In last year October, we had posted in CoP the launching of DHIS2 based Maldives Electronic Immunization Registry [EIR] (Maldives Launches Electronic Immunization Registry [EIR] - based on DHIS2).
This current post is mainly intended to give an update to those interested, where we are now, post 10 months of nation-wide implementation.
Maldives - Country overview
Situated in South Asia (more specifically in the Indian ocean), Maldives is a small island nation that has a high geographical dispersion. It consists of 1,192 islands out of which only 188 islands are inhabited. According to 2022 census conducted in Maldives, its current resident population is 515,132 (includes 382,639 resident Maldivians). The yearly birth registration in the country is 6,000 to 7,000 births.
Why did we introduce the EIR?
Maldives was recording and maintaining the immunization/vaccination data manually using paper forms, Microsoft Excel and Google Sheets which made tracking completeness as well as monitoring of data quality a challenge. Accessibility to past vaccination records was limited due to missing data or difficulty accessing them where available. It is also very common in Maldives for a child to be vaccinated in multiple facilities due to internal movement between islands for accessing health care (eg: the child may be given birth dose in their birth facility in the capital island, while the rest of the vaccines may be administered in the child’s resident island).
The laws in Maldives stipulates that a child should be up to date with their routine vaccinations before they can be enrolled in formal schooling. The current document used as the proof of routine vaccine completion is the paper based “Child Health Record” book. While each parent is given a copy of this book at time of initial birth dose, and the administered vaccines are regularly updated in this book, there are several instances where this book gets misplaced/ lost. In such situations its a challenge for the parents as well as the facilities to search, verify and update a child’s full vaccination record (especially when multiple vaccination centers are involved). Hence, one of the key reasons why EIR was introduced was to provide a solution to tackle this long standing issue of real time longitudinal tracking and verification of a child’s vaccination record.
Where are we now?
Maldives officially launched the EIR on 14th October 2022. During the span of 10 months post launching, we had made remarkable progress in scaling up the use of EIR. For instance, focal points of more than 70% of vaccination centers across the country have been trained and are active users of the EIR, including all birth facilities across the country. This had resulted in more than 85% of this years births to be registered and their vaccination records updated in the system. In terms of legacy data, the system had already captured more than 17,100 children including more than 50% of all children born between the years of 2020 to 2022. Despite the challenges in human resource at central team, efforts are currently underway to identify the missing children born in the past 3 years by triangulating with national birth registration system and proactively encouraging facilities to update these children’s records in the system.
Future plans for EIR
While the focus of the EIR was originally to capture childhood vaccination, the system had already evolved to capture traveler’s vaccination, Adverse Event Following Immunization [AEFI], vigiflow integration and the reporting of vaccine preventable diseases (VPD program). We are currently in discussions on scaling up the use of these additional modules within this year. Nevertheless, the icing on the cake is the development of the beneficiary portal which is intended to be used as a public portal by registered parents/guardians to access their child’s vaccination records. The sample of the digitally verifiable vaccination certificate which can be issued via the beneficiary portal is shown below. We are targeting to rolling out this portal within this year.
Who are the contributors to this initiative?
The continued implementation of EIR is the result of ongoing collaborations between the Ministry of Health (including National Immunization Program of Health Protection Agency), WHO consultants (including HISP LK team) and financial support from WHO and UNICEF. UiO had also extended support for sustaining technical assistance for the implementation. The core team acknowledges the ongoing support from vaccination centers who continues to champion the national roll out of EIR.
EIR as a catalyst for digitalization
It could be argued that the successful implementation of EIR had acted as a catalyst to prompt the use of DHIS2 as a solution for other health data needs in the country. For example, Maldives is currently using a primary Health Care [PHC] registry to screen the population aged 18 years and above for NCDs based on WHO PEN package in the demonstration site for PHC in the country. We are also in the finalization stages of the National Cancer Registry. Additionally, today, we have formally initiated the training of 11 staff within MoH who will work together with the consultants to customize, develop and pilot the initial designs of RMNCAH module, Communicable Disease (including surveillance) module and mental health module by end of this year. This “DHIS2 local capacity building initiative” is a critical step to ensure sustainability of the progress we are making towards digitalization of the health sector.
Thank you for reading this long post 
.
(Posting on behalf of EIR core team)