eHealth Africa works across the continent to strengthen health systems through integrated data and technological products and systems. eHealth Africa supports data management and logistics support, emergency preparedness, disease surveillance, laboratory and diagnostic systems, and nutrition and food security. Over the past year, eHealth Africa has been working in Nigeria supporting the National Primary Healthcare Development Agency to improve the functionality of the Electronic Management of Immunization Data (EMID) system. Funded by GAVI, this project supports an electronic system that integrates COVID-19 vaccination data with routine immunization data.
What is the EMID system?
An Electronic Management of Immunization Data (EMID) system is a software platform used for collecting and managing immunization data. The EMID system was developed to address COVID-19 vaccination deployment and data management challenges such as user experience, breakdown in the system’s server and data loss, and link with the District Health Information System (DHIS2) and integrate with a routine immunization module. Ultimately, the goal was to create a system that could manage COVID-19 and other immunization data as well as other primary health care service data in Nigeria.
Why is having an integrated vaccination data system important?
A system that links immunization data with other primary healthcare service data increases the timeliness and quality of data collection and reporting. The integration of the COVID-19 vaccination and routine immunization promotes efficiency and overall health system strengthening where both sets of vaccination data can be recorded on a centralized system. A centralized data system provides an avenue for improved visibility, planning, coordination, and decision making among key stakeholders at national and sub-national levels. It also provides an opportunity for one individual to collect data for both sets of vaccination thereby reducing the complexity of using two systems. An integrated system could therefore bring personnel, both for service delivery and data management for COVID-19 and routine immunization together, helping to improve service delivery and better utilization of human resources for health.
What worked well about this data integration and system scale up?
We developed the COVID-19 data entry module first and then built on that to develop the routine immunization module (modular approach) as opposed to developing both systems at the same time. This provided an opportunity to leverage our previous experience and expertise for effective and timely delivery of the whole integrated system. For example, the experience gained from the integration of the COVID-19 module with the DHIS2 provided a seamless experience and timely integration of the routine immunization module. The modular approach (in which smaller components of a system are independently developed) gives room for scalability where, if needed, one can add additional modules for whatever immunization campaign that may come up—such as HPV or polio immunization—without having to start from zero or adversely affecting existing modules.
Secondly, the DHIS2 had existing software (referred to as Application Programming Interfaces or APIs), which allows the system to receive and/or export data to other platforms—essentially enabling the DHIS2 to connect and communicate with other applications. The existence of the DHIS2 APIs ensured that we did not have to start from zero in connecting the DHIS2 and EMID system together, nor spend a lot of time developing and testing new APIs. To put it graphically, if you need to make a handshake, it means hands on both ends must have fingers. If one hand does not have existing fingers, it means you have to create the fingers first before the handshake can take place. But if both hands have fingers, the handshake is fast. The DHIS2 had fingers (APIs) that would make the handshake with EMID.
Thirdly, we applied the AGILE Methodology in the development and integration of both systems. This meant developing the solution in phases, ensuring continuous collaboration with stakeholders and improvement based on periodic feedback received from these stakeholders. This ensured that little or no changes were required at the end of the development phase and the integrated system could be deployed within the shortest possible time once completed. Stakeholder engagement also ensured ownership and buy-in from relevant government and non-governmental partners.
What was the biggest challenge you faced in designing a system for integrated health data?
While the existence of the DHIS2 interface ensured that we did not have to build the EMID system from scratch, such interfaces make accessing and using the DHIS2 platform somewhat cumbersome. We had no control over what was built; we had to work with what was existing. This results in some issues with data synchronization and loss. For example, to send a patient’s enrollment information, we had to break it into two. First, send the demographic data followed by the vaccination information and then find a way to link them up in DHIS2. We are also unable to send multiple patients’ records at once, instead we send one record at a time. These procedures slow down the performance of the system.
Having different data management partners managing different components of the system also posed a challenge. The DHIS2 system, which serves as the backbone for the EMID, is currently being managed by a different partner. Any changes to the EMID system need to be implemented on the DHIS2 system first for seamless integration, which is not within the control of eHealth Africa. This requires constant engagement with the DHIS2 management partner, including having additional protocols for approvals to ensure necessary changes are affected, which sometimes causes delays for simple requests, thereby affecting turnaround time on delivery.
How will this integration activity inform your future work?
With the achievement of the COVID-19/routine immunization data integration, there are plans to scale up the use of the EMID system for the management of other immunization campaign data including Polio Supplementary Immunization Activities (PSIAs), Non-Polio Supplementary Immunization Activities (NPSIAs), Adverse Effect Following Immunization (AEFI) tracking, HPV, and Malaria, among others. This is also planned to serve as a precursor to the integration of a vaccine logistics module to enable end-to-end visibility and traceability of vaccines.
The successful integration of both systems also provides an opportunity for the replication of a similar system in other countries across Africa with similar immunization data management challenges.
If someone in another country or context was interested in developing a similar integrated electronic system, what advice would you have for them based on your experience?
To ensure the development of a robust, integrated system, ensure that you consult widely all key stakeholders to garner their support and buy-in. Where there are different data management partners working to achieve a similar goal, clearly defining roles and responsibilities is essential to ensure seamless implementation and avoid duplication of roles. Relatedly, having a well-defined data security and governance framework is essential. You need, for instance, to define who is responsible for what, and at what level to ensure the security of data.
Employing the AGILE methodology – where progress is reviewed, feedback is provided and necessary changes are made along the way as the product is being developed – and developing one module after another, not simultaneously (modular approach) is highly effective for projects involving several stakeholders whose activities are dependent on each other.
How if at all, do you think this type of data integration will strengthen the overarching health system?
The data integration will serve to strengthen the overarching health system through improved data visibility, data-driven decision making and improved planning and coordination around vaccine delivery including closing the gap of individuals supposed to receive vaccines but that are not (immunization zero-dose gap) in Nigeria.
In addition, integrated services will lead to improved cost efficiencies in terms of human resources for health, as a single health worker who is trained to use the system can work on data for several immunization campaigns without having to employ multiple individuals.
We anticipate improved funding from the private sector for vaccination. Baseline assessments from the GAVI Technical Assistance for Vaccine Deployment have shown very low engagement of the private sector in terms of funding. The use of data during strategic meetings with the organized private sector can change this trajectory.