Home-based records (HBRs) are a vital tool that can support countries in achieving and sustaining high levels of vaccination coverage. However, many countries continue to face challenges, including low retention rates by parents, difficulties in the printing and distribution of the document, and training health workers in its appropriate use. The goal of this Home-based Records Revitalization Workshop was to improve the design and functionality of countries’ home-based records, with a focus on both the design of the record and the system that supports it. The focus on immunization was chosen as an opportunity to demonstrate a systemized approach that can be applied to other elements of integrated health systems and materials. The workshop focused on improving: 1. The design of the record from the immunization program perspective. 2. The broader system that supports the HBR, from approval and production to distribution and use.

1. Home-based Records Revitalisation: Africa
April 2017

2. 1 | Introduction

3. Home-based records (HBRs)
are a vital tool that can
support countries in achieving
and sustaining high levels of
vaccination coverage.
However, many countries
continue to face challenges,
including low retention rates
by parents, difficulties in the
printing and distribution of the
document, and training health
workers in its appropriate use.

4. The broader system that
supports the HBR, from
approval and production to
distribution and use.
The design of the record from
the immunization program
perspective.
The goal of this Home-based
Records Revitalization Workshop
was to improve the design and
functionality of countries’ home-
based records, with a focus on
both the design of the record and
the system that supports it.
The focus on immunization was
chosen as an opportunity to
demonstrate a systemized
approach that can be applied to
other elements of integrated health
systems and materials.
The workshop focused on improving:
1
2

5. 2 | Why home-based records?

6. Home-based records (HBRs) are medical
documents issued by a health authority. They
provide a record of an individual’s history of
primary healthcare services (e.g., vaccinations)
received. They are maintained in the household
by an individual or their caregiver.
Home-based record vaccination section from Liberia.
HBRs date back to the 19th century, and have served an
important role in the recording of vaccinations around the
world. Since the beginning of the Expanded Programme
on Immunization (EPI) in 1974, HBRs have reached a
global adoption rate of approximately 80%. However,
retention rates in many countries remain significantly low,
which is prompting the global community to seek ways to
help improve the use and availability of this important
tool.
What are home based records?

7. HBR examples

8. Evidence of services
Act as a source of individual patient-
level data to cross check during
national surveys and other data
collection events.
Care Reminders
Provide a record of the care given, and a
reminder for future health care (e.g.
upcoming immunization visits).
Continuity of Care
Document services that have been
provided to support health care
workers in provision of continued
effective care.
Reduced inefficiency
Provide information at the time of
care to reduce unnecessary re-
vaccination and minimize missed
opportunities for vaccination.
There are multiple ways
that HBRs can function to
increase the effectiveness
and efficiency of
immunization programs.
When widely available and
effectively used, HBRs provide
care reminders, support
continuity of care, reduce
inefficiencies (e.g. over-or
under-vaccination), and provide
evidence of services.

9. Simultaneously considering and addressing the needs of HBR’s three primary user groups is
vital to improving the availability, utilization, and adoption of HBRs.
Caregivers
Parents, grandparents, aunts,
uncles, siblings, any other primary
care provider responsible for the
child’s health and immunization.
Responsibility
Advocating for HBR availability,
keeping HBR safe and brining it
to immunization visits and
other healthcare encounters,
retaining HBR.
Health workers
Vaccinators, midwifes, nurses,
community health workers, or other
individuals directly involved with
delivering immunization services.
Responsibility
Updating HBR at each visit with
child, use HBR for counseling
with caregiver, and including
data from HBRs in reports to
health administrators.
Health administrators
Facility managers, health officials at
district, regional or national level,
international community committed
to immunization initiatives.
Responsibility
Verifying HBRs are available and
in use by caregivers; conducting
quality assurance and
supervision of their use with
health workers.

10. 3 | The challenge around home-based records

11. Challenges facing HBR use and adoption
HBRs are unable to fulfill their critical functions when:
• They are not readily available in the right place, at
the right time, and in the right quantity
• The document is not adopted, valued, and retained
by caregivers, nor appropriately utilized by
healthcare workers
Many countries continue to face challenges related to:
• Retention and use of HBRs
• Printing, supply, and distribution of the document
• Training of health workers in the appropriate use
of the record
Nearly 25% of the countries with an HBR
retention rate lower than 50% are in the
Africa region.
Current HBR ownership prevalence for the WHO
African Region
50%0 80%
Prevalence

12. <50%, 22
50%-79%,
37
80%-89%,
22
90%>, 13
The prevalence of home-based records varies across geographies
Source: Latest national estimated prevalence of home based vaccination cards based on MICS or DHS survey results
for the period 2000-2015, 21 December 2016 https://sites.google.com/site/vaccinationcardprevalence/
No DHS or MICS
<50%
50-79%
80-89%
90-99%

13. Half of the birth cohort in 32
countries in the AFRO region
lack home based records
Several countries
with low current HBR
ownership levels
have large birth
cohorts; thus, the
burden of absent
documented
vaccination history is
of great concern.
Low HBR retention is particularly worrying in countries with high birth cohort

14. Most governments still depend on complex multi-partner financing of HBRs
EPI/MoH alone (20 countries)
Development partner alone (12 countries)
EPI/MoH + Development partners (31 countries)
EPI/MoH and partners exclusive of development partners (53 countries)
Other combinations of partners (19 countries)
HBRs might be financed by EPI/MoH
alone, or depend on the funding
from a development partner. In most
countries however, financing of HBR
comes from a combination of
EPI/MoH and different partners.
HBR not used (2 countries)
No response to question (3 countries)
Non-respondent country (55 countries)
Legend

15. HBRs are often damaged due to environmental conditions, or not wholly completed by
health care workers

16. HBR prevalence, funding models, and
retention might often feel like complex
administrative challenges, with unclear
entry points to begin to solve for.
However, there are often
challenges that can be identified
and addressed that can improve
availability, functionality, and
utility of the HBR for each of the
three key user groups.

17. Improvements in HBRs should address the challenges of the three key users
• Illiteracy makes it hard for some
caregivers to understand the
HBR.
• Caregivers may have trouble
preserving the HBR due to rough
environmental conditions (see
page 18).
• Health workers struggle with the
workload of filling out all the
sections in the HBR.
• Quality and availability of HBRs
is often an issue that health
workers try to resolve with their
own work arounds.
• Lack of resources makes it hard to
ensure the availability of stocks at
all times.
• Low HBR retention can
negatively impact coverage
estimates due to lack of
verifiable data for surveys.
Some commonly identified challenges of HBR users
Health administrators’
challenges
Health workers’
challengesCaregivers’ challenges

18. A user-centered, needs-
driven approach, which has
proven track record of
success in many industries.
A system perspective that
looks beyond the HBR to
improve the broader system
that supports it.
To improve the availability,
utilization, and adoption of home-
based records, countries need to
ensure that their HBR meets the
needs of its three key user groups;
and that it is available at the right
place, at the right time, and in the
right quantity.
This requires:
1
2

19. 4 | HBR revitalization workshop for the Africa region

20. The HBR Revitalization workshop for the
Africa region
Took place in 2017, with regional and global
experts to:
Improve the design of the record, with a focus
on the sections related to immunization.
Identify and prioritize challenges, and design
improvement strategies for parts of the
broader system that supports the HBR,
including printing, supply, and distribution of
the document, as well as the training of health
workers in the appropriate use of the record.
1
2

21. The workshop objectives included:
• To use well-established and proven design principles to
develop a redesigned paper-based prototype of an HBR
that better suits the identified needs of caregivers,
health care workers, and health administrators.
• To identify a clear roadmap for further country
engagement and eventual implementation of the revised
HBR, with a goal of improving adoption, perceived value,
retention by caregivers, and appropriate utilization by
healthcare workers.
• To identify challenges in the HBR supply chain, and
develop a plan to increase the likelihood that HBRs are
available in the right place, at the right time and in the
right quantity.
Participants adopted a user-centered
approach and a system perspective to reach
these goals.

22. The workshop was one element of a longitudinal process that included pre-workshop field work
and post-workshop implementation activities. This integrated, cross-cutting process is essential to
the success of the initiative.
1.
Knowledge
Gathering
2.
Cross-country
Workshop
3.
Implementation

23. 1. Knowledge gathering
Understanding and addressing the needs of the
three user groups is key to making the HBR
more effective and to improve utilization.
To gain this understanding, participants:
• Visited and observed vaccination activities in
health facilities
• Interviewed caregivers and health workers
• Mapped out how home-based records are
prepared, produced, distributed, and used in their
countries.
Through these activities participants better
understood the needs of and developed empathy for
other user groups; and questioned their pre-existing
assumptions regarding challenges to effective use and
adoption. This knowledge was used to inform
decisions made in the workshop.

24. Throughout four full days in the workshop, participants worked in their country teams to move through a
stepwise process from identifying user needs to creating a practical and actionable implementation plan.
2. Cross-country workshop
Day 1 Day 2 Day 3 Day 4
Define Explore Build Implement
Frame the challenge Empathize with users Generate a concept Create a prototype Plan and pitch
Align on the challenge
for the workshop and
build a common
understanding of needs
and potential solutions.
Empathize with the needs and challenges
of HBR users and generate solutions both for a
revised HBR design and for system improvements.
Communicate the
team’s solutions and
iterate based on
feedback.
Plan for next steps to
support implementation
of the revised HBR and
systems solution(s).

25. Participants came out of the workshop with three key
outcomes:
• Paper prototypes of refined HBRs, with improvements
based on design principles tailored to identified user
needs.
• A roadmap to address identified challenges in the HBR
system (preparation, production, distribution and use
of the HBR)
• An implementation plan for the paper prototype and
system solution with immediate, actionable, next steps
Following the workshop, teams will engage with decision-
makers and key stakeholders in their countries to build on
work completed during the workshop and support
implementation. Regional and local partners will work
with each country team to support this process.
3. Implementation

26. 5 | Opportunities

27. The opportunities identified during the workshop can be grouped in two categories, which complement
each other to maximally impact the utilization of HBRs.
Improvements on the
DESIGN
of the HBR tool
Improvements on the
SYSTEM
In the following sections we share
common themes that emerged
across countries, as well as
identified potential solutions.
Individual accounts of each
country’s outputs are available in
the appendix.
Country teams in the
workshop also developed
clear implementation plans to
realize the identified
opportunities for
improvement.

28. Re-thinking the
Home-Based
Record design

29. To ensure that HBRs meet the needs of the users on the ground, their design should follow well established and
proven design principles that reflect the rules of effective communication in printed documents.
Offer information hierarchy
that accounts for needs of
multiple users
Provide space for notes
& additional vaccinations
Consider color, contrast, and
format for reproduction
Use illustration and imagery
to support text descriptions
Make the record recognizable
as an official health document
Make the ‘date of next
vaccination’ highly visible
1 2 3
4 5 6
For more detail on design guidelines see Practical Guide for the Design, Use and Promotion of Home-based Records in Immunization Programmes,
available at http://apps.who.int/iris/bitstream/10665/175905/2/WHO_IVB_15.05_eng.pdf

30. Some of the challenges that
emerged as common patterns,
which the teams addressed
through the design of the HBR
were:
1. How can we use design features to increase the perceived
value of the HBR for caregivers?
2. How can visual language increase the usability of the HBR?
3. How can we reduce the burden of completing the card for
health workers?
4. How can we leverage an understanding of user needs and
design to reconcile the optimal degree of integration
(stand-alone vaccination cards vs integrated handbooks)?
In the following pages we present example cases and potential solutions for each.
Following these principles, and based on their learnings from interacting with users on the
ground, country teams reviewed the design of their HBRs and identified opportunities for
improvement.

31. Re-thinking the
Home-Based
Record system

32. The most common system
challenges that emerged during
the workshop included:
1. Awareness and advocacy building
2. Building a business case for HBRs
3. Obtaining sustainable funding
4. Designing effective supply and distribution
5. Defining and negotiating the level of integration
In the following pages we present example cases and potential solutions for each.
To ensure the HBR is available at the right place, at the right time, in the right quantity,
countries need to work to ensure that the preparation, production, distribution and use of the
HBR is planned and executed in the most effective manner.

33. 6 | Key lessons for HBR revitalization

34. Begin with a focus on clearly
defining and understanding
user needs and experiences.
1
Focus on not only the HBR,
but also the system that
supports it.
2
Home-based records are a vital
tool for increasing vaccination
coverage.
However to reach their full
potential, they need to be
understandable, usable and useful
for caregivers, health workers and
health administrators.
Any efforts to revitalize the HBR should:

35. • Check your prevalence and drop out rates, and think about how they can be
improved.
• Evaluate the HBR for changes that could positively impact its use and effectiveness.
• Seek to understand if the design of your HBR is effective in meeting user needs:
Engage users on the ground; observe how they’re using the record and what they’re
struggling with; identify the main challenges and why they occur.
See appendix 5: “Immersion pack” for a guide on how to engage users
• Explore ways to improve funding, printing, distribution systems, and how the
caregivers and health workers are trained to use the HBR
See appendix 3: “Workshop exercise templates” for structured exercises on systems thinking
• Build a business case for HBR funding in your country.
• Identify and work with other stakeholders in your country (e.g. nutrition, primary
care).
To better
understand the
status of HBRs in
your country’s
context and
improve it, there
are some
immediate actions
you can take:

36. For more information, please contact:
Rich Radka | Claro Partners
Rich.radka@claropartners.com