Background There is growing interest and investment in electronic immunization registries (EIRs) in low- and middle-income countries. EIRs provide ready access to patient- and aggregate-level service delivery data that can be used to improve patient care, identify spatiotemporal trends in vaccination coverage and dropout, inform resource allocation and program operations, and target quality improvement measures. The Government of Tanzania introduced the Tanzania Immunization Registry (TImR) in 2017, and the system has since been rolled out in 3736 facilities in 15 regions. Objective The aims of this study are to conceptualize the additional ways in which EIRs can add value to immunization programs (beyond measuring vaccine coverage) and assess the potential value-add using EIR data from Tanzania as a case study. Methods This study comprised 2 sequential phases. First, a comprehensive list of ways EIRs can potentially add value to immunization programs was developed through stakeholder interviews. Second, the added value was evaluated using descriptive and regression analyses of TImR data for a prioritized subset of program needs. Results The analysis areas prioritized through stakeholder interviews were population movement, missed opportunities for vaccination (MOVs), continuum of care, and continuous quality improvement. The included TImR data comprised 958,870 visits for 559,542 patients from 2359 health facilities. Our analyses revealed that few patients sought care outside their assigned facility (44,733/810,568, 5.52% of applicable visits); however, this varied by region; facility urbanicity, type, ownership, patient volume, and duration of TImR system use; density of facilities in the immediate area; and patient age. Analyses further showed that MOVs were highest among children aged <12 months (215,576/831,018, 25.94% of visits included an MOV and were applicable visits); however, there were few significant differences based on other individual or facility characteristics. Nearly half (133,337/294,464, 45.28%) of the children aged 12 to 35 months were fully vaccinated or had received all doses except measles-containing vaccine–1 of the 14-dose under-12-month schedule (ie, through measles-containing vaccine–1), and facility and patient characteristics associated with dropout varied by vaccine. The continuous quality improvement analysis showed that most quality issues (eg, MOVs) were concentrated in <10% of facilities, indicating the potential for EIRs to target quality improvement efforts. Conclusions EIRs have the potential to add value to immunization stakeholders at all levels of the health system. Individual-level electronic data can enable new analyses to understand service delivery or care-seeking patterns, potential risk factors for underimmunization, and where challenges occur. However, to achieve this potential, country programs need to leverage and strengthen the capacity to collect, analyze, interpret, and act on the data. As EIRs are introduced and scaled in low- and middle-income countries, implementers and researchers should continue to share real-world examples and build an evidence base for how EIRs can add value to immunization programs, particularly for innovative uses.

Electronic immunization registry (EIR) development benefited from a phased scale-up approach, including multiple system iterations in each country. Although this lengthened the timeline, the process ultimately strengthened the system. nThe role of the software developer was a key difference in partnership approaches. Challenges resulting from working with international developers were addressed by also contracting a local software partner. n Significant in-kind time contributed by the ministries of health and donor investment enabled these EIR implementations. Unanticipated costs resulted from system technical issues and the need to expand the server as new children are registered.n The technological infrastructure in each country informed EIR design decisions, with adaptations made for level of computer literacy and Internet connectivity.

BACKGROUND There is growing interest and investment in electronic immunization registries (EIRs) in low- and middle-income countries. EIRs provide ready access to patient- and aggregate-level service delivery data that can be used to improve patient care, identify spatiotemporal trends in vaccination coverage and dropout, inform resource allocation and program operations, and target quality improvement measures. The Government of Tanzania introduced the Tanzania Immunization Registry (TImR) in 2017, and the system has since been rolled out in 3736 facilities in 15 regions. OBJECTIVE The aims of this study are to conceptualize the additional ways in which EIRs can add value to immunization programs (beyond measuring vaccine coverage) and assess the potential value-add using EIR data from Tanzania as a case study. METHODS This study comprised 2 sequential phases. First, a comprehensive list of ways EIRs can potentially add value to immunization programs was developed through stakeholder interviews. Second, the added value was evaluated using descriptive and regression analyses of TImR data for a prioritized subset of program needs. RESULTS The analysis areas prioritized through stakeholder interviews were population movement, missed opportunities for vaccination (MOVs), continuum of care, and continuous quality improvement. The included TImR data comprised 958,870 visits for 559,542 patients from 2359 health facilities. Our analyses revealed that few patients sought care outside their assigned facility (44,733/810,568, 5.52% of applicable visits); however, this varied by region; facility urbanicity, type, ownership, patient volume, and duration of TImR system use; density of facilities in the immediate area; and patient age. Analyses further showed that MOVs were highest among children aged &lt;12 months (215,576/831,018, 25.94% of visits included an MOV and were applicable visits); however, there were few significant differences based on other individual or facility characteristics. Nearly half (133,337/294,464, 45.28%) of the children aged 12 to 35 months were fully vaccinated or had received all doses except measles-containing vaccine–1 of the 14-dose under-12-month schedule (ie, through measles-containing vaccine–1), and facility and patient characteristics associated with dropout varied by vaccine. The continuous quality improvement analysis showed that most quality issues (eg, MOVs) were concentrated in &lt;10% of facilities, indicating the potential for EIRs to target quality improvement efforts. CONCLUSIONS EIRs have the potential to add value to immunization stakeholders at all levels of the health system. Individual-level electronic data can enable new analyses to understand service delivery or care-seeking patterns, potential risk factors for underimmunization, and where challenges occur. However, to achieve this potential, country programs need to leverage and strengthen the capacity to collect, analyze, interpret, and act on the data. As EIRs are introduced and scaled in low- and middle-income countries, implementers and researchers should continue to share real-world examples and build an evidence base for how EIRs can add value to immunization programs, particularly for innovative uses.

Background: There is growing interest among low- and middle-income countries to introduce electronic immunization registries (EIRs) that capture individual-level vaccine data. While practical EIR guidance documents are available, the real-world implementation experience varies by country. There is an opportunity to learn from countries that have experience implementing EIRs to inform other countries considering the same. Methods: This qualitative study provides a cross-case comparison of the design, development, and deployment of EIRs in three countries: Vietnam, Tanzania, and Zambia. The countries were selected based on PATH’s role in providing technical support to the governments to introduce and scale their EIRs. Through desk review and thematic analyses, we consider findings related to four implementation factors: time, partnerships, financial costs, and technology and infrastructure.Results: The country cases highlight the multi-year timeline required to implement an EIR at scale. Of the 3 countries, only Vietnam has achieved nationwide scale of the EIR after implementing a series of iterative cycles to pilot and redesign the system over 7 years. In terms of partnerships, all three case countries established interdisciplinary national teams with experience in leadership, technology, and immunization, and incorporated end user perspectives from subnational levels in the EIR design and development. It was important for the national government to play an active role to ensure country ownership and sustainability. Financial investment was necessary for design and development, as well as to maintain the EIR beyond the initial deployment, including all recurring costs for system maintenance, updates, and end user support. Finally, technology and infrastructure were important considerations in the EIR design and choice of equipment in each country, and all 3 countries have a local partner to provide ongoing technical support.Conclusions: Comparing implementation factors across these cases highlights practical experience and recommendations that complement existing EIR guidance documents. The findings and recommendations from this study can inform other countries considering or in the process of implementing an EIR.