) among those who patronize private hospitals. There is evi- dent worsening satisfaction of hospital ser- vices over the years compared to Kano re- ports a decade ago by Iliyasu et al. when the satisfaction level was 83% (13). The satisfac- tion level is lower than reports from different parts of Nigeria and Ethiopia (14–19). This could be attributable to infrastructural and personnel deficits despite an increasing pop- ulation, bureaucracy, and ongoing disruption of healthcare services due to industrial ac- tions by health workers. Based on the per- ceived reasons for dissatisfaction, any inter- vention that will shorten the duration to re- ceiving care within the first 30 minutes, teach an empathic and memorable staff attitude, provide access to quality drugs and ensure appropriate feedback will significantly im- prove clients' satisfaction. There is a need to enhance the satisfaction level, especially to the older respondents and females. The dif- ferential satisfaction between the public and private hospitals calls for studying and emu- lating the delivery of services in private hos- pitals so that the public hospitals could equally improve the satisfaction. Digital health and home healthcare have the potential of filling these gaps. Digital technology can facilitate healthcare delivery at different lev- els (system, center, professional and patient levels). Supply chain management and an in- tegrated platform for booking and payment can be facilitated at the system level. At the same time, the availability of remote patient monitoring and remote diagnostics can be improved at the center level. Similarly, edu- cation/training and data collection and report- ing will be relevant at an individual profes- sional level. At the same time, health and wellness information and medical advice will affect patients' levels (20). The World Health Organization (WHO) classified DH interven- tions into interventions for clients, interven- tions for healthcare providers, interventions for a health system or resources management, and interventions for data services (21). DH improves access to health, quality of care and reduces healthcare costs through many appli- cations that can contribute to sustainable de- velopment goals. These applications include electronic health records (EHR), telemedi- cine/telehealth, mHealth, eLearning, the con- nection of medical devices via the Internet of Things (IoT), and personal health using wear- able devices (20,22,23). There is an unprece- dented rise in Teledensity, internet penetra- tion, and social media usage globally, but more phenomenal in Africa. There are 1.049 billion mobile users, 473 million internet us- ers, and 216 million active social media us- ers, representing 80%, 36%, and 17% pene- Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 10 of 16 tration in Africa (24). The available DH ser- vices in Africa include mHealth, Social me- dia, Telemedicine/Telehealth, eLearning, EHR, and big data analytics in order of pref- erence (4,5). Nigeria is strategically located to benefit from the digital economy. It ac- counts for about 47% of the West African population, and a half (about 100 million) of its population is under 30 years and is leading the continent in the economy (25). The coun- try is also experiencing this trend of increas- ing mobile, Internet, and social media pene- tration. According to the Nigerian Communi- cations Commission (NCC), the number of mobile phone subscriptions in Nigeria was 176, 897, 879 (92.7% Teledensity), while in- ternet subscriptions were 122, 975, 740 (56% penetration) as of August 2019 (26). The number of smartphone users in Nigeria is es- timated to be 36 million (18.37% penetra- tion). This could be attributed to an influx of low-priced smartphones (the average cost of smartphones decreased from $216 in 2014 to $95 in 2018). There are 24 million (12% pen- etration) social media users, and in 2018, 44% and 4% of mobile users use 3G and 4G technology, respectively, and the number keeps increasing (26,27). Despite these po- tentials, Nigeria was ranked 143rd among 176 countries on the ICT development index (IDD) in 2017. It did not feature among the top 16 countries on the eHealth priority rank- ing of Sub-Saharan African countries and is ranked 15th among the top 17 countries on the eHealth regulating readiness index. This is due to barriers such as infrastructure and device access challenges, funding, human re- sources capacity, and policies and govern- ment leadership (28,29). To establish sustain- able digital health and other digital services, there is a need to build critical digital pillars such as digital infrastructure, digital plat- forms, digital financial services, digital entre- preneurship, and digital skills and literacy (25). Covid-19 has brought the role of tele- health during the pandemic and beyond all over the world to the fore. McKinsey con- ducted Covid-19 consumer surveys in April and May 2020, which showed an apparent in- crease in the adoption of telehealth services in the USA. Telehealth usage was 11% in 2019, which increased, and 76% were inter- ested in using telehealth with a 50-175 times increase in the number of telehealth visits and 80 new telehealth services approved by the centers of Medicare and Medicaid. Pre- Covid-19, the total annual revenue of Tele- health players was estimated at $3 billion and postulated that up to $250 billion of current US healthcare spending could be virtualized (30,31). The DH awareness of the respond- ents was low (39.4%), even though this level of awareness could have improved after the Covid-19 pandemic when some DH services were used to provide virtual medical care. The result calls for creating more awareness amongst females and clients. Access to book- ing for consultation is a challenge, especially for rural dwellers. A window for remote booking for a medical consultation is needed, as indicated by the respondents, in addition to virtual medical consultation, health educa- tion, and remote patient monitoring. The preference for online over mobile DH ser- vices point to an interesting scenario despite mobile technology penetration being better than internet penetration. This and the pre- ponderance of Android phones should guide any DH platforms in software development and technology deployment. Currently, most Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 11 of 16 home healthcare services are offered at the individual and informal level, and there is a need to coordinate the services to ensure quality, reliability, and interoperability with other DH services. Home antenatal care, im- munizations, management of chronic dis- eases including HIV-AIDS are low-hanging fruits to consider for HHS. There is a need for a massive HHS awareness campaign targeted at clients and those patronizing private hospi- tals. Our findings show that there is a notable willingness to pay for the DH and HHS. Alt- hough the amount the respondents were will- ing to pay for both services in this study seems low, it is significant when related to the prevailing minimum wage of $50 per month. It might increase after experiencing their value and advantages. The potential early adopters of DH with the willingness to pay higher will be the healthcare providers, younger clients, and those patronizing private hospitals and should be the first marketing targets. Gradual engagement of older re- spondents and public health users will ex- pand the DH market base. Females will likely adopt HHS early, especially since they attend hospitals more frequently to seek care for themselves or their children and hence face the challenges more. Healthcare providers' willingness to pay higher for the digital and healthcare services could likely be due to their exposure to healthcare delivery and challenges, bias because they were potential beneficiaries for the payment, and possible higher disposable income than the clients. In response to the above data, a team (compris- ing two medical specialists, a biochemist, three IT experts, and a financial expert) de- veloped an integrated (hospital-based, digi- tal, and home healthcare) healthcare ecosys- tem and named it eDokta. It was designed to provide hospital-based care, telemedical care, home healthcare, diagnostic and phar- maceutical services, remote patient monitor- ing, health education, medical education, and universal medical identity services. It is aimed at removing barriers to accessing healthcare by providing virtual access to healthcare providers using mobile and inter- net technology for personalized, seamless, and quality care by patients and expand the providers' customer base and returns. The critical disruptions are the local content via the inclusion of local languages and the one- stop health solution nature of our services. It has a potential for facilitating DH innova- tions such as drones (for delivery of medical supplies to difficult terrains), big data (for managed care, disease prediction, and more accurate treatment), Artificial intelligence-AI (for workflow management, precision in di- agnosis and treatment aid) and IoT (for re- mote patients monitoring). Some of our key partners include specialists, hospitals, diag- nostic centers, pharmaceutical shops, mobile telecommunication companies, Govern- ments, and Non-governmental agencies. The telemedicine software is developed, and more than 1,000 patients benefit from free consultation during the Covid-19 lockdown. The entire eDokta project will be launched in May 2021. Conslusion The digital and home healthcare ecosystem is a new frontier for healthcare globally and is gradually being applied in Africa especially following the Covid-19 pandemic. Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 12 of 16 The growing dissatisfaction with the current hospital-based healthcare system, the mas- sive health workers' brain drain, and the une- qual distribution of health personnel and in- frastructure threaten the attainment of Uni- versal Health Coverage in Nigeria and thus pave the way for introducing DH and home healthcare services. Our attempt at translat- ing DH and home healthcare survey to real life (eDokta) is on the verge of debuting, gal- vanizing the triple helix collaboration be- tween government, research institutes, and industry to develop a sustainable healthcare ecosystem by utilizing digital technology to leapfrog the attainment of UHC in Africa. Acknowledgement I, Jameel Ismail Ahmad, acknowledge the mentorship offered to me by Professor Mod- est Mulenga, Chair of the TDR joint Coordi- nating Board. References 1. United Nations. World population prospects 2019 highlights [Internet]. Newyork; 2019. 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Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 15 of 16 © 2021 Ahmad; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: A Quarter-Tril- lion-Dollar Post-COVID-19 Reality? McKinsey Company Publ May [In- ternet]. 2020;29. Available from: https://www.mckinsey.com/indus- tries/healthcare-systems-and-ser- vices/our-insights/telehealth-a-quar- ter-trillion-dollar-post-covid-19-real- ity __________________________________________________________________________ Ahmad JI, Jibril M, Ahmad BI, Suleiman A, Inuwa NS, Ali AG, Ismail SI. Digital and Home Healthcare Survey among Nigerians: Assessing Awareness, Preferences, and Willingness to Pay for an Integrated Healthcare Ecosystem to achieve Universal Health Cover-age (Original research). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4471 Page 16 of 16