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Digital monitoring and action planning to reach zero-dose and under-immunised children: Leveraging data for targeted immunisation responses

Mariam Zahid Malik, Naeem uddin Mian, Zahid Memon, Muhammad Wasim Mirza, Umer Farooq Rana et al. · 7 Mar 2026

Abstract

Abstract Background Persistent inequities in immunisation coverage, particularly among zero-dose and under-immunised children, continue to challenge Pakistan’s Expanded Programme on Immunisation. Weak feedback loop, inconsistent data quality, and limited real-time monitoring impede effective decision-making. This Implementation Research was conducted under the MAINSTREAM Initiative funded by Alliance for Health Policy and Systems Research (AHPSR) and supported by the Aga Khan Community Health Services Department and National Institutes of Health Pakistan to design, implement, and evaluate a digital monitoring and action planning tool to strengthen data-driven decision-making within routine immunisation systems. Methodology/Principal Findings A co-creation approach was employed to design a digital monitoring solution through inclusive consultations, key informant interviews, and focus group discussions with EPI Punjab at provincial and district levels. The solution included a customized mobile application for data collection and a Power BI visualization dashboard to map low-coverage areas, identify drivers of dropouts and zero-dose children, and capture caregivers’ information sources to inform targeted communication. The intervention was piloted in 60 households across six clusters of a Union Council of District Lahore. Advanced analytics identified reasons for non-vaccination and missed opportunities, generating tailored recommendations and practical plans for program managers. The analysis assessed acceptability, adoption, fidelity, and perceived scalability through field observations, system use, and stakeholder feedback. The co-developed digital tool enhanced visibility of coverage gaps through UC-level mapping, real-time dashboards, and structured action planning. Pilot testing in Lahore showed strong acceptability, ease of use, fidelity, and adaptability among managers, supervisors, and vaccinators. Scalability and sustainability potential were demonstrated, though barriers included leadership turnover, system fragmentation, workload pressures, and resource constraints. Conclusion The tool demonstrated feasibility to strengthen immunisation equity, accountability, and responsiveness. Co-creation with stakeholders enhanced ownership, operational relevance, and adoption, while complementing existing platforms. Sustainability will depend on effective integration, local ownership, capacity building, and accountability, while scalability requires interoperability, resource commitment, policy support, and alignment with existing workflows. Author Summary Many children in Pakistan still miss routine vaccinations, especially those who have never received any vaccines or who drop out before completing the schedule. These children are often invisible within routine reporting systems, making it difficult for health managers to identify gaps and respond effectively. In this study, we developed and evaluated a digital monitoring and action planning tool designed to help immunisation managers and frontline workers better identify and respond to these gaps. We worked collaboratively with provincial and district immunisation staff to co-design a user-friendly system that combines mobile data entry with interactive dashboards for supervision and planning. The tool was piloted in an urban district of Lahore, where health workers and managers reported high acceptability and ease of use. The system helped improve visibility of missed children, supported follow-up actions, and strengthened accountability across different levels of the immunisation program. Our findings show that digitally enabled, co-created tools can strengthen routine immunisation systems by improving data use for action, supporting more responsive service delivery, and promoting equity. This work offers practical insights for scaling digital solutions to reach underserved populations and improve immunisation performance in similar low- and middle-income settings.