Electronic data tools help advance immunization equity in Tanzania

Routine immunizations and new vaccine introductions have proven to be some of the best investments to improve the health of all people. However, many countries, including Tanzania, struggle to meet the World Health Organization’s (WHO) target of 90 percent coverage for the recommended childhood vaccination package. In WHO’s Immunization Agenda 2030, it notes that since the COVID-19 pandemic, gains in immunization coverage and equity have been reversed, including an increase in the number of zero-dose children—children who receive no vaccines through immunization programs.

Several factors have been found to influence vaccine access and completion of the vaccination schedule. In Tanzania, these factors include socioeconomic status, gender dynamics, limited knowledge on the importance of immunization, and poor access to vaccination services.

Health care workers are on the frontlines of helping to get infants off to a healthy start and on track to complete lifesaving vaccinations. Immunization workers have often been overworked, sometimes seeing more than 100 children in the clinic in one day. The Ministry of Health (MOH) in Tanzania, with partners such as PATH’s Better Immunization Data (BID) Initiative, developed and launched digital tools meant to help immunization workers simplify their patient registration, data collection, and patient tracking tasks.

These tools include the Tanzania Immunization Registry (TImR), launched in 2014. Initial data from 2018 showed that TImR reduced the amount of time spent registering and vaccinating each child by more than 40 percent while also eliminating outmoded paper records.

But challenges remain. For instance, it is difficult for some health workers to switch from paper records to the electronic system, due either to lack of comfort with and skills for using an electronic system or inability to access maintenance support when tablets break or need software updates. In addition, the data collected in TImR did not provide immunization managers with all the information needed to determine immunization trends and population groups at risk of low immunization coverage and non-completion of the vaccine package.

Health officials are accessing and using the TImR to make decisions about where to allocate human and financial resources, but one key piece has been missing: information on the socioeconomic status of families who are and are not completing the childhood vaccination package.

Without collecting data on the socioeconomic status of caregivers, decision-makers do not have the whole story on immunization inequities and who is being left behind. This means that in some cases, health care workers and policymakers develop outreach plans and immunization campaigns based on assumptions, rather than data. This hampers their ability to effectively target resources, advance immunization equity, and improve immunization coverage.

Tanzania started the journey of implementing TImR in 2014 as one of the solutions to address immunization data challenges. Health care workers use tablets and the TImR software to register patients, record the vaccinations they receive, and identify when they need to return for future doses.

TImR was designed to be appropriate to Tanzania’s context so that it could be scaled and enhanced to accommodate new changes and designs as new needs arose. Therefore, when additional data were needed for tracking immunization equity, the tool could be revised to better meet the needs of immunization managers and other data users.

PATH and partners created socioeconomic stratification indicators—a solution to meet the growing data needs—to be added to TImR. The socioeconomic status (SES) tool includes a short series of questions for caregivers. The answers are then used to categorize families into five socioeconomic quintiles (poorest, very poor, poor, less poor, and least poor) using Demographic and Health Surveys SES score values and scales.

“It is advisable to track the socioeconomic status of caregivers when their children are enrolled for routine vaccinations. This helps us identify communities that are at risk,” said Hassan Mtenga, Regional Director, Digital Square Anglophone Africa, PATH. “The TImR was a good solution to capture such information.”

PATH’s BID Initiative, which was conducted between 2013 and 2019, was grounded in the belief that better data and better decisions will lead to better health outcomes. The BID Initiative team worked with the Tanzania MOH to develop TImR using a collaborative human-centered design process. This ensured that throughout the development process, there would be continuous verification and communication to ensure that the tool would meet all user needs. By working closely with the government and health care workers throughout the development process, PATH was able to build a tool that was feasible for the context and adaptable as new needs were identified. The tool continues to be in use today.

Therefore, when the MOH, along with additional partners such as Gavi and UNICEF, identified the need for additional immunization data to support improved vaccine coverage and targeting, it was clear that PATH would be the best partner to move forward that work using TImR, which had already been rolled out and demonstrated ease of use across Tanzania.

PATH developed the SES assessment tool with the Tanzania MOH through the Immunization and Vaccine Development Program, in collaboration with UNICEF and researchers from Muhimbili University of Health and Allied Sciences (MUHAS). The process of integrating the SES assessment tool into TImR started with engaging MUHAS researchers to assess the validity of a short, streamlined SES questionnaire by testing to see how well it captured socioeconomic status of households when compared to the standard wealth index survey.

The questionnaire needed to be concise to not take up too much time for immunization workers and patients, but also achieve accurate results in determining the socioeconomic status of families. Researchers from MUHAS conducted the assessment successfully and shared their report with identified optimal SES questions with the MOH.

Six questions were determined to be optimal for inclusion in the TImR system. They were written to be answered by a child’s mother, as mothers are typically the caregiver that accompanies children to the clinic for vaccinations. The questions are:

• Can you read and write?
• What is your current occupation?
• What is the highest level of school attended by your partner?
• What is your partner’s current occupation?
• Does your household have electricity that is connected?
• What is the main roofing material at your household?

The MOH through the Immunization and Vaccine Development Program approved the SES questions, and they were integrated within TImR first in a staging environment to ensure the technology platform was working properly and easy to use for health workers with the addition of the new survey questions.

By the end of 2020, the enhanced TImR had been deployed to 15 regions, covering a total of 3,748 health facilities. This process of successfully developing the SES tool showed it is possible to conduct a streamlined SES survey and receive results that are useful in categorizing families and tracking trends in which segments of the population maintain the childhood vaccination schedule and which fall behind.

Initial challenges were faced during the testing of the SES tool. For instance, it could not be deployed according to the planned timeline due to the COVID-19 pandemic and heavy workload for immunization workers to conduct awareness-raising campaigns and deliver the vaccine.

The Ministry of Health and implementation partners will continue working to strengthen health worker capacity and use of the TImR platform. Increased use of the TImR data, and the rollout of the SES tool, will contribute to the Tanzania’s goals of reaching high risk and marginalized groups, including zero-dose children.

Rolling out the SES tool—and understanding the value of the data it collects—is still a work in progress. Once PATH and partners have better quantified health workers’ reception of the SES tool and whether the tool can be successfully integrated into routine patient registration, we will further understand how this tool can contribute to the many efforts underway to increase equity in immunization.