Using EMID for RI (EIR) to measure PHC performance

Data-driven planning and use for action in the PHC context is important in improving health outcomes and enhancing program efficiency. Unavailability of quality data and poor use of data can undermine the government and stakeholders’ decision-making and action for improvement in the system and performance management[1]. The World Health Organization’s (WHO) Immunization Agenda 2030 recognizes that reliable data will help countries continuously improve their performance and efficiency [2]. In 2010, Nigeria adopted the use of District Health Information Software (DHIS2) as the platform for the National Health Management Information System. With the successful scale-up of the project, routine immunization data in the country has become accessible, visible, and available for decision-making. However, the entry occurs at the district (LGA) level following monthly submission from all health facilities within each district, and this delays prompt action, thus, reducing the opportunities to identify and correct data quality issues and improve PHC performance management. Also, the lack of reliable internet connectivity and discrepancies in administrative data from point of care and household survey data remain high, impeding resource planning and PHC performance[3]. Studies in low- and middle-income countries, including Nigeria, show that interventions that encourage the positive practice of health workers improve compliance and achievement of broader system health goals and PHC performance management[4][5].

[1] Policy Brief: Understanding key drivers of poor data quality, usability, and use in Kano, Yobe, Niger, and Lagos, Nigeria Policy Brief: Understanding key drivers of poor data quality, usability, and use in Kano, Yobe, Niger, and Lagos, Nigeria - Clinton Health Access Initiative

[2] World Health Organization. Immunization Agenda 2030.

[3] Administrative data is sourced for children aged 0-11 months while survey data looks at the corresponding birth cohort aged 12-23 months. Administrative data was sourced from DVD-MT and DHIS2 in 2015 and 2017 respectively. Survey data from 2016/2017 MICS-NICS and 2018 NDHS.

[4] MCHIP. (2012). Creating Stronger Incentives for High-Quality Health Care in Low- and Middle-Income Countries. Retrieved from https://www.mchip.net/sites/de... and PBI_Full report_Final.pdf

[5] Ogundeji, Y. Can Performance Based Financing Improve Quality of Healthcare in Nigeria? http://afhea.org/docs/presetationspdfs/Yewande%20Ogundeji%20-%20Can%20RBF%20improve%20quality%20and%20access%20to%20care%20in%20Nigeria%20-%20Copy.pdf. 2016

CHAIs solution seeks to provide an improved performance measurement system for PHC facilities using a real-time data, low cost, fit-for-purpose electronic data management tool called Electronic Immunization Registry (EIR). This tool will be streamlined to include real time data collectors at the health facility levels, and also would activate an automated feedback mechanism for the frontline health workers who could have an opportunity to participate in an innovative digital learning solution called the Immunization Academy (IA) in collaboration with Bull City Learning, as part of the PHC performance improvement efforts for the Health workers. This will be achieved by working with the National Primary HealthCare Development Agency (NPHCDA) and other partners such eHealth Africa and Health Information Systems Program Nigeria HISP leveraging on the existing (EMID) system, networks, and workflows to streamline real-time collection and interpretation of data to support meaningful use of primary health care data and capacity building for the healthcare workers.

 

In 2021, Nigeria introduced the Electronic Management of Immunization Data (EMID) system for COVID-19 response. The tool currently provides real-time data on COVID-19 vaccination in the country. Essentially, it provides an opportunity for health facilities to be tracked and followed up immediately, to ensure data reported is verified and issues around immunization for COVID-19 are identified and promptly addressed. This effort has led to high-performance management of COVID-19 program intervention in Nigeria. Gains from the use of EMID have led to the county aspiring to leverage the EMID system as an opportunity to improve the quality of immunization and overall PHC data transmitted from each service delivery point, ensure the operationalization of the data quality improvement plan, and bridge the gap between administrative and household survey data.

 

CHAI will collaborate with the National Primary Health Care Development Agency (NPHCDA) to include additional features on the EMID system that will be used by healthcare workers to collect real-time facility-level data and transmit daily health services data. The EMID platform is a recognized tool for real time data collection, including offline data. It is also suitable for the selected data of interest to PHC performance management, which includes data on routine immunization (EIR).  Additionally, the EMID is suitable within the Nigerian terrain in which most health facilities are in geocoordinate locations with 3G low bandwidth connectivity.

 

The daily transmitted RI/PHC data will be housed in a national database with a dashboard, which will communicate with the DHIS2 platform to provide valuable insights for performance management, including reliable and high data quality for real-time informed decision-making for primary healthcare programs. The EMID will communicate with the immunization academy platform to provide targeted feedback to healthcare workers on needed improvement strategies and capacity-building areas. This will meet health workers' needs and data accountability (Data bank on immunization), this solution would also enable Health care workers to track clients, especially those who are defaulting from vaccination. The Electronic Management of Immunization Data (EMID) has been developed and deployed for the collation of COVID-19 data across the 36+1 states. This expansion of EMID capacity to record real-time data will be extended to include RI services (Electronic Immunization Registry) and subsequently other PHC services and Polio Supplemental Immunizations PSIAs/Non-Polio Supplemental Immunizations NPSIAs campaigns.

CHAI proposes to have a pilot of the solution in 2 states (Kano and Oyo) and would implement it in 4 health facilities each. The team will monitor, evaluate, troubleshoot, and gather lessons that will inform the nationwide scale up.

Our solution stands to serve different stakeholders, this includes, health care workers (health providers), EPI managers, Donors etc..Healthcare workers who generate health data will use smart gadgets rather than paper-based to upload daily health facility events. This will reduce lean time, improve visibility efforts, upscale efficiency, and provide real-time feedback to the healthcare workers for improvement and capacity building. Quality, reliable and real-time RI/PHC data will be made available to PHC managers for informed decision and performance management.

The solution also benefits donors who are interested in reviewing real time data that can be triangulated with surveys as well as admin data. This is used to measure the impact of donor funding on the PHC program. In addition, the realtime data also serve to provide reliable RI/PHC data to researchers for health-related studies.  

Health information system is not well developed in most parts of the country. We propose to use locally available data on immunization performance to make them more informative and useful for implementing and supervisory personnel. Reclassification of data according to an estimated number of eligible, monthly performance, and age of children immunized can be given impressions about coverage, sustainability of services, and their quality. Similarly, area and institution-wise data can be used to identify places needing more attention. Active use of available real-time data will help in the improvement of vaccine coverage and control of target diseases and improve performance management.

The proposed solution will impact on the EPI manager, health workers, and other stakeholders in accessing the following;

§  The real-time report, feedback, and recommended solution which in turn will lead to better PHC and Health Care worker performance.

§  Adequate management of facility Performance management.

§  Continuous learning of health care workers leveraging on Immunization academy.

§  Monitor vaccine refusals (if the EIR includes refusal data).

§  Monitor coverage by cohort: the denominator used can be dynamic and not an annual fixed goal, as is the case with non-individualized immunization information systems.

§  Provide timely knowledge of immunization status for the country and/or a specific geographical area.

§  Calculate the productivity and workload of health facilities and vaccinators at a given time, if the necessary variables are available.

§  Facilitate the traceability of program vaccines, if the EIR includes lot number data.

§  Improve planning of resources, since the system provides more detailed information on vaccination activities.

§  Detect program errors, e.g., immunization of non-target populations.

§  Detects pockets of unvaccinated individuals.

§  Provide reliable vaccine data at the individual level in case of outbreaks and for special studies, among others.

§  Facilitate and optimize data visualization and analysis at all levels of responsibility in the health system.

§  Helping reduce errors in data entry and in calculation of health indicators

§  Improving the efficiency of processes and information and workflows

§  Helping identify problems and opportunities to improve the use of resources and inputs

§  Reducing the administrative burden, facilitating timely access to information, and automating the generation of key reports

§  Facilitating communication of results to the population, community, and beneficiaries

§  Allowing automatic aggregation and disaggregation of data and indicators by geographical levels

Technical capacity and similar experience around Data

CHAI has been working with various levels of government around data issues and challenges; these challenges range from poor data quality, poor HCWs and data officers’ capacity on data, the multiplicity of data tools, etc. Over the years CHAI has demonstrated a great capacity and capability to implement programs that seek to improve data quality and use across programs.

CHAI provided technical support to data improvement approaches. We have supported our Focus states (Kano, Niger, Yobe and Lagos) to conduct an assessment of drivers of poor data quality and used the findings to inform development of a Data quality improvement plan (DQIP).

Some key results show:

§  73% of health workers expressed that their superiors pushed them to submit data on short notice to meet up with the submission deadline on DHIS2. This serves as an external influence on poor data quality at the facilities.

§  68% of health workers in the state indicated that the time given was insufficient to complete numerous data tools, owing to the increased workload.

§  84% and 64% of health workers and LGA managers, respectively, reported feeling unappreciated and unacknowledged for good data quality by supervisors. Underpayment of salary is a high demotivating factor among healthcare workers.

§  Provision of feedback and review of the National Health Management Information System (NHMIS) tools were identified as some of the key factors to incentivize and improve health worker practices

Utilizing these findings, CHAI is working with the Federal Ministry of Health to streamline and simplify data tools, taking into consideration the preference and perspectives of health workers.

Explore opportunities to digitize and automate data collection and validation at health facility and LGA levels for improved quality of data. In addition to, updating existing policy around the validation process accordingly. CHAI is therefore well positioned to provide program support towards PHC data improvement.

 

We also worked with the teams at the national and sub-national levels to improve the technical capacity of data officers, in collaboration with the National Primary Health Care Development Agency (NPHCDA) and Bull City Learning introduced the Immunization Academy (IA)—a CHAI-supported e-learning platform that uses a combination of demonstrational videos and skills-based online assessments to teach and reinforce essential immunization skills.  

Over the last decade, efforts by the National Primary Healthcare Development Agency (NPHCDA) and its partners to strengthen health worker capacity have yielded results. Between 2016 and 2018, health workers were evaluated across four immunization skill areas: vaccine handling, vaccine administration, communication and advocacy, and data management. The results found an average improvement of 21% and 12% points in Kano and Lagos states respectively1  

CHAI worked with the government and Expanded Program on Immunization (EPI) partners at the state and national levels to co-design and guide the rollout of the platform to over 2,200 health workers and managers based on findings from the needs assessment. These inputs were also used by IA to create a custom interactive tool for Nigeria, called IA Score Nigeria (more details about the platform here), which provided a personalized training approach to target and remediate individual learning gaps.

The program also offered certification endorsed by NPHCDA upon achieving a passing score of 70% to motivate healthcare professionals to participate and complete the program. Additionally, a dynamic dashboard was created to allow managers to review state, LGA, and individual learner data. With this practical dashboard, managers could easily see where skill and knowledge strengths and gaps existed. A leaderboard was also created to highlight immunization professionals in each LGA who had high scores and those who showed great improvement in their post-test scores.

Following 15 months of expansion and use of the IA platform by different health workers, there was a 230% increase in enrolled users from nearly 10,000 before implementation to over 37,000 after across the country. Between November 2020 and July 2021, IA videos had been viewed approximately 20,000 times in Nigeria; and over 550 NPHCDA-endorsed certificates have been awarded to health workers and managers through the IA score platform with average score improvements of 13 percent.

The use of the platform also showed tangible improvements in immunization practices among health workers.

The successful rollout of IA in Nigeria highlights opportunities to expand the scope of digital learning to include the full suite of primary health care (PHC) services to improve health system performance and ultimately save millions of lives.

CHAI has built reputable relationships and bridges with Ministries of Health, Primary Health care agencies and development partners which strategically positions us to be the catalyst in improving RI and PHC data quality.

Ensuring that everyone immunized from COVID-19 and Vaccine preventable diseases in Nigeria is properly documented at the health facility level, as this would help the country to ensure reconciliation of the vaccines used against the immunized and also to ensure administrative data are equal or very close and comparative with survey data.

We’re applying to ensure that the use of an electronic system is used to collect reasonable and more accurate data in the country. The country has deployed EMID for COVID-19 and intends to scale up EMID into RI and SIAs. The use of EMID for COVID-19 vaccination has not been as effective as it should be probably due to issues around the following:

§  How it is designed,

§  Health workers' training on how to use it,

§  Issues related to hosting rights,

§  Collation of data and how it is linked to other services such as the logistics aspect and wastage rate of the vaccines.

This has resulted in the weak data collation system in the country which resulted in the disparity seen in the EMID data. All hands have been on deck in trying to reconcile this but this has been difficult and the EMID isn’t yet delivering to its potential.  These issues need to be resolved before integrating COVID-19, RI, SIAs and NPSIAs into the EMID platform.

We are also aware that other partner organizations are being funded to support Nigeria in improving EMID scope and efficiency, however, there are numerous areas of improvement and CHAI can lend its expertise to optimizing the EIR to its full potential.

The conceptualization and design of the EMID system is based on Nigeria’s proven experience in the development and implementation of mHealth projects and programmes, such as Auto-Visual AFP Detection and Reporting (AVADAR), Surveillance Outbreak Response Management and Analysis System (SORMAS), customized RI-module on DHIS2, and RI SMS reporting platform using DHIS2. The EMID system design was also guided by the health facility and COVID-19 tool kits developed by the university of Oslo and approved by WHO.

The architecture of the EMID was framed to be easily adaptable to suit the need according to planned roll-out phases of COVID19 vaccination. During the initial phase, the structure supported COVID-19 introduction activities (e-microplanning, e-registration with unique identification, vaccination scheduling, vaccines tracking and tracing and AEFI reporting) and thereafter, the architecture will be seamlessly transitioned for routine immunization and other PHC programme data management.

The DHIS2 instance for this system was domiciled at the NPHCDA, where it serves as a repository for registration, vaccination, follow-up and logistics data. The server was connected to an SMS service to allow for use in locations with poor internet connectivity.

Electronic immunization registries (EIR) are computerized individualized immunization registries that are part of the immunization information system. Just as immunization information systems are designed to provide relevant information related to the distinct management areas of the Expanded Programme on Immunization (EPI), EIR provides information on immunization regarding the program’s target populations. PAHO/WHO recommends the use of EIR systems given the potential benefits that these information systems can provide to the countries.

Available evidence also suggests that EIR is a cost-effective tool that helps to increase coverage, improve the timeliness of vaccination, reduce revaccination, and provide reliable data for decision-making, e.g., where to find unvaccinated individuals in order to ensure right to equitable immunization. EIRs also enable monitoring of the immunization process with a view to optimizing RI related activities. For example, EIRs provide accurate and timely information, thus facilitating efficient use of resources and activities. This tool also allows detection of potential problems in administration of vaccines to target populations and assists in directing training and supervision activities.

Essentially, immunization schedules have become a great deal more complex with the introduction of new, more expensive vaccines that benefit not only the under 2 population, but the general population throughout the life cycle. This has led to an increase in program budgets, which, in turn, created a need for increasingly precise, complete, and systematic accountability. In a context of relatively high vaccination coverage, it has become more difficult to detect who lacks complete compulsory vaccine coverage, thus hindering strategies for identification and immunization of these individuals.

In other words, information, communication, and technologies (ICTs), geographic information systems (GIS), are increasingly universal and attainable, which has allowed the development of user-friendly information systems and databases to handle large volumes of information simultaneously and rapidly while ensuring data security and confidentiality.

Nigeria plans to implement individualized offline immunization registries as those that identify vaccination data for each person and allow access to each individual’s vaccine history, thus facilitating active search, in addition to supporting monthly planning of who needs to be vaccinated and monitoring of defaulters or dropouts.

EIRs require a database with two types of information:

§  Demographic data: identification of the vaccine recipient (unique or individualized identifying information, place of residence of each person, contact data, etc.).

§  Vaccination-event data: information on the vaccination event itself (date administered, doses applied, place of administration, and who administered it, among others).

These data are then processed, and aggregated immunization data are generated by dose applied, age, sex, or other variables of interest, as well as data on the vaccine history of each individual.

CHAIs approach will leverage on existing work and research conducted on optimizing and deploying Electronic Management of Immunization Data (EMID) for Routine Immunization (RI) and other Primary Health Care (PHC) Services beyond COVID-19 for real time data collection from HF into DHIS2 (Electronic PHC Information System – EPIS), additionally, we will coordinate, streamline, and triangulate various surveys conducted in the country for uniform measurement of coverage.

we plan to achieve impact through an;

• Opitimized Realtime data reporting for Routine Immunization on the EMID platlform
• Instituted targeted feedback and recommendations prompts to healthcare workers
• Improvement in the continuous learning for PHC workforce 

The following indicators will be measured:

1. Availability of the Electronic Immunization real time data  (Y/N)
2. Number of health care workers trained on the EIR -( #)
3. Number of Health Facilities reporting on the EMID for RI features
4. Number of Health care workers enrolled on the immunization academy solution (#)
5. Improvement in core PHC indicators for RI and other PHCs (Penta 3, MVCs etc)

Project Overall Goal Key Objectives  Primary Outcomes Secondary Outcomes Key Outputs  Optimization of EMID for RI to improve PHC performance and increase healthcare workers' capacity Opitimized Realtime data reporting for Routine Immunization on the EMID platlform Avalaibilty of quality data to measure PHC perfromance  Avalibilty of real time data for routine immunization in pilot HFs 1.1.1. Conducted deck review on the EMID platform and scoping for inclusion of the additional features  Expansion of EMID capacity to record real-time data to include RI services (electronic immunization registry) and subsequently other PHC services  and non-polio supplemental immunizations 1.1.2. RI and other PHC real-time data available for decision making to improve the health facility performance Reduction of errors at data entering the level and in calculation of health indicators 1.1.3 Reliable point of care data available to guide the PHC program planning and execution Reduction in discrepancy between admin and survey daa 1.1.4 Reliable quality data to measure PHC performance  Instituted targeted feedback and recommendations prompts to healthcare workers Increased use of real-time data for prompt and proactive informed decision for RI activities Reduction in the administrative burden, facilitating timely access to information, and automating  the generation of key performance indicators and reports  1.2.1. Automated feedback response developed and deployed in pilot health facility  Improved use of real-time data for action 1.2.2. RI/PHC real-time data generated and transmited to server Improved planning and use of limited resource for RI and PHC inervention 1.2.3. Daily transmitted RI/PHC data dashboard that communicates with existing DHIS2 platform to provide insights for performance management of PHC system  Improvement in the continuous learning for PHC workforce   Improved health care workers skills and capacity to provide quality and efficent service deivery through digital learning platform Increased knowledge and capacity of HCWs for quality service delivery 1.3.1. Healthcare workers trained on the use of immunization Academy (IA) to guide the daily provision of RI/PHC services. Documented evidence in the productive and workload of health facilities and vaccinators at a given time. 1.3.2 Collaborate with Bull City learning to include easy-to-learn videos and documentation of health facility performance 

The conceptualization and design of the EMID system is based on Nigeria’s proven experience in the development and implementation of mHealth projects and programmes, such as Auto-Visual AFP Detection and Reporting (AVADAR), Surveillance Outbreak Response Management and Analysis System (SORMAS), customized RI-module on DHIS2, and RI SMS reporting platform using DHIS2. The EMID system design was also guided by the health facility and COVID-19 tool kits developed by the university of Oslo and approved by WHO.

The architecture of the EMID was framed to be easily adaptable to suit the need according to planned roll-out phases of COVID19 vaccination. During the initial phase, the structure supported COVID-19 introduction activities (e-microplanning, e-registration with unique identification, vaccination scheduling, vaccines tracking and tracing and AEFI reporting) and thereafter, the architecture will be seamlessly transitioned for routine immunization and other PHC programme data management.

The DHIS2 instance for this system was domiciled at the NPHCDA, where it serves as a repository for registration, vaccination, follow-up and logistics data. The server was connected to an SMS service to allow for use in locations with poor internet connectivity.

Electronic immunization registries (EIR) are computerized individualized immunization registries that are part of the immunization information system. Just as immunization information systems are designed to provide relevant information related to the distinct management areas of the Expanded Programme on Immunization (EPI), EIR provides information on immunization regarding the program’s target populations. PAHO/WHO recommends the use of EIR systems given the potential benefits that these information systems can provide to the countries.

Available evidence also suggests that EIR is a cost-effective tool that helps to increase coverage, improve the timeliness of vaccination, reduce revaccination, and provide reliable data for decision-making, e.g., where to find unvaccinated individuals in order to ensure right to equitable immunization. EIRs also enable monitoring of the immunization process with a view to optimizing RI related activities. For example, EIRs provide accurate and timely information, thus facilitating efficient use of resources and activities. This tool also allows detection of potential problems in administration of vaccines to target populations and assists in directing training and supervision activities.

Essentially, immunization schedules have become a great deal more complex with the introduction of new, more expensive vaccines that benefit not only the under 2 population, but the general population throughout the life cycle. This has led to an increase in program budgets, which, in turn, created a need for increasingly precise, complete, and systematic accountability. In a context of relatively high vaccination coverage, it has become more difficult to detect who lacks complete compulsory vaccine coverage, thus hindering strategies for identification and immunization of these individuals.

In other words, information, communication, and technologies (ICTs), geographic information systems (GIS), are increasingly universal and attainable, which has allowed the development of user-friendly information systems and databases to handle large volumes of information simultaneously and rapidly while ensuring data security and confidentiality.

Nigeria plans to implement individualized offline immunization registries as those that identify vaccination data for each person and allow access to each individual’s vaccine history, thus facilitating active search, in addition to supporting monthly planning of who needs to be vaccinated and monitoring of defaulters or dropouts.

EIRs require a database with two types of information:

§  Demographic data: identification of the vaccine recipient (unique or individualized identifying information, place of residence of each person, contact data, etc.).

§  Vaccination-event data: information on the vaccination event itself (date administered, doses applied, place of administration, and who administered it, among others). These data are then processed, and aggregated immunization data are generated by dose applied, age, sex, or other variables of interest, as well as data on the vaccine history of each individual

• The healthcare workers will collect the data using smart mobile phones with optimized EIR app

• Daily sessions and selected PHC service data and clients sociodemographic will imputed by the health worker and uploaded into server via the app

• Their incentive will include provision of smart phones

• Provision of monthly data bundle

• Awards and recognition for performance
• Continuous training will provided to the healthcare workers

Through technical and analytical assistance provided to the government, CHAI will champion the drive to ensure the existing strategies are implemented through a gender mainstreaming lens specifically focusing on evaluating the considerations the strategies make for the implications of these existing

strategies for women including legislation, policies and programmes, across all service delivery levels in the country. Additionally, CHAI will work with the government to ensure that all strategies integrate the concerns and experiences of women, as well as men, into the design, implementation, monitoring, and evaluation of the program with a view to promoting equality and not perpetuating inequality.

 

CHAI believes that to make programs sustainable and scalable, they must strengthen the mainstream government health systems so that impact is sustainable after CHAI. To achieve this, CHAI works with national and county-level government staff, providing direct technical and analytical support for crucial programmatic interventions and, usually, strengthening the government system and capacity required for implementation. In Nigeria, with this model, CHAI has built relationships across all levels of government (Legislative, Ministries of Health, Finance, Budget and Planning, NPHCDA, SPHCDAs, Nigeria Governors Forum, State and Local government). For example, we work closely with the Ministry of Health across multiple programs, including Vaccines, Family planning, SRH, Lab Access, Diagnostics, and Cancer. In addition, CHAI has state offices in 13 states in Nigeria and works closely with the state leadership in those states, albeit across different programs, including vaccines; CHAI will leverage this relationship to implement this project.

Beyond national and Country governments, CHAI has strong collaborations with different domestic and international partners and will continue to engage them to identify and integrate best practices into the implementation of this solution.

We plan to continuously seek funding opportunities such as this, apply for grant challenges and submit proposals to donors such as BMGF, GAVI amongst others.

Since 2011, we have successfully applied for and won several grants from various donors some of which include: Bill and Melinda Gates Foundation and GAVI, the Vaccines Alliance to the tune of millions of dollars.

Some examples of grants implemented by CHAI:

• Provision of Technical Assistance for Covid-19 Vaccine Delivery Preparation and Readiness – Nigeria - GAVI

• Technical Assistance to Nigeria’s National Primary Health Care Development Agency for Implementing Vaccine Financing Commitments - GAVI

• Nigeria Immunization Strengthening: improving coverage and equity - BMGF