Mobile Network Operator Partnerships in Action for Health: A Vietnam Case Study on Mobile Network Operator and Ministry of Health Engagement for Electronic Immunization Registry Application

"As health experts, governments, and policymakers around the world harmonize their goals to improve health outcomes through the use of better data and digital tools, the importance of partnerships with key technology stakeholders has become increasingly apparent."

After reviewing the pilot of an electronic immunisation registry (EIR) that was implemented by the global health nonprofit organisation PATH in Ben Tre province, the government of Vietnam partnered with Viettel Business Solutions (Viettel), a Vietnamese mobile network operator (MNO), and PATH to develop and scale up the National Immunization Information System (NIIS). The objective of this case study is to share lessons learned from this partnership so as to serve as a guide for others to build alliances with or as MNOs in order to expand immunisation coverage, especially in Vietnam's Mekong region and other low- and middle-income countries (LMICs).

In its earlier phases, the National Expanded Program on Immunization (NEPI) relied on paper-based methods for immunisation record keeping and vaccine supply management and tracking. This system created gaps and multiple challenges (e.g., incorrect, incomplete, and/or delayed data) in expanding immunisation coverage. PATH theorised that by transitioning from paper to digital records, Vietnam's immunisation system could operate more effectively, with improved timeliness and coverage of childhood vaccinations.

So, working with NEPI, in 2012, PATH designed ImmReg, an immunisation registry software programme, and piloted it in a district in Ben Tre province in the south of Vietnam in 2014. PATH also helped develop VaxTrak, a digital tool for tracking vaccine stocks. In 2014 and 2015, PATH worked with the Ben Tre Provincial Health Department and the Preventative Medicine Center to scale up the system from district to provincial level. Launched in March 2017, NIIS is the result of the collaboration between the Ministry of Health (MOH), Viettel, NEPI, General Department of Preventive Medicine (GDPM), and PATH. It is now used in all 63 provinces across the country; as of July 2019, over 17 million records had been registered into the system.

NIIS works as follows:

1. Health workers register pregnant women and newborns in the NIIS via smartphone or computer. Each child is assigned a unique identification number in the system.
2. The system automatically generates a list of children due for vaccinations and sends a text message to caretakers to remind them to get their child vaccinated.
3. When caretakers bring the child in for vaccinations, health workers enter data on the vaccine, doses, and date delivered.
4. NIIS provides the commune health worker with information about the types and amount of vaccines that the centre has on hand and needs to administer monthly. These data are then reported up to the district and provincial levels to prevent vaccine wastage and shortages.

The case study explores how the partnership worked to make this system a reality. For example, a NIIS Technical Working Group (TWG) was formed to finalise and maintain the user-friendliness of the NIIS system, to collaborate on meeting end-user needs with regard to client and vaccine-tracking capabilities, and to generate reports for high-level decision-making.

Data for the NIIS are extensive, so the NIIS had to be capable of high-capacity data storage, organisation, and analysis. This meant partnering with an MNO that could meet the need for large data capacity, upkeep of organisation, and the financing to maintain capacity and allocation of resources. As reported in the case study, Viettel, a state-run organisation, has a well-established relationship with the government of Vietnam. "Viettel trusts the government, and the government trusts them. When MOH trusts PATH, then there is a big circle of trust," said Dr. Vu Minh Huong of PATH. Viettel was also able to check certain boxes of global framework assets described in the case study: core connectivity, core support infrastructure, and business infrastructure.

"Motivators for MNOs to partner with mHealth service providers like the MOH, NEPI, GDPM, and PATH include improving health in society, health initiatives setting them apart and above other MNOs as more invested in the health and well-being of the population, using their already developed information communication technology functionalities, and increasing revenue..." Specific to Vittel:

• PATH and MOH provided high-level health information knowledge-sharing (such as immunisation materials and general health system background materials).
• It was key to share technological information about the system and why it would fit the needs of end users, as well as to focus on the populations that needed the system the most.
• The success of the PATH pilot of ImmReg and PATH's already existing relationship with the government provided evidence that PATH was capable of scaling up and supporting the implementation of high-level health initiatives.
• Viettel's work with the Vietnamese government could encourage future collaboration and continued selection of Viettel as the choice MNO for projects.
• Viettel's revenue has the potential to increase based on increased brand recognition and the enhanced likelihood of further projects outside of Vietnam.

Challenges present in the Viettel-MOH-PATH partnership included:

• Being part of a partnership that was designed for long-term investment and continuous upkeep of a national system required adaptation of Viettel's existing business models, as well as knowledge acquisition about communication and exchange strategies between partners.
• Viettel pays for many things, such as research and testing of the system, out of pocket.
• Viettel faced a significant learning curve when developing the system, as the MNO is not a health or immunisation expert and had little experience with mHealth initiatives.
• Viettel's security and sensitivity with internet protocols in support of government standards at times prevented PATH from fully accessing the system.
• The translation of information from highly technical teams such as MOH, GDPM, and NEPI to Viettel in order to paint a clear picture of Viettel's role, the project, and the end goals took time and collaboration.
• The lack of coordination and a formal, signed agreement created a discrepancy in decided and agreed outcomes, roles, deliverables, and financial responsibilities.

Recommendations based on these challenges include:

• Establishing a strong partnership early on enables MNOs and mHealth service providers to grow together with the project and create understanding on both sides, which could reduce learning curves and provide real-time experience to perfect the system and synergistically facilitate the expansion of uptake.
• Beginning the project with a foundation of trust with an established MNO with history in the country and a long record of services is important.
• Viettel recommends that other MNOs move toward similar projects globally, as this cross-sector collaboration fosters the betterment of society.

Looking ahead:

• Incorporating nutritional data and noncommunicable disease information into the current system could further improve data quality, decrease time spent on data input, and improve health outcomes.
• Viettel envisions the creation of an electronic individual identifier for each person to include prescriptions, health conditions, medical services, administration records, and user-interactive services such as appointment scheduling - all integrated into one system.
• GDPM has a goal for all newborns to be vaccinated and for 1.7 million individuals to be given unique bar codes in the NIIS. The goal is to have a national ID connected to the NIIS and other health trackers.
• GDPM suggests that PATH, Viettel, and NEPI should continue working together and testing new software that would expand the concept of the NIIS to a larger scale, including tracking and storing data from various focus areas.
• Viettel and PATH anticipate working on more projects together, potentially in other Mekong-region countries (Myanmar and Laos).

Click here for the 24-page report in Vietnamese in PDF format.