Andreas Hasman
Anna Rapp
David Brown
Publication Date
November 11, 2016

UNICEF Regional Office for South Asia (Hasman); Bill and Melinda Gates Foundation (Rapp); Brown Consulting Group International (Brown)

"There is growing interest to invest in improving our understanding of how HBRs function in practice, how they may support good recording practices that benefit facility-based recording systems, how they may support more effective communication between caregivers and health workers as well as support greater demand for immunization services."

When well-designed, available in adequate supply, adopted, and used appropriately, home-based records (HBRs) complement facility-based records within routine health information systems by providing a standardised form for legibly recording an individual's vaccination history in an organised and consistent manner for future reference and review. To support this argument, this commentary explores a March 2016 gathering of participants from Afghanistan, India, Nepal, and Pakistan, as well as representatives from Sri Lanka, who shared positive experiences from Sri Lanka's HBR. Organised by the United Nations Children's Fund (UNICEF) Regional Office for South Asia and the Bill and Melinda Gates Foundation, the 4-day workshop aimed at optimising the quality, availability, and use of HBRs through a collaborative south-south exchange of state and national officials, development partners, data experts, and design professionals.

As detailed here, Sri Lanka introduced a home-based immunisation record more than 40 years ago; all children born in the country are issued an HBR, which is used until the age of 14 years. Sri Lanka has established "a culture of responsible ownership and utilization of the document", with current HBR ownership prevalence levels of greater than 90%. Since its introduction, the record has undergone numerous modifications to reflect the evolving needs of the programme. Today, the Sri Lanka home-based record (images available online here) is integrated into the national child health programme and includes information needed by caregivers to optimise children's nutrition and health status. It covers a range of topics, including newborn care, breastfeeding, complementary feeding, immunisation, and psychosocial development.

The workshop hinged upon a user-centred approach whereby participants began by focusing on the users - caregivers, healthcare workers, and public health officials - who routinely engage with HBRs, then worked together to hypothesise how this tool could better serve the needs and challenges of each of these users over time. Teams collaboratively generated a concept for improvements to the HBR, visualised and prototyped changes aligned with the specific country context, and created a plan for implementation. The actions proposed in these implementation plans were tailored to the distinctive roles of the HBR in the local context (e.g., degree of integration with health programmes other than immunisation and balance between role of HBR as delivering health education messaging and as serving as a data recording tool). However, it is noted that "motivating real change in national immunization programmes will ultimately require leveraging existing opportunities in health system strengthening. For instance, all countries can ensure plans for HBR printing and distribution are integrated into comprehensive health planning processes (e.g., comprehensive multi-year plans), including dedicated resources through annual budgeting." It is also necessary, according to the commentary, to identify and address knowledge gaps, such as those related to appropriate utilisation of HBRs by health workers (e.g., document design, absent or lacking pre-/in-service training on the appropriate use, individual behaviour of health workers, and institutional behaviour of the health system vis-à-vis use of and value towards HBRs).

Not all countries are like Sri Lanka, though. In many countries, a child's vaccination status is first recorded in facility-based registers. Although such registers provide a potentially important source of information for frontline health workers, they are often poorly designed and/or implemented resulting, in information that is of poor or unknown quality and falling short of providing a useful tool to facilitate tracing of a child's vaccination history and/or follow-up of drop-outs through outreach activities. "Current inefficiencies (i.e., missed opportunities for immunization, extra-immunization) that result from suboptimal documentation are no longer acceptable; a more effective and efficient system is imperative. Put very simply, too much that needs to be known remains unknown, and, unfortunately, the poor quality data that exist in many areas of the world fundamentally shapes what we know about the performance of immunization programmes which in turn shapes how decisions are made. We believe HBRs represent an opportunity as a cost-effective frontline mechanism supportive of (i) improvements in caregiver awareness, compliance and empowerment to seek out health services for their child, (ii) public health monitoring through improved survey coverage estimates based on greater proportions of documented evidence and (iii) high quality primary care service delivery."


Vaccine Volume 34, Issue 47, November 11 2016, pages 5697-5699 - sourced from Home-based Record Repository, November 10 2016.