The BID Initiative Story
Implementation
Balancing implementation timelines and software development in Zambia
Initially, the BID Initiative and Zambia Ministry of Health partnered with technical experts to develop an EIR for Zambia using a patient-level Android application built on the DHIS 2 platform in late 2015. The aggregate version of this open-source platform was already implemented in Zambia as an online, national-level health management information system.
After initial tests of the system did not meet health worker requirements and revealed a lengthy software development timeline, we turned to the Open Smart Register Platform (OpenSRP) in early 2017 to develop a registry for Zambia. OpenSRP had previously been implemented in Bangladesh, Indonesia, and Pakistan, providing a foundation against which Zambia could launch its EIR.
The resulting Zambia Electronic Immunization Registry (ZEIR) supports nurse workflows for child vaccination and growth monitoring. Data visualization tools make it easy for health workers to understand their individual and facility performance. Clean graphics, colors, and symbols designed for community health workers track coverage rates and indicate when a certain service, such as the second or third dose of a vaccine, is overdue. Key features of ZEIR include:
- A unique login for health workers in the same facility, allowing them to easily log in and out of a shared device to access data, even without an internet connection.
- A simple birth registration form that resembles the paper cards mothers bring with them to clinic visits.
- Data on growth monitoring, deworming status, and Vitamin A supplementation, among several other metrics, to mirror nurse workflows and help health workers avoid duplicative data entry.
After pilot use in six facilities in early 2017, ZEIR was rolled out across all health facilities that deliver immunization services in Southern Province. ZEIR is also interoperable with DHIS2 to share the critical data across the health system, and work is underway to integrate with UNICEF’s mobile app for community health workers to send reminders and register new births into ZEIR to gain even greater insights into the target population to be served.
“We have children who don’t come for immunizations, and so they are vulnerable to sicknesses, and different types of diseases. Now it’s very easy to capture that child who has missed a vaccine, because the tablet will show us.”
– Regina Chikelwa, nurse at Mahatma Gandhi Clinic, Livingstone District
Photo: Bill & Melinda Gates Foundation/Riccardo Gangale. Nurse Calorine Agade gives a polio vaccine to a child at the Green Hope Dispensary in Arusha, Tanzania.
Introducing and refining a comprehensive rollout strategy in Tanzania
Progress and growth is often a nonlinear process. Sometimes it is defined by significant gains and great leaps forward, and other times it is slow and steady. In keeping with this trajectory, BID’s mission to improve data quality and data use in Tanzania and Zambia has—at times—been a rollercoaster of both successes and challenges. Implementation has been one such example of BID’s ability to adapt in the face of new and evolving circumstances. In Tanzania, we first introduced our full suite of interventions, including the EIR, in two districts in Arusha Region. We piloted use in a handful of facilities and then incorporated feedback before extending interventions to other districts.
Implementation specialists visited each facility four times to ensure that tools were fully functional and that health workers not only knew how to use the EIR but understood how to interpret its outputs. Making data more pervasive and accessible isn’t enough. BID is working to foster a culture of data use in which health workers are incentivized and enabled to access, analyze, and interpret data. As a result, they feel a connection to the numbers they collect. The numbers aren’t just statistics—they are the names and faces of their community.
“After implementing BID, I am looking forward to everyone using better immunization data to make decisions…. When I close my eyes, I see people visiting my district from different parts of the world to learn how we improved immunization data. I also see government officials using our data to stress the importance of childhood vaccination.”
– Anna Nanyanje, immunization mentor, Meru District, Arusha Region
We learned a lot during implementation in our first region and were able to apply those learnings not only to Zambia, but to the subsequent regions in Tanzania (Tanga and Kilimanjaro). We adjusted our rollout strategy for providing on-the-job training to health workers by introducing data use mentors, who are district health staff, and transitioned to BID staff offering only need-based visits. This led to faster implementation, increased ownership at the local level, and significant cost savings with each successive introduction.
Implementation in the rural areas of Tanga Region presented logistical challenges but also validated that the interventions could be scaled to multiple geographic and health contexts. In Tanga, for instance, TImR was rolled out across all health facilities in just under two months. In Kilimanjaro Region, we proudly took a supportive role as the MOHCDGEC led the implementation launch meeting with the region’s most senior officials in attendance—including the highest regional leader, the Regional Commissioner.
Progressive implementation across the three regions not only demonstrated the scalability of the interventions but also illustrated the government of Tanzania’s commitment to the work.
“Expansion of the BID Initiative in the Tanga Region gives us confidence that our hard work of providing input in the design and testing of interventions in Arusha has paid off. We were involved in the BID Initiative from its inception, and health care workers at all levels gave their valuable inputs tirelessly. We are hoping that the lessons learned from Arusha will be a stepping stone toward successful rollout in the Tanga Region and beyond.”
– Dr. Wonanji V. Timothy, Regional Medical Officer, Arusha Region
Graphic: PATH. The journey of data from a facility to a national level may result in missed opportunities to improve performance if there are no feedback loops in place.
Rolling out interventions in Zambia’s Southern Province
Taking a cue from Tanzania, Zambia developed a rollout strategy that centered on change management interventions, such as data use campaigns and peer support networks in the form of WhatsApp groups. In doing so, BID established a culture of data use before introducing the EIR. For example, we required a greater level of change management experience for the BID staff in Zambia as we grew to appreciate their critical role as change agents. We also focused on building health workers’ confidence in using ZEIR and other intervention tools. While tablets and barcode scanners enable health workers, the data itself are also a tool. The health workers were encouraged to see the value and utility of more accessible data. Timely, actionable data allow health workers to promptly reference patient records, ultimately resulting in better health outcomes.
Recommendations and lessons learned: Data use
In July 2017, the BID Initiative sponsored a showcase event in Lusaka to celebrate successes in Zambia, including the formal release of ZEIR. The event featured remarks by First Lady Esther Lungu; Dr. Chitalu Chilufya, MP, the Minister of Health; and other special guests. The high-profile speakers signified the government’s strong commitment to the work.
“Immunization is not sufficient if we don’t know who should receive vaccines, where these children are, and what vaccines they should be getting. This information matters as much as the vaccines. Data is a critical tool in the health service and all measures to improve its integrity at the health facility level should be put in place.”
– Mrs. Esther Lungu, First Lady of Zambia
Even as BID clocked achievements in Tanzania and Zambia, it took every opportunity to learn from other countries implementing similar information platforms. In August 2017, BLN members traveled to Santiago, Chile, to share information with representatives of the Pan American Health Organization (PAHO). Chile developed an EIR in response to the AH1N1 flu pandemic that hit South America in 2010. Registro National de Immunizaciones, or RNI as it is also known, has registered more than 10 million people since its launch. Given that TImR and ZEIR have not yet scaled nationally, the study visit provided BLN members with an opportunity to swap experiences and lessons. Chile also benefited from the exchange. Intrigued with the data visualization dashboards available in the Tanzania and Zambia EIRs, the PAHO representatives began to consider similar visualizations for their own registries.
