The Use of Digital Technologies and Approaches for Real-Time Monitoring of Supplementary Immunization Activities

"Ultimately, the use of real-time data systems for real-time decision-making is not about technology. It is about a strategic and cultural environment that enables technology to be utilized as support to organizational decision-making and institutional digital transformation."

Supplementary immunisation activities (SIAs) and mass immunisation campaigns are strategies for delivering vaccination to children who have otherwise been missed by routine services. Real-time monitoring (RTM) - which is conducted using digital tools such as RapidPro, Open Data Kit (ODK), and District Health Information System (DHIS) 2 to accelerate the sharing, analysis, and use of data - can enhance the quality of SIAs and campaigns. This joint United Nations Children's Fund (UNICEF) and Gavi - the Vaccine Alliance report compiles good practices and lessons learned from countries implementing RTM for immunisation campaigns. Four countries - Indonesia, Pakistan, Uganda, and Zambia - are included as case studies; overall, 13 country experiences and nearly 70 good practices and lessons learned are documented in this report.

Data and information were collected using a mix of interviews (UNICEF, World Health Organization (WHO), and regional and country office staff); consultations with key partners; a field mission to Pakistan; and documents and journal articles. The literature review found that RTM was associated with: outcomes that bolster campaign effectiveness, including improvements in data quality, timeliness, and completeness; more accurate micro plans; stronger accountability of field teams; and better collaboration, partnership, and communication at all levels. Challenges spanned both technological and programmatic areas. In some places, there were very short timeframes for planning, leading to insufficient stakeholder and user engagement. Network connectivity was a common challenge, and some countries' field teams had difficulty accessing their data on the same day due to a requirement for central-level data cleaning/downloading/approval.

Case studies focus on the following; each one features, among other elements, specific lessons learned:

1. Pakistan conducted a national measles campaign in 2018 that reached 37 million children and a typhoid campaign in Sindh province in 2019 that reached 9.5 million children. In both campaigns, RTM data collected through RapidPro Surveyor, KoBo Toolbox, and WhatsApp were used to reach millions of people, with a focus on missed children, in short time frames. The Pakistan case illustrates how the combination of data and communication tools enabled prompt action and ultimately contributed to quality improvements at every stage of the campaigns.
2. Indonesia conducted a nationwide measles-rubella campaign in 2017-2018 to reach 68 million children in 2 phases. RTM, using RapidPro as a short messaging service (SMS) tool, facilitated timely and efficient tracking and analysis of coverage against targets. Users reported high rates of satisfaction with the platform, analyses showed consistency with official data submitted through the manual reporting system, and districts with higher reporting rates were more likely to achieve their target coverage rate. The case confirmed the importance of quality assurance measures and a theory of change to conducting successful campaigns and improving process and outcomes.
3. Uganda conducted a nationwide measles-rubella campaign to reach 18.1 million children and a polio/oral polio vaccine (OPV) campaign to reach 8.2 million children, beginning in October 2019. The national response team combined the data collection abilities of ODK with a DHIS2 dashboard to consolidate, visualise, and analyse the data. RTM approaches supported timely campaign progress, results, and feedback, which in turn facilitated corrective actions and helped Uganda save on costs associated with transporting data and printing forms.
4. Zambia has implemented RTM for cholera, measles-rubella, and polio immunization campaigns since 2015. RTM approaches were deployed for campaigns that vary greatly in scope (nationwide vs. targeted) and delivery methods (static-site vs. school-based vs. outreach vs. house-to-house) and that seek to reach a broad range of populations (infant through adult age). For this reason, the good practices and lessons learned outlined in this case study could apply in any country wishing to use RTM approaches, regardless of campaign strategy. Stakeholders and users reported satisfaction with the speed of access to data, the ease of coordinating with colleagues at all levels, the ability to monitor activities everywhere (even in remote areas), and the level of teamwork.

High-level benefits of using RTM included that RTM can: contribute to the achievement of campaign targets; enables the rapid use of data for decision-making and prompt corrective actions; improve data quality; help enforce accountability at all levels; support improvements in campaign planning; refine outreach strategies; strengthen routine immunisation systems; support rapid collection of standardised data and its integration with other digital solutions, over paper-based approaches; support daily immunisation activity monitoring; and be used for media monitoring and addressing vaccine hesitancy and rumours. To elaborate on the latter, the report notes that negative messages about vaccines build distrust and give rise to myths. Monitoring public opinion in real time allows authorities to learn about opinions, misconceptions, and fears before they become widespread, and to respond to them before they escalate by initiating a dialogue with the audience and managing uncertainty.

High-level good practices include:

• Use RTM before, during, and after campaigns (e.g., to strengthen accountability).
• Leverage and align with existing technology and eHealth programme structures, using the staff, systems, and processes developed through other vaccination initiatives (e.g., polio).
• Consult users and stakeholders continually (e.g., to gather the intelligence needed to take corrective action).
• Test and iterate systems to meet user needs and to identify and address bottlenecks.
• Choose complementary and interoperable technologies.
• Invest in the capacities of users at multiple levels of health systems.
• Ensure information technology and network assistance are available.
• Apply effective data use processes for RTM (e.g., the use of colour-coded maps, lists, alerts, action-takers, and other RTM data outputs to facilitate meaningful discussions and corrective action).

High-level lessons learned include:

• Initiate RTM planning early, and consider using a human-centred/design-thinking approach that involves actual users in programme design.
• Rely on government ownership and leadership to accelerate adoption and ensure sustainability.
• Minimise the number of platforms and forms, the use of paper, and manual data processing and downloading.
• Prioritise the "real-time" (same-day) element during platform selection, with appropriate processes in place to, for example, prioritise timely communication and coordination across levels to clarify and address issues.
• Develop (and then locally tailor) training materials, data entry forms, dashboard templates, and other tools at the global or regional levels for platforms used by multiple countries.
• Use RTM data to improve public awareness and strengthen local advocacy, ensuring that all campaign staff who interact with other sectors, the media, and local leaders have the skills to interpret and use RTM data for public advocacy.
• Reserve additional resources for implementing corrective actions beyond what is normally budgeted for supervision.

Annex 1 (of 3) includes data collection instruments for regions and countries.