Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation

"The WHO [World Health Organization] and others have identified the need for implementation research to understand the complexities of implementing and scaling digital interventions."

Vietnam's National Immunization Information System (NIIS) is an example of an electronic immunisation registry (EIR), a confidential, computerised, population-based routine system to capture, store, access, and share individual-level, longitudinal health information on vaccine doses administered. In Vietnam, the EIR, which includes SMS (text message) reminders, has been found to improve immunisation coverage and timeliness of vaccination (see Related Summaries, below). The aim of this qualitative study was to understand the determinants of scale-up of the national EIR in Vietnam, one of the few low- and middle-income countries (LMICs) with an EIR at national scale.

The paper provides context. The Vietnam National Expanded Program on Immunization (NEPI) was first introduced in Vietnam in 1981. Until 2009, Vietnam's immunisation records and vaccine supply tracking were paper based. Health centres began to be equipped with computers in 2005; internet connection at the commune level became available in 2012. From 2010 to 2012, NEPI and PATH, an international non-governmental organisation (NGO), collaborated with the WHO to develop and pilot an electronic vaccine stock management system (VaxTrak) in 3 provinces and an immunisation registry software (ImmReg) in one district of Ben Tre province. The goal of the software was to improve the ability to track babies who were due for vaccination and reduce the time for immunisation recording and reporting compared with a paper-based system. These 2 systems were combined, upgraded, and then deployed by NEPI with support from PATH in all districts of Ben Tre province from 2014 to 2015. In 2016, this combined system was integrated into the NIIS, which was deployed nationally in June 2017.

The study explored the facilitators and barriers to national scale-up of the EIR in Vietnam using the mHealth Assessment and Planning for Scale (MAPS) Toolkit as a conceptual framework. Codeveloped in 2015 by the WHO, the United Nations Foundation, and Johns Hopkins University, the MAPS Toolkit outlines 6 axes to measure digital health project maturity: groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation (M&E). Each of these axes is divided into more specific drivers of success.

PATH staff conducted 6 in-depth semistructured interviews in person with key informants from October to December 2019. The semistructured interview guide was developed based on the evaluation questions and the MAPS framework.

The partnership and operations axes were most commonly perceived to be critical to the successful deployment and scale-up of the EIR in Vietnam. For example, PATH (a civil society organisation) could act as a liaison between the Ministry of Health (a health system–focused entity) and its mobile network operator (MNO) partner Viettel (an information technology entity), given PATH's experience in global health and digital technologies. This partnership was built on a foundation of trust, which key informants identified as an important driver of successful scale-up and sustainability. This partnership was operationalised through a cascading training-of-trainer approach, which used training materials that were iteratively refined during each phase of implementation.

Analysis and quotations from research participants along the lines of the other 4 axes are also provided. For example, key informants noted 3 main technology and architecture facilitators to successful scale-up of the EIR related to the technology itself: its user-centred design, adaptability, and strong data security and privacy. It was also stressed that the multiple phases of the EIR that preceded NIIS national scale-up created many opportunities for learning and optimisation.

The financial health, technology and architecture, and operations axes were most commonly perceived to be barriers to the successful deployment and scale-up of the EIR in Vietnam. For instance, there were 3 key barriers to successful scale-up and sustainability identified within the operations axis: dual reporting (both paper and digital), low computer literacy of end users, and high turnover of healthcare workers.

Reflecting on the research process, the researchers note that, overall, the axes of scale and their specified definitions that are part of the MAPS Toolkit helped ground the analysis for this evaluation. Using the MAPS Toolkit also allowed for comparison between the experience in Vietnam with that of Tanzania and Zambia, where a recent study explored the factors influencing the introduction and adoption of EIRs in low-resource settings using the MAPS Toolkit. Tanzania and Zambia took a similar approach by starting implementation in a single pilot district or province before expanding the EIR further, which was also perceived as a facilitator of scale-up, as it allowed for opportunities to learn and iterate. (The paper provides a comparison of the experiences in the 3 countries.)

In conclusion, as more countries aim to introduce EIRs, the findings of this study could inform efforts to plan for scale-up. One key message: "The central role of the partnership model in Vietnam cannot be overstated."