Electronic Immunization Information Systems: A Case Report of Lessons Learned from Implementation in Pakistan

"This program learned that an immunization information system with the capability of sending SMS vaccination reminders and awareness messages to caregivers, reminders to vaccinators to visit specific villages, and notifications to community focal persons informing them of vaccinator visits to their villages has the potential to become an important component of community-based demand generation for vaccination."

Pakistan ranks third globally in the number of unvaccinated and under-vaccinated children, and Sindh province has one of the lowest vaccination rates in the country. Among the factors that have had a negative impact on Pakistan's vaccination coverage are: outdated census estimates, which make it difficult to set and achieve realistic immunisation targets; incomplete and inaccurate vaccination reports; poor worker motivation and supervision of vaccinators; and missed opportunities to link polio eradication and routine immunisation (RI) activities. This is a case report of technical support provided to the Sindh Department of Health/Expanded Program on Immunization (DOH/EPI) from 2015 to 2017 to strengthen RI through electronic census-based immunisation information systems.

Over an 18-month period, the team worked with 16 districts to improve immunisation microplanning, establish more regular vaccination services, provide information to parents and communities about immunisation, strengthen the knowledge and capacity of vaccinators and district health managers, and monitor and refine RI service delivery approaches. The team developed an immunisation information system that was comprised of:

• A web portal that allowed users to: store data on individual children and pregnant women; manage, search, and filter client records; and monitor vaccination coverage and vaccinator performance; and
• An integrated mobile messaging platform that sent: short message service (SMS) vaccination reminders and 5 different awareness messages to caregivers; one reminder for vaccinators to visit specific villages based on their microplans; and one notification to community focal persons informing them that vaccinators would be visiting their villages on certain dates.

As the case study details, district immunisation officers (DIOs) assisted their district health management teams and supervisors to use registration and service data stored in the immunisation information system database to prepare microplans, monitor catchment area performance, and solve problems.

Between March 2016 and August 2017, civil society partners registered 830,610 children (aged 0 to 23 months) and 348,315 pregnant women in 28,565 villages in 8 of the intervention districts and entered their data into the electronic immunisation information system. By the end of the intervention period, 65% of all registered women had been vaccinated with 2 or more doses of the tetanus toxoid vaccine (compared to 26% at baseline); Penta 3 vaccination coverage had increased from 27% to 64%; and 52% of the registered children (aged 0 to 23 months) were fully immunised (compared to 18% at baseline).

In discussing the experience, the team notes that the immunisation information system: helped district managers identify and focus limited resources on high-risk populations; reminded families and health providers when vaccinations were due or missed; assisted managers in monitoring vaccination coverage, vaccinator performance, and vaccine stocks; and encouraged local problem solving to improve RI performance (e.g., data generated from the immunisation information system was incorporated into district- and provincial-level data review meetings, and these data visualisations catalysed discussions around performance gaps and how to address them).

The team began transitioning key elements of the approach to the Sindh Department of Health in late 2017. As part of the transition, plans were to create a single digital immunisation information system by merging the system described here with the "ZindagiMehfooz" ("Safe Life") mobile application that was being tested in Sindh province with Gavi support and the Government's vaccine Logistics Management Information System (vLMIS). Vaccinators and their supervisors are being trained to keep this new, fully automated digital information system up to date and use the data it produces to develop and adjust their individual immunisation session plans, as needed, to improve RI performance.