How did the national scale-up of the digital immunisation registers make The Gambia a pioneer in the continent?
By Sarah Strassburger
Insufficient immunisation coverage rates that are especially challenging in rural areas and the most remote communities lead to recurrent outbreaks of vaccine-preventable infectious diseases. In 2021, the Gambian government launched a nationwide polio vaccination campaign after the virus was detected in sewage samples in August. The first round of the nOPV campaign was carried out during November 2021 and the 2nd and final round in March 2022. These campaigns are quite costly and (human) resource intensive as well as logistically challenging in comparison to routine vaccinations. The approved budget for the nOPV campaign designed to reach 382.908 children with 2 doses each was $1,270,526 excluding costs for local and international consultants as the Expanded Program on Immunisation (EPI) informed. This accounts for 1.7 USD per child. In contrast, routine vaccination using SPT generates cost of 0.16 USD per child followed over 1 year (REF. Independent Assessment 2019 — Evaluation report)
To solve these and other challenges, many developmental projects focus on providing the best short-term support for improving standards in low and middle income countries (LMICs). However, these projects often do not achieve the intended results or miss out on the potential long-term benefits as they merely not integrate into the existing structures.
A country might get tired of the vast number of interventions that are offered that bring only short-term results for the time a project lasts and even succumb the notion of only serving as a test bit for the ego of innovators from industrial countries wanting to proof a point. Nevertheless, there is a general movement of philanthropic organisations attempting to support LMICs’ efforts to improve their Human Development Index (HDI) more long-term.
The Ministry of Health (MoH) in The Gambia, ActionAid International The Gambia (AAITG) and Shifo have signed a Memorandum of Understanding (MOU) to agree for a sustainable integration of the MyChild project in The Gambia with the goal to sustainably improve the Expanded Programme on Immunisation (EPI) performance, eventually leading to a significant reduction of zero-dose children. By implementation of SmartPaper Technology (SPT) through the MyChild project a digital immunisation register is produced that allows to identify and follow each individual child that has received vaccinations until reaching the status of being “fully immunised” according to the national immunisation scheme and beyond.
Understandably it took a long time for the project to be seen and accepted as more than a project, but once national scale up was reached by January 2021 it was able to unfold its true value and replace the existing Health Management Information System (HMIS) without any geographical gaps. One year has passed since SPT was nationally implemented in The Gambia to support EPI service provision.
As a result The Gambia has been ,and still is, the first African country to have a national electronic immunisation register. This said, it should be noted that the majority of Western industrialised countries, that are assumed to live to a higher digital standard, do not have a nationwide and all level encompassing digital system at their disposal. Immense challenges to efficiently manage the COVID-19 pandemic of European countries without sufficient progress in digitalisation over the past two years has even proven more vividly the inherent advantages brought by digitisation of HMISs
The analogue-digital hybrid set-up of SPT allows health workers to use paper forms for documentation during sessions regardless of infrastructure constraints (i.e. internet connectivity, electricity etc.) paired with the availability of up-to-date electronic data at the point of care that are of importance for health workers to provide informed and high quality EPI services. The significant achievement of national scale-up allows health facility, regional and central level staff to track a child nationwide.
Since the beginning of 2021, when all EPI-service providing health service delivery points in the country became operational, 88.984 children were registered with SPT, resulting in a total of 360.654 children that have evidently received life-saving vaccines by the end of the year. This is a continuous increase of registrations of approx. 10% per quarter in 2021 and as measured from Q2 2021 about 30% of registered children in each quarter are from the 5 new regions that were acquired by the MyChild project from January 2021 pointing towards the significance of achieving national scale-up (Fig.1a).
Moreover, 116.525 children have been fully vaccinated in-line with the national immunisation schedule, which equates to 32% of all children registered with SPT. 98.958 children that are fully immunised have received all vaccines under 1 year of age (27 % of registered children), which constitutes 84.9% of children being fully vaccinated timely (Fig.1b)
The current scale of SPT implementation in The Gambia demonstrates that Shifo’s solutions can successfully replace an existing HMIS at large and even national level. It now remains to prove that Shifo’s solution is also sustainable beyond the duration of a project to distinguish from other — only temporary successful — interventions that have been brought to LMICs and specifically to The Gambia.
An external final evaluation planned to be completed by the project end in December 2022 shall inform about the likelihood and potential of SPT to be owned and sustained by the Gambian government. Until then new and potentially yet unknown challenges are to be overcome as Shifo and its partners embarked on a first of its kind journey with uncertain end.
@Shifo Foundation is transforming healthcare in low & middle-income countries. Our solutions become the backbone for stronger health systems since they replace inefficient, fragmented, and expensive information systems with simple, cost-effective alternatives. Find out more about us at www.shifo.org.
