The paper-based information systems that nowadays support the immunization programs in developing countries have long struck me as arcane and ineffective. All around the world, at the end of each month nurses and other health workers typically take a break from their real job to prepare a set of reports for their district supervisors, to report the numbers of children they vaccinated, the quantities of vaccines they used and the orders they want to place for next month. Yet despite their best efforts, this data gets distorted as it moves up the chain, and by the time it reaches its final destination, the information is not detailed, timely or even accurate enough to use for meaningful decision making.
At best, an immunization manager will find out coverage by district (but not who the unimmunized are or why they were missed), and stock balances and stock-outs in those districts (as recorded two months before the EPI manager reads this report). Problems with cold chain or vaccines are even less likely to be reported. Not many countries manage to capture any closed vial wastage data, for example. At lower levels, the information systems will provide even less benefits to its users, so all this input at the bottom of the hierarchy – effort and time – is translated into an unsatisfactory trickle of bad data at the top. I believe that this can only be remedied if future information systems give back more benefits to users than the effort they require from them.
At Optimize, the collaborative project between WHO and PATH where I work, we strongly believe that better information systems are an essential part of the portfolio of innovations that are needed to prepare in-country vaccine supply systems for the flood of new vaccines that are many countries are about to introduce. Two of our interventions that excite me most are “last mile logistics management information systems” and “immunization registries”.
What if health workers could easily register every stock transaction (receipts, issues, use), rather than report these on a monthly basis? Managers would then gain real time access to stock levels, get to know about stock outs and be able to fine-tune distribution practices to make sure that supply is driven by actual demand and consumption at the service level. This system is being piloted in two ways: in Tunisia through the use of cell phones by health workers at peripheral levels, and in Vietnam through the installation of fridge-based devices at intermediate levels that can be used to scan vaccines as they are moving in and out.
Computerized immunization registries are even more ambitious and may not be a good solution for many countries. But where they can be implemented, the benefits compensate for the higher complexity. They track each child’s vaccinations, and feed that information into a national database. This personalized recording system allows for individualized follow-up, helping ensure that children receive all necessary vaccinations no matter where in the country they move. By tracking this information, immunization programs can reduce the number of defaulters, find the unimmunized, and ensure the right vaccines are distributed when and where they are needed, minimizing vaccine wastage, loss and stock outs. They also allow for lot tracing down to the child level, which is an essential tool for vaccine safety and the management of Adverse Events Following Immunizations (AEFI).This system is currently being piloted in Albania, Vietnam and Guatemala by project Optimize.
–Jan Grevendonk is a Immunization Information Systems Specialist at PATH, Geneva, Switzerland