 And thank you very much for joining us today in this session on the scale up of COVID-19 vaccine delivery solutions. Today's presenters, we show with us some experiences on DHS2 users and implementations. In some of their most complex points. So for example, planning, monitoring, costing, and also at the same time, some insights and best practices and some tips on their firsthand experience in these implementations. Just a few quick reminders. The slides will be shared. They will be uploaded in sketch. Feel free to ask any question in the chat of these presentation. If we have time, we might answer a question or two. But nonetheless, your questions will not be lost. They will be posted in the community of practice. And the links are in the description of this session. So you, the presenters will be able to share with you the answers and you can continue the discussion there. And lastly, of course, as you've seen the session will be recorded and recording will be available later on. So let's get started for real now. Okay. So just to give you a little bit of background, since the 2017, the University of Oslo has been designated as a WHO Collaboration Centre for Innovation and Implementation Research. And to strengthen the systems, of course, the WHO has approved a bunch of metadata packages that the countries can freely download and install and modify according to their needs. In particular, today we're going to talk about the WHO-approved DHS2 immunization toolkit, which ranges from the routine EPI module, both in a tracker and aggregated form. And of course, what we can call somehow mass campaigns or any kind of supplementary vaccination activities that you might need to roll out. In this case, for example, it was the COVID-19 delivery strategies. We have also come up with some logistics data modules for stock management and cold chain management. And of course, the adverse events for following immunization, which has peeled up in implementation greatly since the COVID-19 immunization activities have started. And lastly, of course, you're also going to hear about these in the presentation. Some electronic health certificate that have been integrated for the production of vaccination cards together with the electronic immunization register for COVID. So just to give you an idea on the uptake of these packages, nowadays we have up to 45 countries that with the general EPI immunization data. 30 countries have already installed the EPI package and 25 are already operational and fully collecting the data on their COVID-19 vaccination activities, fully in DHIS too. And we have still eight under development, but they will be operational soon. So today presentations, today presentation are incredibly interesting and might be slightly biased, but I really hope you can enjoy them as much as I did. We have Dr. Pomoda from Sri Lanka that is going to tell us more about the challenges with the large scale implementation of the COVID tracker. And he's also going to give some recommendation and best practices in order to overcome these challenges. Then we're going to have Professor Achala who is a consultant at HMS Consultant for the WHO at the moment who is going to show us some good examples of integrations of multiple components of the immunization toolkit and he's going to show us how the supervision and the daily reporting have also been strengthening the local national system. And finally, Adolf from Hisperanda who is going to give us an overview on how Hisperanda has fully remotely supported huge scale implementation of the COVID delivery toolkit in Madagascar. So without further ado, because of course we don't have a lot of time unfortunately, but I'll leave the floor to Dr. Pomoda. Thank you. Good morning, good afternoon, good evening everyone. Let me share my screen. So in 19 minutes, what I hope to discuss is how we use DHS for COVID vaccination in Sri Lanka and what are the lessons learned and the best practices other countries can use when you are implementing COVID vaccination on DHS to platform. So a little bit of background about what happened in Sri Lanka as some of you may be aware that Sri Lanka was one of the first countries to start using DHS for COVID immunization for COVID information management. As you can see here from January to April 2020 that is around the pandemic, we were able to develop more than eight modules to serve the requirements around the COVID information on top of DHS. All these information modules in place for COVID surveillance on DHS to platform. Towards the latter part of last year what we embarked on was to customize DHS to for collecting information around COVID immunization. So the work was initially started with of course the pioneers by the WHO country office in late October 2020. And the work that was started that time is still ongoing and we have been able to get this system operational with entire adult population register. Right, so limit of history. As you are aware like there were a couple of vaccines that received approval for emergency use towards latter part of last year and Sri Lanka within one week of receiving approval and recommendation by WHO towards the last and the latter part of January 2021 we started COVID-19 vaccination and by the time we started our vaccination our information system was ready on DHS to platform to collect COVID vaccine related information. So let me quickly summarize the ecosystem of modules that we have in the surveillance system. So as I highlighted before we have all these modules to collect different information components for COVID related requirements and the latest addition was of course the immunization portal which again has several other components which I will explain later. So basically Sri Lanka was the first country to deploy COVID immunization package on top of DHS to platform and they were like mainly four components. First thing is the immunization tracker to collect the individual data and then we had the aggregate stock monitoring component and a digital vaccination certificate and also citizen portal that is another, I mean it's an outside module which is connected to DHS to schedule appointments vaccination appointments. So these are the four components that we have in COVID vaccination or COVID immunization package. Right, so the aggregate component is mainly targeting as I mentioned before the stock monitoring where the stock information is captured at national, regional, that is at district level and the vaccination center level and we also have aggregate vaccine data reporting like I mean it's about how many vaccines were received and how many were injected which is reported from vaccination centers in addition to the tracker. And the case-based component of course has three modules three main sections. First thing is about COVID vaccination information that is about the first and second dose of the currently ejected vaccines and the adverse events following immunization modules there and also the latest one is we have started the country has started immunizing the pregnant mothers so we capture that information as a separate module because it's a kind of a cohort follow-up that happens which even lasts even after the delivery. And of course the analytic components the standard analytics that we generally use in DHS to our all there that is like we have different charts maps and everything on the usual analytics which of course embedded into the DHS to dashboards and in addition for the line list and reporting purposes we have also instructed the vaccination centers to keep Excel line lists and in addition there are a few analytics which goes like for example number of events that were entered today I mean so that kind of information is currently not possible to directly obtain from DHS to the existing dose so for these ones we are using SQL weights. And our technical approach has been like this so we had a couple of broader requirements the first thing is to have an electronic immunization registry for COVID-19 and pre-registration of the entire adult population of Sri Lanka and to provide real-time analytics in means of dashboards to all the stakeholders at district and national level and to produce the digital immunization certificate so there were like main challenges that we really didn't know initially how to address so few of them are how to pre-populate the 16 million track entity instance so the 16 million number is the entire adult population of Sri Lanka which was of course made available to us by the electoral database so we had the entire list of adult population which was readily available but how to get it into DHS to and then again providing real-time analytics in this kind of a large-scale track implementation and to produce vaccination certificate so let's see how we address these these three main challenges so the challenge about how to import the 16 million track entity instances well it was never easy we kind of experimented using few methods so our first approach was to push this information from the CSV file to the DHS to instance using the web API and as you can see here these are some statistics like we did some stress testing and some kind of experimenting around how many concurrent requests have to be sent and all but unfortunately what happened was it was not predictable so it was giving us figures like it will take around 40 days initially and when we try to optimize it was telling us this would take 16 days to import the entire database into the DHS to so this was not working like we didn't have that much time so this is when we explored the support of University of Oslo as well as the regional his pub so for example his Vietnam who had done some work around it before we contacted them and we discussed like what would be the best approach and this is when we when we decided that we would go ahead with the SQL insertion approach so what we basically did was we tried to directly import the data into the DHS to database which is kind of a risky procedure so which required a lot of testing but basically it involved finally seven steps the first thing is to map the organization units then to filter out any invalid entries and age of course it's a very custom requirement we had we had to calculate that and then we imported the track entity instances first then the attributes then enrollments that they utilized to do this is available so we can hear you very well now it seems like the internet is lagging so we couldn't hear about the last last minute of it I'm going to share my screen and you stick with the audio okay do you see my screen it seems like we lost Pamoud okay I see he's been having some problems with internet today we can recover Pamoud in a bit and I'm going to try to talk to him on the side the beauty of live sharing but if in the meantime you want to get started and maybe if we manage we can resume with Pamoud thank you can I start good morning good afternoon and good evening everyone I'm going to discuss how we customized and implemented COVID immunization tracker in Timor-Leste let me share my screen can you see my screen yes perfectly okay thank you okay let me start for those who are not familiar with Timor-Leste it's quite a new country located in south Asia it's an island country with an area of 15,000 square kilometers and roughly 1.3 million population there are 13 districts of municipalities in the country there are centers of CHCs and five referral hospitals, one national hospital and at the grassroots level there are 330 health posts all over the country although it's a new country which got its independence in 1999 in 2013 Timor-Leste has decided to implement its national HMIS based on the HIS too it is called Timor-Leste Health Information System the HIS the HIS was mainly established to enter aggregated data from community health centers paper based forms are collected at health post level and entered into the system at community health center level the HIS was fully implemented in 2017 covering the entire country this year in 2021 with the launch of COVID-19 immunization tracking campaign the HIS to tracker was introduced to Timor-Leste so before we move on moving on to the details of the immunization tracker let's have a look at the situation of COVID-19 cases in Timor-Leste until end of December 2020 Timor-Leste had only few cases and no deaths exactly around 30 cases but also the majority was asymptomatic however cases started to increase from early this year and the government negotiated with partners to get vaccine doses for Timor-Leste population finally COVAX facility agreed to send first consignment of allocated 20% in the first week of April then immunization team started developing the deployment plan and explored the options for managing immunization data then decided to use TLHIS for that purpose it was quite challenging as we had only few weeks remaining to receive the vaccine by then WHO Sri Lanka country office with the help of his Sri Lanka has customized DHIS to instance to capture immunization data in Sri Lanka so in Sri Lanka vaccination started in February so using the same metadata and their help we customized an instance of DHIS to for Timor-Leste to capture COVID-19 immunization data COVID-19 immunization vaccination was launched in Timor-Leste on 7th April 2021 on the World Health Day together with immunization tracker TLHIS immunization tracker was officially launched by the Prime Minister of Timor-Leste and the president of the parliament of Timor-Leste on 7th April this is the overall workflow of the immunization tracker all vaccinations are happening at the vaccination posts vaccination posts are operated from community health centers or CHCs or hospitals here you can see reporting and feedback flaws let me show you this with more details so we get vaccines talks to main vaccines go at the ministry of health from abroad and then distributed to the districts from the district stores vaccines are distributed to hospitals, community health centers and health posts where there are refrigerators from there the daily issue vaccines to a vaccination post vaccination happens at the vaccination post and after vaccination they prepare two main forms a line list of people who are vaccinated on that particular day and an aggregated daily return for the vaccination post in main many vaccination posts in remote areas so they don't have enough staff equipment or internet to enter data therefore paper forms are sent to either community health center or hospitals at hospitals, community health centers and municipal health topics there are dedicated staff to enter data they have computers and internet connection in case if they have any issues with data entry at community health center level the forms sent to the upper level that is municipal or national by WhatsApp or Viva so this is the data entry screen of the TECA capture more or less similar to what Pamod showed you so as you all are anyway familiar with the HSU TECA capture I am not going into details so this is the aggregated data end form so in addition to individual data vaccination post daily return vaccination post daily return is the main aggregated form and using that total number vaccinated is entered into the system by vaccination product because we have we are using currently two different products AstraZeneca and Sinovac and the doses along with AESI if any so which enabled us to monitor the vaccine and other than that we enter vaccine stock movements also to the system so that enables us to regularly monitor the vaccine stock in the country so other than TECA capture and aggregated data entry we use event capture for supervision and monitoring to enter supervision and monitoring reports so this is one of the dashboards again I am not going into details as you all are familiar with the HSU dashboards so before launching the system we conducted island wide training within a month so several one page documents or quick user guides or quick reference guides were prepared especially in local language and distributed among the users although we managed to launch the tracker successfully it was not an easy journey we had to face many challenges main challenge we faced is the lack of human resource or lack of trained staff although there was a staff who were trained to enter aggregated data they didn't have any experience in entering individual data so I had to train them intensively over a period very short time period and due to the travel restrictions I didn't have the luxury of getting more trainers or resources from abroad and unfortunately locally there are no trainers available lack of internet connectivity and lack of devices were other challenges some users still use their personal mobile phones and data for this purpose fortunately we had some tablets both for a different purpose and we managed to use them for the vaccination campaign speed of the internet connection and location of the server even matter for example at the beginning during the training period we were using a server located in Europe but later we changed it to Singapore and to improve the speed and accessibility as I mentioned before we entered aggregated data by vaccination post so vaccination posts are not permanent org units so it was planned at the beginning to prepare a list of all the vaccination posts at the beginning but due to the dynamic nature of the campaign we couldn't do it so I have to create new org units that is the vaccination post almost every day that is challenging because they start data entry after completion the vaccination that is usually after 4 or 5 pm and they request us to create vaccination post even around midnight and although we plan to bulk register individuals to the tracker due to the incompleteness of data we couldn't do it so then we had to enumerate the population prior to the vaccination campaign although it is not directly related to the information system another challenge was lack of information about vaccine arrival and other related information although it was very challenging we have achieved a lot we have managed to roll out the tracker nationally with the launch of vaccines national daily reports are generated from the system every day at 10 am and it is to the relevant authorities and media we managed to train HMI staff in the entire country within a month so enumeration of population although data was not complete at the beginning we managed to enumerate eligible population at household level and the TLHIS immunization tracker can generate smart vaccination certificate this is based on WHO recommendations however it was not officially implemented yet so these are the references we used in this project and that is all I have today before concluding I should say that Timor-Leste is a very beautiful country and after Covid-19 pandemic is over I invite all of you to visit if you get a chance thank you thank you Chala and I am putting myself as the first one to come over and visit thank you very much it's always beautiful to see all the things that can be done with the system and how you guys implemented it over there despite everything it's almost inspiring thank you so much I saw before that Pamod tried to reconnect but then he dropped off again so I'm trying to catch up with him on the side so Adolf if you want to go ahead and start presenting already and then we can start continuing to catch up with Pamod on the side thank you good morning good afternoon good evening to some of us I hope you all see my screen yes we do go ahead yes so my presentation is going to share with you the experience of his Pruanda together with the ministry with the government of Madagascar and partners our journey while trying to put in place a system to support the Covid-19 vaccination service delivery to of course to Madagascar people so as you can read from the first slide the universe of Oslo and the collaboration with Dabratio and other experts have elaborated a DHS based Covid vaccine delivery toolkit that comprises of vaccination registry and also with a module help to track the adverse event following the immunization and also with the aggregate part of helping you to capture and report daily reports on Covid-19 vaccines distribution across the country so this PowerPoint this presentation is going to share with you how we what we did and how we managed to scale up this package at the countrywide and share with you the involvement and input from different actors while implementing this package as an overview Madagascar is one of the African country as you can see from this map from war map this is the country in the in the Indian oceans of the if I can say in the east part of Africa so it has over 27 millions of operations in two regions and 140 districts the government plans to start vaccinating population in Madagascar his as the the partner normally supporting countries implementing DHS in the eastern part of Africa and Central Africa with French and English speaking countries in our normal collaboration with the and the Ministry of Health and the Department of Information Systems and the program for the next session we are together to see how best we can elaborate how best we can customize or add out this response to Madagascar needs so we started by putting in place a coordination team made by of course made by the president's office unit in charge of digitization in collaboration also with the Ministry of Health and his technical people to see what are the requirements in terms of infrastructure in terms of tools for this package to be rolled out so during this COVID-19 period as you understand it wasn't really quite easy for some of us who are supposed to provide technical assistance to country team but we have to work with the in-country stakeholders to make sure that the package is adopted to respond to government needs to target 2038,000 population over 18 age by then the country has already received over 2250,000 doses for this service so despite the very limited time we had so we try to collaborate and of course partnering with different MOH and the government partners 277 tablets where we are very able to support this initiative because Madagascar the internet coverage is not so big and looking at the vaccination services the service was not mainly supposed to be offered into the existing facilities rather than having ad hoc vaccination sites to make sure that the targeted population are all reached. Also by then the government has also started using a pre-registration tool this is a digital solution that has been developed by the government to make sure that whoever is in the targeted population is pre-registered so that at every vaccination point the officers are at the site and the people are being expected to come for that service in a very specific site so as I mentioned so the vaccination or the planning started this year April and one of their approach implementing or adopting this package as I said was to make sure that everybody targeted is pre-registered in the national census system and this system was later operated with a DHIS instance that holds this COVID-19 vaccination toolkit so for your information in Madagascar so they have opted to take the package and use it for registration of people vaccinated and also be able to track those who who got the adverse event for immunization and also on daily basis report the stock of vaccines administered to the population so one of the other strategies we used to make sure that we are re-adulting and also comply with the type deadlines was to use a WhatsApp group for feedback and technical assistance so as you can so Rwanda and Madagascar are two different countries and technical assistance was mainly supposed to come from our technical people who were not able to travel to Madagascar for COVID restrictions so through the WhatsApp group we had a number of consultation meetings and provided all guidance and remotely configured servers for this package and also in collaboration with the country the HMIS team we set up servers we configured users and as I said most of the vaccination were not supposed to happen in the existing premises so we had to create ad hoc sites so this also has been through the mentorship and the capacity building sessions with the country team we regularly updated the organization unit of the system to make sure that every new vaccination site is created into the system and all the responsible vaccination officers and data collectors are assigned to the site what I can also mention here the big disimplementation really depends on the use of tablets so computers were quite few and based in the existing facilities so as you understand at the vaccination point they only relied on the use of tablets because they are more portable the battery so you don't complain on the power issues that was also the beauty of using TABRAGE in this implementation of course the other strategy we used to put in place this package was to have a joint national DHS team including as I said multiple stakeholders and what I can here recommend is the government commitment to make sure that a digital solution is put in place to support the vaccination service delivery and to be sure that every person registered is vaccinated and the service and whether antigen, a diverse event everything is directly recorded into the system so in this implementation you combine the use as in most of many developing countries you combine the use of web channels, tablets and also paper forms whereby it wasn't really possible to have a tablet or a computer so as I mentioned the other tool that supported this implementation is among of those at every vaccination site there is a vaccination registry to make sure that if there is any technical problems with the tool people can get vaccinated and go to register into the registers and have vaccination cards and of course use daily reporting forms to as a mitigation plan to when there is an issue with the technologies so on this image you can this is like a picture of the vaccination card that is being used to record information on the first dose received and the second dose received this is of course was in a sense that for the maximum dose for people are two doses so the key points of success in this implementation that I can share with you here present of course the DHIS COVID-19 vaccination toolkit it's ready to use toolkit that has been reviewed with indicators with charts with maps with every features that any country may require to starting from data entry interfaces up to information use features so this was one of the factors that helped us to achieve the success also the country the government ownership and the country team ownership so the implementation of this package has been enforced by the ministry guidelines to make sure that every vaccinated person is registered in the chess tracker whether the vaccination is not done maybe based on different circumstances that those person can have to be recorded after receiving the service so it means at the end of the day the in charge of vaccination sites they have to see to compare case reported into the HIS and case recorded and registered to make sure that numbers are matching of course the third point of success for us is having a daily high level meeting to discuss the implementation issues as we understand during this COVID era there are a lot of circumstances whether internet issues, transportation and so forth so that can affect the progress of any activity so we had to see it on daily basis and share the feedback but for some of us this has been followed up remotely making sure that whether technical part of whether issues shared are addressed remotely of course we had also a small team of technical people of digitalization who on daily basis on every time look at the feedback shared on the WhatsApp groups to make sure that any user feedback, any user concerns are timely addressed of course the last key point of success is we have actually been on the existing experience using the HIS because the country has been using the HIS for a while of course even though we are talking about success of course we made some challenges and we try to come up with some solutions mainly as you may know in some countries adopted the COVID initiative a little bit late and this also as you understand it is time to as a technical team to re-adapt the tool, do configurations, server configuration and so forth the second challenge is the limited time as I said, the limited time to do preparations and train people of course funding gaps are always but also we have also faced the same ones as you understood using tablets means the tablets has to be connected so they have to have internet credits to make sure that at the end of the day on a given set time tablets synchronize with the central server to make sure that any information that are captured in tablets automatically synchronize with the central system of course studying the vaccination so we have much resources in terms of tablets and in terms of computers so that also was another challenge and of course as the previous presenter shared it there is also a skills gap in terms of people using DHIS and tablets especially on some basic troubleshooting skills that for every user who is using tablets has to consider before going to the field especially when it comes to when you are going to there are quite updates that may happen to the central system and if you don't synchronize with the system before you go to the field it may create conflicts and you fail to synchronize especially when you have photos and multiple cases of course we have also faced some delays in the communication with regards to this as vaccination as I previously mentioned people were supposed to be pre-registered into the government system and that system automatically pushes every registered person to the DHIS so that a person comes at the vaccination site already the demographic information already pre-registered and the vaccination, the antigens and so forth so we faced some delays with regards to those. Trying to address to those number of solutions has been thought of so we have developed guidelines to address capacity gap challenges using whatsapps to exchange knowledge and taking some basic troubleshooting skills and of course the government managed to convince partners to cover some part of the internet to ensure that the synchronization of vaccination people is being done and the posts are being generated of course on the field because it happens so fast also in the fields partners including the bridge show consultants has been helping the government people to make sure that on sites whether recording cases or whether supporting in terms of logistics using of tablets, building capacity and so forth. The last and not the least is the high commitment and the ownership of government staff that we try to build in them so that even though we are a little bit supporting the military so we wanted them to have to own the process make sure that every user, every actors that collect us on the fields waiting that the issue is reported on whatsapp it might be a little bit slow the process so we built into the government team the ownership and commitment to make sure that they are equipped with enough skills and the will to support field officers. Even though we managed to come up with some solutions of course there are some persistent challenges that the current implementation is still facing especially when trying to implement advanced strategies so there is still a lack of enough resources and planning to make sure that any mobile or advanced strategies that are being carried out they are well coordinated and also enough resources are available for to support the activity. The second challenge is we need to keep on monitoring because as I said with the technology there might be a lot of people who can be registered on papers and where to be maybe at the end of the day to be captured in the system so there is still that this slowness for site coordinators to capture on legally people recorded on papers and also this can contribute to data quality issues especially where there are reports or weekly reports on how many people have been vaccinated how many the vaccines have been distributed and so forth. There is also still a tendency to change from different users of course if you have been using used to use papers and now we are bringing in tablets bring in technology solutions so of course there are still those challenges but progressively we hope this will be resolved. So the the other challenge that is still there is the remote capacity building as you understand the technical assistance is mainly provided to country team on remote even though we can easily access the servers, troubleshoot servers reconfigure or update servers on to any technical troubleshooting this is being done remotely so it is still a challenge but you are trying to have different work rounds to make sure that the system is always online too and ready to serve. So in Madagascar Madagascar is a French speaking country and of course so we have to implement the French version which still have some bugs and system limitations that are not yet not yet fixed. These ones are mainly in the area of data use whereby there are still some bugs to download, pivot tables to if they have to do analysis on in-exit but this part that the system is able to support and to help to record on daily basis, vaccination cases and also generic reports and system outputs the current status of the system as for the first batch of this I need you to start wrapping up soon because we need to leave the room for the next session soon. Yes please so as the current status so we have completed the first batch of vaccination this June and of course we are now the country is now busy trying to make sure that every case recorded on papers is directly captured in the system and every case that are not synced with the central server are synced to make sure that the quality issues, the type of issues is addressed and also try to see how can improve the quality as we are aiming to a more wider vaccination campaign so that's what I have to share with you I can't end without acknowledging a different individual's efforts starting from the global community that helped us to develop this toolkit that we started and customized it the University of Oslo, his community the Ministry of Health of Madagascar and different departments and of course the partners of the Ministry of Health of Madagascar. Thank you very much I think the you can share your questions and comments on the community of practice and I think the link of this presentation will be shared with you. Thank you very much Thank you very much Adolf, super interesting as usual and it's a pity that Pamela got disconnected and such but probably we will be able to provide a recording of his presentation later on we need to drop off because the next session was not soon I thank you all for your presence and participation and yes I hope you enjoyed just as much and you found some useful points for your own implementation or just in general some interesting points on VHS too