Background
Evidence-based healthcare requires high-quality and readily-accessible data. Recent years have seen a proliferation of projects in low- and middle-income countries promoting the deployment of Digital health interventions (DHIs) to improve the management and utilization of health information. Electronic immunization registries (eIRs) and electronic logistics management information systems (eLMIS) have been implemented in several countries to support better immunization services within the Expanded Programme for Immunization. Yet, few of these systems have been evaluated to date and evidence is still sparse on their cost of implementation or their impact on national or external budgets. This study contributes to filling this gap by estimating the initial expenditures and routine operational costs for one integrated eIR-eLMIS in Tanzania, the eIRs in place in Rwanda and Honduras, as well as an eLMIS of Guinea.
Methods
The analysis took the perspective of the third-party payer, including both national governments and external donors. The cost of deploying the DHIs was estimated by collecting financial reports from the implementers and other secondary sources. Routine operational costs were estimated using activity-based costing and tracing direct and indirect costs to a set of pre-specified activities related to the management of immunization and vaccine logistics data. Primary data were collected through questionnaires in all countries from a total of . Comparisons with paper-based registries were done using a cross-sectional design whenever possible or a pre-post comparison alternatively.
Results
Honduras, Tanzania and The context, timeline and strategy of implementation of the systems varied across the countries, with upfront implementation expenditures between USD 45K and 12.6M covered almost entirely by external donors. Most of the initial expenditures were related to training of healthcare staff and purchasing of equipment. The yearly routine cost per health facility of managing immunization or vaccine-logistics data was estimated between USD 200 and 1,850. Compared to paper-based systems, savings were observed in Tanzania (USD -1,307), but not elsewhere. The continued operation of paper registries after the implementation of the DHIs, and the limited use of the electronic data for reporting or decision-making, were two of the main factors contributing to higher costs. Several shortcomings in terms of human resources, trainings, IT infrastructure, and equipment were observed which hampered the widespread adoption of the DHIs and negatively impacted the perceived trust in the quality of the electronic data.
Conclusions
By improving the quality and accessibility of data, eIR and eLMIS systems have the potential to optimize healthcare worker performance and provision of care, and to lower costs. Nonetheless, savings are unlikely to be generated unless the switch to electronic registries is complete, eliminating duplication of work, and the electronic data is incorporated into decision-making processes . Further investments are required to ensure an enabling environment for the continued use of the systems, all of which need to be considered by countries when deciding on the adoption of these solutions.