Maturity of the patient registration system and factors associated with ICD-10 adoption in Côte d’Ivoire: a national analysis of the 2023 HHFA survey

Every time a person visits a doctor, a record is made. In a well-functioning health system, these records are not just notes on a piece of paper; they are the raw material for understanding the health of a nation. When a doctor writes down a diagnosis, that information needs to be translated into a universal language so that statistics can be counted, compared, and used to plan future care. This universal language is known as the International Classification of Diseases, a system that allows a hospital in one country to speak the same statistical language as a hospital in another. Without this standardization, it is impossible to know which diseases are killing people, where they are spreading, or how to allocate resources effectively. In many parts of the world, however, the bridge between the patient sitting in the exam room and the national health planner remains fragile, often relying on paper registers that are difficult to search, hard to share, and rarely updated with the latest coding standards.

In Côte d'Ivoire, researchers recently set out to see how well this system was working across the entire country. They wanted to know two specific things: how mature the system was for recording patient visits, and how many facilities were actually using the standard disease codes to describe what was wrong with their patients. To find the answers, they did not look at a single city or a single hospital. Instead, they analyzed data from a massive national survey that visited more than 1,100 health facilities, ranging from small rural clinics to large university hospitals. This survey, conducted in 2023, provided a rare, complete picture of the health information landscape in the country, revealing a system that is deeply uneven and struggling to move from paper to digital.

The researchers found that the foundation of the system—the patient registration process—was still in its very early stages of development. They created a simple score to measure how well facilities were managing their records, looking at things like whether they had a unique ID for every patient, if they used individual files, and if they had computers to store the data. Across the entire country, the average score was less than one point out of a possible five. This low score tells a clear story: most health centers are still relying on paper. Only a tiny fraction of facilities, about 3.6 percent, had even begun to use a computerized register for outpatient visits. Furthermore, fewer than one in ten facilities had a system to give every patient a unique identifier, which is the first step in tracking a person's health history over time. The situation was slightly better in larger hospitals, but even there, the systems were far from perfect.

When the team looked at the use of the standard disease codes, the picture was similarly stark. Only about 15.6 percent of all the health facilities surveyed reported that they were using the international coding system to classify diagnoses. This means that for the vast majority of patients seen in the country, their specific medical conditions are not being translated into the universal language needed for national statistics. The gap was even wider when it came to recording causes of death. Among the hospitals that had recorded at least one death in the previous year, only about 13 percent were actually using the standard codes to determine and record what caused the death. Without this data, the country cannot build an accurate picture of why people are dying, which makes it incredibly difficult to fight preventable diseases or plan for the future.

The study also investigated why some places were doing better than others. The most powerful factor was simply the size and level of the facility. Hospitals that were part of the secondary or tertiary levels of care—meaning larger regional hospitals and university centers—were much more likely to use the coding system than small primary care clinics. A secondary-level hospital was nearly five times more likely to use the codes than a primary clinic, and a tertiary hospital was even more likely to do so. This suggests that the ability to use these complex systems depends heavily on having more doctors, more resources, and more specialized staff. Interestingly, the researchers found that who owned the hospital did not matter. Public hospitals, private clinics, and faith-based facilities all performed similarly; ownership was not the deciding factor. Instead, the key was having the right tools. Facilities that had both a working computer and an internet connection were significantly more likely to use the coding system, showing that digital infrastructure is a critical enabler for modern health data.

The findings suggest that the path forward requires a targeted approach. Because the system is so weak at the primary level, where most people first seek care, there is an urgent need to train staff in how to use these coding tools. The researchers noted that simply having a computer is not enough; the people using them need to know how to translate a diagnosis into a code. They also highlighted that the current low level of adoption poses a challenge for the future, as the world is preparing to switch to a newer version of the disease classification system. If countries cannot master the current version, moving to the next one will be even harder. The study concludes that strengthening the health information system in Côte d'Ivoire will require a focused investment in training and digital tools, particularly for the smaller clinics that serve the majority of the population, to ensure that every patient's story is recorded in a way that can help the whole nation.