By: Aly Azhar, Program Associate

In the past three years, the VaxTrac system has been implemented in three countries, Benin, Nepal, and Sierra Leone. The operational models for each country have been different and each project has allowed us to identify key Critical Enabling Factors (CEFs) for successful project implementation. As many other technology-enabled solutions, it is essential for us to look at the CEFs that would allow our product (VT’s digital immunization registry system in this case) to effectively meet the needs of our system users, scale-up if necessary, collaborate effectively with partners, and fit into the current context of health services delivery.

Meredith interviewing health workers in Freetown during a requirements gathering visit

Meredith interviewing health workers in Freetown during a requirements gathering visit

When VaxTrac was exploring an expansion into Sierra Leone in mid-2016, we had a good sense of which CEFs we wanted to have in place before considering implementing a project there. Whereas we did not have a formalized list of high-priority CEFs in place when starting projects in Benin or Nepal, we were able to apply lessons learned from those project countries to best inform our research into the potential of a Sierra Leone project. Now that the Sierra Leone project is being successfully piloted and scaled-up according to a pre-determined project timeline with local stakeholders, we have learned that having the following categories of CEFs in place is crucial.

 

Context/Sufficient Infrastructure: Knowing the current immunization program context in which we would be implementing our system is incredibly important. When conducting landscape analysis, we look at the current structure of the Ministry of Health at large, whether or not there is an EPI division present, what sort of strategic immunization plan the EPI division is working under, and what the current vaccine supply-chain model looks like. We also analyze the current HMIS system in-country and how high functioning a national DHIS2 is in order to assess the current data flow and any possible technical issues that may arise from adding a digital solution into the mix. Having all of those puzzle pieces figured out before leaping into conversations about project implementation with possible partners or product development with technical staff is of high priority.

 

Quality/Type of Partnerships Available: Once we have a sense of the current immunization program, how it is structured, and how a technology-enabled solution such as VaxTrac can best fit, we look for possible private, public, and NGO partners. What we learned from our experiences in both Benin and Nepal is that successfully implementing the VaxTrac system into the ehealth ecosystem of a country is best done when you can closely partner with a local NGO that can take over many of the project implementation responsibilities.

To assess the potential of partnerships available to us in Sierra Leone, we looked for organizations that had experience implementing digital health solutions, what sorts of business development and program management collaboration opportunities there were with such organizations, and what the capacity was for these organizations to be able to take on a VaxTrac project. In Sierra Leone, we found that many multilateral agencies such as UNICEF, WHO, and the World Bank were  active in health systems strengthening activities, advancing HMIS interoperability, and implementing Results-Based Financing within the health center level. We also found that agencies such as the E.U. and GAVI invested heavily to restore immunization services in Sierra Leone after the Ebola crisis. Since the Ebola crisis created a dramatic need for health services delivery and communications strengthening, there was no shortage of current or former digital health initiatives that were being piloted in Sierra Leone.

From IBM, Magpi, and Fionet which worked to make the health data collection process more efficient, to Frontline SMS and mHero which were communications interventions meant to tighten the feedback loop and reporting systems, there was a breadth of interventions from which VaxTrac could learn and build upon. Given the robust number of potential partners, the business development opportunities, investment levels within the immunization services program, and the current infrastructure of pilots being implemented, Sierra Leone proved to be a promising new project country.

 

Compatible Regulatory Environment/Research+Evaluation: After identifying the best fit for VaxTrac and potential partners within the digital health field with whom to collaborate, we then look at the compatible regulatory environment within a potential project country. Specifically, we analyze the current status of eHealth policy in the country, whether or not central level stakeholders have set data security protocols or frameworks, and what the current demand levels are for real-time data. We assess what other data-driven decisions the government has made in the past using data produced through technology-enabled interventions. For example, we found that in Sierra Leone there was a large demand for data because of the Ebola crisis and because of the government’s investment in strengthening DHIS2 and the national monitoring and evaluation plan.

With the culmination of various CEFs from the above three categories, we are able to assess the project implementation, partnership development, and technology and human capacity needs to successfully implement a VaxTrac project. Recently, when we conducted the landscape analysis process for Sierra Leone, we were able to successfully partner with eHealth Africa, the Centers for Disease Control, the Ministry of Health and Sanitation, and Africell. Sierra Leone proved to have a lot of the high-priority CEFs that we were looking for (interoperable DHIS2, engaged central-level stakeholders, robust digital health partnership network). Although it did not fully complete our list of CEFs (i.e. a lack of a public eHealth policy framework), the CEFs that it did have in place proved fruitful enough for us to pursue a project.

Bryan Gastonguay (eHealth Africa) collecting requirements in Freetown

Bryan Gastonguay (eHealth Africa) collecting requirements in Freetown

Since the landscape analysis process, the VaxTrac system has been piloted in 10 health facilities in Freetown with the goal of covering 50 facilities by May 2017. The partnership with eHealth Africa has led to a very successful project implementation model and we have seen great successes thus far in the way that the VaxTrac system has been rolled out. What we have learned from successfully launching our pilot in Sierra Leone is that although it’s crucial to conduct analysis of high-priority CEFs prior to launching a digital health project, it’s difficult to find a potential project country that meets all of the desired CEFs. In VaxTrac’s case, applying lessons learned from our prior two project countries led us to a stronger and more robust project implementation model in Sierra Leone and allowed us to better identify high-priority CEFs. The CEF analysis process is partly learned through intensive research, but also partly learned through prior implementation experience. Our list of high-priority CEFs is a living document that will remain flexible and adaptable to both the current system and specific user requirements.