Vax Data Health Systems Map: connecting local, national, and global systems interventions

This piece introduces our Vax Data Health Systems Map that highlights the interconnections between local, national and global factors in strengthening vaccine data systems. We hope this Health Systems Map is useful for systems change innovators, and vaccine data practitioners alike.

Vaccine Data CoLab’s Vax Data Health Systems map

Why a Vax Data Health Systems Map?

The complexity of problems such as vaccine uptake and using data-for-decision-making make linear approaches (which assume that one thing leads predictably to another) unsuitable. Instead, a systems approach helps us appreciate the interconnectedness of people and institutions across silos, and allows us to design a network of small changes that can set off a new, emergent, pattern.

Credit: B. Hayes/National Institute of Science and Technology, USA

Building a world where data is not seen as a shiny tool, but instead as an enabling environment requires both ‘thinking differently’ and ‘acting differently’.

Against this backdrop, simple tools that prompt a holistic perspective and offer a common language to understand the system and discuss change together, can be very helpful.

The Vax Data Health Systems Map is an evolution of the WHO ‘7 strategic pathways to support data systems strengthening at country level’, which highlights interconnected pathways that work together to ensure data can be used for decision making. The Vaccine Data CoLab (and many of our CoLabs) found a systems framework helpful at the start of our work at country level, to anchor discussions amongst multiple stakeholders about challenges and opportunities for change. Together with government, funders, academics, NGOs, data experts, and behaviour change specialists, we identified several interconnected opportunities, which formed the basis of our learning portfolio: 3–4 grantees in each country testing and learning in those different areas. (You can read more here).

Vaccine Data CoLab’s take on the WHO 7 strategic pathways to support implementation and sustainability at country level

The VaxData Health Systems Map emerged as we tried to capture and express the learning from our grantees about what it takes to make change happen in their various fields of intervention. Our interconnected portfolio across Nigeria and Uganda looks at:

• Policy: ABBRS and Sydani are exploring national level policies on data sharing and interoperability across data sources
• Process and Tech: HISP, Sydani and Corona Management Systems are developing digital tools such as dashboards to visualise existing data and make it more accessible to decision makers
• People: CUAMM and Brooks Insight are delivering capacity development and training people in using data tools and participatory approaches for decision making.

Vaccine Data CoLab’s grantee portfolio in 2023 covered these systemic entry points

You can read more about the work in Uganda (here) and Nigeria (here).

Meanwhile, a separate experiment in Indonesia with BIT was exploring specific options for messaging and activities at the community level to improve uptake of vaccines.

This means that we had the opportunity to learn about the minutiae of promoting change at local and national level, and appreciate the imperative for global discourse, policy and practice to better align with ground realities.

What’s in the Vax Data Health Systems Map?

The Vax Data Health Systems Map is our first effort to capture different elements of the vaccine data system at local, national and global levels. It’s necessarily a short hand (though not particularly short!) which simplifies the dimensions of the system, and connects it with the type of intervention governments and international stakeholders might be undertaking.

We built on the 7 pathways already identified by the WHO, which speak to the technical aspects of systems change. We add three distinct extra lenses:

• A behavioural lens: thinking about what influences people’s behaviour, including norms and the choices they have available to them.
• A political lens: thinking about how power and politics influence the system, including individual and institutional incentives.
• A spatial lens: how the behavioural and political lenses, alongside the ‘technical’ lens offered by the 7 pathways, play out at local, national and global levels, and how they relate to each other.

First, we’ll talk about the dimensions we spotted at the local, national and global levels, and unpack the questions we found ourselves asking. Then, later, we’ll highlight a few concrete lessons on vaccine data strengthening.

At the local level, we found the following dimensions to be important.

• Mindset and capacity: how do people think, what do they value, what incentives do they act on, what skills and space do they have to act? And how does leadership, skills building and incentives impact behaviour?
• Policy and regulation: what are the policies and guidelines in place there? To what extent are they applicable in that context? Are people aware of them, and are they enforced?
• Infrastructure: does the physical and digital infrastructure enable wider changes? What are the costs of accessing/using it?
• Products: what tools and products are available? Are they fit for purpose in that context? Are all connected products, like consumables, also available to make equipment work?
• Partnerships: what partnerships for change exist? What is the extent of collaboration, cooperation and coordination between different types of actors? How do these help or hinder change, and what are the unexplored possibilities?
• Governance and decision making: what are the power dynamics and the local political settlement, and how does that affect behaviour and incentives? How are important decisions normally made, and by whom? To what extent are unheard voices part of decision making?
• Learning: how do people and institutions learn about what works, and adapt? Can we capture those lessons to enable change to spread?

The national level perspective thinks more about national governance structures, institutions and incentives, as well as ‘country level’ efforts (such as a start up with national level scale ambitions, or an international partner working in multiple locations trying to create coherence at country level.) Examples of some of the questions at national level are:

• Within capacity: are there sufficient numbers of health workers with the right skills and incentives to act?
• Within product, tools and platforms: are the tools/platforms interoperable with other tools/platforms in use? Are they cost-effective to manage in the long run?
• Within partnerships, collaboration and coordination: what are the norms and mechanisms for collaboration, coordination and information sharing within government, amongst international partners, and amongst government and international partners? Are key areas siloed from each other?
• Within governance and policies: is there a shared vision for change amongst stakeholders?

Global standards and institutions are in part shaped by dynamics at national levels: global normative bodies are inherently political and influenced by the national politics of member countries, but are also technocratic, intentionally building on evidence that is originally rooted in real contexts (a process which is not as equitable as we’d all like it to be). The norms and discourse shaped at global level in turn affect the behaviour of influential international actors at national and local levels.

Some questions that came up for us when considering the global dimension included:

• Capacity and mindset: what are the mental models which influence decision making in international institutions? What skills and space to act do innovators in those institutions who are working differently have?
• Financing: what funds are available for change, what kind of financing is it (e.g. grant making, impact based finance, or profit driven investment?), and how does it incentivise systems transformation?
• Legal and policy standards: what policy standards are countries held to? What accountability measures are in force?

Lessons from the Vaccine Data CoLab: the origins of the Health Systems Map

We created the Vax Data Health Systems Map because we couldn’t ‘fit’ what we’d learned about vaccine data system strengthening onto the WHO 7 Pathways without our additional behavioural, political and spatial lenses.

We will write more in coming weeks about the lessons learned from implementation, but here are the some highlights that inspired the Health Systems Map. They all speak to the idea that getting the details right can make the difference between data being available, people accessing it, and then actively using it to make more informed decisions.

For quality data to be available, facilities are testing how to improve collection and uploading to the system. When getting equipment or tools to help with this, facilities also need ongoing access to consumables, comprehensive training, and maintenance to keep collecting the data needed: often these are costs that we forget to include in our plans. At a local level, things are very different from how you might expect sitting in urban centres, and health workers are very, very busy and under-resourced. We learned that we needed to better recognise the challenges faced by busy health workers and craft solutions that ease their burden.

For example, CUAMM was trialling Smart Paper Technology in Karamoja, Uganda. This meant that health workers could fill in a form directly onto Smart Paper, which facilities could scan to automatically upload into health information management systems- instead of writing on normal paper, then doing manual data entry. Health workers were very excited about this. However, to get Smart Paper to work, facilities also needed new filing systems (because the paper can’t be hole punched), and people needed to start writing carefully and clearly on their forms (instead of dashing it off and correcting it later during manual data entry).

To get data from ‘accessible’ to actually used in local decision making, we spotted various blockers and opportunities that connected the local experience of health workers and district officials with each other and with national systems. For example, officials and community members really valued Brooks Insights’s roll out of participatory decision making using human centred design methods alongside training on how to use data- but noted that they don’t always have the decision space to do more than think about how to execute vaccine programmes created at higher levels.

National systems are also under significant pressure. These pressures include the fact that public digital infrastructure struggles to keep pace with digital innovations being tested. However, we also found that silosation between different parts of government, compounded by fragmentation in international funding, is stressing this relationship between digital infrastructure building and health systems strengthening.

To continue with the Smart Paper example, we discovered late in implementation that there wasn’t sufficient server space nationally to accommodate all the newly digitised information even from our relatively small pilot. However, because this problem is not specifically ‘owned’ by any one government partner, it may not have momentum to be resolved.

What’s next for the Vax Data Health Systems Map

This is our first quick and dirty effort at expressing our learning. In the months since we came up with the Health Systems Map, we’ve learned much more about what it takes to create change, and strengthen vaccine data systems. In the coming weeks, we’ll be synthesising our learning so far and at that point, we’ll probably update our Health Systems Map. In the meantime, we welcome your thoughts.