Impact of Electronic Immunization Registries and Electronic Logistics Management Information Systems in four Low-and Middle-Income Countries: Guinea, Honduras, Rwanda, and Tanzania

Background There is increasing interest in low-and middle-income countries (LMICs) to introduce and scale-up digital health tools like electronic immunization registries (eIR), and electronic logistics management information systems (eLMIS) to support immunization services. An evaluation of the use of these tools was conducted in four countries to inform decisions about their further expansion and investments.

Purposive sampling of regions, districts, and health facilities was done in each country based on predefined criteria. Primary data were collected between October 2021 and September 2022 in 50 health facilities in Guinea, 88 in Honduras, 36 in Rwanda, and 101 in Tanzania using semi- structured questionnaires, standardized competency assessments and data accuracy checks. Data focused on electronic tool usage, user experience, infrastructure, workforce needs, and decision- making, as well as immunization data quality and perceptions of health workers and vaccine recipients. Data analysis combined both quantitative and qualitative methods. Findings The implementation of eIR and eLMIS was associated with improvements in National Immunization Programme (NIP) processes and outcomes. Users were satisfied with the tools (87% satisfaction rate), and 95% of users in Africa valued the accessibility of information, with 91% finding it accurate and complete. Some caregivers reported better organization and shorter waiting times in health facilities using the tools. Most eIR users noted improvements in process efficiencies (81%) and immunization service delivery (89%). In Rwanda and Tanzania data accuracy was higher in exclusively paper or electronic settings (60%) compared to dual paper-electronic systems (45%). eLMIS use was associated with improvements in vaccine stock data quality and reduced stock-outs. While 77% of health workers were digitally literate, inadequate digital infrastructure was a key barrier to tool use. Interoperability with the Civil Registration and Vital Statistics system (CRVS) was limited, hindering the tracking of unimmunized children.

To fully realize the potential of electronic tools in LMICs, full government ownership, targeted infrastructure investments, migration to fully electronic systems, and integration of eIR with the CRVS are essential. Competing Interest Statement The authors have declared no competing interest. Funding Statement The evaluation was financially supported by the BMGF, Seattle, WA and technically supervised by the WHO and Gavi. The funding source was involved in the final country selection process, but had no role in the collection, analysis and interpretation of data or the writing of the report. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All protocols and data collection instruments received ethical approval under the procedures set by the Guinea National Health Research Ethics Committee, the Pan American Health Organization (PAHO) Ethics Review Committee (for Honduras), the Rwanda National Ethics Committee, the Tanzania Medical Research Coordinating Committee and the Bocconi University Research Ethics Committee. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability All data produced in the present study are available upon reasonable request to the authors.