|By Elizabeth Ankunda
4th April 2023
The Government of Uganda has over the years invested in a concerted effort towards the immunization of children to protect them from killer diseases as a preventive approach of fighting disease.
However, the efforts are still thwarted by a number of hindrances especially in the hard to reach rural areas. It is upon this back ground that development partners like the United Nations Children’s Agency (UNICEF) partnered with the Ministry of Health to push their mandate of ensuring that all children are accorded with equal opportunities to a happy healthy childhood.
Last year, the Government of Japan released a grant to Uganda worth 1.5 million dollars approximately Sh5.71bn as a contribution through UNICEF to support the Government of Uganda to improve the tracking of under-immunized and unimmunized children at community level.
UNICEF has since utilized the funds in rolling out a digital health information system that has helped and is still helping reach unimmunized and under-immunized children with the required vaccines, and those targeted for COVID-19 vaccination; assist health workers to plan for vaccination supplies; and track vaccination.
According to Ms Catherine Ntabadde, a recent “zero-dose” survey conducted in four urban districts revealed that there are still a significant number of children who are either not immunized at all or under-immunized.
“Before a child celebrates their 1st birthday, they should have received BCG, Diphtheria-HepB-Hib, Hepatitis B, OPV, IPV, Rotavirus, Yellow Fever, Measles-Rubella, PCV vaccines. 10-year-old girls in school and community are required to receive the HPV vaccine” she asserts.
However, she adds but that the absence of an accurate or near-accurate source of the actual number of children who have defaulted on vaccine doses, complex data collection forms, lack of a simplified way to visualize stock status, defaulters, and children due for immunization in each month, difficulty in ensuring accurate monitoring of vaccine stocks, receipts and deliveries are some of the challenges that were impacting the way immunization services are delivered in most remote communities and thus thwarting all the ministry of health and UNICEF’s efforts.
The Health Management Information System (HMIS) is a major health system building block which provides basis for decision making and tracking progress across the health sector.
The Ministry of Health electronic Health Management Information System (eHMIS) houses the digital micro maps and dashboards generated from this initiative. Once the digital tracking system is implemented, the Ministry of Health and partners are able to improve the quality of services and coverage to reach the unimmunized and under-immunized wherever they are through outreaches and improved planning.
HMIS involves the collection, processing, storage, retrieval and dissemination of health information for decision-making.
The commissioner health services, Dr. Henry Mwebesa says the information is generated at different levels of planning and health service delivery among many countries Uganda inclusive.
He says that over 350 health workers and 60 Ministry of Health and Regional Referral Hospital officials directly benefit from this innovation while 1.3 million under five children in the pilot districts of Kamuli, Kampala, Kamwenge, Lamwo, Mukono, Ntungamo and Wakiso, have benefited indirectly.
Data is collected from the Out Patient Registers and entered in to the HMIS tool every month by health facility in-charges or records officers at bigger health facilities.
It is then relayed to the bio-staticians at the district headquarters before the 15th day of the month.
Districts are being governed under a decentralized system and at this level bio-staticians analyze and interpret the data for health planning purposes but also enter the data into District Health Information System (DHIS II) for onward electronic submission to the ministry of health resource center for further analysis, interpretation and utilization especially in planning for effective health service delivery.
At Community level, community workers known as Village Health Teams (VHTs) collect the data but community data collection systems are not fully developed yet due to motivation related challenges, logistics and literacy levels.
Data from VHTs is submitted to nearby Health facilities to be entered in HMIS via DHIS II system.
The intervention has in the past one year benefited about 60% of the targeted 10 million under five children at national level although still dragging on the 21 million targets of vaccinated children aged 12-18 years against COVID-19 at just 30%.
The project targets are anticipated to be realized by the end of 2024.
According to Ms Ntabadde, the grant by UNICEF to the Government has tremendously supported the Ministry of Health to implement a digitized health information micro planning system that is helping a great deal in addressing challenges experienced in the delivery of immunization services and to achieve Universal Health Coverage (UHC).
UNICEF has held interventions that have greatly contributed to the improvement of estimation of “zero-dose” children and better identification of where such children are located at the lower community level within the districts.
According to Dr. Michael Sekitooleko, a General Practitioner at Kasenge Health Centre II at Namawojolo village in Nama Sub County in Mukono district, the system has changed by 360 degrees how health care is delivered and how health systems are run.
He says it supports critical functions by improving the ability to gather, analyze, manage and exchange information in all areas of health, from research to large-scale humanitarian interventions and disaster relief.
“We have used information and communication technologies to improve the timeliness and accuracy of public health reporting and record keeping by asking all the relevant questions, we capture basic information like the date of birth, when and where the child first received their first vaccination and when and where they last received it. We ask parents about the number of children they have and how many of those completed their routine vaccination, their places of residence as well as their medical history. This helps us keep track,” Dr. Sekitooleko explains.
He adds that this helps them facilitate disease monitoring and surveillance like the case was during and after the Covid-19 and Ebola outbreaks. The systems are fundamental in enabling rapid response in emergencies.
Dr. Sekitooleko explains that “Before this digital tracking system, we had problems keeping watch of the populations, our data was very inconsistent as it was always recorded manually, files would get lost or damaged especially in areas where we experience natural calamities like floods, but we now use a system that is intact on both the district and national database.”
He says that they work with VHTs who help the health centre track children who may be due for immunization and haven’t received their doses in reference to what they entered in the data base on the previous outreach.
“They follow up when a child is born, register them and see to it that they get all their vaccine doses. In Nama subcounty alone, over 1600 children who were behind their immunization schedule or were never immunized at all have been added to the data base and are now traceable from their remotest villages,” Dr. Sekitooleko says.
Sister Maria Nakate, a nursing officer at Kyampisi health center III which serves both Mukono and Buikwe district populations, says that despite the limited resources and numerous challenges affecting the system, it is established and functional.
She says it has gone a long way in strengthening the utilization of information through harmonization of health-related datasets to create standard data collection tools, carrying out regular data validation and verification exercises.
“The work lord reduced, we have now gone paperless and rely entirely on machines for record keeping and tracking” sister Maria says.
Sister Maria applauds the systems saying she used to rely on her paper files and a pen to enter records but keeping these was always a challenge as they would easily tear which always made procurement of vaccines a challenge, but now the system helps them with timely delivery of vaccines in the right quantities.
“It is easier now, because when a mother comes, I only look them up in the system and administer the right vaccine to the child also saving us a lot of time,” she says.
“I am even able to serve more mothers per day as compared to the previous manual system. I now serve over 200 mothers on a busy day as compared to before where I would stop at about 70-75 mothers per day and refer the rest to the next day. It was very inconveniencing for the mothers and was always on a first come first serve basis.”
She however notes that despite the development of a curriculum for use in training health-related professionals and provision of better storage facilities and computerization of the system, there are still huge gaps in training professionals to operate the systems especially in the remote areas.
“Our people are not yet well versed with how to operate these machines, most of our new recruits are totally green about this technology, we need trainers who are costly and not easily accessible,” sister Maria complains.
She adds that the other challenge limiting the system is the almost nonexistent monitoring and evaluation of public health projects especially the immunization and vaccination projects and so the data just sits there with no relevance.
Sister Nakate says they lack political commitment and support and worries this may fail the systems if the local leaders don’t step up to provide them with enough funding to train individuals, buy data or internet connection as well as constant power supply to keep the machines running. “Honestly these costs are killing us”.
“There is also low utilization of HMIS including poor data quality, late submission of reports, not capturing data from the private health providers and only focusing on public or government health centers which creates gaps and renders the systems inadequate,” she asserts.
The UNICEF Representative to Uganda, Munir Safieldin says collecting accurate data in a timely manner is vital in the improvement of the immunization coverage specifically through better estimates as to the quantity and location of the target population at the community level.
Jalia Nakanyike, a mother of four and resident of Buntaba in Kyampisi sub county says the problems they face as mothers that act as major barriers to effective immunization include vaccine stock outs, transport difficulties or long distance to health facilities or a difficult geographical terrain which also affects the steady supply of immunization consumables from the district stores to the various health facilities.
Nakanyike however says that the health management information systems have helped them especially with the outreaches done by health workers in their villages.This is because they come armed with all the correct information and valid data making the exercise less tedious and less time consuming.
However, she says the limitations need to be addressed for smooth running of the data management systems.