EVACCS
PUNJAB INFORMATION TECHNOLOGY BOARD

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In Pakistan, more than a 1,000 children under the age of five die every day from vaccine preventable diseases. Pakistan is also one of the only three countries in the world that remain polio-endemic. Because the number of health facilities in rural areas is low and a majority of births take place at home, children across Pakistan are administered vaccines by mobile teams under the World Health Organization’s (WHO) Expanded Program on Immunization (EPI). The EPI is implemented by provincial health departments, with the Government of Pakistan overseeing and coordinating their efforts. In Punjab, the most populous province of the country, the provincial government employs 3,750 officials to implement the program. These field vaccinators have been divided into district-level teams, each headed by a District Superintendent Vaccinator (DSV). The DSV is responsible for making a quarterly vaccination work plan identifying pockets of population that have to be covered. Given that a DSV oversees between 70 to 130 vaccinators who are mobile and spread out in a district, it is hard to accurately monitor vaccinators’ attendance and performance of duties. Furthermore, vaccinators maintain a daily register to record inoculation data during field work. This is manually copied onto a permanent register at the end of a work day. Given the nature of record keeping, it is difficult to keep track of the number of children immunized, vaccines administered to them (antigen coverage), number of doses completed and due date for next vaccine administration. In such instances, it is feared that antigen coverage may decrease for vaccines of diseases such as measles, which is administered many months after birth. In addition to the daily and permanent registers, vaccinators also maintain an Adverse Effects Following Immunization (AEFI) register for infants who suffer an allergic reaction to a vaccine. Data from the daily, permanent and AEFI registers is aggregated and then passed onto the district headquarters. This procedure is time consuming, inefficient, and susceptible to misrepresentation of data. Since the district government receives only aggregate numbers, there is no way for it to verify the accuracy of the data shared with it. In these circumstances, the following problems existed in the structure of the vaccination program: ● Inefficient and lengthy procedures for monitoring attendance and maintaining record of daily work of the immunization staff. ● No verifiable and foolproof mechanism for measurement of geographical coverage of the vaccination program. ● No foolproof record of vaccines administered to children. ● No feedback and awareness mechanism in place.

B. Strategic Approach

 2. What was the solution?
Punjab Information Technology Board (PITB) conceived and developed an immunization information system (IIS) called E-Vaccs. It made use of smartphones to track attendance of field staff, satellite imagery to monitor geographic coverage of the vaccination program, individual-level real-time evidence of inoculation to increase antigen coverage and a remote messaging service to increase retention rates.

 3. How did the initiative solve the problem and improve people’s lives?
Under the PITB’s E-Vaccs initiative, using smartphone application for tracking vaccinators, satellite imagery analysis to monitor coverage, and real-time evidence of inoculation, between October 2014 and May 2016, attendance of vaccinators improved from 36 percent to 93 percent, geographical coverage of vaccinations increased from 29 percent to 88 percent, and Punjab’s coverage rate of fully immunized children increased from 56 percent to 73 percent. Increase in immunization staff’s attendance rate (Refer to Figure 2) Under the E-Vaccs program, the manual system for documentation of attendance was replaced with an automated system. Using their Android phones, vaccinators were required to report their location to supervisors thrice daily - on checking in at a pre-assigned location at the start of the day, on reaching the kit station in the area where vaccinations are to be administered, and at check-out, at the end of the day. Besides reporting their locations, mobile vaccinators are also required to communicate information about the number of infants vaccinated and the antigens used on a daily basis. This technology-based intervention enabled the provincial Health Department to improve vaccinators’ attendance rate from 36 percent to 93 percent between October 2014 and May 2016. Improvement in Antigen penetration (Refer to Figure 3) Vaccinators were required to report the following details from their interaction during the vaccination process depending if the child is to be vaccinated for the first time (Non-EPI) or is he already part of the vaccination process (EPI): 1- First Time Registration: Name, register number, picture, address and date of birth of the child and CNIC and/or mobile number of the parents. The vaccinator also issues the child an EPI number and records which vaccine is administered to the child. 2- After First Time Registration: EPI number, picture, CNIC and/or mobile number of the parents and which vaccine is administered to the child. In this way the manual system for documentation of child data was replaced with an automated system. Measuring and expanding geographical coverage (Refer to Figure 1) A major challenge was unavailability of a recent population density map and identification of population pockets in rural areas, in the absence of recent census data (last census was conducted in Pakistan in 1998). To solve this problem, a novel machine learning and GIS based algorithm was developed for analyzing satellite imagery to identify and divide administrative districts into a virtual layer of polygons, each representing a household cluster. (Refer to Figure 5) The areas that had been ignored to date could now be identified and resources allocated to these areas to expand coverage of the program. The intervention resulted in a three-fold expansion in geographical coverage from 29 percent to 88 percent between October 2014 and May 2016. As a result of these measures, Punjab’s coverage rate of fully immunized children increased from 56% to 73% between October 2014 and May 2016. (Refer to Figure 4) The total number of vaccination activities entered into the system for 2016 stands at 8.75 million performed by 3511 vaccinators across 36 districts of Punjab.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
An innovative solution included in the E-Vaccs program was the distribution of redesigned Near-Field Communication-enabled immunization cards among parents. The redesigned cards contain a NFC tag that enables real-time information sharing between the card and the smartphone applications used by vaccinators. This helps generate and update digital record for each child. This initiative was taken because a trend was noticed among parents that they lost the immunization cards. E-Vaccs program is the combination of four different interventions gelled together – use of low-cost smartphones to monitor and manage vaccination staff’s performance, automated analysis of satellite imagery to estimate geographical coverage, use of photographic evidence to verify the number of infants inoculated and the use of cellular communication (text messages and robocalls) to send reminders to parents in order to maintain continuity of child enrollment in the program. Deploying an Immunization Information System (IIS) in developing countries is a challenging task, given that desktop computers require uninterrupted power supply, are prone to virus attacks and require wired internet. However, a smartphone is low-cost, battery powered, equipped with GPS sensors and a camera, and has ubiquitous cellular connectivity.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
E-Vaccs, as a tool of EPI, is executed by directorate of health- a specialized wing operating under the primary and secondary health department (letter of reference attached). PITB, the Information Technology wing of the provincial government of the Punjab, spearheaded the E-Vaccs initiative. The first E-Vaccs application was deployed in June 2014 in four districts. It was scaled to all 36 districts by October 2014. Smartphones were provided to the vaccination staff with support of the World Bank funded-Punjab Public Management Reform Program (PPMRP) and DFID. Training sessions on use of these phones and the E-Vaccs application were also held under the program. The PITB maintains and oversees a central database of the record of children vaccinated so far in various districts of the province. 6. How was the strategy implemented and what resources were mobilized? (600 words) Through the assistance of World Bank, PITB purchased and distributed 3750 mobile phones worth Rs. 46 million for field vaccinators in Punjab. The annual operational and communication cost of mobile phones is 18 million Rupees. There is a team of 3 to 4 developers at PITB that oversees maintenance and development of the E-Vaccs application. Following steps were implemented for systematic execution of the strategy: ● E-Vaccs Phase I was launched in June 2014. Initially, it was piloted in four districts of Punjab: Hafizabad, Multan, Bahawalpur and Okara. Mobile phones were distributed to vaccinators and training sessions were conducted by PITB. ● Later the initiative was completely rolled out in all 36 districts of the Punjab by October, 2014. The PITB team went to each of the 36 districts and gave hands-on training to the vaccinators. They were taught how to conduct operations and use the android application for efficient delivery of vaccination services. ● Another team of supervisors were assigned above the team of vaccinators working in the field. This team of supervisors went through training sessions in Lahore. They were given training on how to monitor the progress of vaccinators and maintain a record of their daily attendance. ● After achieving the desired targets for attendance, the next version of E-Vaccs application started maintaining a record for every child vaccinated under the program and calculate vaccination coverage in Punjab. In this regard, Phase II of the program was launched in Gujranwala on a pilot basis. Under this program, the best performing employees of Gujranwala from Phase 1 were selected and trained by the PITB team. ● The whole scale launch of Phase II took place in May 2015 in three districts of Punjab, namely Multan, Gujranwala and Vehari. ● Phase II was launched across all districts of Punjab in October 2015. The PITB team revisited all the 36 districts of Punjab and gave refresher trainings to vaccinators on the additional requirements of Phase II of the E-Vaccs application. ● In addition to training on how to use the mobile application, training was also conducted to provide instruction to supervisors on how to use the dashboard. Maps were developed on the dashboard which was accessible on the web. The maps gave an overview of the activities performed by vaccinators in different areas of Punjab. Therefore, the maps served as a tool for identifying areas which would need further focus and how the program could improve efficiency going forward. ● Rota vaccine was introduced in the application for Rota Virus in January 2017. • New mandatory checks for child level data were added in the application in February 2017. It improved and enhanced the quality of the application and dashboard by keeping a more accurate and up-to-date record of the children vaccinated under this program. • Latest development of E-Vaccs is in trial phase. Under this development, NFC-enabled immunization cards have been issued to the parents. This would help in card retention by parents as the card is a mandatory component of recognizing a child. It started in October 2016, and is being run in two districts of Punjab, Sheikhupura and Sahiwal. To date, 10,500 newborns have been registered. • A review meeting chaired by Secretary Health Department is held every month which includes EDOs from all districts. Progress of all health projects and initiatives is reviewed.
 6. How was the strategy implemented and what resources were mobilized?
Through the assistance of World Bank, PITB purchased and distributed 3750 mobile phones worth Rs. 46 million for field vaccinators in Punjab. The annual operational and communication cost of mobile phones is 18 million Rupees. There is a team of 3 to 4 developers at PITB that oversees maintenance and development of the E-Vaccs application. Following steps were implemented for systematic execution of the strategy: ● E-Vaccs Phase I was launched in June 2014. Initially, it was piloted in four districts of Punjab: Hafizabad, Multan, Bahawalpur and Okara. Mobile phones were distributed to vaccinators and training sessions were conducted by PITB. ● Later the initiative was completely rolled out in all 36 districts of the Punjab by October, 2014. The PITB team went to each of the 36 districts and gave hands-on training to the vaccinators. They were taught how to conduct operations and use the android application for efficient delivery of vaccination services. ● Another team of supervisors were assigned above the team of vaccinators working in the field. This team of supervisors went through training sessions in Lahore. They were given training on how to monitor the progress of vaccinators and maintain a record of their daily attendance. ● After achieving the desired targets for attendance, the next version of E-Vaccs application started maintaining a record for every child vaccinated under the program and calculate vaccination coverage in Punjab. In this regard, Phase II of the program was launched in Gujranwala on a pilot basis. Under this program, the best performing employees of Gujranwala from Phase 1 were selected and trained by the PITB team. ● The whole scale launch of Phase II took place in May 2015 in three districts of Punjab, namely Multan, Gujranwala and Vehari. ● Phase II was launched across all districts of Punjab in October 2015. The PITB team revisited all the 36 districts of Punjab and gave refresher trainings to vaccinators on the additional requirements of Phase II of the E-Vaccs application. ● In addition to training on how to use the mobile application, training was also conducted to provide instruction to supervisors on how to use the dashboard. Maps were developed on the dashboard which was accessible on the web. The maps gave an overview of the activities performed by vaccinators in different areas of Punjab. Therefore, the maps served as a tool for identifying areas which would need further focus and how the program could improve efficiency going forward. ● Rota vaccine was introduced in the application for Rota Virus in January 2017. • New mandatory checks for child level data were added in the application in February 2017. It improved and enhanced the quality of the application and dashboard by keeping a more accurate and up-to-date record of the children vaccinated under this program. • Latest development of E-Vaccs is in trial phase. Under this development, NFC-enabled immunization cards have been issued to the parents. This would help in card retention by parents as the card is a mandatory component of recognizing a child. It started in October 2016, and is being run in two districts of Punjab, Sheikhupura and Sahiwal. To date, 10,500 newborns have been registered. • A review meeting chaired by Secretary Health Department is held every month which includes EDOs from all districts. Progress of all health projects and initiatives is reviewed.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Punjab Information Technology Board: PITB is the Information Technology wing of the Punjab government. It has been involved in both the design and implementation of the initiative. PITB designed the E-Vaccs application. It oversees both operations and management of the initiative and also maintains its data. Chief Minister Secretariat: A special task force known as CM Roadmap team oversees the overall implementation of the initiative, tracks its progress and compiles monthly reports of performance of each district. Expanded Program on Immunization (EPI) Punjab: EPI Punjab is a subsidiary department of the Punjab Health Department. It is responsible for implementation of the initiative. This department provides vaccines to the district governments. EPI also oversees allocation of resources for operations and management for provision of immunization services. District Governments: After getting vaccines from EPI, the Executive District Officers (EDOs) in all 36 district governments further distribute it among various towns and communities with the help of local health officers including Districts Officers (DOs) and Deputy District Officers (DDOs). World Bank: World Bank is the funding agency for E-Vaccs. It funded the initiative under the Punjab Public Management Reform Program (PPMRP). DFID: United Kingdom’s Department for International Development (DFID)

 8. What were the most successful outputs and why was the initiative effective?
Attendance of Vaccinators After successfully using smart-phones to track field staff attendance, the major problem of absenteeism (and ghost attendance) of field vaccinators was effectively resolved in phase 1 of this initiative. Attendance of vaccinators improved from 36% to 93% between October 2014 and May 2016. Geographical Coverage and Retention Rate Phase 2 of E-Vaccs made sure that the vaccines are successfully administered to children. This goal was achieved by using a novel machine learning algorithm which uses trained SVM for texton based features detection on satellite imagery. This method resulted in detecting population pockets. Between October 2014 and May 2016, geographical coverage of vaccinations increased from 29% to 88%, and Punjab’s coverage rate of fully immunized children also increased from 56% to 73%. Comparison between data of November 2015 and February 2017 shows 25% growth in total number of children vaccinated by EPI. Total number of entries of Non-EPI children in 2015 were 463,568 and it increased to 1,205,961 in 2016. The total number of new children inducted into the E-Vaccs system was 463,568 in 2015. However the total number of vaccinations in the same year was 2.28 million. Against this, there has been a growth of nearly 160% (1205961 new children added into the system in 2016). The total number of vaccination activities entered into the system for 2016 stands at 8.75 million. Latest figures for February 2017 indicate 0.89 million vaccination entries with an addition of 104,570 new children into the system. Eradication of Vaccine-Preventable Diseases Despite the EPI program being in place in Pakistan since the late 1970s, the country still accounts for substantial amount of the world’s polio cases. In this regard, the E-Vaccs initiative is a big leap forward in order to eradicate all the nine vaccine-preventable diseases including Poliomyelitis, Neonatal Tetanus, Measles, Diphtheria, Pertussis (Whooping Cough), Hepatitis-B, Hib Pneumonia, Meningitis and Childhood Tuberculosis. Due to this program, using smartphone application for tracking vaccinators, satellite imagery analysis to monitor coverage, and by replacing manual vaccination registers with electronic vaccination records, between October 2014 and May 2016, attendance of vaccinators improved from 36% to 93%, geographical coverage of vaccinations increased from 29% to 88%, and Punjab’s coverage rate of fully immunized children increased from 56% to 73%.

 9. What were the main obstacles encountered and how were they overcome?
In EDO conferences (where progress of the vaccinators on ground was reviewed every month) paper-based techniques were used to measure geographical coverage of vaccination program. It led to areas being missed. This was countered by introduction of polygons based digital maps. It was noticed that parents were losing or misplacing vaccinations cards. To counter this card was redesigned to include an NFC chip which needed to be tapped with the smart phone so that data could be uploaded. This made the parents more careful in keeping the card safe. Another challenge faced by the program was to train staff with almost no experience of using smart phones. The program was mainly hindered because of the diversity in education (mostly high school graduates) and age bracket (mostly ranging from 45 to 60) of the staff. The pilot mobile application was not successful because it had instructions in English, a non-native language that most of the vaccinators are not comfortable with, hence, it faced resistance from vaccinators. Once the problem was identified, the mobile application was revised to use text and fonts in Urdu. In the district of Faisalabad, the application training was completely boycotted because of a tussle between the vaccinators union and the EDO of Faisalabad. The issue was later resolved and trainings were conducted again. In October 2014, the revised and updated application was launched as Evaccs 1. There were also cases where some vaccinators suspected that their every activity, including their personal lives, would now be tracked through these phones. The vaccinators were assured that E-Vaccs will only monitor their attendance, and later it will be used to gather the data of every child who is vaccinated through this initiative. In addition, the vaccinators were reluctant because they knew that they would have to go into the field and do their assigned jobs now. A big challenge during implementation of the initiative was to convince vaccinators about the benefits of using E-Vaccs. These issues were resolved with help of the Punjab Public Management Reform Program (PPMRP) team, the Punjab Health Department and the Chief Minister’s Secretariat team (also known as the CM Roadmap team). The vaccinators had to be convinced about the benefits of using the application and trained on how to use it. For this purpose, special training sessions were organized in various districts. Also “master trainers” were identified among the vaccinators who would further train their colleagues. In this way, the difficult and time consuming process of training the vaccinators was delegated to these master trainers.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Initially the primary focus of this initiative was to improve the attendance of vaccinators. After solving the issue of attendance, geographical coverage was increased. Finally retention rate of the vaccines was also brought up. The overall impact of E-Vaccs between October 2014 and May2016 shows that attendance of vaccinators improved from 36% to 93%, geographical coverage of vaccinations increased from 29% to 88%, and Punjab’s coverage rate of fully immunized children increased from 56% to 73%. By achieving these primary targets of the E-Vaccs system, multiple complementary benefits accrued to the people: The successful roll out of E-Vaccs has gone a long way in creating an element of trust within the public with regards to the government at large, and specifically on its public health initiatives. Public service has been rife with inefficiency. However, the E-Vaccs system has created a layer of accountability which has led to health workers performing full duty hours. This in turn has benefited the public that they now have access to these workers through the full day. While vaccines are available in the market, their quality and integrity is questionable. Under E-Vaccs, the quality of the vaccine is guaranteed. This again benefits the end user as he will be secure in the knowledge that the vaccine administered to his child is genuine. At the same time, the E-Vaccs system will ensure that there will no shortage of vaccines, and the fact that there is no cost involved to the end user also makes it more viable for them. Also, importantly, where previously families have had to go out in search of vaccinators, and pay for it as well, the E-Vaccs system has turned it around, delivering the vaccines, free of cost, at their doorstep.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The induction of geo-tagged and verifiable electronic record of data with pictorial evidence has resulted in a self-accountable mechanism. This data is accessible to all stakeholders to review and monitor progress of the program. At the same time, Chief Minister has taken it upon himself to call a quarterly meeting and review the progress of all existing health projects and new initiatives in the province called health stock take. In this regard, E-Vaccs is an important component. Senior civil and political leadership is present at the meeting. Also, every month the secretary health chairs a meeting of EDOs of all 36 districts of the province. All health projects including E-Vaccs are discussed and reviewed and actions taken accordingly. While on the ground level, whenever a vaccinator approaches a new child in an area, some basic information of the child is collected and recorded. Among other entries, it records the contact and/or CNIC number of the child’s parents as well as a list of which vaccination(s) has (ve) been administered. In this way a comprehensive list containing contact numbers of parents is maintained at the central database of E-Vaccs dashboard. Later in order to get feedback from parents, phone calls are made to a random five percent of the parents every month (or three months). Parents are asked if they are satisfied by the services provided by the vaccination staff and if they want to lodge any complaints. So a general feedback is received and compiled at the dashboard. This feedback on the dashboard is made available to all the stakeholders so they can initiate inquiry and take action against any discrepancies thereafter. This initiative of PITB was also recognized in the 2014 and 2015 annual reports of GAVI (attached)- a distinguished public–private global health partnership committed to increasing access to immunization in poor countries. “It’s not often you pick up the phone and hear the voice of a senior minister at the other end, asking how you think local immunization services could be improved. Yet this is soon to become reality in Punjab province, where Chief Minister Shehbaz Sharif is so committed to public health services that he has recorded a personal telephone message inviting citizens to share their experience of vaccination,” says the GAVI report.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The E-Vaccs system has led to a mass improvement of vaccinations in lower income rural areas which may have been missed out in the previous manual mapping procedures. Due to the conservative nature of a large segment of Pakistani society, women and girls remain the most separated from basic health facilities. Even when health facilities are available in their neighborhood, there is also the concern of whether they will be allowed to leave without a male chaperone. E-Vaccs, by taking vaccinations to the doorsteps of people, will directly impact the percentage of women and girls that are vaccinated. It is understood that 50% of the children vaccinated under are females. Vaccinations outside the public sector are usually not affordable and accessible to the poor. Even where vaccinations may be available its integrity may also be questionable. And due to this problem the poorest segment of society remains most affected by it. Through E-Vaccs vaccinations are provided to this segment free of cost, at their doorsteps and most importantly the integrity of the vaccinations is also ensured

Contact Information

Institution Name:   PUNJAB INFORMATION TECHNOLOGY BOARD
Institution Type:   Government Department  
Contact Person:   sarah Ahmad
Title:   PC  
Telephone/ Fax:   +923214017788
Institution's / Project's Website:  
E-mail:   sarah.ahmad@pitb.gov.pk  
Address:   arfa tower, 11th floor, 346-B, ferozpur Road
Postal Code:   54000
City:   Lahore
State/Province:   Punjab
Country:  

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