Home-based records (HBRs) are an important tool for recording and communicating within primary healthcare service delivery. Unfortunately, HBRs are currently unable to fulfil their intended purpose in many communities either because the HBR is not functionally well-designed to serve its objectives, not made available, not fully adopted and/or not appropriately utilized by caregivers and/or health workers. This brief report describes the occurrence of nationally reported HBR stock-outs and HBR financing patterns during 2014 and 2015 across 195 countries reporting immunization system performance data to the World Health Organization and United Nations Children’s Fund. National level HBR stock-outs were reported by 19 and 22 countries during 2014 and 2015, respectively, with eleven countries reporting stock-outs during both 2014 and 2015. During 2015, 12 of the 22 countries reporting HBR stock-outs were from the African Region and two-thirds of the countries were Gavi-eligible. Information on HBR stock-outs was either not available or not reported by 66 countries (19 were Gavi-eligible) for 2014 and 53 (11 were Gavi-eligible) countries for 2015. Among the 22 countries reporting HBR stock-outs in 2015, 12 (54%) countries reported a single HBR financing source, and nine (41%) countries reported more than one source for HBR financing. The occurrence of HBR stock-outs remains a concern, particularly in Gavi-eligible countries introducing new vaccines where dedicated funding is received for revising and printing new recording tools, including HBRs. Additional attention is needed to understand the root causes for stock-outs and identify solutions to ensure a well-designed, durable HBR is readily available in the right quantity, in the right place at the right time in all countries.
Home-based personal health records―from this point forward referred to as home-based records (HBRs)―used to record immunization and other primary care services received (including the date-of-service) by individuals are an important tool within primary healthcare service delivery that encourages a partnership in the care of the child between the healthcare worker and the caregiver. Within primary healthcare service delivery, HBRs are an important recording tool and information resource (i) to enhance health professionals’ ability to make appropriate clinical decisions (e.g., which vaccinations have been received already and which vaccinations remain outstanding) and improve continuity of care across providers in the absence of other health records, (ii) to empower individuals or their caregivers as a vehicle for health education about which primary healthcare services have been received and those which remain outstanding as well as (iii) to support public health monitoring efforts (i.e., through population-based vaccination coverage surveys). Unfortunately, HBRs are currently unable to fulfil their intended purpose in many communities either because the HBR is not functionally well-designed to serve the needs above, not made available, not fully adopted and/or not appropriately utilized by caregivers and/or health workers.
The challenges of HBR availability have previously been highlighted with nearly one-quarter of respondent countries reporting national level HBR stock-outs during 2013 [
Since 1998, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have jointly collected national immunization system performance data using a standardized data collection form, the Joint Reporting Form on Immunization (JRF). Since its inception, the JRF, which was implemented to avoid the publication and dissemination of discrepant immunization system performance data and to take advantage of operational efficiencies within each agency, has evolved from a limited set of information collected using a paper-based form to one based in MS Excel (Microsoft Corporation, Redmond, Washington) capturing a wide range of domains of standard performance, planning, financing and quality indicators (Box 1). The information collected in the JRF serves as a critical resource for tracking implementation of the Global Vaccine Action Plan (GVAP), endorsed by all WHO Member States at the World Health Assembly (WHA) in 2012 [
The form which is coordinated and maintained by WHO Headquarters (Geneva, Switzerland) and UNICEF Headquarters (United Nations, New York), is distributed via e-mail to national immunization programmes or the immuniza-
Box 1. Information collected from national immunization programmes through the WHO-UNICEF joint reporting form on immunization.
tion focal person in the Ministry of Health in all Member States of the WHA, the State of Palestine (a non-voting observer to the WHA) as well as several Western Pacific territories in January/February each year by WHO and UNICEF regional and country offices. Once completed by national immunization programme staff in collaboration with WHO and UNICEF country office counterparts, the forms are returned to WHO/Geneva and/or UNICEF/New York via e-mail attachment along the same reporting channels by which the forms were distributed. National authorities are currently requested to return data submissions by mid-April; prior to 2009 data submissions were requested by mid-May. For the most recent reporting period in 2016 (data collected for 2015), 96% (187/195, inclusive of the State of Palestine) of countries reported data on the JRF, an improvement from 68% (131/192) of countries in 2000.
The immunization system performance data are collected for a calendar year, January through December, and countries may update prior years’ data at any time through written communication to WHO and/or UNICEF. After forms are received by WHO and UNICEF, data are extracted, reviewed for completeness and consistency and queries are sent to countries to clarify absent information and inconsistencies. The nationally reported immunization performance data are then made publicly available on the WHO website (www.who.int/immunization/monitoring_surveillance) and updated on the website twice per year (June, December).
During 2014 and 2015, the JRF included the following question for countries to respond: “Was there a stock-out of home-based vaccination records for children (no remaining home-based records for any period of time) at the national level during 201(4/5)?” Countries were also asked, “Which organization is responsible for financing the home-based records for children in your country?” A multi- select multiple choice response category was provided allowing the respondent to select any combination of the following: (i) immunization programme or Ministry of Health (EPI/MOH), (ii) other government agency and (iii) other with request for additional explanatory detail.
Results were tallied at the global level and by WHO operational region (see www.who.int/about/structure) and eligibility for Phase 2 financial support from Gavi, the Vaccine Alliance (see www.gavi.org).
A total of 19 countries reported national level HBR stock-outs during 2014, and 22 countries reported HBR stock-outs during 2015 (
Reported HBR stock-out | 2014 | 2015 |
---|---|---|
Yes | 19 (10%) | 22 (11%) |
African Region (n = 47 countries) | 11 | 12 |
Region of the Americas (n = 35) | 4 | 3 |
Eastern Mediterranean Region (n = 22a) | 1 | 1 |
European Region (n = 53) | 0 | 0 |
South-East Asia Region (n = 11) | 0 | 1 |
Western Pacific Region (n = 27) | 3 | 5 |
Gavi-eligible (n = 73)c | 10 | 15 |
No | 108 (55%) | 118 (61%) |
No Report/No Data | 66 (34%) | 53 (27%) |
HBR not used in systemb | 2 (1%) | 2 (1%) |
Total no. countries | 195 | 195 |
aState of Palestine is included in the Eastern Mediterranean Region here but is not a Member State of the World Health Assembly as of this writing and not officially part of the WHO Regional Office for the Eastern Mediterranean; bBased on a prior report to the World Health Organization [
were from the African Region, five from the Western Pacific Region, three from the Region of the Americas and one each from the Eastern Mediterranean and South-East Asia Regions (Annex). Seven of the 11 countries reporting HBR stock-outs during 2014 and 2015 were from Africa, two from the Region of the Americas and one each from the Eastern Mediterranean and Western Pacific Regions. Among the countries reporting HBR stock-outs in 2014, nearly half were Gavi-eligible; in 2015, two-thirds of the countries reporting stock-outs were Gavi-eligible.
Information on HBR stock-outs was either not available or not reported by 66 countries (19 were Gavi-eligible) for 2014 and 53 (11 were Gavi-eligible) countries for 2015. We are aware of two countries, Belarus and Norway that notified the WHO in 2014 that they do not utilized HBRs in their immunization system. Of the 53 countries without a report on HBR stock-outs for 2015 (Norway and Belarus reported during 2013 that they do not use home-based records [
Overall, 80 countries reported that EPI/MOH was solely responsible for HBR financing, five countries noted that another government agency was solely responsible and 11 countries noted that other non-governmental partners were solely responsible for HBR financing. Among the remaining 99 countries, 40 countries reported more than one source of HBR financing (59 countries either chose not to report information on HBR financing or had no data to report). Among the 22 countries reporting HBR stock-outs in 2015, 12 (54%) reported a single HBR financing source (EPI/MOH: 9; other non-government partners: 3), and nine (41%) countries reported more than one source for HBR financing. Among the 118 countries not reporting a HBR stock-out during 2015, 69 (58%) countries reported a single source for HBR financing (EPI/MOH: 60; other government: 3) and 24 (20%) countries reported more than one source for HBR financing. Of the 38 countries noting non-governmental HBR financing support during 2015, 21 (55%) countries noted UNICEF, either alone or in combination with other partners; no other partner was noted as frequently (WHO was mentioned by 10 countries). Similar HBR financing results were observed for 2014.
Of the more than 140.2 million estimated births during 2015, roughly 9% (estimated 12.4 million) were born in 22 countries reporting a national level HBR stock-out. Two-thirds (or 8.3 million) of these children resided in one of 12 countries in the WHO African Region, and more than half (4.8 million) of these children resided in the Democratic Republic of Congo or Kenya. Other countries with large (>500,000) birth cohorts reporting national level stock-outs included the Philippines, Ghana, Cameroon, Malawi, Chad and Venezuela. Taking into consideration results from an assessment of national level HBR stock-outs in 2013 collected using a similar approach [
The presence of HBR stock-outs observed here for Gavi-eligible countries introducing new vaccines into the routine immunization schedule is particularly troubling given that these countries receive dedicated funding for revising and printing new recording tools, including HBRs, as part of the introduction grant. For this reason, it is seemingly worthwhile to further explore the system breakdowns which led to HBR stock-outs in the countries that introduced either pneumococcal conjugate vaccine (PCV) or rotavirus vaccine (rota) within two years of the reported HBR stock-out, including: Burundi (rota, 2013), Cambodia (PCV, 2015), Cameroon (rotavirus vaccine, 2014), Democratic Republic of the Congo (PCV, 2013), Guinea-Bissau (PCV, 2015), Kenya (rota, 2014), Kiribati (rota, 2015), Laos (PCV, 2013), Mauritania (PCV, 2013; rota, 2014), Niger (PCV, 2014; rota, 2014), Solomon Islands (PCV, 2015) and Togo (PCV, 2014; rota, 2014).
Presumably HBR stock-outs in these countries would be related to poor planning and lacking attention to the time necessary to update and print new HBRs (and other recording tools such as registers and tally sheets) as part of the new vaccine introduction planning process. Reports on lessons learned during new vaccine introduction and the post-introduction evaluation reports highlight lacking immunization programme control over the HBR and recording tool updates as a bottleneck leading to delays in form updates and distribution [
The reported two-year HBR stock-out in Kenya coincides with healthcare devolution in the country; health service delivery is now the responsibility of the 47 county governments formed after the 2013 general election. Based on reported data from the Government of Kenya, HBR procurement and distribution in 2014 and 2015 remained a responsibility of the Ministry of Health at the national level, but it is possible that procurement of the HBR, and perhaps other recording tools, “fell between the cracks” in the changing landscape of healthcare/medical supplies and commodities and as well as the financial flows supporting them. Recent immunization programme reports highlight reductions in funding and delays in securing funding for vaccines and it is reasonable to presume recording tools are similarly impacted [
The number of countries who either did not report or did not have data on whether there was a HBR stock-out is also concerning. Countries have been encouraged to include HBR availability among the programme performance indicators [
It is important to note that the data reported here only reflect information regarding stock-outs at national level. HBR stock-outs at the district level may occur either in the presence or absence of stock-outs at national level. Unfortunately, the questions asked of countries for the 2014 and 2015 periods did not ask about HBR stock-outs at this level, which is an important limitation as highlighted by others [
Our understanding of the root causes behind HBR stock-outs is currently lagging behind but it is necessary in order to develop sustainable solutions for both the near and long-term. Prior work [
Home-based records offer a simple and relatively inexpensive means to foster coordination and continuity of immunization service delivery while facilitating communication, promoting childhood immunization, educating caregivers about their child’s immunization status and stimulating demand for services that complements facility-based recording practices. However, in order to meet these ends, first-and-foremost, a well-designed, durable HBR must be readily available in the right quantity, in the right place at the right time. HBR stock-outs, as with stock-outs of other vaccine delivery supplies, are avoidable given appropriate attention amongst the other priority areas of vaccine delivery. National immunization programmes, and the development partners supporting them, are encouraged to include monitoring HBR availability and adoption among their programme indicators, to raise their awareness of the challenges surrounding HBRs in their context and to leverage existing investment opportunities [
The findings and views expressed herein are those of the authors alone and do not necessarily reflect those of their respective institutions.
The authors have declared that no competing interests exist in conjunction with this work.
MDG completed this work under her duties as an employee of the World Health Organization, Geneva, Switzerland. DWB completed this work as an employee of the Brown Consulting Group International, LLC under a professional services consultancy contract with the Bill and Melinda Gates Foundation. The authors received no specific funding for this work.
MGD was involved in the collection of the data and final review and editing of the manuscript. DWB prepared the manuscript and was involved in the final review and editing of the manuscript.
Brown, D.W. and Gacic-Dobo, M. (2017) Reported National Level Stock-Outs of Home-Based Re- cords―A Quiet Problem for Immunization Programmes That Needs Attention. World Journal of Vaccines, 7, 1-10. http://dx.doi.org/10.4236/wjv.2017.71001
*Countries reporting national level HBR stock-outs in both 2014 and 2015 are shown in bold type below.
1) Countries reporting a national level HBR stock-out during 2014
WHO African Region
Botswana, Burundi, Cameroon, Chad, Democratic Republic of the Congo,
Equatorial Guinea, Gabon, Guinea-Bissau, Kenya, Niger, Togo
WHO Region of the Americas
Argentina, Belize, Dominican Republic, Venezuela
WHO Eastern Mediterranean Region
Somalia
WHO Western Pacific Region
Lao People’s Democratic Republic, Tuvalu, Vanuatu
2) Countries reporting a national level HBR stock-out during 2015
WHO African Region
Botswana, Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Ghana, Guinea-Bissau, Kenya, Malawi, Mauritania, Namibia
WHO Region of the Americas
Belize, Panama, Venezuela
WHO Eastern Mediterranean Region
Somalia
WHO South-East Asia Region
Timor-Leste
WHO Western Pacific Region
Cambodia, Kiribati, Lao People’s Democratic Republic, Philippines, Solomon Islands
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