In the clinics of Adamawa State in northeastern Nigeria, two ways of counting sick children have been running side by side: a tablet that guides a health worker through each consultation, and a paper-based state register typed up by hand each month. Like many efforts to see clearly in hard places, this one reveals that the act of counting is never neutral, since each system carves illness into categories and sends its tally along a different path. Born of a region scarred by insurgency and poverty, the digital tool was meant to steady the workers who stayed behind, and its promise is real even
Digital Child-Health Tool and National Records Diverge Sharply in Nigerian Study
Two systems counting the same sick children, and they often do not agree
Mark
So the headline is that two systems counting the same sick children disagree. Why does that matter?
Mimi
Because managers use these numbers to allocate drugs and staff. For malaria, the routine system counted 233,548 cases and ALMANACH 116,018. Planning on one or the other would look very different.
Mark
Is the digital tool the more accurate one, since it avoids manual entry?
Luke
The study explicitly says it can't tell. There's no gold standard. Manual typing errors are a known problem, but that doesn't prove ALMANACH is right.
Mimi
And ALMANACH only captures children seen with the tablet, so coverage and definitions could explain part of the gap.
Mark
Do the gaps shrink as the tool spreads?
Mimi
The opposite. They widened as scale-up reached toward all 412 centres, especially for malaria and, from 2020, pneumonia.
Luke
Worth noting the direction isn't uniform. Measles was higher in ALMANACH, 4,355 versus 2,508, and that estimate has a very wide confidence interval.
Mark
What about the 2017 measles spike?
Luke
ALMANACH showed it and the routine data didn't. The source doesn't explain why, so that's unknown.
Mimi
What the authors do ask for is harmonised definitions and coordination, with health workers involved.
O Pulso
- Two counts of sick children under five in the same Adamawa clinics refuse to agree, and the gap keeps widening as the tablet tool spreads.
- Malaria figures diverge most sharply, with the state's routine system recording more than double the cases logged by the ALMANACH tablet.
- Measles runs in reverse, as the digital tool reports far more cases than the official register, leaving planners unsure which spike is real.
- Researchers cannot name a winner without an independent gold standard, so the discrepancy stands unresolved in the data.
- Authors are pressing for shared definitions, tighter coordination between systems, and health workers' voices before any policy rests on these numbers.
In the clinics of Adamawa State in northeastern Nigeria, two ways of counting sick children have been running side by side: a tablet that guides a health worker through each consultation, and a paper-based state register typed up by hand each month. Like many efforts to see clearly in hard places, this one reveals that the act of counting is never neutral, since each system carves illness into categories and sends its tally along a different path. Born of a region scarred by insurgency and poverty, the digital tool was meant to steady the workers who stayed behind, and its promise is real even as its numbers wander from the official record. What the study leaves open is which count reflects the children themselves, a question that cannot yet be answered without a truth against which both can be measured.
In Adamawa State, in northeastern Nigeria, two systems have been counting sick children under five at the same clinics. One is a tablet that walks a health worker through each consultation and uploads the record when a connection allows. The other is the state's routine health information system, fed by paper registers that staff type in by hand each month. A recent PLOS Digital Health study lined up five years of both and found they often disagree.
The tablet tool, ALMANACH, was introduced in 2016 by the Swiss Tropical and Public Health Institute, the International Committee of the Red Cross and the state's primary healthcare agency. Adamawa is one of Nigeria's poorest states and was badly damaged by the Boko Haram insurgency, which drove many health workers away or killed them. ALMANACH was meant to support the low-level staff who remained, and its scale-up across all 412 primary health centres began in 2018. Earlier work had linked it to better paediatric care and fewer antibiotic prescriptions.
The numbers do not line up. For malaria, the routine system recorded 233,548 cases against 116,018 in ALMANACH, and its curve climbed more steeply. Gastrointestinal illness and pneumonia were also higher in the routine register, though the two tracked each other closely in some years. Measles ran the other way, with ALMANACH logging far more cases than the official records.
The authors are careful. Without an independent gold standard, the study cannot say which system is closer to the truth. Manual entry is prone to typing errors, while the tablet sees only the children who come to it, and the two may define illnesses differently. Still, the gaps grew as the digital programme expanded. The researchers call for shared definitions, closer coordination and greater involvement of health workers and local decision makers before digital tools are used to guide policy.
In Adamawa State, in northeastern Nigeria, two systems have been counting sick children under five at the same clinics. One is a tablet that walks a health worker through each consultation and uploads the record when a connection allows. The other is the state's routine health information system, fed by paper registers that staff type in by hand at the start of each month. A study in PLOS Digital Health lined up five years of both and found they often do not agree.
The tablet tool is ALMANACH, short for Algorithms for the MANAgement of Childhood Illness. It was introduced in 2016 by the Swiss Tropical and Public Health Institute, the International Committee of the Red Cross and the Adamawa State Primary Healthcare Development Agency. Adamawa is one of Nigeria's poorest states, with a poverty rate of 74%, and it was hit hard by the Boko Haram insurgency, during which many health workers fled or were killed. ALMANACH was seen as a way to support low-level staff who remained. Scale-up began in 2018, aiming at all 412 primary health care centres in the state, its largest deployment to date. It has also been used in Afghanistan, and is in use in Somalia and Libya.
Both systems feed into the same platform, DHIS 2. Earlier work found that ALMANACH improved the quality of paediatric care and cut antibiotic prescriptions, and a 2020 observational study showed higher recovery rates among children treated with it. Before the tool, a survey had found consultations lasting one to two minutes without triage, antibiotics given to 77.7% of children, and 70.5% of treatments judged inappropriate. The researchers asked whether the data it generates match the official record for malaria, pneumonia, gastrointestinal disorders (mainly acute watery diarrhoea) and measles.
For three of the four, the routine system reported more. Malaria showed the widest gap: 233,548 cases in the routine system against 116,018 in ALMANACH, a median difference of 6,055 cases and a relative difference of 80.6%. The routine system's malaria curve rose more steeply and peaked at the end of 2020, while ALMANACH peaked in mid-2020. Across facilities, the routine system recorded on average 40.2 more malaria cases per facility per quarter, and the share of facilities with large discrepancies began climbing after 2019 and kept rising.
Gastrointestinal disorders came to 62,412 cases in the routine system versus 43,003 in ALMANACH, a relative difference of 32.6%. The two tracked each other closely in 2018 and 2019, and the gap was widest at the end of 2017. Pneumonia totalled 29,416 against 20,980, a relative difference of 34.0%. Counts were similar until the end of 2019; from 2020 the routine system recorded more, including a 2021 peak ALMANACH did not capture.
Measles ran the other way. ALMANACH logged 4,355 cases to the routine system's 2,508, with a relative difference of 86.2% and a wide confidence interval. ALMANACH showed a sharp 2017 spike above 400 cases that the routine data, comparatively low and stable, did not reflect.
The authors are careful about what this means. With no independent gold standard, they say, the study cannot show which system is closer to the truth. The routine system's manual entry is known for typing errors, but the digital tool captures only children seen with it, and definitions may differ. The gaps grew as the digital programme scaled up. The authors call for harmonised definitions, closer coordination between the systems, better data collection practices, and more involvement of health workers and local decision makers before digital tools are used to guide policy.
Citações Notáveis
Without a gold standard, the results cannot identify which system is more accurate; they point to the need for coordination, harmonised definitions and better data practices.— Study authors, PLOS Digital Health
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