Better Immunization Data (BID) Initiative

To address a number of the critical data-related challenges facing immunization programs that were identified with government officials and partners, a package of interventions was designed with users and deployed with three key focus areas: 1) an electronic immunization registry, 2) stock management at the facility-level and 3) a culture of data use. One of the largest and most intricate interventions developed is the national electronic immunization registry, which will ensure all children are registered from birth and do not miss a potential life-saving vaccine. The registry is an electronic database that will contain all children and their immunization data. In Zambia, tablets with the Zambia Electronic Immunization Registry (ZEIR) application were deployed to all 274 facilities providing immunizations across Southern Province. The government chose a fully electronic approach as a way to address the timeliness of data, and so as long as a tablet has a wifi or data connection it can sync its data to the national registry. For facilities with connectivity challenges, ZEIR was designed to also work in offline mode, providing a local cache on the tablet so nurses could still search for and update the records of children belonging to the specific facility. Every child is entered into the immunization registry at birth (or shortly after, within 48 hours ideally). Only basic information is needed to register a child (e.g. mother’s name, baby gender, village, and date of birth). This registration can be done by the health facility into the immunization registry, or in the event of a home birth, by a community health worker through Short Message Service (SMS) that will create a new record in the registry. An immunization schedule is then automatically generated for each child. To ensure the correct child receives the correct vaccine at the correct time, each child is uniquely identified with a QR code, which goes onto the child health card that the mom/caregiver keeps. When that child returns, the nurse can use the tablet to scan the QR code and pull that child’s record for a more efficient assessment of which dose the child is due for and when. Another challenge with immunizations is difficulty identifying infants who do not start immunizations, and without knowing that number it also skews the service performance data because the target population for calculating immunization rates is uncertain. In the process of partnering with UNICEF on their mobile vaccination (mVacc) initiative that collects information on home births via SMS. While ZEIR collects data on births at the facility, this partnership with UNICEF will strengthen the identification of the true number of children due for immunizations, ensuring that all children are accounted for. This also facilitates the calculation of coverage estimates, as well as knowing the exact population to serve for ordering stock and supplies. ZEIR also addresses issues around defaulter tracing and planning for the provision of immunization services. Rather than going out looking for 10% more children, health workers are looking for 15 specific children by name and with their caregivers’ contact information. Having this information can change everything about how a facility can plan and deliver services. In addition, since the immunization registry contains all children in the province, they can tell if a child was vaccinated outside of their “home” facility. Ultimately, health workers can even identify the patterns of where the individual seeks care, which will allow support to be targeted at those facilities that are being underutilized. Due to real time data entry, there will be no need for health workers to generate reports at the end of the month. For facilities with internet access or in offline mode, the registry produces automatic reports based on the data entered. This will ensure the data is timely and available to all levels of the health system. Data can be disaggregated down to the individual village and provide detailed information to help with resource allocation and planning. Since many reports can be generated from individual records, it is entirely possible to analyze that data in multiple ways that are not currently possible. Furthermore, integration with DHIS2 allows the data entered into ZEIR to sync into the appropriate indicators for immunization, Under 5 services and growth monitoring segments of the HMIS report, saving nurses valuable time from double entry and monthly report generation. With these streamlined processes in data collection, behavioral and organizational activities have also been designed to generate quick, visible change in order to demonstrate the value of using data and information as part of planning, supervision, and performance improvement. As part of our work the Initiative has designed interventions with the Government of the Republic of Zambia (GRZ) to improve the way data is collected and used at the district level down to the facilities themselves, empowering communities and facilities to make better decisions. Still, providing data is not enough- what it also focuses on is the cultural shift from data pushers to data users. Health workers at all levels of the health system need to recognize the power of data to make evidence-based decisions. In doing so, the implications and potential for streamlining their work is boundless. For example, health workers can plan outreach activities to specific children in their known catchment area for specific vaccines. Where there are defaulters, tracing to the village, child, and caregiver helps to increase vaccination rates. This actionable data assists the health worker to adjust their strategies accordingly and eventually become more efficient in their planning. Data that compare performance amongst facilities and districts can help identify opportunities for improvement and highlight successes. For facilities that are challenged and resources are scarce, targeted support can be implemented through change management interventions such as supportive supervision, community mobilization, etc. In this way, opportunities to learn from each other are created and often address issues in an innovative way. In addition to creating a data culture that seeks improved information to make decisions, the interventions seek to change individual behaviors related to the collection and use of data. For example, micro-training videos that are on the same tablets as the ZEIR application provide short training videos, capturing successful best practices and innovations to improve data use at facilities. Data visualization/dashboards include the most functional and relevant information at each level of the health system (facility to national) on a monthly basis. Peer networking through WhatsApp connects and increases informal interaction between health workers, encouraging peer-supported problem. Targeted supervision from districts will use improved data and monthly reports from facilities to target monthly, onsite one-on-one capacity building with identified under-performing facilities. Workflow redesign seeks efficiencies with the integration of the tablet into the workflow to improve general process flow and streamline immunization service provision. Data use guides for the facility and district walk healthcare workers through the analysis of their data to understand what their data means, how it can be used and the impact of the decisions made.

The BID Initiative was designed in partnership with countries to create an environment where reliable, easily accessed, and actionable data can be used to improve health outcomes. While the initial focus is on immunization data to first test and prove the approach, the Initiative is designed to be applicable for and adaptable to several health areas such as nutrition or maternal, newborn and child health. The BID Initiative is country-owned and country-led. Working initially on a small scale in two demonstration countries, Zambia and Tanzania, the Initiative has taken an iterative, evolutionary approach to developing and perfecting solutions and partnered with countries to identify the most critical routine immunization service delivery problems including the following: incomplete or untimely data, lack of unique identifiers for infants, inaccurate or uncertain target population for calculating immunization rates, difficulty identifying infants who do not start immunization or drop out (defaulter tracing), poor data visibility into supplies at the facility-level and district-level, complex data collection forms and tools, insufficient supply chain and logistics management and inadequate data management and use capacity at all levels of the health system. The BID Initiative believes a collection of multiple interventions is key to helping address data quality and use challenges. A holistic investment is needed in data management policies and practices, information system products, and the people who will use them. With country partners, a suite of interventions have been designed, tested, and fine-tuned to be flexible enough to “fold in” to countries’ overall directions and existing strategies: electronic immunization registry with stock management information; automated, simplified report generation, micro-training videos, peer support networks, QR codes on child health cards, targeted supportive supervision for health workers and dashboards to monitor facility and neighbouring facility performance. In Zambia, the suite of data quality and use interventions have been deployed to all 274 facilities providing immunizations across 13 districts in Southern Province. The Zambia Electronic Immunization Registry (ZEIR) – built on the open source platform Open Standard Registry Platform (OpenSRP) – currently has more than 63,857 children registered. ZEIR operates on mobile/tablet devices that integrate into clinical workflows, including outreach sessions away from the facility, allowing nurses to collect critical data on children who are due for and receive immunizations. Beyond immunizations nurses are also able to collect and track growth monitoring data for children from birth to 5 years of age. The improved availability of data with ZEIR allows nurses to identify and trace defaulters. Rather than going out looking for 10% more children, nurses can look for the 15 specific children by name and with their caregivers’ contact information. This service delivery information captured at the facility also allows district, provincial and national-level staff to see the aggregate information for performance. This process is done through ZEIR’s integration with another open source tool used in Zambia: District Health Information Software 2 (DHIS2). This integration between ZEIR and DHIS2 improves the timeliness of data both for reporting and action, especially through targeted supportive supervision from the district to low-performing facilities. Developing sustainable solutions to scale beyond test sites and demonstration countries will be critical to sustained impact and health benefits. This requires close partnerships with country leaders and stakeholders. PATH is actively working with country partners to seek additional resources to help the demonstration countries plan for national scale and sustainability. While the Initiative is initially working in two demonstration countries, many countries in sub-Saharan Africa participated in the design and testing of tools and interventions through the BID Learning Network (BLN). The BLN enables peer-to-peer learning exchanges and will help ensure the suite of data quality and use solutions will be relevant for and facilitate adoption by not only the two demonstration countries but also other countries interested in improving their health programs through better data and decision-making. The BLN currently consists of a vibrant community with representation from 20 sub-Saharan African countries. If countries continue to be successful in this work, a true tipping point will occur— one in which countries can access, analyse, and act upon accurate immunisation data anytime, anywhere—resulting in improved health outcomes, healthier families and communities, strengthened immunisation service delivery and progress toward addressing challenges in equity.

From a technology perspective ZEIR uses international standards such as ICD-10 and SNOMED which allow it to readily and easily interoperate with other technologies such as DHIS2. This interoperable functionality aligns with Zambia’s Smart Zambia legislation which envisions integration and data sharing across multiple ICT platforms as well as clinical care services. The value it also adds is streamlining the data collection and reporting processes for healthcare workers, creating efficiencies in timeliness. In the process of working with UNICEF to exchange data from their SMS application called mVacc which runs on the RapidPRO platform. This mVacc application collects data about home births which is a critical piece of immunization service delivery as a way to identify children who need immunizations but may have not yet come to the facility. ZEIR will provide source data on stock at facility level that districts can use to monitor and update stocks in Logistimo, a stock management system that is currently operational at district level. From a data perspective the suite of interventions also strengthens the culture of data use, a fundamental part of all clinical care services. We have anecdotal data to show that nurses have used the data use guide techniques to address service challenges in other areas of health such as malaria. ZEIR has also been adopted by Zambia’s Catholic Medical Mission Board (CMMB) for use in nine facilities CMMB supports in Western Province and also by the International Training and Education Center for Health (I-TECH) who will use the system in Kenya.