CERGAS Seminar "The costs of digital health interventions to improve immunization data in low- and middle- income countries. A multi-country study in Guinea, Honduras, Rwanda and Tanzania."

Meeting people

Coauthors: Maria Verykiou, Marianna Cavazza, Flaminia Sabatucci, Claudio Jommi, Viviana Mangiaterra, Aleksandra Torbica


Evidence-based healthcare requires high-quality and readily-accessible data. Recent years have seen a proliferation of projects in low- and middle-income countries promoting the deployment of Digital health interventions (DHIs) to improve the management and utilization of health information. Electronic immunization registries (eIRs) and electronic logistics management information systems (eLMIS) have been implemented in several countries to support better immunization services within the Expanded Programme for Immunization. Yet, few of these systems have been evaluated to date and evidence is still sparse on their cost of implementation or their impact on national or external budgets. This study contributes to filling this gap by estimating the initial expenditures and routine operational costs for one integrated eIR-eLMIS in Tanzania, the eIRs in place in Rwanda and Honduras, as well as an eLMIS of Guinea.


The analysis took the perspective of the third-party payer, including both national governments and external donors. The cost of deploying the DHIs was estimated by collecting financial reports from the implementers and other secondary sources. Routine operational costs were estimated using activity-based costing and tracing direct and indirect costs to a set of pre-specified activities related to the management of immunization and vaccine logistics data. Primary data were collected through questionnaires in all countries from a total of 281 health centers. Comparisons with paper-based registries were done using a cross-sectional design whenever possible or a pre-post comparison alternatively.

Results: Honduras, Tanzania and Rwanda implemented the eIR in 2012, 2017 and 2019 respectively, whereas Guinea implemented the eLMIS in 2018. The context, timeline and strategy of implementation of the systems varied across the countries, with upfront implementation expenditures between USD 45K and 12.6M covered almost entirely by external donors. Most of the initial expenditures were related to training of healthcare staff and purchasing of equipment. The yearly routine cost per health facility of managing immunization or vaccine-logistics data was estimated between USD 200 and 1,850. Compared to paper-based systems, savings were observed in Tanzania (USD -1,307), but not elsewhere. The continued operation of paper registries after the implementation of the DHIs, and the limited use of the electronic data for reporting or decision-making, were two of the main factors contributing to higher costs. Several shortcomings in terms of human resources, trainings, IT infrastructure, and equipment were observed which hampered the widespread adoption of the DHIs and negatively impacted the perceived trust in the quality of the electronic data.


By improving the quality and accessibility of data, eIR and eLMIS systems have the potential to optimize healthcare worker performance and provision of care, and to lower costs. Nonetheless, savings are unlikely to be generated unless the switch to electronic registries is complete, eliminating duplication of work, and the electronic data is incorporated into decision-making processes . Further investments are required to ensure an enabling environment for the continued use of the systems, all of which need to be considered by countries when deciding on the adoption of these solutions.


Carlo Federici is a Researcher of Health Economics and Health Technology Assessment (HTA) at the Center for Research on Health and Social Care Management (CERGAS) of SDA Bocconi School of Management.

At SDA Bocconi Carlo teaches the Advanced Decision Modelling course at the Master of International Healthcare Management, Economics and Policy (MIHMEP) as well as several courses on HTA and economic evaluations of healthcare technologies. He conducted numerous research, training and consulting projects with Medtronic, Janssen, ABBOTT, Chiesi Farmaceutica, Assobiomedica, and many others. He contributed to several European research projects such as the H2020 projects MedtecHTA and COMED addressing the assessment of medical devices from different perspectives. In the past years, Carlo has also conducted several research activities with the Italian Ministry of Health on both reimbursement and regulatory aspects of medical technologies.

His research activities focus on the area of HTA and Health Policy Evaluation. His current research addresses both methodological aspects as well as applied case studies on decision analytical models to estimate cost-effectiveness of innovative health technologies as compared to other policy options. Other recent research areas include the identification of different dimensions of value when assessing health interventions, such as for example the real option value and insurance value of health technologies; the impact of technologies characteristics on organizational impact and operations management; or the study of performance-based risk sharing agreements between payers and technology developers (e.g., coverage with evidence development, payment by results etc.)

He is the author of numerous articles on the subject. His work has been published in Journal of Value in Health, PlosOne, Pharmacoeconomics, Health Policy among others. Carlo serves as a topic editor in the pharmaeconomics and outcome research area for the Journal Clinical Therapeutics. He is a member of the Italian Association of Health Economics (AIES) and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

Carlo earned his MSc in Health Economics from the University of York and his Ph.D. at the University of Warwick.

Link zoom: https://unibocconi-it.zoom.us/j/95543465665?pwd=Z0J5RVFKOHJwd2d6Mm9zbG1KM05kZz09

Meeting ID: 955 4346 5665

Passcode: 537147

For those willing to participate in person, please write to erica.dugnani@sdabocconi.it before Friday, January 13th.