Landscape Analysis of Electronic Immunization Registries

"EIRs can enhance immunization programs by improving the data collection process, easing immunization programs' ability to track individual children and by supporting more specific monitoring of program inefficiencies and coverage..."

Immunisation data in low- and middle-income countries (LMICs) have traditionally been collected and managed with paper-based tools at the health facility level. Electronic immunisation registries (EIRs) can help improve immunisation data quality, use, and resilience - ultimately increasing immunisation coverage and equity. From VillageReach, this landscape analysis identifies EIR implementations in LMICs and shares lessons learned in sustainability, implementation planning, functional requirements, and equity. This research, begun in spring 2019, was part of planning for the implementation of an EIR in partnership with the Mozambique Ministry of Health Expanded Programme on Immunization (MoH-EPI) programme.

EIRs are computerised, individualised immunisation registries that are part of the immunisation information system (IIS). Containing both demographic data on individual children and immunisation events, they can help to facilitate: (i) the individualised and timely monitoring of immunisation schedules, (ii) the monitoring of vaccination coverage, disaggregated by vaccine, dose, geographical area, age, and provider or facility, (iii) the active search of unvaccinated individuals, and (iv) the identification of immunisation supply requirements at all levels of the health system, especially at the operational level (Pan American Health Organization (PAHO), 2018).

The landscape analysis began with a literature review that focused on: EIRs in Africa, Asia, or Latin America; EIRs that were scaled beyond an initial pilot and/or included more than 50 sites; and systematic reviews of EIRs or summaries of implementation best practices. The literature review ultimately identified 30 articles published from 2009-2019. The majority of these articles focused on individual programmes or systematic reviews in LMICs in the PAHO region or documented the Better Immunization Data (BID) Initiative's work in Tanzania, Zambia, and Vietnam. Grey literature was also included to answer two key questions on transitioning from paper-based to electronic-only systems and developing a unique identification (ID) for EIRs. Finally, VillageReach conducted interviews with six subject matter experts.

Findings are presented in four areas:

1. Sustainability: Given the substantial cost and effort required for launching an EIR, VillageReach suggests creating a shared plan for the long-term use of an EIR and designing the EIR to meet the needs of its intended users. Lessons include:
   • Inspire country ownership with early/regular collaboration with government and other stakeholders.
   • Articulate the current and future value of an EIR to the overall health system.
   • Create a roadmap for system and data interoperability.
   • Plan for continuous financial and human resources for the ongoing use of the EIR.
   • Actively understand vaccinator needs and ensure that this knowledge guides solution development.
   • Approach implementation with flexibility to ensure the system meets user needs.
   • Incorporate data quality and use components to reinforce value of the EIR.
2. Functional requirements: Critical functional capabilities include: enrollment at birth in the EIR; a unique and unequivocal identifier; vaccine event data; client management; mechanisms for aggregating data at different geographic levels; identification of under-immunised children/missed vaccinations; data security and protection and patient confidentiality; data entry as close to the time of vaccination as possible; offline capability; reports; and stock management. Six potential goals of an EIR: (i) improve vaccine coverage and equity, (ii) improve dose timeliness, (iii) improve vaccine accuracy, (iv) improve immunisation programme efficiency, (v) improve data quality, and (vi) improve primary health care service delivery. The report outlines how forward-looking functional capabilities can assist in meeting these goals. Finally, the report examines three common open-source EIR platforms; OpenSRP, DHIS2 Tracker, and Shifo MyChild.
3. Promising practices for implementation: VillageReach finds that the process for integrating an EIR into a healthcare worker's daily workflow is even more critical than the functional requirements necessary for developing an EIR. The report describes considerations and promising practices related to change management, data burden, training, data use, and the transition from paper to digital records. For example, in addition to using peer mentoring as a training method, ongoing peer learning and support is important to ensuring the sustained use of an EIR. The BID Initiative used WhatsApp to allow health workers to share experiences and support each other with the EIR and data collection and use generally.
4. Equity: Implementers are advised to consider how to:
   • Identify under-immunised children (i.e., drop-outs) and unimmunised children (i.e., zero dose children), assuming data are available - For example, individuals that move from place to place can be difficult to track using a paper registry system; as EIR records are regularly synced to a central database, migrant families can recover their records at any connected health facility where they seek service once the child's record is identified in the system. More detailed data on these individuals collected in the EIR could also allow better prediction and preemptive action to prevent missed immunisations.
   • Ensure equitable implementation of EIRs - For example, ensuring that an EIR can work in offline mode in clinics that have intermittent internet connectivity could support the widest number of health clinics in using the EIR. In areas where there is no connectivity, health facilities may also benefit from using smart paper technology to support digitalising data initially collected on paper forms. In addition, community health workers, as potential drivers of outreach to under-reached groups, can be equipped with EIR-enabled smartphones.
   • Preventing misuse of data - The ability to direct vaccination campaigns and alternate outreach methods to under-reached groups must be balanced with privacy concerns, especially for vulnerable groups. For example, it has been suggested that religion and ethnicity are two data points that should not be collected, given their use at different times in history to discriminate and incite violence against minority populations.

The report concludes by identifying existing knowledge gaps and future directions for enhancing the usefulness and value of EIRs. Questions to be explored include: To which groups and in which settings are EIRs most beneficial? What is the appropriate scale to get maximum benefit from an EIR (i.e., targeted locations vs. nationally scaled)? How can EIRs be used to address the most vulnerable groups? How can they advance the delivery of primary care? What is the role of the private sector in creating an enabling environment?

Appendices A and B highlight findings on the two implementation challenges that were identified during the landscape analysis process, and Appendix C includes a table of references for publications detailing specific EIR implementations in LMICs. In addition, on August 14 2020, the BID Learning Network (BLN) hosted a webinar titled "Lessons from the Landscape Analysis of Electronic Immunization Registries", which may be of interest to data management specialists, EPI managers, health management information system (HMIS) specialists, and other healthcare specialists committed to improving data collection, quality, and use across health systems. To watch it, click on the video, below.