Vaccinations in low-income countries: Why technology is not enough

Immunization is a cornerstone of public health, saving millions of lives every year. Yet in LMICs, ensuring the effectiveness of vaccination programs is a complex undertaking, partly due to poor data quality and difficulties in managing the vaccine supply chain. 

These systems have traditionally relied on paper-based methods, which are not only prone to errors; they are also inefficient when it comes to providing timely information for strategic decision-making. In recognition of the potential of digital technologies, there is growing global interest in adopting and ramping up tools such as eIRs and eLMIS. Although they have already delivered positive results in high-income countries, their application and evaluation elsewhere in the world remain problematic. 

This research project examined the effect of eIRs and eLMIS in four LMICs to support decisions on the scale-up and future investments in these technologies, seeking answers to questions such as:   

• What impact do these systems have on national immunization schemes as far as programming and economic aspects? 

• What are the main barriers and opportunities arising from their implementation?

Researchers assessed the introduction of eIRs and eLMIS in 50 health facilities in Guinea, 88 in Honduras, 36 in Rwanda, and 101 in Tanzania from October 2021 to September 2022. Two separate papers presented conclusions on the clinical and economic aspects of the experiences in these four countries. 

In the analysis, purposive sampling was applied to select regions, districts, and health facilities based on predefined criteria, including facility type, population size, vaccination coverage, and level of implementation of the electronic tools. Researchers adopted a mixed-methods approach, collecting primary data through semi-structured questionnaires, standardized assessments of healthcare workers’ skills, and audits of data accuracy. Information was gathered on the utilization of digital tools, user experience, infrastructure, staff needs, decision-making processes, and the perceptions of healthcare workers and vaccine recipients. 

In each of the four countries, the research team established steering committees with local stakeholders, including members of the Ministry of Health, members of the Expanded Programme on Immunization (EPI), and local immunization experts and consultants.

The findings show that the introduction of eIRs and eLMIS is associated with perceived improvements in the processes and outcomes of national immunization programs. In particular, user satisfaction with the tools was high at 87%. Additionally, most eIR users noted higher levels of both process efficiency (81%) and quality of vaccination services (89%). Finally, eLMISs were linked to improved perceived quality of vaccine stock data and a reduction in stockouts. 

However, the studies also reveal what needs to happen to fully realize the potential of these digital tools. In all four countries, the electronic systems were implemented while retaining the previous paper-based system as the main source of information for vaccination management and reporting. This dual-system approach made the impact on costs unclear, and in fact only Tanzania recorded a reduction in management costs. Moreover, the use of electronic systems for local-level decision-making was found to be extremely limited in all four countries. 

Major barriers to maximizing the benefits of these tools included inadequate digital infrastructure, despite high levels of digital literacy among healthcare workers, and poor interoperability with civil registries, which limits the ability to track unvaccinated children. 

The researchers concluded that to optimize the effectiveness of electronic tools in LMICs, there must be full governmental ownership, targeted infrastructure investments, and a shift to fully digital systems. Even more importantly, adopting such advanced tools only makes sense if they are leveraged for decision-making, not just for reporting and statistics. 

SDA Bocconi continues to conduct global health research through the European Horizon project Reach Out, aimed at closing the immunization gap by reaching unvaccinated children with more equitable and economically sustainable delivery strategies. 

Federici C, Verykiou M, Cavazza M, Olomi W, Irakiza P, Kayumba K, Rodriguez E, Castillo Mendoza L, Malvolti S, Hugo C, Ntinginya N, Camara S, Sabi I, Sano N, Sibomana H, Condo J, Torbica A, Jommi C, Mantel C, Mangiaterra V. “The Costs of Digital Health Interventions to Improve Immunization Data in Low- and Middle-Income Countries: Multicountry Mixed Methods Study.” J Med Internet Res 2025;27:e62746. DOI: https://doi.org/10.2196/62746. 

Mantel, C. Hugo, C. Federici, N. Sano, S. Camara, E. Rodriguez, L. Castillo, J. Condo, P. Irakiza, I. Sabi, E. Nyanda, W. Olomi, M. Cavazza, V. Mangiaterra, M. Verykiou, E. Ferenchick, A. Torbica, T. Cherian, S. Malvolti, “Impact of electronic immunization registries and electronic logistics management information systems in four low-and middle-income countries: Guinea, Honduras, Rwanda, and Tanzania” Vaccine, Volume 54, 2025. DOI: https://doi.org/10.1016/j.vaccine.2025.127066.