Developing an electronic immunization registry in Malawi
By: Victory Kamthunzi, Communications Officer, Digital Square
Malawi's Ministry of Health (MOH) stakeholders, GIZ and Digital Square at PATH team at the System and User Requirement Gathering workshop in Salima, Malawi
The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) launched the Digital Innovation in Pandemic Control (DIPC) project to bring digital health technical expertise to countries to create better pandemic-prepared health systems. In collaboration with Digital Square at PATH, the DIPC project embarked on its mission in 2022 to transform how immunization services are planned, deployed, and sustained in Ghana, Malawi, and Tanzania.
In Malawi, the DIPC project is building the nation's electronic immunization registry (EIR) to capture and provide access to immunization data in real-time, resulting in a system that is more efficient and responsive to pandemics like COVID-19 than the current paper-based immunization registration system.
Understanding the landscape
To determine where DIPC’s resources would be most impactful, Digital Square partnered with the Ministry of Health's Digital Health Division (MOH-DHD) and the Expanded Program on Immunization (EPI) to map Malawi's current immunization ecosystem. This review delved into Malawi’s health and digital governance documents, including the Malawi National Digital Health Strategy 2020—2025, which emphasizes the need to, “strengthen the sharing and accessibility of data across systems to enable use.”
The ecosystem mapping assessment reveals robust digital health governance mechanisms in Malawi, including an active Digital Health Technical Working Group. The report further identifies nine existing digital tools for immunization, though many operate in isolation, hindering the ability of the various systems to exchange data. The MOH has started incorporating standards such as HL7 FHIR® (Fast Healthcare Interoperability Resources) and Simple Object Access Protocol to support health information systems. The MOH also uses standard operating procedures and guidelines to ensure new systems align with overarching digital health policies. Despite the rapid growth in digital health system adoption, the MOH identified persistent challenges including poor data management that leads to incomplete record keeping, stockouts of essential medicines at different supply chain distribution points, inadequate use of data for informed decision making, and top-down decision making that does not incorporate input from facility-level workers. Some healthcare workers also lack proficiency in digital health systems, highlighting the need for capacity strengthening.
Leveraging collaborative synergy
During a pivotal consultative meeting which included the deputy directors of MOH-DHD and EPI, the DIPC project team became privy to plans to develop a national EIR that would include both immunizations for children and adults within the Malawi Healthcare Information System (MaHIS) to cover all public hospitals. Resource constraints had, however, hindered progress on that system’s development which EPI and DHD had discussed before. Fortunately, the MOH-DHD and EPI recognized the DIPC project as the right initiative to support development of a national EIR, which became the focus of DIPC in Malawi. The EIR pilot implementation will include 24 strategically selected health facilities (21 facilities in Mchinji district and 3 in Ntcheu district), with a planned rollout date of April 2024.
Validating the existing immunization ecosystem findings
To finalize the assessment of Malawi's immunization system and validate the ecosystem mapping, a workshop held on July 24, 2023, brought together 54 high-level healthcare sector stakeholders. Stakeholders confirmed gaps in existing systems, duplication of efforts, and the pressing need for system interoperability (i.e., the ability of systems to talk to one another) to enhance data efficiency and quality. Additionally, stakeholders identified systems to securely exchange information including client identification, demographics data exchange, facility identification, and product data.
Dr. Mike Chisema, Deputy Director Preventative Health Services, Expanded Programme on Immunization Manager, Ministry of Health Malawi
Empowering healthcare providers
To ensure that the EIR is user-centered, Digital Square convened 67 facility-level healthcare sector stakeholders following the workshop between July 25-27, 2023. Professionals from all levels of the healthcare system gathered to outline immunization business processes, identify essential system features, and align digital systems with healthcare providers' needs. Participants provided input on 5 immunization workflows:
Awareness and demand generation
Planning and managing service delivery
Administering and documenting care
Managing inventory and
Monitoring and evaluation.
Validation of these defined requirements from the July 2023 workshop will be done in October 2023 to ensure the documentation aligns with the standard procedures and processes.
Photo Gallery: Malawi Ministry of Health (MOH) stakeholders, GIZ and Digital Square at PATH team at the Validation and User Requirement Gathering workshops in Salima, Malawi
Charting the ambitious path
In close collaboration with the MOH-DHD, Digital Square has charted an ambitious path to build Malawi's electronic immunization registry, including:
1. Localizing the system and user requirements document for immunization.
Stakeholders at the workshops developed a generic System and User Requirements Document for Immunization (SURD), which uses WHO’s Digital Adaptation Kit format and is intended to complement WHO’s Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable (SMART) Guidelines initiative. This adaptation focuses on embedding national clinical guidelines for immunization into digital health systems, ensuring alignment with local needs so that health workers can more easily adhere to standards and provide high-quality care.
2. Developing a national electronic immunization registry.
The EIR will replace paper-based immunization registers, providing digitalized and centralized immunization record-keeping across static sites so health workers can better plan for and deliver immunization services. The new EIR will be user-friendly with mobile and web interfaces, it will have interactive dashboards and reports to support decision-making at all levels, and it will be integrated with other digital health systems. The EIR will serve as a module within the MaHIS, with plans to expand to all 900+ static sites in the country beyond the DIPC project, which will cover an initial 24 facilities.
3. Strengthening capacity for sustainability.
Digital Square will fully engage DHD and EPI during the EIR development to ensure an understanding of how the system operates. Digital Square will assess capacity needs and readiness within the MOH and provide technical training to DHD and EPI staff to ensure the continued operation, support, and sustainability of the EIR even after DIPC concludes. Training will also be provided to EPI and its stakeholders on how to access and use the reports and dashboards from the new EIR to facilitate planning and improvement of the immunization program. Digital Square will ensure that all necessary documentation, including user guides and system manuals, is updated and accessible.
Participants at the workshop shared their expectations for the EIR:
Felix January, Ntcheu District Health Office, Expanded Programme on Immunization Coordinator, Ministry of Health Malawi
Martha Madalo, Mchinji District Health Office, Senior Health Surveillance Assistant, Ministry of Health Malawi
Strengthening the future of immunization in Malawi
With a focus on localization, interoperability, and capacity strengthening, the DIPC project aims to create a resilient EIR capable of delivering high-quality immunization services to Malawi's population. The development of the EIR within the MaHIS represents a significant step toward a more unified system. By developing this EIR to provide real-time access to immunization records and strengthening capacity to sustain the new system, the DIPC project is contributing to a more resilient health care system that can effectively respond to and combat future pandemics, improving overall health outcomes for all. Stay tuned for more updates as the system rolls out next year.