Revamping immunization services in Pakistan

How digital technology may help ensure timely vaccinations for children and improve citizen experience

Oral polio vaccine being administered to a child. (Gavi)

Note: A version of this post appeared on Apolitical.

This blog post is a final assignment for the course DPI-662 Digital Government: Technology, Policy, and Public Service Innovation at Harvard Kennedy School. The fictional scenario and prompt are as follows:

You are on the National Advisory Council for a federal government for a country of your choosing. The World Bank is interested in making an investment of $50 million to you country to fund a digital government project, in alignment with the Sustainable Development Goals. The investment is aimed at incentivizing resilient, 21st-century states with enhanced government agility, efficiency and user-centricity through digital best practices. You have been asked to write a memo outlining how your country should think about using this seed investment, including prioritizing the top user needs, the minimum viable product, and how various user needs hypotheses might be tested.

Executive Summary

World Bank Digital Development Fund (DDF) seed grant presents an opportunity to support a digital government project around Sustainable Development Goals (SDGs). The immunization services in Pakistan provides an ideal use case to demonstrate impact and realize the potential for digitalization across government services. Pakistan remains in the bottom quintile of countries in terms of immunization coverage and has the highest under-5 child mortality rate outside Africa. Immunization services may be redesigned around an Immunization Information System (IIS) that facilitates citizens and health workers to ensure timely vaccinations for children. A three-phase implementation strategy is proposed to test a minimum viable product, scale IIS across districts, and integrate related government services. Challenges and risks are also presented along with mitigation strategies to successfully execute the project and pave the way for future DDF support towards digital government in Pakistan.

Immunization Crisis in Pakistan

Sustainable Development Goal (SDG) 3 aims to “ensure healthy lives and promote well-being for all at all ages”. Targets 3.2 and 3.B aim to reduce child mortality and increase vaccination coverage, respectively.[1] Immunizations are considered as one of the most successful health interventions in the world. Not only are they cost-effective but they save up to 2–3 million deaths every year.[2]

The situation regarding child mortality and immunization in Pakistan is particularly worrying. Under-5 child mortality rate stands at 69 deaths per 1,000 live births and is around 3 times above the target set by SDG Goal 3.2 to be achieved by 2030. Furthermore, Pakistan has the highest under-5 mortality rate outside Africa, above such countries as Afghanistan, Sudan, and Yemen. Immunization coverage, as measured by DTP3 vaccination, is 75% putting Pakistan among the bottom 20% of countries.[3] Additionally, only 66% of children between the ages 12 and 23 months are fully immunized while only 55% have had all age-appropriate vaccinations.[4] However, this figure masks the wide disparity in percentage of fully immunized children in this age group across the 4 provinces ranging from 80% in Punjab to 29% in Balochistan.[5]

Progress on immunizing children in Pakistan has been frustratingly slow despite significant financial and technical assistance from organizations such as World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Gavi, and Gates Foundation. There are 3 major challenges in administering immunizations in Pakistan from a service delivery perspective that are worth highlighting:

• Inadequate follow up on children for subsequent rounds of vaccination: While 75% of children receive the first dose of DPT vaccine, only 65% receive all 3 doses. Similarly, 90% of children receive the first dose of polio vaccine while 80% receive the third dose.[6]
• Weak resource management and surveillance mechanisms: Vaccinators and lady health workers are inefficiently utilized and immunization delivery records are manual.[7] This weakness in monitoring and evaluation negatively impacts program efficacy.
• Lack of awareness around vaccination schedules: Up to 35% and 18% of parents cite lack of awareness of vaccination and non-availability of vaccinators, respectively, as factors for non-vaccination or incomplete vaccination of their children.[8]

The existing immunization process places undue burden on citizens (Exhibit 1). Parents receive an immunization card that lists the various vaccinations a child is to receive over a course of 15 months. Parents are expected to visit a public health center to get their child vaccinated according to the immunization schedule on this card.[9] Separately, they also register their child’s birth with National Database & Registration Authority (NADRA) citizen database through local union councils. Given these challenges and established practices, there is significant potential to improve administration of immunizations to children in Pakistan through an integrated digital platform.

Digitalization Prospects

The World Development Report 2016 presents level of citizen interest, routineness of tasks, and measurability of outcomes as indicators to classify to what extent public services can be improved using digital technology.[10] The higher a given public service ranks along each of these three indicators, the greater the scope of improving that service using digital technology. Government of Pakistan’s Expanded Program on Immunization (EPI), coordinated at the national level by Ministry of National Health Services Regulation & Coordination, scores high along these indicators as discussed below:

• Level of citizen interest: Citizens have an inherent interest in monitoring the immunization program. There is increasing recognition of the importance of immunizations especially ones for polio virus in response to awareness campaigns following polio-related global travel restrictions to and from Pakistan few years ago. Given the link between lack of immunizations and child mortality discussed earlier, an efficient immunization service is essential for citizens.
• Routineness of tasks: Children are vaccinated through door-to-door campaigns or visits to local public hospitals and basic health units. Administering vaccines is a relatively straightforward task that is performed on a regular basis. Hence, vaccination can be characterized as a standardized, repeatable task suitable to be monitored and facilitated using digital technology.
• Measurability of outcomes: The success of a public immunization program can be assessed by measuring the percentage of children receiving a certain vaccination. This metric can be disaggregated by vaccine type, age of child, and region to identify any gaps in the delivery of immunizations.

Window of opportunity: World Bank’s Digital Development Partnership (DPP) provides technical and financial support for the development of digital solutions, in line with the World Development Report 2016, to implement SDGs.[11] Digital Government is identified as one of six priority work areas with a focus on improving service delivery through digital platforms and shared services. Furthermore, Articles 10.1 and 12.2 of the Digital Pakistan Policy relate to delivery of public services using information and communications technology (ICT) and digitization of health-related records through central databases, respectively.[12] Digital Pakistan, the nationwide digital program that Prime Minster Imran Khan recently launched, also includes Digital Infrastructure and eGovernment as two of 5 priority areas.[13] The IIS can be integrated with the National Database & Registration Authority (NADRA) citizen database as a step towards realizing Government-as-a-Platform (GaaP). This window of opportunity may be leveraged to implement IIS given potential support from World Bank DDP and the keen interest of the donor community involved with the immunization program in Pakistan.

Immunization Information Systems

An immunization information system (IIS) is a confidential, population-based database that contains information on immunizations administered to persons in a given area.[14] These systems have been implemented across the world including US (at the state level), EU (national immunization registries such as Praeventis in Netherlands), and India (national Mother and Child Tracking System). The major goals of an IIS include the following:

• Provide immunizations to all children in a timely manner: Data collected at the individual level can help public health officials determine which children have yet to receive vaccinations.
• Establish a real-time immunization surveillance and response system: Officials may analyze vaccination coverage rates by type of vaccine, region, and other background characteristics to ensure equitable provision of immunizations.
• Automate existing tasks to reduce administrative burden on staff: Automating paper-based processes may enable public health workers to spend valuable time on more productive activities such as vaccinating children.

An evaluation of IIS-based immunization registries implemented across the world suggests three core features i.e. unique identification, real-time tracking, and automated reminders. These features may be incorporated in the IIS for Pakistan by leveraging existing databases and ICTs to enable a better citizen experience as described below (Exhibit 2):

• Utilize unique IDs from NADRA: Unique IDs are necessary to track immunization delivery at the individual level. Options for unique IDs include creating one specifically for IIS or using a national ID from the population registry. The latter option is more attractive especially as it enables integration across services in the future and is already available through the NADRA citizen database. NADRA maintains a record of child births and assigns a unique citizenship number upon registration.
• Enable real-time records at point of service: Health workers must be able to record immunization delivery be it at a health facility or in the field. The alternative is to update records at a central facility after field visits which may compromise data integrity and create unnecessary administrative delays. Real-time reporting is possible by providing internet-enabled devices to health workers — this practice already exists for school monitoring assistants of the School Education Department in the province of Punjab.
• Generate automated reminders through SMS: One of the major issues with vaccinations in Pakistan is the lack of awareness especially with regards to immunization schedule. The immunization record for an individual on IIS enables automated reminders to be sent to both health workers and families. These reminders may be used to schedule field visits by health workers or to encourage families to visit their nearest health facility so that their child can receive the scheduled immunization.

Pilot Testing

The concept of e-government in immunization services can be tested using an agile and cost-effective approach by developing a minimum viable product (MVP) that tests hypotheses on digitalizing the immunization workstream using relevant metrics.

MVP to test IIS: Developing the IIS system itself including integration with NADRA and automated reminders is a technical task. However, success of the system depends on whether eventual users respond as intended e.g. parents visiting a public health center to get their child immunized and health workers updating immunization records in real-time. User response to the proposed interventions can be tested using the following minimum viable product(s):

• SMS for parents: Automated SMS messages can be sent to parents and their likelihood to bring their child to a nearby public health facility measured. Focus groups with parents can help craft effective messaging by understanding issues including language, size, and content.
• Mobile app for health officials: In parallel, a simple mobile app can be created to allow health workers to update immunization records. Existing recordkeeping processes and the app design itself will influence adoption of an eventual real-time tracking system. Therefore, administrators and vaccinators should be engaged during the design and development of the prototype app.

Hypotheses and metrics: The IIS aims to improve immunization delivery by addressing challenges with the existing process. Based on these challenges and goals of the IIS, the following hypotheses should be tested:

• IIS encourages parents to visit immunization centers: Measure the proportion of parents who receive reminder messages that bring their child to a nearby public health center to receive immunizations relative to parents who do not receive a reminder message.
• IIS reduces administrative burden on health workers: Measure time savings by comparing time to record vaccination in real-time using an app relative to existing paper-based process.
• IIS increases vaccination coverage: Measure the proportion of children who actually receive scheduled vaccinations. More visits to immunization centers do not necessarily imply higher vaccination coverage. For instance, parents may visit nearby immunization centers only to learn that the facility is short of vaccinations.

Implementation Challenges

Nationwide implementation of the IIS entails several technical, operational, and legal challenges. These challenges and strategies to address them are described below:

Technical

• Standardizing data: Data fields and formats should be decided based on intended function with input from relevant stakeholders including national EPI office, provincial health departments, and multilateral agencies. Information such as unique identifier, vaccination type, vaccination batch, date of vaccination, and vaccinator credentials are important. Free form text should be limited wherever possible and replaced with dropdowns e.g. vaccine type. Integration of services such as child nutrition program and electronic health records must also be considered from the outset for future interoperability.
• Encouraging child registration: Parents are required to register child births with the relevant union council after which they are issued a child registration certificate that contains the child’s citizenship number. In practice, birth registration rates vary especially between rural and urban areas. However, recent pilot programs show a threefold increase in child registration rates from 30% to 90% and are being expanded across the country.[15] Prior immunization records for existing children will also have to be digitized in the eventual nationwide IIS rollout.
• Conducting data validation: Manual entries may have to be made in cases where a child’s birth has yet to be registered. This data may be validated against other data fields (child name, parent name, parent ID) to prevent duplicates. Additionally, such entries may automatically notify NADRA about the case of a child that is yet to be registered in the latter’s national citizen database. Furthermore, IIS immunization data may be verified through third-party audits and official household surveys on a regular basis.

Operational

• Enhancing departmental capacity: Health workers need to be reoriented to record immunizations in real-time. Logging these events on paper (as is current practice) and then recording in bulk on the IIS defeats the purpose of a digital system. Not only does this compromise data integrity but it also creates unnecessary administrative work. In the province of Bihar in India, a 72-day delay was observed between initial data entry on paper and creating a digital record with only 0.04% of the data entered into the IIS on the same day.[16] Existing procedures must therefore be redesigned to realize the benefits of digitalization.
• Ensuring stakeholder coordination: The EPI program in Pakistan involves multiple stakeholders at the national, subnational, and international levels. Most digital transformation projects fail due to lack of ownership and clearly defined project responsibilities. The IIS program should be implemented under the EPI program at the Federal Ministry of National Health Services Regulation & Coordination and ultimately by provincial health departments. Digital Pakistan program may provide technical program management support especially in the development phase and include the project in its plan under the Digital Infrastructure and eGovernment pillars.
• Increasing mobile penetration: SMS-based automated reminders are effective if people have access to mobile phones and cellular coverage. Mobile penetration in Pakistan is around 76% while 90% of the population lives in areas with cell phone coverage.[17] For the proposed use case it is sufficient for a single member of the household to have a mobile phone so that immunization reminders can be sent. Experience suggests that this usually is the case especially in rural areas where the head of household has a mobile phone even if other family members do not.

Legal

• Enforcing provincial compliance: Provinces are responsible for administering health after the 18th Amendment to the Constitution of Pakistan enacted in 2010. This may raise implementation challenges even though the federal government continues to finance, coordinate, and supervise provinces in implementing the EPI program. However, Prime Minster Imran Khan’s party is governing 2 of 4 provinces i.e. Punjab and Khyber Pakhtunkhwa. His support for both Digital Pakistan and the immunization program may be leveraged to scale the IIS project in these provinces during piloting and beyond.
• Addressing privacy concerns: Data privacy concerns will inevitably exist as with any database. Various measures may be considered to address potential privacy concerns. For instance, the IIS may only record immunizations received in early childhood and individuals may be allowed to opt-out as adults. Additionally, IIS should not allow data that is irrelevant for an operationally useful immunization record. These measures can limit the impact of breach of privacy if the IIS database is compromised. In terms of relevant threat model, malicious actors may be more interested in accessing the NADRA citizen database (to which IIS would be linked) and not the IIS itself. Penetration testing may reveal vulnerabilities and help develop security protocols to prevent any such backdoor access.
• Determining access privileges: User privileges must be defined to prevent unauthorized access to the IIS database. This includes defining user types (e.g. administrator, vaccinator) and user permissions (e.g. view-only, update record). Additionally, the question of whether individuals have digital access to their records or those of their children will have to be addressed. Initially, individuals may request a copy of their immunization records from the relevant authority and eventually allowed to access these records remotely.

Way Forward

Vaccination coverage in Pakistan can radically be improved by leveraging digital technology through an Immunization Information System. A three-phase strategy described below is proposed to utilize World Bank Digital Development Fund support to realize digital government using immunization services as an initial project. The challenges and risks presented in the preceding section should be considered during implementation across these three phases.

• Phase 1 — Pilot proof-of-concept for IIS: Digital Pakistan has the political muscle to see through bureaucratic hurdles as it is based in the PM Office. As such, a core team led by Digital Pakistan should lead proof-of-concept tests of a minimum viable product (SMS reminders to parents and mobile app for health workers) in a district with sufficient capacity. The team should include individuals spanning a range of relevant backgrounds including product management, design, development, and public health.
• Phase 2 — Scale implementation at district-level and up: A steering committee may be constituted to oversee development of IIS and implementation of the system at the district-level followed by gradual phase-in across provincial districts. This steering committee should include officials from health and information technology departments at the federal, provincial, and district levels. The core team from the first phase should continue to provide technical guidance on implementation.
• Phase 3 — Integrate related services to the platform: The IIS can be one component of the “Pakistan Stack” envisioned by Digital Pakistan. It can be expanded in the future to include related health services including child nutrition and maternal care. Buy-in from concerned line departments can be obtained based on successful execution of the prior two phases for the proposed digitalization of immunization services.