DIGITAL SAFEGUARDS & ENABLERS FOR COVID-19 VACCINE DELIVERY: COUNTRY CASE STUDIES © 2022 International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW, Washington, DC, 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Cover and document design by Nik Nikam Photo credits: shutterstock.com TABLE OF CONTENTS Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Israel | Foundational digital infrastructure and robust data analytics accelerate the vaccine response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Lebanon | The IMPACT Vaccine Management Platform: Succeeding amidst unprecedented crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Philippines | The Philippines Vaccine Management Platform: Fit-for-Purpose Tools Meet the Needs of a Diverse Population and Set the Stage for Accelerated Digital Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Rwanda | Paving the way for regional adaptation of global digital public goods to meet local needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Tunisia | eVax: Unprecedented coordination drives vaccine delivery and sets the stage for ongoing digital development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 4 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies ACKNOWLEDGMENTS These case studies were prepared by Chrissy Martin Meier as part of an ongoing collaboration between World Bank Group’s Digital Development and Health, Nutrition & Population teams on digital safeguards and enablers for COVID-19 vaccine delivery. This note benefited greatly from input and review by World Bank Group staff, including Marie Eichholtzer and Audrey Ariss; and was prepared under the supervision of Vyjayanti Desai. Critical insights were provided by: Israel | Gabriel Catan from the World Bank, as well as government officials including Adam Cutler and Dafna Segol. Lebanon | Abdallah Jabbour, Rita Kerbaj, Hiya Mahmassan, and Ronald Eduardo Gomez Suarez from the World Bank. The team is also grateful for feedback from the government through IMPACT. Rwanda | Patrice Mwitende, Wilson Muyenzi and Luda Bujoreanu from the World Bank. The team is also grateful for feedback from government officials, including Hassan Sibomana, Albert Tuyishime, and Baptiste Byiringiro. Philippines | Jonathan Marskell, Ronald Mutasa and Vida Gomez from the World Bank, as well as government officials from the Department of Health. Tunisia | Eric Dunand and Denizhan Duran from the World Bank, as well as government officials including Ines Ayadi and Hassen Harrabi. This work is supported by the Digital Development Partnership, administered by the World Bank. The Digital Development Partnership (DDP) offers a platform for digital innovation and development financing. DDP brings public and private sector partners together to advance digital solutions and drive digital transformation in developing countries. To find out more about the DDP, visit http://www.digitaldevelopmentpartnership.org WITH SUPPORT FROM: WITH SUPPORT FROM: Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies 5 INTRODUCTION Two years after the start of the COVID-19 pandemic, the world has witnessed the largest vaccination effort in history. Successful delivery of vaccines has been the global hope to end this public health crisis. Countries have relied on highly scalable, reliable, and efficient digital systems and digital health solutions to organize the orchestration at record breaking speed of mass vaccination programmes. These solutions support functions across the whole vaccine deployment lifecycle, from planning and management, to supply and distribution, program delivery, and post vaccination monitoring and care. Figure 1: Digital Solutions Play a Role at Each Step of the Vaccine Delivery Source: World Bank, 2021 The ability for such solutions to help, rather than hinder, depend on a range of factors, including a country’s digital readiness, such as the quality and coverage of its internet, digital literacy of workers and the population, existing enablers such as digital health information systems and foundational ID system, as well as pre-existing legal frameworks for data protection and cybersecurity. Coordination between health and ICT institutions across government and an active private sector have also been critical factors in successful implementation of COVID-19 rollout. Through five country case studies, this report aims to share the experiences of different national digital vaccine delivery initiatives, the challenges faced and success factors, and draw lessons learnt from these experiences. The World Health Organization (WHO) is already warning about the need to prepare the next pandemic that will disrupt the world and potentially lead to the 6 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies death of millions of people, which is unfortunately a statistical certainty.1 It is all the more important that we take stock of the successes and challenges of the COVID-19 vaccination efforts to date, continue to invest in resilient digital, health, and digital health ecosystems. Overview of the case studies Five countries were selected for these case studies, spanning multiple regions and covering a range economic contexts and levels of digital health maturity: Israel, Lebanon, Philippines, Rwanda and Tunisia. The countries were selected in large part for the speed and innovation with which they implemented digital solutions for COVID-19 vaccine delivery. The latter four benefitted from World Bank financing and technical assistance support. All of these countries launched new platforms in just a few months, some within just a few weeks. The case studies were developed based on background research as well as semi-structured interviews conducted virtually with World Bank staff, government and private sector representatives involved in the vaccine rollouts. Israel demonstrated how a strong foundational digital health infrastructure paired with robust data analytics enabled the earliest and one of the world’s fastest vaccination campaigns. The country was able to rely on established digital platforms and infrastructure, as well as skilled individuals and a culture of data-driven decision making. Once challenges linked to vaccine hesitancy started emerging, Israel was able to use the strong evidence collected regarding vaccines’ safety and efficacy and launch broad communication campaigns via a variety of channels, including social media platforms. Lebanon managed to launch a successful vaccine management platform (IMPACT) while facing unprecedent financial crisis exacerbated by both the COVID-19 pandemic and the Beirut port explosion. The platform was developed in just a few weeks thanks to the excellent collaboration with a local consultancy firm which ensured an agile and modular approach to development and the oversight of the Central Inspection which ensured the solution was developed in adherence with international best practices in terms of data privacy and security, as well as ensured minimal risks of fraud and misuse that would have undermine the population’s trust in the campaign. The Philippines deployed a fit-for-purpose vaccine management platform to facilitate the consistent capture and processing of vaccination data across the country, as well as launched in a record time a digital   For more information about pandemic preparedness, see the website of WHO at https://www.who.int/ 1 westernpacific/activities/preparing-for-pandemics Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies 7 COVID-19 certificate to answer the pressing needs of its 2 million overseas foreign workers (OFWs). The Department of Health leveraged a digital public good with long term vision of investing in key building blocks of an overall digital health ecosystem for the country, and integration with the newly established digital identity system (PhilSys), rather than one-off solutions. Rwanda demonstrated the value of its long-term investment in digital public goods and developing local digital skills and competences. The country was able to customize and expand its existing implementation of DHIS2 to create new modules to manage COVID-19 vaccine delivery fit for the specific needs of the country. This deployment was done as part of a Joint National COVID-19 Task Force tasked with identifying the needs in terms of supply and delivery of vaccines, healthcare professionals staffing, and internet to ensure that the solution developed is fit to the local context. Tunisia turned the COVID-19 response challenge into an opportunity for the country’s long term digital health goals. Thanks to an unprecedented coordination between health and ICT government institutions, the country developed the eVax platform to securely store all transaction records, and track and certify COVID-19 vaccinations. The platform is paving the way for a fully-fledged immunization registry and was the catalyst for the introduction of an electronic health record in the country. The system was able to rely on pre-existing investments made by the country in building a near universal foundational ID system. To ensure the success of the eVax platform, the country implemented extensive measures to increase digital adoption and provide digital skills training to healthcare staff. ISRAEL Foundational digital infrastructure & robust data analytics accelerate the vaccine response Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Israel 9 Highlights from the case study • Israel’s vaccination campaign benefited from decades of investment in reliable digital platforms, infrastructure, and skills, which allowed for a digital, data-driven approach from inception. • The country’s vaccination strategy placed a large emphasis on data infrastructure, data management, and data analytics. • The Ministry of Health combined the analytics with broad communications campaign to reduce vaccine hesitancy, sharing data through a wide variety of channels, including local news stations, the MoH website, and social media platforms. Context: Strong digital foundations can be attributed to a number of factors, both support unprecedented response intrinsic and extrinsic to the healthcare system.3 Israel is a relatively small, high-income county times with a population of 9.3 million and a GDP per capita of USD 44,168. The country has one of the Israel implemented one of the fastest COVID-19 most advanced healthcare systems in the world— vaccination programs in the world, delivering two ranked 6th globally by the Bloomberg Index4—and doses to over half of the country’s population by spends the equivalent of 8 percent of GDP on health the end of March 2021, just three months after annually. The healthcare system benefits from the first COVID-19 vaccine was approved1 by the longstanding investments in organizational, IT, World Health Organization (WHO). The country’s and staff capacity. This strong foundation aided highly data-driven approach informed strategies the implementation of a well-tailored vaccination worldwide, inspiring many countries to begin distribution strategy. a booster program after Israel’s data provided evidence of waning immunity from the initial Even still, Israel has suffered during the ongoing vaccine protocol in late 2021. The country is also COVID-19 pandemic. There have been at least 1.35 a leader in administering fourth doses, with people million confirmed cases in the country, experienced over the age of 60 and healthcare workers who in five waves.5 Israel has mitigated the impacts received their first booster more than four months of these waves through a number of measures ago eligible for a second booster.2 focused on four key principles: improving hospital infrastructure, ensuring accessible testing, data- Israel’s rapid and effective vaccination campaign based decision-making, and pursuing widespread 1   “WHO issues its first emergency use validation for a COVID-19 vaccine and emphasizes need for equitable global access,” World Health Organization, December 31, 2020, https://www.who.int/news/item/31-12-2020-who-issues-its-first-emergency-use-validation-for-a- covid-19-vaccine-and-emphasizes-need-for-equitable-global-access. 2  As of January 2022. 3   Bruce Rosen, Ruth Waitzberg, and Avi Israeli, “Israel’s rapid rollout of vaccinations for COVID-19.” Israel Journal of Health Policy Research 10, no. 6 (2021): https://doi.org/10.1186/s13584-021-00440-6. 4  “Israel Award 6th Place in the Health Care Efficiency Index,” Sheba Global, 2018, https://www.shebaonline.org/health-care- efficiency-index/#:~:text=Israel%20Awarded%206th%20Place%20in%20the%20Health%20Care,ranks%20the%20health%20care%20 efficiency%20of%2056%20countries. 5  A wave is defined as a significant increase in the overall number of cases for a specific period of time. 10 Israel Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies vaccination. The vaccination campaign benefited automated system was developed to support the from decades of investment in reliable digital unique nature of the vaccination operation: the platforms, infrastructure, and skills, which allowed short shelf life for vaccines required a single, cold for a digital, data-driven approach that was in storage facility nationally with distribution directly place in advance of the first vaccine delivery. As of to the points of administration. A web-based February 1, 2022, 72 percent of the population had inventory and supply chain management system received two doses of the vaccine, and 66 percent allowed vaccine centers to place orders based on had received three doses.6 booked appointments and taking into account existing inventory for all vaccine components. This gave MoH centralized control over vaccine Design and implementation: Existing supplies, eliminating waste. digital solutions are adapted for the COVID-19 vaccination campaign The third priority was to strengthen the availability and use of anonymized data for decision-making. Israel’s vaccine management approach was In Israel, each citizen has a digital medical record implemented by the Ministry of Health (MoH), which tied to their national ID number. Patients’ medical worked with the country’s four health maintenance information can be presented in a hospital or organizations (HMOs) to ensure appropriate and medical facility for use during their visit. The effective systems to support both the patient personal data stays with the patient’s primary journey and supply-chain management.7 In care provider, and never transfers to a new facility addition to ensuring that the delivery approach for use beyond their visit, nor is it transferred to and systems were in place before any vaccines the MoH. Due to the extraordinary nature of the were delivered, the digital approach benefited from COVID-19 emergency, an exception was made, three key success factors. allowing MoH to receive data on confirmed cases, demographics, and vaccinations for use in a First, to ensure a smooth patient journey, the national database. This anonymized data was MoH expanded and adjusted the existing web used to identify trends and drive evidence-based application used for routine vaccinations in decision making for policymakers in Israel and schools. A team of MoH personnel then conducted across the globe. online, remote trainings on the system for each health facility to ensure correct data entry for Insights: Digital data drives vaccine each vaccine recipient. The MoH also improved uptake existing infrastructure, ensuring that servers were robust and had sufficient space available to handle As Israel experienced rising infection rates leading the new use case and data load. In addition, HMO’s to a fourth wave of infections in mid-2021, this high- appointment booking systems were adjusted and level data proved crucial in identifying a principal utilized, ensuring that individuals could book their challenge: waning immunity. When policymakers vaccine appointment through familiar systems saw that infections among vaccinated individuals and in convenient locations. were caused by waning vaccine effectiveness, rather than breakthrough infections, they quickly Second, for supply chain management, a largely 6   Data from Our World in Data and NYTimes.com, accessed 25 April 2022. 7   By law, every Israeli resident must be registered with an HMO. There are four main HMOs in the country, which operate as non-profits. All offer the same general services as mandated by law, with a choice of hospitals, doctors, and complementary services. HMOs only share data with the MoH, even for statistical purposes, with legal permission granted for specific health reasons, such as the COVID-19 pandemic. For more: www.btl.gov.il/English%20Homepage/Insurance/Health%20Insurance/Registration/Pages/default.aspx Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Israel 11 launched one of the world’s first booster programs.8 and drove vaccine uptake across the population. The booster campaign, launched quickly and prioritizing the most vulnerable (those over age Looking forward: A global example of 60), saved countless lives (figure 2). In addition, data-driven decision making the country avoided a fourth lockdown, preventing further economic and social damage resulting from Israel’s example provides direction for other restrictions that prevent individuals from earning countries with less advanced healthcare systems. income and maintaining social ties. Furthermore, The country pursued a data-driven approach that Israel’s data-driven approach inspired other informed decision-making while still protecting countries to launch their own booster programs. personal data. Because the data collected was robust, Israel was able to inform policymakers Throughout the vaccination campaign (including the worldwide, allowing for studies on the real-life booster campaign), the MoH published the number effectiveness9 of COVID-19 vaccines that would of hospitalized individuals among vaccinated and not have been possible otherwise. Through the use unvaccinated groups. This data conveyed a clear of familiar and user-friendly systems, preparation message: vaccines work, minimizing the effects of of systems and approaches in advance of the illness and keeping people out of the hospital. vaccine distribution, and use of data to launch a The MoH distributed this data through a wide booster program quickly enough to counter the variety of channels, including local news stations, fourth wave, Israel continues to avert infections, the MoH website, and social media platforms. This hospitalizations, and deaths—and help other messaging helped to overcome vaccine hesitancy countries to do the same. 8  A “breakthrough” infection refers to a confirmed case of COVID-19 in a previously vaccinated individual. A “booster” shot is a given after a previous vaccination in order to maintain or increase the protective immune response provided by the previous vaccination. For COVID-19, most of the available vaccines are administered initially as two doses; thus, the booster shot is a third dose. 9   Hagai Rossman et al.,“COVID-19 dynamics after a national immunization program in Israel,” Nature Medicine 27, (April 19, 2021): 1055–61 Figure 2: A life-saving booster campaign Following the booster a decrease in confirmed infections was observed among people aged 60+ Source: Sharon Alroy MB, MPH, MBA, and Ron Milo, PhD, “Booster protection across ages—data from Israel,” (presentation, Vaccine and Related Biological Products Advisory Committee Meeting, October 14–15, 2021), https://www.fda.gov/media/153086/download 12 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies LEBANON The IMPACT Vaccine Management Platform: Succeeding amidst unprecedented crises Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Lebanon 13 Highlights from the case study • Lebanon’s vaccine management platform was developed in just a few weeks, and launched before the beginning of registrations. Use of an agile, iterative and modular approach to development enabled a launch with essential features at first, adding functionalities and updating based on user feedback over time. • Developed in collaboration with a consultancy firm, access to the right advanced digital skills within the private sector was primordial. • Overseen by Central Inspection, a government oversight and public reform body, and integrating oversight mechanisms and adherence to international good practices for data privacy and security from the start was critical to avoiding fraud and misuse that could quickly undermine trust in the platform. Context: Launching during particularly challenging time Globally, the success of each country’s COVID-19 vaccination campaign was critical to mitigating Designed, built, and implemented in a short the impacts of the pandemic. In Lebanon it was period of time, the IMPACT vaccine management even more so, with multiple protracted crises and platform in Lebanon overcame significant trust in public authorities at an all-time low. Thus odds in order to launch quickly and operate the Government of Lebanon, with the support successfully in a country experiencing multiple, of the World Bank and other partners, prepared severe crises. The COVID-19 crisis hit Lebanon thoroughly for the vaccination campaign: at a particularly precarious time in the country’s conducting a vaccine readiness assessment, history: in 2020, as the virus spread, Lebanon establishing the COVID-19 Vaccine National saw unprecedented devaluation of its currency Coordinating Committee (NCC), preparing the along with inflation rates in the triple digits. The National COVID-19 Deployment and Vaccination economic situation led to record unemployment Plan (NDVP), and building the IMPACT digital and a decrease in purchasing power that resulted vaccination management platform.2 in well over half of the population falling below the poverty line. Furthermore, the country experienced The vaccination campaign, launched with acute shortages of fuel and electricity blackouts financing from the World Bank, began on February across the country. In the same year, Lebanon 14, 2021. The IMPACT platform was launched suffered the Beirut Port Explosion, the world’s in time to register the first dose, then rolled largest non-nuclear explosion, which killed out in March. IMPACT, the Inter-Ministerial and hundreds, wounded thousands, and destroyed Municipal Platform for Assessment, Coordination, several hospitals with the capacity to treat and Tracking, is owned and overseen by Central COVID-19 patients.1  Inspection, a government oversight and public 1 Ghina R. Mumtaz, et al, “Modelling the Impact of COVID-19 Vaccination in Lebanon: A Call to Speed-Up Vaccine Roll Out.” Vaccines 9, No. 7 (2021), 697, https://www.mdpi.com/2076-393X/9/7/697/html, and “The World Bank in Lebanon” (website), https://www. worldbank.org/en/country/lebanon. 2 “World Bank and IFRC Support Independent Monitoring of COVID-19 Vaccine Campaign in Lebanon,” International Federation of Red Cross and Red Crescent Societies, updated February 2, 2021, https://www.ifrc.org/press-release/world-bank-and-ifrc-support- independent-monitoring-covid-19-vaccine-campaign-lebanon. 14 Lebanon Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies reform body tasked with inspections and audits Design: Supporting a data-driven and of public bodies. The platform played a key role secure vaccination process in driving transparency and trust in the overall vaccination campaign. As of June 28, 2022, over The IMPACT platform supports the vaccination 2.5 million individuals in Lebanon had received at process from registration through certification, least one dose of the COVID-19 vaccine.3 and has been adapted over time to account for multiple dose regimes and booster shots (figure 3). The IMPACT platform was designed to work despite Using anonymized data, the IMPACT platform the limited digital government infrastructure provides all stakeholders with a comprehensive available. While Lebanon has strong broadband overview of the nationwide vaccination campaign and mobile coverage rates, there is no national through a public dashboard (figure 4). The public health information system. Past efforts to use dashboard provides a wealth of information digital information systems to drive transparency based on the anonymized data, including high- and efficiency within the government failed, due level statistics on the number of registrations in large part to a fragmented approach caused and vaccine doses, disaggregated by segments by insufficient budget allocations and lack of interest (healthcare workers, teachers, of coordination among government bodies. those with co-morbidities, refugees, etc.) and Government systems are not interoperable, and geographic breakdown. often do not use a common list of basic data points, such as names of districts with consistent The IMPACT platform stores all data relevant to spelling, to support data sharing between the vaccination process securely and complies administrative bodies.4 with Lebanese Law 81/2018 on e-transactions and data protection. Furthermore, it aligns with Despite these challenges, a bright spot in Lebanon’s the European data protection regulations as digital development is the level of talent and outlined under the European Union’s General Data innovation among the young and urban population.5 Protection Regulation (GDPR) (see figure 5). For example, in 2019, INSEAD ranked Lebanon fourth in the “new product entrepreneurial Sensitive and personally identifiable information activity” category in its Global Talent Competitive are kept private and secure, while data classified Index, indicating that entrepreneurs are not only as public is systematically archived and displayed active, but also producing innovative and original on the public dashboard in line with the Access products and services. The presence of local digital to Information Law (Law 28/2017). Access rights talent and skills, albeit concentrated among a to the data are restricted and provided on the small portion of the population and threatened basis of need. For example, medical staff can by emigration6 resulting from the series of crises, see appointment data only, whereas Ministry provided a strong starting point for the success of of Public Health (MoPH) administrators are also the IMPACT platform. able to access an individual’s registration data in order to send appointment invitations. In terms of cybersecurity, access to the platform requires two- 3 IMPACT platform accessed June 28, 2022. 4 Jessica Chemali, “Lebanon’s Digital Transformation Exposes Fundamental Administrative Shortcomings,” The Legal Agenda, March 3 2021, https://english.legal-agenda.com/lebanons-digital-transformation-exposes-fundamental-administrative-shortcomings/ 5 Due to the political and economic situation in the country, many young professionals are now leaving. See, for example, World Bank, “Lebanon is in a Deliberate Depression with Unprecedented Consequences for its Human Capital, Stability, and Prosperity,” December 1, 2020, https://www.worldbank.org/en/news/press-release/2020/11/30/lebanon-is-in-a-deliberate-depression-with-unprecedented- consequences-for-its-human-capital-stability-and-prosperity 6 ibid Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Lebanon 15 Figure 3: Overview of vaccine process as supported by IMPACT 1 2 3 4 5 6 After 1st dose, the IMPACT sends IMPACT sends vaccination center a reminder Once registered, profiles Registration can and SMS enters dose on after each dose are deduplicated, and Upon arrival at the be completed invitation IMPACT (type of enter adverse the individual receives vaccination center, online, by calling to book an vaccine and batch event following an SMS verification the individual the hotline, or in- appointment, number). Individuals immunization; of registration, which must show their person through choosing the receive SMS with a there is no includes an automatically confirmation SMS municipalities or date, time and link to access their reminder for those generated 10-character and ID. at the hospital. vaccination vaccine certificate.** that miss an identifier for each person. center.* appointment. Source: World Bank staff (Note: Invitations were initially sent to priority segments of the population. This step was dropped when vaccines became broadly available. Certificates are automatically updated with each new dose.) factor authentication, and data is sent between appointment booking, SMS reminders for vaccine services over SSL connections using encrypted doses, the ability of vaccinated individuals to record digital certificates. Data is stored on dedicated side effects, and the ability to view and print EU- servers under the oversight of Central Inspection. compliant vaccine certificates. Implementation: Adaptation to overcome The team faced several challenges during challenges and create an effective platform implementation. Deduplication of individuals in the To roll out and organize the vaccination campaign, the system was the first. All residents are eligible for MoPH reached out to Central Inspection to request vaccination, thus the national ID (only available to use of the existing IMPACT platform. The IMPACT citizens) could not be used as the sole identifier in the platform was developed in collaboration with Siren system. Initially the system attempted to tackle this Associates, a consultancy firm with local offices by using a phone number for registration, creating an and staff to face the specific needs of the COVID-19 identifier for deduplication using first name/ middle vaccination campaign. Siren built the vaccine portion name/ last name/ phone number. However, some of the platform from scratch, entirely pro bono, by five people used a family member’s phone number to dedicated developers and several interns. IMPACT register since they did not have their own phone. Siren launched a pre-registration form on January 28, responded by adapting the system to deduplicate 2021, enabling people to register for vaccination, and identities by name and date of birth. the first vaccine was delivered through the system on February 14. Thus the registration, appointment, and Power outages presented a second challenge, hospital modules were deployed and active within hindering both vaccine registration and the recording three weeks, providing the base platform on which of doses. To address this, IMPACT released an offline future modules could be built. registration module to enable healthcare workers to register individuals and record a vaccination outside As the vaccination campaign progressed, Siren added of a vaccine center, or if a vaccine center’s systems more modules, responding to new requirements are offline. The information is uploaded later, when through an agile development approach. The system systems are back online. initially allowed anyone to register, regardless of vaccine availability. Later, a feature was updated Finally, data storage presents an ongoing challenge. to allow private employers to send invitations to The system initially used a data storage provider their employee to make a vaccination appointment in Germany, Leaseweb. Due in part to political (many of whom procured vaccines separately from pushback about storing data in a foreign country, the government). Client-facing features include data is now stored in Lebanon at Ogero, a local, 16 Lebanon Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Figure 4: Screenshot of the vaccine management platform public dashboard Source: Sharon Alroy MB, MPH, MBA, and Ron Milo, PhD, “Booster protection across ages—data from Israel,” (presentation, Vaccine and Related Biological Products Advisory Committee Meeting, October 14–15, 2021), https://www.fda.gov/media/153086/download Figure 5: Lebanon’s Vaccine Management Tool is GDPR-compliant Privacy by Design Breach Notification Right to Access & Consent Matters Right to be forgotten Data protection is Breaches to the data are Portability Users are explicitly asked Users have the right to respected from the first immediately reported and Users are notified on the to give consent once they opt out of the process and written line of code. It is not handled by the technical usage of their data. start filling the information. erase their data from the a retrospective addition. team. system. Source: Data security PowerPoint produced by IMPACT, unpublished state-owned, fixed-infrastructure operator. This Insights: Coordination and oversight move is a nod to the ongoing, global debate around data localization, data sovereignty, and trans- Unlike past efforts, relevant government bodies national data flows.7 This decision presented initial managed a sufficient level of coordination to enable challenges, as Ogero had never provided cloud the IMPACT platform’s success. Coordination was data storage services before. Looking forward, it encouraged in several ways, starting with the NCC, is likely to present additional challenges, with the chaired by a non-governmental senior medical ongoing power outages in the country threatening practitioner, which developed the vaccination data security and business continuity. strategy. The strategy is being implemented by the 7 Many countries also require data to be held in servers located in-country, which is referred to as data localization. This is motivated by many political factors, including the desire to ensure that data can be accessed by local law enforcement and cannot be accessed by foreign actors. While data localization may seem attractive, decision makers must consider potential downsides including weaker security, an undermining of data portability and interoperability, and challenges related to business continuity in the face of an emergency. Traditional justifications for data localization is also flawed because other parties can still gain access to data, regardless of location. For more: https://blogs.worldbank.org/digital- development/connecting-developing-countries-cloud-critical-debates-data-infrastructure. Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Lebanon 17 COVID-19 Vaccination Executive Committee, which compensation, ensured that an effective is chaired by the MoPH. Buy-in from the MoPH, platform was developed and launched in time particularly since the government transition8 in for the vaccination campaign, and subsequently September 2021, has been instrumental. The MoPH sustained and optimized. coordinates outreach to targeted individuals and is responsible for training healthcare workers in the Looking forward: Toward more effective vaccination centers to ensure effective data entry. digital government in Lebanon Furthermore, the MoPH maintains a call center to answer COVID-related questions and act as grievance The vaccine management platform overcame redress mechanism (GRM) to field complaints. significant challenges to operate effectively within a country enduring multiple severe crises. Thanks Integrating oversight mechanisms from the to a strong private sector partner, the technology is start was also critical to avoiding fraud and robust, aligning with global best practices in data misuse that could quickly undermine trust in the protection and ensuring inclusive access through platform. There are two oversight bodies involved. offline capabilities, among other adaptations. Through As mentioned, Central Inspection oversees the the support of the current MoPH, the strength of the platform, auditing governance and performance, IMPACT platform, and strong oversight, the platform and publishing audit reports. Furthermore, as part has succeeded in driving efficiency and transparency of World Bank financing of vaccine procurement, where previous digital government platforms, the International Federation of Red Cross and implemented in easier times, failed. Red Crescent Societies (IFRC) is acting as a third-party monitoring agency, helping to ensure This success can, potentially, be leveraged to vaccine deployment complies with the World build a national health management information Health Organization’s National Deployment system: the system already contains a unique and Vaccination Plan9 for COVID-19 vaccines, identifier which can now be used as a health ID, and World Bank requirements. This oversight, and individual profiles can be expanded to serve as in combination with the digital platform, is electronic health records linked to this ID. As part of instrumental in allowing priority individuals to the broader IMPACT platform, which also contains receive designated vaccines. modules related to public administration and rural development, there is potential for a strong Hosting the platform under the existing IMPACT contribution to nascent efforts to make public platform helped to ensure independence and sector data more readily available and accessible. accountability, as IMPACT has experience The IMPACT platform not only supports vaccine building e-government tools through its Public management and health system digitization Administration, Rural Development, and Lebanese efforts: it might also be instrumental in setting the Parliament modules.10 These factors, combined stage for a cultural shift toward data sharing and with the expertise, commitment, and willingness evidence-based policymaking.11 of Siren Associates to work quickly and without 8 Will Todman, “Lebanon’s New Government,” Center for Strategic and International Studies, September 10, 2021, https://www.csis. org/analysis/lebanons-new-government. 9 “COVID-19 national deployment and vaccination plan: Submission and review process, 29 January 2021,” World Health Organization, 2021, https:// www.who.int/publications/i/item/WHO-2019-nCoV-NDVP-country_plans-2021.1. 10 For more information on these platforms, visit https://impact.cib.gov.lb/home#platforms_section. 11 Karim Merhej and Maysa Baroud, “The Digital Economy as an Alternative in Lebanon: Focus on Micro, Small, and Medium Enterprises,” Issam Fares Institute for Public Policy and International Affairs, American University of Beirut, Policy Brief #5, December 2020, https://www.aub.edu.lb/ ifi/Documents/publications/policy_briefs/2020-20/20210201_The_Digital_Economy_as_an_Alternative_in_Lebanon.pdf. 18 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies PHILIPPINES The Philippines Vaccine Management Platform: Fit-for- Purpose Tools Meet the Needs of a Diverse Population and Set the Stage for Accelerated Digital Development Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Philippines 19 Highlights from the case study • The Philippines developed its vaccine information management system (VIMS) to facilitate the consistent capture and processing of vaccination data across the country and gather key insights to inform the supply chain management of the COVID-19 vaccines. • Combining an agile development approach and the use of digital public good, the Philippines were able to start issuing digital COVID-19 certificates in less than 3 months. • Initial manual data entry and quality issues in the immunization registry demonstrated the transformation potential of the newly established Digital Identity (PhilSys) for the country. • Reliance on local government units was critical to the success of the vaccination campaign considering the limitations in terms of connectivity and digital infrastructure of the country. Context: A Vaccination Campaign to between 2010 and 2019. This trend relied on a Support Renewed Economic Growth larger and young population, strong consumer demand, and remittances from the sizable portion The Philippines’ vaccine information management of the population working abroad as OFWs. The system (VIMS) was developed to facilitate the COVID-19 pandemic and related restrictions consistent capture and processing of vaccination severely impacted economic growth in 2020 as data across the country and gather key insights exports, tourism, and remittances all but came to inform the supply chain management of the to a halt. Strict lockdowns in 2020 helped to slow COVID-19 vaccines.1 The system has contributed to the spread of the virus, and restrictions were 54 percent of the population receiving a complete relaxed in the second half of 2020.2 Cases spiked initial vaccine protocol by February 2022, and the again in early 2021, leading to new quarantines in vaccine certification module known as VaxCertPH some parts of the country. Throughout the crisis, has helped to restart the economy by allowing the government has responded with strong social the country’s 2 million overseas foreign workers protection measures, starting with US $4 billion to (OFWs) to return to work abroad. address immediate needs and provide emergency subsidies for about 18 million households.3 More than 2 million overseas Filipino workers As the global economy improved in 2021, the were relying on international travel to send Philippines economy seemed to return to a pre- remittance back home, representing 10 pandemic growth of 5.6 percent. With continued percent of the country’s gross domestic recovery and reform efforts, the country looks product (GDP). forward to moving from a lower middle-income The Philippines is a dynamic economy that country to an upper middle-income country experienced rapid growth in the years preceding (moving from gross national income [GNI] per the pandemic—6.4 percent average annual growth capita of US $3,430 in 2020 to surpass the 1 https://www.healthcareitnews.com/news/asia/philippines-issue-digital-vaccination-certs-overseas-workers-september 2 World Bank Philippines country overview. Accessed April 14, 2022. Available at: https://www.worldbank.org/en/country/ philippines/overview#1 3 https://documents1.worldbank.org/curated/en/368351625163110870/pdf/COVID-19-G2P-Cash-Transfer-Payments-Case-Study-Philippines.pdf 20 Philippines Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies benchmark of US $4,096). The mass vaccination immunization registry in the country and supports campaign is critical to supporting this recovery.4 the pre-registrations for vaccination, includes five key modules: The vaccination campaign began in March 2021, a year after the government declared a public health • DVAS (3.0): the online role-based vaccine emergency. Considering the ongoing challenges administration system; presented by the spread of the disease and the presence of new variants, President Rodrigo R. • DVAS-M: the version of the administration Duterte signed the COVID-19 Vaccination Program system allowing for offline encoding, designed Act of 2021. The Act authorized the government as for areas with little to no internet connection; well as private entities and the Philippine Red Cross • VAS LL: the module enabling LGUs to uploads to procure vaccines.5 The Act also mandated the their list of vaccinated individuals; Department of Health (DOH) to maintain a central database of vaccinations and the availability of a • VORS: the inventory and jab accomplishment vaccine card. The Department of Information and reporting tool; Communications Technology (DICT) and National • VaxCertPH: the interface through which Vaccination Operations Center (NVOC) developed a individuals can generate their digital digital system and applications, implemented by local vaccine certificate, which is based on the government units (LGUs), that maintained quality, Digital Infrastructure for Vaccination Open safety, ease of use, and accessibility for all Filipinos.6 Credentialing(DIVOC).7 The successful rollout of VIMS and VaxCertPH The Data Ease of Access and Management provides insight into the opportunities for creating (DREAM) team under the leadership of DICT and fit-for-purpose tools for population segments NVOC deployed VIMS. The DREAM team, created with different capabilities and needs. Specifically, by the Inter-Agency Task Force (IATF) for the the VaxCertPH digital vaccine certificate meets Management of Emerging Infectious Diseases the needs of the Philippines’ OFWs, while the Resolution No. 85, issued on November 26, 2020, paper certificates issued by LGUs serve as the designed, deployed, monitored, and evaluated wider population’s copy of their recorded data in the VIMS.8 The DREAM Team is composed of the the vaccine information management system. DICT as the chair, Department of Interior and Looking forward, the VIMS and VaxCertPH are Local Government (DILG), Department of Health influencing the government’s efforts in digitizing (DOH), Department of Science and Technology immunization data as the country is in the process (DOST), Philippine National Police Directorate for of rolling-out digital identification (ID) systems as Information and Communications Technology part of a robust national digital health system. Management (PNP DICTM), and the Armed Forces of the Philippines Information Systems Design and implementation: Management Division (AFP ISMD).. Stakeholder Alignment Drives Both The DICT led the VIMS deployment through the Data Effectiveness and Complexity Ease of Access and Management (DREAM) team. The VIMS, which consists in the official and primary The DREAM team, created by the Inter-Agency 4 https://www.worldbank.org/en/country/philippines/overview#1 5 Joint Administrative Order No.2021-0001, March 26, 2021. 6 Joint Administrative Order No.2021-0001, March 26, 2021. 7 https://dict.gov.ph/dict-and-san-juan-pilot-dict-vaccine-administration-system-d-vas/ 8 https://www.officialgazette.gov.ph/downloads/2020/11nov/20201126-IATF-Resolution-No.-85.pdf Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Philippines 21 The DOH has been mandated to issue vaccine cards For example, during the initial registration for to all persons vaccinated, in line with national data vaccines in March 2021 (before actual doses were protection framework.9 administered), health workers in rural areas had to individually register residents on a sheet of paper The vaccine information management system before manually entering their details in the local from the Philippines was designed, tested, system. This process of locally enrolling individuals and deployed in less than three months. was then used to create local master lists.12 The The DREAM team piloted VIMS in partnership LGUs had to submit a master list with candidates with the City of San Juan in April 2021. Within for vaccination, which was used to prefill the VIMS three months (April to June 2021), the VIMS was database. However, the DICT had to press LGUs to receiving vaccination data from 1,650 cities and submit master lists with the support of the DILG.13 municipalities. With the transition to the online The 1,650 LGUs all had their own processes for system, average processing time of vaccination creating these master lists, many of which were per person has been cut down to 10 minutes from paper based. Some used Google forms and others 20 minutes in the manual process.10 Excel spreadsheets, which were more efficient but presented data privacy risks. Challenges: Ensuring Widespread Once the LGUs started to administer vaccines, the Access and Effective Data Capture LGUs were required only to submit a “quick count” Despite a high number of Internet users among its of the number of vaccinations every day. This led young and urban population, the Philippines falls to delays in submitting the actual data required to behind when it comes to overall digital adoption. produce a certificate. Digital infrastructure gaps While on average, every Filipino spends nearly 10 exacerbated this. For example, in Quezon City—the hours a day on the Internet (predominately on largest LGU—800,000 vaccinees were recorded messaging and social media applications), nearly on paper because of software problems. This led 60 percent of households do not have access to data entry errors because many of the paper to the Internet—signaling stark disparities in records were illegible, inaccurate or incomplete. access. Furthermore, despite investments over Some paper records were also lost or misplaced. the past decade, digital payments are still in their Data entry errors meant that individuals infancy. When the pandemic started, there was requesting a certificate often could not find their no national ID system to support the reliable and personal record in the system. When an individual unique identification and authentication of people was unable to find her record, they would put to support service delivery, such as the mass in a request to the LGU. This process, by design, vaccination campaign.11 The government had was supposed to take two days but often took passed the Philippine ID System (PhilSys) Act of five days or more, mainly because of lack of staff 2018; however, the pandemic significantly delayed at the LGU level to encode and correct data. implementation of both the law and system. These gaps in digital infrastructure presented Obtaining proof of vaccination took five days challenges throughout the rollout of the VIMS. or more because of lack of automation and 9 Joint Administrative Order No.2021-0001, 26 March 2021. 10 https://dict.gov.ph/dict-and-san-juan-pilot-dict-vaccine-administration-system-d-vas/ 11 Philippines Digital Economy Report 2020. PhilSys, the biometric-enabled foundational ID system for the country, began operations in 2020. As of March 16, 2022, over 60 million Filipinos have registered for a PhilSys ID. 12 https://www.weforum.org/agenda/2021/06/how-to-accelerate-vaccine-rollouts-to-reach-everyone/ 13 https://www.cnn.ph/news/2021/4/21/DICT-rollout-vaccine-information-management-system.html 22 Philippines Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies quality issues. VaxCertPH made this process push to find an internationally recognized digital instant. certification solution. To develop such a solution, the government tapped DIVOC, an open-source Over time, the DREAM team improved processes software stack that has issued more than 900 and found ways to overcome infrastructure million vaccination certificates in India.16 Ernst & gaps to improve this process. For example, DICT Young (EY), a consulting firm already working for provided mobile and Wi-Fi devices to health care the government, provided support to customize centers to improve Internet connectivity and DIVOC to the Philippines. By 15 September 2021, access in centers across the country. They have 99,897 OFWs and travelers had obtained a also provided training and hypercare support on VaxCertPH.. the ground to address technical issues with less downtime, including centers made available to With this new system, when a person needs a LGUs as encoding facilities.14 The implementation vaccine certificate, they can visit the online portal leveraged national agencies to coordinate from and enter their name and date of vaccination to the central to the local level to ensure vaccination get their certificate instantly. VaxCertPH includes data is submitted across all levels. In terms of the holder’s personal data, brand of vaccine, lot IT program management, government agencies number of each vaccine dose, and the place and learned on the fundamental aspects of a rapid date when the doses were administered. It also deployment of information systems, such as contains a quick response (QR) code that links introducing strong governance, implementing back to the VIMS.17 The VaxCertPH certificate information and enterprise architecture, and provides an internationally accepted QR code, health data standards. in line with World Health Organization (WHO) standards,18 which can work on a smartphone or Deep Dive: VaxCertPH be printed to work offline. Remittances from OFWs account for 10 percent of As of April 2022, 3.5 million VaxCertPHs GDP. Thus, OFWs’ ability to travel for work abroad is have been issued, and it is now recognized by a lifeline for millions of families. With an increasing nearly 90 countries. number of countries introducing COVID-19 This solution works well for overseas travelers, vaccination requirements for international who generally have higher incomes and access arrivals, the Philippines had to introduce a digital to smartphones by nature of their work. The vaccination certificate that would comply with vaccination centers maintained by the LGUs international standards and be recognized by as and some private companies continue to issue a many countries as possible.  paper-based vaccine card that everyone gets and In early August 2020, the foreign affairs is accepted for local purposes. department of Hong Kong announced that the city, home to many OFWs, would not recognize Looking Forward: Toward an Effective vaccination cards issued by LGUs as these do not Digital Economy come from a single source.15 This, among other challenges with the physical cards, prompted the The Philippines VIMS is an example of a modular 14 https://dict.gov.ph/dict-and-san-juan-pilot-dict-vaccine-administration-system-d-vas/ 15 https://www.healthcareitnews.com/news/asia/philippines-issue-digital-vaccination-certs-overseas-workers-september 16 https://divoc.egov.org.in/ 17 https://www.cnnphilippines.com/news/2022/2/7/VaxCertPH-COVID-19-vaccination-certificate.html 18 WHO. Digital documentation of COVID-19 certificates: vaccination status: technical specifications and implementation guidance, August 27, 2021. http://apps.who.int/iris/handle/10665/343361 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Philippines 23 Figure 6: Sample of VaxCertPH certificate and web portal Source: https://vaxcert.doh.gov.ph/ approach to vaccine management that has overcome are now efforts underway to launch a VaxCertPH a number of local and international obstacles through application, which will follow the verifiable iteration and flexibility. Furthermore, the VIMS credentials standard. This will be the Philippines’ supports multiple solutions for vaccine credentials first implementation of verifiable credentials, to fit the needs of different segments: a paper- which could create further opportunities for based card for the majority of the population, which better identity management systems in the health faces persistent digital infrastructure gaps, and a sector, as well as facilitate payment for health digital solution for OFWs, whose needs are driven by services through digital wallets moving forward. international standards. Much of this flexibility can Furthermore, VaxCertPH provides potential for be attributed to the use of DIVOC, a digital public more accessible and verifiable proof of identity, good that provides a core platform while allowing for that can be downloaded and printed on paper, customization to local needs. which can complement the physical national ID cards.19 Thus, the VIMS has supported the The VIMS effort is helping to drive equitable emergency response while providing momentum digitization in the Philippines. For example, there for future recovery and growth. 19 This will allow registered persons to download a PDF of their ID, without having to wait to receive it by mail, which is currently a bottleneck. While 60 million have registered for PhilSys, there have been delays in the delivery of cards. As of April 2022, cards may take up to two years for delivery because of challenges related to personalization. 24 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies RWANDA Paving the way for regional adaptation of global digital public goods to meet local needs Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Rwanda 25 Highlights from the case study • Rwanda built on its existing use of DHIS2 to create new modules to manage COVID-19 vaccine delivery. • Coordination between all ministries and key public agencies through the creation of a Joint National COVID-19 Task Force was key to identify needs in terms of supply and delivery of vaccines, healthcare professionals staffing, and internet access to adopt mitigation measures. • The flexibility offered by the use of the use of open-source solutions enabled the quick expansion of existing systems’ functionalities to address the needs of the COVID-19 vaccination campaign. • The availability of local skills and competences enabled the country to customize additional modules quickly despite scarcity of skilled resources at a global level and tailor the solution to the specific needs of the country. Context: The COVID-19 pandemic Pre-pandemic digital infrastructure investments disrupts decades of progress included achieving near universal coverage of the national ID and improving birth registration2 Rwanda has made impressive progress in recent through digitizing of the national civil registration years toward its goal of becoming a middle- and vital statistics (CRVS) system. As part of this income country by 2035 and a high-income investment in digital infrastructure, the Ministry country by 2050. The country significantly of Health (MoH) established the Rwanda Health reduced poverty, maternal mortality, and the Management Information System (R-HMIS), Gini index measurement of inequality. Just operational nationwide since 2012. The R-HMIS before the pandemic, Rwanda was in the middle runs under DHIS2, an open-source digital public of an economic boom, with 10 percent growth in good that is used by more than 73 countries to 2019, largely driven by public investment. This collect and analyze health data.3 growth was supported by strong government This digital infrastructure is supported by investment in the country’s digital transformation, relatively high mobile access rates at a national including digital government systems and digital level (82 subscriptions per 100 people as of 20204). connectivity to increase affordability and access.1 However, stark regional disparities remain. For With the onset of the COVID-19, Rwanda was example, in the Southern Province, only 35 percent able to leverage pre-pandemic economic growth of the population owns a mobile phone. Only and investment in digital infrastructure to 22 percent of the population uses the internet, respond to both the economic and health crisis. slightly more than the regional average in Sub- Saharan Africa, but far below the global average 1 The World Bank in Rwanda, The World Bank,  https://www.worldbank.org/en/country/rwanda/overview 2 Maletela Tuoane-Nkhasi et al, “In Rwanda, Making Every Life Known is Enhancing Human Capital,” World Bank Blogs, World Bank, February 17, 2021, https://blogs.worldbank.org/health/rwanda-making-every-life-known-enhancing-human-capital 3 DHIS2 is a global public good focused on transforming health information management. It is used by more than 73 developing countries worldwide, covering 2.4 billion people. For more information see https://dhis2.org/ 4 “Mobile Cellular Subscriptions (per 100 People) Rwanda,” World Bank, 2022, https://data.worldbank.org/indicator/IT.CEL.SETS.P2?locations=RW 26 Rwanda Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies of 49 percent.5 Furthermore, while more than 90 to COVID-19 testing needs.9 This module tracked percent of healthcare facilities are connected to both PCR tests (processed only at specific national the internet via 4G connections, these connections laboratories) and rapid tests (processed at public are not always reliable. These last-mile challenges health facilities and private clinics nationwide). require short-term mitigation strategies while Individuals received notification of test results to also motivating further investment to address their phone with a unique code. Subsequently, they remaining infrastructure gaps. could visit an online portal (available through the MoH and RBC websites) by entering their phone Design and implementation: number and unique code to access the results and corresponding test certificates.10 Responding to COVID-19 by building on existing digital systems To prepare for the vaccination campaign, MoH created a similar module, repurposing the portals for The first case of COVID-19 in Rwanda was reported test results and to manage vaccine appointments, on March 14, 2020. As of February 1, 2022, track vaccine doses, and deliver certificates.11 In there were 128,933 confirmed cases, with 1,444 addition, a full, customized COVID-19 Vaccine confirmed deaths.6 To respond to the pandemic, Delivery Toolkit was put in place to deliver a Rwanda created a Joint National COVID-19 paperless process from enrollment of eligible clients Task Force that included all ministries and key through each dose and to vaccine certification. public agencies, including health, agriculture, From the toolkit, the Rwanda team (comprised of commerce, local government, emergency and staff from both MoH and HISP Rwanda) used the disaster management, education, transport, standard DHIS2 Electronic Immunization Registry security organizations, and points of entry/ exit. (EIR) package and then integrated the DHIS2 The vaccination campaign launched on March 5, Tracker module to capture and maintain patient- 2021, with 75,000 doses administered on the first level vaccination information. Figure 7 illustrates, day alone.7 As of February 1, 2022, 64 percent at a high level, the process flow for administering of the population had received at least one dose, and tracking vaccine doses in the preliminary and 53 percent were fully vaccinated. Across the stages when vaccines were available only for continent, only 16 percent of Africans had received priority segments.12 at least one dose by the same date and only 11 percent were fully vaccinated.8 As of December 2021, with the testing and vaccination management module fully When the pandemic began, the MoH worked with implemented, the MoH was working to implement local partners to create a new module to respond an integrated planform with R-HMIS for vaccine 5 Data points from OurWorldinData.org, accessed February 23, 2022. All individuals who have used the Internet in the last three months are counted as Internet users. The Internet can be used via a computer, mobile phone, personal digital assistant, gaming device, digital TV etc. Source: International Telecommunications Union (ITU) via the World Bank. 6 OurWorldinData.org, accessed February 8, 2022. 7 World Bank Virtual Support Mission Aide-Mémoire, September 29-30, 2021. 8 “Coronavirus (COVID-19) Vaccinations,” Our World in Data, accessed 17 January 2020, https://ourworldindata.org/covid-vaccinations. 9 HISP Rwanda is a private company that operates as part of the global HISP network associated with DHIS2. For more information, refer to https:// hisprwanda.org and https://dhis2.org/hisp-network/ 10 Ministry of Health representative, interview by author, December 2021. 11 The portals used to access test results and vaccine certificates are not created by DHIS2: they are simple, one-page interfaces that use an API to pull information from the DHIS2 platform. 12 Once the country received enough doses to make the vaccine available to the general population, the government shifted its approach, using existing communication channels such as radio, social media platforms and community meetings to invite people to be vaccinated. Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Rwanda 27 Figure 7: Process Flow: Rwanda’s Vaccine Management System At clinic, After 2nd List of SMS is staff After the 1st dose, SMS eligible sent with digitally dose, new is sent with individuals appointment confirm SMS for 2nd unique code is imported details and code and dose sent and link from ID unique code register the automatically to access registry client certificate Tracker EIR Android ID integration Portal Portal Package Capture App Source: World Bank staff (Notes: The blue boxes are the different R-HMIS modules, while orange boxes are functionality built outside of DHIS2. The image is illustrative of the technical specifications involved across the vaccine delivery platforms, and is not exhaustive. EIR is the Electronic Immunization Registry, a version of the DHIS2 standard Tracker module. The DHIS2 Vaccine Delivery Toolkit include a module for reporting adverse side effects, which Rwanda implemented. For more information see: https://dhis2.org/metadata-package-downloads/#covax-eir) supply chain management.13 The new module established open-source solution. This approach will replace existing Excel-based processes for meant that it was easier for the MoH to train warehouse management and tracking of vaccine healthcare staff, particularly data managers, on inventory. The module will track vaccines as they the new modules, as they were already familiar are distributed to health facilities, and then link with the R-HMIS platform. Furthermore, by using to the vaccine management platform so that an open-source platform, MoH was able to iterate the stock of each facility will be automatically and improve upon the system on an ongoing basis updated as vaccines are administered.14 This in order to best meet local needs and opportunities. system will provide dashboards and reports to For example, in August 2021, the MoH linked the bring transparency and real-time insight into the vaccine module directly to Rwanda’s National ID nationwide supply of vaccines. registry to allow for an automated registration process. This linkage eliminated errors with data Success factors: Interoperability, entry, such as incorrect names and dates of birth, coordination, and local digital skills while speeding up the registration process and drive an effective platform allowing more individuals to be registered at each facility.15 Since this integration, the amount of time The rollout of the COVID-19 vaccine management spent on data entry per client has decreased by 90 platform has been largely successful, with all percent, saving individuals’ time and reducing the vaccination data entered, and anonymized number of staff required for data entry. Finally, data related to the rollout (number of vaccines this approach meant that vaccine management administered by age and district, for example) data could be held on existing servers which are displayed on public dashboards to drive hosted at the National Data Center. transparency. This points to another key success factor: The first key success factor in the rollout of coordination at all levels of government. The the vaccine module was customization of an vaccination campaign, including implementation 13 As of December 2021, this platform has just completed initial user acceptance testing. 14 This will happen in the second phase. 15 “Investigating the use of digital solutions in the COVID-19 pandemic: an exploratory analysis of eIR and eLMIS in Guinea, Honduras, India, Rwanda, and Tanzania,” SDA Boccini School of Management and Global Health Consulting, November 2021: p26. 28 Rwanda Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies of the vaccine management platform, required access from the beginning. DHIS2 can work offline: a combined centralized and decentralized if there is no internet access, healthcare staff can approaches. Successful coordination started with still enter patient data and administer vaccines the leadership of the MoH, who tasked the RBC and data uploads at a later time or in different with implementing the vaccination campaign. location. To increase the reliability of internet The RBC established a technical team, led by the access in healthcare centers, the MoH provided MoH and RBC. Every evening, the technical team wireless internet (Wi-Fi) boxes to reduce reliance gathers with all district coordinators, who are on mobile internet coverage. appointed by the Ministry of Local Government (MINALOC), on one phone call. During the call, However, challenges remained. For instance, the each district coordinator provides an update. The SMS containing a vaccination code is generated district coordinator’s responsibility is to flag any at the central level, and an internet connection challenges in their district in terms of the supply is required to send the SMS with the unique of vaccines, the number of healthcare staff, or code to the patient’s phone. Without an internet internet access needed to register all data in the connection, people leave the health center without R-HMIS platform, etc. These calls take up to two their code, making it harder to access the next hours per evening, and have been held continuously dose or their documents on the portal.17 To address from the start of the vaccination campaign.16 these challenges in the short-term and ensure access even for those without a cell phone, the A final key success factor is the reliance on MoH maintains a toll-free hotline for all questions local skills and competencies to customize and related to COVID-19 (114). This also allows people contextualize global digital public goods. Many without the internet to access information requests can be handled directly by the MoH otherwise available through the online portal, team or through local support teams such as HISP including the one-time access code that would Rwanda, while the University of Oslo is available otherwise be sent via SMS. for additional support when necessary. This streamlines requests for system modifications to At the same time, the GoR is looking forward and investing in sustainable ways to address last-mile meet local needs. challenges in the long-run. Much of this work will Challenges: Investing to overcome be completed in partnership with the World Bank through the Rwanda Digital Acceleration Project.18 last-mile gaps The initiative will support evidence-based Despite this success, key challenges related to last- decision-making, by, for example, gathering more mile digital infrastructure gaps remain, causing nuanced information on regional digital access frustration for patients and healthcare staff. While and ownership, and gaining insight into how many many aspects of the system work offline, other unique mobile phone and internet users exist in aspects require reliable access to mobile phones each region.19 This data will help the initiative and internet for both individual patients and to increase smartphone ownership (currently healthcare staff. The MoH-led team considered 20 percent) through new financing schemes the lack of fully universal and reliable internet to increase device affordability, especially for 16 Ministry of Health representative, interview by author, December 2021. 17 Ministry of Health representative, interview by author, December 2021. 18 “World Bank Provides $100 Million to Accelerate Rwanda’s Digital Transformation,” the World Bank, December 1, 2021, https://www.worldbank.org/en/news/press-release/2021/12/01/world-bank-provides-100-million-to-accelerate-rwanda-s-digital-transformation 19 Currently, the only data point available is the total number of mobile subscriptions. Since one person can have two or more mobile subscriptions, these statistics do not provide a comprehensive understanding of mobile access. Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Rwanda 29 those in rural areas.20 Furthermore, the Ministry role, HISP Rwanda sets up DHIS2 deployment with of Information Communication Technology and the relevant applications for vaccine tracking and Innovation (MINICT) and MoH will work together certification, and then facilities ‘academies’ for to provide all healthcare facilities with high speed training local developers so that countries are able broadband connectivity. Finally, the project will to manage the DHIS2 deployment on their own help scale up digital literacy training across the going forward.22 country with a key focus on rural areas. Looking forward: Sustaining Knowledge sharing: Informing digital development goals amidst the crisis vaccine delivery across the continent As Rwanda sought ways to tackle the challenges The capacity of the MoH and local partners to presented by the COVID-19 pandemic, the country optimally configure and customize the DHIS2 did not lose sight of its overall strategic goals. platform benefits countries beyond Rwanda. While building an effective digital system for Rwanda is considered a “mature DHIS2 user” and vaccine delivery, the GoR leveraged the opportunity now shares lessons and applications with the rest to invest in MoH capacity, local private sector of the continent. For example, Rwanda developed partners, and improvements in the broader digital an app for displaying negative COVID-19 test health system. certificates (and later, vaccine certificates). This Furthermore, Rwanda has set an example for the app is now used by travelers moving between rest of the African continent, playing a strong Uganda and Rwanda, and will soon be adopted by role in the region in terms of sharing knowledge neighboring Tanzania.21 related to building effective digital health systems Another example is the regional expansion of and nurturing digital skills and human capacity. HISP Rwanda. In part due to capacity built while In doing so, Rwanda is delivering on the promise working with the MoH, HISP Rwanda is now able of DHIS2 and other digital public goods to deliver to act as a service provider for other countries sustainable, positive impact through global, who have asked the company to build DHIS2 low-cost solutions that can be modified to meet deployments for their specific contexts. HISP local needs and contribute to local private sector Rwanda is working in Chad, Comoros, Madagascar, development. With continued efforts to close last- and Sudan on vaccine delivery, and will potentially mile infrastructure gaps, the country continues do the same for Djibouti in the near future. In this pursuing the goal of becoming a knowledge-based economy even as it deals with the crisis at hand. 20 World Bank Rwanda representative, interview by author, December 2021. 21 Scott McKee Russpatrick, et al., “Digital Resistance to COVID-19: A model for national digital health systems to bounce forward from the shock of a global pandemic,” 1st Virtual Conference on Implications of Information and Digital Technologies for Development, May 2021, https://arxiv.org/abs/2108.09720 22 World Bank Rwanda consultant, interview by author, December 2021. 30 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies TUNISIA eVax: Unprecedented coordination drives vaccine delivery and sets the stage for ongoing digital development Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Tunisia 31 Highlights from the case study • Tunisia developed the eVax platform to securely store all transaction records, and track and certify COVID-19 vaccinations, using blockchain technology. • Collaboration between health and ICT government institutions was critical to address transversal problems and work toward a common goal, including collaboration with the private sector. • The system benefits from the use of Tunisia’s foundational ID system, which has near universal coverage for those over the age of 18. • Extensive measures to increase digital adoption and provide digital skills training to healthcare staff were critical to ensure the use of the digital solutions deployed and avoid parallel paper-based systems. • The success of the eVax system is paving the way for a fully fledge immunization registry and necessary catalyzed support of decision makers for the introduction of an electronic health record in the country. Context: Economic and political momentum for the ambitious digital development challenges drive a common sense of and governance plans set forth in Tunisie Digitale 2020.2 The severity of the pandemic motivated urgency stakeholders to work together on a vaccine management solution, driven largely by mutual The Tunisian eVax platform is a strong example understanding of the need to mitigate the impacts of a what a country can accomplish in the face of the pandemic through an efficient vaccination of crisis when all stakeholders are aligned and campaign.3 moving in the same direction. COVID-19 hit Tunisia when the country was facing significant eVax uses blockchainto securely store alltransaction economic challenges, including high levels of records and does not require individuals to have public debt and weakening public services. Tunisia internet access or a smartphone to benefit from experienced a sharper economic decline as the platform’s services. Despite some challenges result of the pandemic than most of its regional in the initial rollout of vaccine certification, the peers, due in part to reliance on tourism and eVax platform is now used nationwide to track protectionist policies, including restrictions on and certify COVID-19 vaccination. As of February investment and competition.1 Within this context 1, 2022, about 60 percent of the population had and amidst political instability, the development received at least one dose, and 52 percent had of the eVAX vaccine delivery platform is providing 1 “The World Bank in Tunisia,” World Bank, https://www.worldbank.org/en/country/tunisia/overview#1; and Vivian Yee, “Pressure Mounts on Tunisia’s President to Salvage the Economy,” New York Times, January 3, 2022, https://www.nytimes.com/2022/01/03/world/middleeast/ tunisia-economy-kais-saied.html 2 “Plan National Stratégique Tunisie Digitale 2020,” Ministry of Communication and Digital Technology of Tunisia, https://www.mtc. gov.tn/index.php?id=14 3 Interviews by author, December 2021. 32 Tunisia Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies received the full vaccine protocol.4 Going forward, coverage among the population over 18.8 eVax has the potential to serve as the basis for creating an electronic management platform for Once a registered person is eligible for an all routine immunizations in the country, and to available vaccine, an SMS invitation is sent for the set the stage for broader digital health reforms. vaccination appointment with the appointment date and location.9 Upon arrival at the vaccination center, a healthcare professional asks the patient Design and implementation: a series of questions to complete the profile with Operating in coordination with eVax. After the vaccine dose is administered, it is existing systems recorded in eVax. This record is then communicated to the existing ePharmacie system, managed by Th In January 2021, the Government of Tunisia the MoH and maintained by the DSSB, which tracks put in place a plan to vaccinate 50 percent of the how many vaccine doses are available at each population by the end of that year. Organization facility. After the appointment, the system sends of the nationwide vaccination campaign was an SMS reminder for the next appointment. Once prioritized to decrease the risk of serious illness the patient completes the full vaccination course, and death, maintain the capacity of the health a certificate with a QR code is sent, which can system, and reduce the social and economic be accessed via smartphone or printed on paper consequences of the pandemic.5 To support the for those without a smartphone.10 The vaccine vaccination campaign, the eVax platform was certificate is now compliant with European Union11 developed under the direction of the Ministry of standards, thus supporting international travel. Communication Technology (MTC), coordinated by a technical team in close coordination with the Success factors: Start small, think Ministry of Health (MoH) and the Directorate of big, change fast Basic Health Care (DSSB).6 Pre-pandemic, there were limited digital or By March 2021, eVax contained 14 modules, interoperable health systems in place. The from patient registration to vaccination vaccination registry for routine, childhood certification. eVax supports registration through vaccinations was not digitized, and there was no four channels: online, via SMS, via USSD, or via a central health identification number or unified toll-free number.7 To facilitate the identification health management information system. While of patients, the eVax system benefits from the regional hospitals and university hospital centers country’s foundational identification (ID), the each maintain a system for identifying patients national ID card (CIN), which has near-universal 4 OurWorldinData.org 5 The Government of Tunisia changed hands in July 2021. This note refers to “the Government” while recognizing this transition during eVax implementation. 6 “Stratégie vaccinale contre la COVID-19 en Tunisie,” Ministry of Health, January 2021, http://www.santetunisie.rns.tn/images/strategie- vaccination-covid-19.pdf 7 Healthcare workers, as a priority group, were vaccinated at their place of work and did not have to go through the same registration process. 8 Registration is also open to non-citizens who do not have a national ID. 9 “Stratégie vaccinale contre la COVID-19 en Tunisie,” Ministry of Health, January 2021. 10 Tunisian guidelines define full vaccination as one dose of the Johnson and Johnson vaccine, two dose of any other vaccine, or or dose of any vaccine if they had prior COVID infection. 11 "Document 32021D2296: Commission Implementing Decision (EU) 2021/2296 of 21 December 2021“ Official Journal of the European Union, Eur- LEX, https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32021D2296 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies Tunisia 33 locally, these systems were not connected, forcing coordination and common direction. individuals to register at each facility separately.12 A second key success factor was the technical In light of this, the technical team needed to build team’s agile approach to development, which can the eVax solution from scratch. The MoH drove the be summarized as start small, think big, change process through its internal IT center, while the fast. The team began work on eVax in November MTC provided the development team and set up a 2020, and the registration module was ready in less call center to register patients, answer questions than two months: by January 6, 2021. Additional related to COVID-19, and track side effects. Advice modules were added over time. The platform was provided by the Independent High Authority was initially available in 25 vaccination centers, for Elections (ISIE), which had set up a system and eventually achieved nationwide coverage with similar registration processes during the last with 94 vaccination centers, 600 healthcare election. Further support was provided, pro bono, centers, and 800 alternative providers including by ProsperUs, a Tunisian company that specializes pharmacies, dentists, and mobile providers. Walk- in blockchain for the financial sector. ProsperUs in vaccinations are now also tracked from eVax. built the QR code used to verify testing and vaccine status, in addition to the online citizen portal. The Challenges: Overcoming cultural and company’s blockchain technology is used to store technical obstacles all transaction data securely. One of the key challenges with the eVax rollout Several actors provided mobile devices and was limited digital literacy and strong resistance supported the expansion of internet connectivity to a digital solution among healthcare staff in to ensure inclusion. ISIE donated devices used vaccination centers. Tunisia has relatively high for election monitoring, and additional tablets mobile and internet adoption rates: 77 percent were purchased through the MoH. The three main of Tunisians owned a mobile phone as of 2019, mobile network operators (MNOs) also contributed and the country’s share of the population using by providing SIM cards free for vaccination centers the internet (67 percent as of 2019) is on par and covering the cost of sending SMS reminders with the regional average for the Middle East and to patients or the government. Furthermore, the North Africa.13 This provided a strong basis for MNOs donated wireless internet (Wi-Fi) boxes moving to a digital solution. However, the lack to vaccination centers without existing internet of a digital healthcare system meant that few connectivity. The World Bank helped to finance healthcare workers were ready to use devices for devices and connectivity in vaccination centers. advanced data entry, and many preferred the existing, paper-based status quo. To ensure that This approach leads to the first key success factor: eVax captured all records to accurately reflect the coordination. Requiring a unique partnership status of the country’s vaccination campaign, it between the MTC, MoH, the DSSB, and ProsperUS, was critical to present eVax as the only option for the technical team led by the MTC united these registering vaccinations, rather than providing a actors to work toward the same objective in paper-based back-up. The key message: there is the context of the crisis at hand. There were no parallel system. no documents or MOUs defining roles and responsibilities, as the clarity of purpose drove Implementing the digital system effectively 12 International Bank for Reconstruction and Development/ The World Bank, “ID4D Diagnostic of ID Systems in Tunisia,” 2019,https://openknowledge. worldbank.org/bitstream/handle/10986/34661/Diagnostic-of-ID-Systems-in-Tunisia.pdf?sequence=1&isAllowed=y 13 OurWorldInData.org, “Share of individuals who own a mobile telephone, by sex, Tunisia, 2019,” accessed April 4, 2022, https://ourworldindata. org/grapher/proportion-of-individuals-who-own-a-mobile-by-sex?country=~TUN; and OurWorldinData.org, “Number of Internet Users (Tunisia),”accessed April 4, 20222, https://ourworldindata.org/grapher/number-of-internet-users-by-country?tab=chart&country=~TUN. The number of Internet users is defined as all individuals who have used the Internet in the last three months via a computer, mobile phone, digital TV, etc. The chart for Tunisia covers 1990–2017. 34 Tunisia Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies without offering a parallel, paper-based system can quickly be validated offline at establishments required extensive support. First, all vaccination requiring proof of vaccination. The downloaded centers required connected mobile devices, an version can be used for electronic verification.15 effort which was supported by MNOs, the MoH, and the World Bank. Furthermore, the MTC and Looking forward: Maintaining MoH conducted extensive training of health momentum for digital transformation care staff to increase their comfort levels and avoid data entry error. Initial visits confirmed As the pandemic continues to evolve, eVax will that while many healthcare staff had their own remain a cornerstone of Tunisian vaccination devices and some level of digital literacy, they efforts, including registration by parents for mainly used phones for calls and social media. their children, as well as for the registration and Thus, all personnel received training on the eVax deployment of booster vaccines. Strengthening application, data entry, and troubleshooting. A information systems and an eventual transition call center was established to provide ongoing to patient-level electronic medical records is a support. Healthcare staff adoption quickened as top policy priority for the MoH. The MoH plans patients started demanding eVax to receive SMS to stabilize, update, and expand eVax to cover all confirmations, appointment reminders, and their routine vaccinations, allowing citizens to make vaccine certificates. appointments, track immunizations, and share vaccine records with relevant health officials A second key challenge arose just before the throughout life. vaccination certification (known as a COVID pass) became mandatory for access to many As eVax aligns with the MoH’s information system establishments on December 22, 2021. Due to priorities, and healthcare staff have been trained technical and security problems with issuing and nationwide, it could set the stage for establishing authenticating the pass through eVax, the system an integrated health management information could not be used by most people. An interim system with a unique patient identifier and solution was developed, and passes were issued portable electronic health records. Particular through USSD, which worked until the issues attention will be afforded to interoperability and with eVax were fixed days later.14 To receive the integration, both within and across levels of care. temporary pass, individuals already registered A phased approach starting with vaccination and with eVax entered a personal eVax code, and then then expanding to other child health interventions verified their name and the last three digits of the will prove to be feasible and sustainable. As the CIN. As of January 2022, the eVax system is fully country works to establish a strategy to tackle operational. The COVID-pass is obtained through its broader political and economic challenges, the a two-factor authentication process and can be eVax platform is a shining example of what Tunisia printed or downloaded from the online web portal. can accomplish when political will and strong Once printed, the QR code associated with the pass coordination align with the needs of citizens. 14 See, for example, Hend Abessamad, “Tunisie/Pass vaccinal : Un service SMS pour contourner les problèmes sur la plateforme Evax,“ Anadolu Agency, December 23 2021, https://www.aa.com.tr/fr/afrique/tunisie-pass-vaccinal-un-service-sms-pour-contourner-les-problèmes-sur-la- plateforme-evax/2455595 15 There is no eVax smartphone application. Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies 35 PREPARING FOR THE NEXT PANDEMIC: LESSONS LEARNT FROM THE CASE STUDIES Overall, the case studies exemplify that pre-pandemic digital investments facilitated vaccine management and that the actions taken during the pandemic have the potential to fill digital health gaps. Over a year after the first COVID-19 vaccine roll-out, it is possible to look back and draw lessons from countries that managed to deliver vaccines effectively to their populations. The following are lessons learnt from the five case studies: ● Leverage existing enablers, such as Digital ID and modular architecture for health information systems: The pandemic has highlighted the fundamental role digital ecosystems can play in helping a country to rapidly, effectively and responsibly deliver services such as social assistance or COVID-19 vaccination to populations. Countries that were able to rely on good connectivity and infrastructure, high-coverage ID systems with digital capabilities, and existing health management information systems were able to more efficiently deliver the COVID-19 vaccines in this challenging context. ● Agile development and availability of skills: Due to the nature of the COVID-19 pandemic, in which new information constantly impacted national response strategies, platforms were adapted quickly and on a continuous basis. To enable rapid use, scalability and adaptability, a common approach was successful: start small and quickly in order to meet initial needs (namely, to register priority segments before vaccines even arrived in the country) and then build new modules over time to meet evolving (eventually issuing globally recognized vaccine certificates that account for multiple booster shots). In Rwanda and the Philippines, the use of digital public goods (DHIS2 and DIVOC, respectively), supported this strategy by providing a robust core system that could be quickly and easily customized to meet local needs. Success also came from the availability of specific user experience (UX) skills to develop fit for purpose systems under a fast-evolving environment, as well as the ability to adapt the systems rapidly to mitigate any risks identified related to unfair access to vaccines. ● Coordination and leadership: Driven mostly by the Ministry of Health in each country, solutions required input from multiple government agencies at both the national and district levels, as well as from the private sector. Coordination was driven both through operational measures (for example, nightly calls in Rwanda with all key stakeholders; an interagency technical team managed by the Department of Information and Communication Technology in the Philippines) and through a common sense of urgency to respond to such an unprecedented crisis (for example, the pro bono support provided by the private sector in Lebanon and Tunisia). In addition, the COVID-19 crisis has underlined the need for further coordination amongst the donor community. One of the great outcomes of this pandemic at the global level has been the set-up of the Digital Health Centre of Excellence (DICE), an initiative co-led by UNICEF and WHO launched in April 2021, aiming at coordinating international donors’ action and providing coordinated technical assistance to national 36 Digital Safeguards And Enablers For Covid-19 Vaccine Delivery: Country Case Studies governments and partners on digital health interventions that address health priorities in the context of the COVID-19 pandemic, as well as post-pandemic health system needs. ● Overcoming last mile logistic and digital literacy gaps: Most countries had to overcome gaps in last mile infrastructure and digital literacy in order to effectively implement a digital system. To overcome digital literacy gaps among healthcare staff, there was an extensive focus on training. Gaps in device ownership were mainly overcome through device subsidies or donations from governments and local telecommunications companies. Similarly, these actors provided internet access free of charge to help healthcare centers connect or stay connected. Non-digital solutions were provided to ensure that those without the means for digital access are informed and are not at risk of exclusion from vaccine delivery schemes. ● Implement strong safeguards: Countries that have implemented digital safeguards – and built stronger trust environments through legal and institutional frameworks for data protection and cybersecurity – are able to scale better and develop more resilient systems. Health data is personal and sensitive by nature, and the establishment of digital platforms and systems needs to be accompanied by the application of operational and technical safeguards. Mitigation measures can be implemented in the digital solutions used to deliver the vaccine to identify risks of exclusions through the monitoring of key indicators, and also reduce the risks of abuse by introducing authorization-based access to the systems and audit trails. ● Investing for the next emergency: The country use cases demonstrate that specific pre- pandemic investments made it much easier to implement a digital vaccine management system. For example, Rwanda, Tunisia, and Israel all leveraged near-universal ID coverage to ensure unique patient records without having to create a new identifier. On the other hand, the vaccine management platforms have the potential to fill existing gaps as these countries look to prepare for future disruptions. For instance, in the Philippines, the vaccine information system is informing the current roll-out of the national ID, PhilSys. As vaccine management systems had to be designed to reach everyone in the country to ensure the widest possible coverage, these countries now have experience with designing and implementing digital systems that are truly equitable – critical for any digitally- enabled to deliver true positive impact. A COLLABORATION BETWEEN: