ACHIEVING FINANCIAL SUSTAINABILITY FOR

IMMUNIZATION IN UGANDA

Presentation to stakeholders,

Wednesday June 25, 2003

Presentation outline

Background information– Workshop objectives and outcomes– UNEPI programme objectives– Financial Sustainability and its process in

Uganda Present and future costs of the EPI

programme Strategies to ensure financial

sustainability

Introduction Immunization

– Reduces unnecessary ill health, death and disability

– Reduces service costs– Improves empowerment (averts disability)– Contributes to child survival, growth and

development– Is the most CE intervention

Is imperative to have adequate, reliable financial resources on long term basis for continuity

How to do this: Develop a FSP

Workshop Objectives To sensitize key stakeholders in the FSP

development process. To share the results of the costing of the

National Immunisation Programme, including demonstration of financial projections to 2010.

To show present and projected trends in funding for EPI.

To discuss proposed strategies to ensure financial sustainability of the EPI.

Desired outcome of workshop

Achieve consensus on relevant, realistic and specific strategies for financial sustainability of immunization program in Uganda.

UNEPIVision, Mission and Goal

Vision:To ensure that the Ugandan population is free of

vaccine-preventable diseases and disabilities

Mission:To contribute to the overall objective of the HSSP in reducing morbidity,mortality and disability due to childhood vaccine preventable diseases, so that they are no longer of public health importance

Goal:To ensure that every child is fully immunized by

the first birthday, and every new born is protected

from neonatal tetanus

UNEPI Program objectives Strengthen service delivery to increase DPT

coverage from 54% in 1999 to 88% by 2010. Increase program effectiveness, efficiency and

quality. Introduce and sustain additional vaccines such as the

DPT-Hepatitis B + Hib vaccine. Improve disease surveillance. Eradicate polio and eliminate MNT by 2005. Reduce measles mortality and morbidity by 90% by

2006.

The FSP addresses all these objectives

Financial Sustainability Plan

Financing strategy for immunization in Uganda

Assesses the key financial challenges facing the immunization programme, and describes the strategies to overcome these in medium to long term

Definition of Sustainability

“Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of the immunization performance”

Developing the FSP for Uganda

On-going participatory process since 2002, involving MOH, MOF, and development partners.

Draft discussed with stakeholders (ICC, HPAC, HDP)

FSP process aims to fit within the Uganda national planning and budgeting cycle (MTEF, LTEF)

Value of the FSP

generates a clear picture of the financing situation and challenges.

identifies relevant, feasible and specific strategies for financial sustainability.

is an advocacy tool for discussion between the MOH, the MOFPED and other partners.

Costs of the immunization

programme in Uganda

Cost items Routine immunisation

– Recurrent costs• Vaccines, injection supplies, personnel (center

to HC2), transport, surveillance, maintenance and overhead.

– Capital costs• Vehicles, cold chain, infrastructure

Supplementary immunisation activities– Polio, Measles, MNT

Costs calculated since FY 2000/01

2000/01 (Baseline year)

The baseline year is the financial year before any support was provided by the Global Alliance for Vaccines and Immunisation (GAVI)

Total routine costs in 2000/01 for provision of vaccines to target population: $4.49 million USD (USD $17.36 per child fully immunized, equivalent to USD $0.18 per capita).

Sources of funding, 2000/01

Government (Central)72%

DFID thru WHO6%

USAID thru WHO1%

JICA17%

Other NGOs (Red Cross)2%

UNF thru WHO2%

2001/02 (First Year)

The first financial year in which Uganda received support from GAVI. This included financial support and vaccines for one month (June 2002)

Total first year costs including shared personnel: $6.38 million USD.

First year financing chart

Government (Central)48%

GAVI-Vaccine Fund29%

DFID thru WHO8%

USAID thru BASICS1%

JICA12%

Netherlands thru WHO2%

Comparison of funding sources 2000/01 – 2002/03

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

GoU GAVI Otherdonors

2000/012001/022002/03

Contributions from the Vaccine Fund (GAVI) in Uganda

Injection safety materials: Auto-disable (AD) syringes ($1,157,000 for 3 years)

Support funds (US$ 910,000 x 2 years) to strengthen the system and increase coverage

Addition of two antigens:– Hepatitis B (Hep B)– Haemophilus influenzae type b (hib) – Using “pentavalent” presentation: DTP+Hep

B+hib ($50 million over 5 years)

Cost drivers: 2002 to 2007 Cost of routine EPI

– 2002: $20,375,520 – 2007: $23,363,763 (USD $0.79 per capita)

Costs rise due to: – population growth: annual increase in size of birth

is 100,000 additional babies (result: 10% of programme cost increases)

– coverage increase: 72% to 85% (result: 4% increase of programme cost)

– Depreciation of exchange rate: rising costs of all vaccines

Cost of vaccines

$-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

USD

7) DTP -HepB-Hib 1

5) OP V

4) Measles

3) TT

1) BCG

Future resource needs by cost category

$-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

2002 2003 2004 2005 2006 2007 2008 2009

Other costs

Shared costs

Other SIA

Measles

Polio

Other capital costs

Cold chain equipment

Vehicles

Other recurrent costs

Transportation

Personnel

Injection supplies

New Vaccines

Traditional vaccines

Funding gap chart

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

2002 2003 2004 2005 2006 2007 2008 2009

Funding Gap

Other Donor 5 (Specify name)

Other Donor 4 (Specify name)

WHO

JICA

UNCEF

GAVI-VF

Donor Pool (if applicable)

National Government

Projections of Secure Financing by Source and Funding Gap

Funding gap implications for achievement of UNEPI objectives

In 2007, when GAVI no longer provides vaccine, there will be a gap of $17.3 million– $16.5 million is the vaccine cost – $0.8 million funding gap for operational costs

Implications– Vaccine shortages– Increased disease burden of immunizeable diseases– Political credibility questioned– Overall Social and Economic development

compromised Social protection strategies of govt towards

vulnerable groups questioned

What are costs of NOT providing hepatitis B and Hib vaccines?

Treatment costs incurred by system– Costs due to illnesses that are a result of a

vaccine preventable disease– Refers to treatment costs to the health system, eg.

due to Hib meningitis– Treatment and vaccine costs of a vaccine include

costs of providing the vaccine, compared to cost of treatment of illnesses due to the immunizable diseases

– As vaccine coverage increases, treatment costs decline

Estimated cost of an illness episode

10.18

53.1633.30

0

50

100

150

200

250

300

Fulminant

hepatitis

Cirrhosis HCC Meningitis Pneumonia

Cost of

pentavalent

Costs of management of a case of selected diseases due to HBV and

Hib

Co

st

(US

D)

Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

DPT DPT-HepB-Hib DPT-HepB DPT-Hib

Treatmentcosts

Vaccinecosts

Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

DPT DPT-HepB-Hib DPT-HepB DPT-Hib

Treatmentcosts

Vaccinecosts

The treatment cost to MOH with no Hep B / Hib vaccine is more

than ten times the cost of DPT

Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

DPT DPT-HepB-Hib DPT-HepB DPT-Hib

Treatmentcosts

Vaccinecosts

Hepatitis B vaccine is very good value for

money

Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

DPT DPT-HepB-Hib DPT-HepB DPT-Hib

Treatmentcosts

Vaccinecosts

DPT-Hib vaccine without Hep B is

an expensive option

Total per capita costs

Cost Per capita costs (USD)

DTP DTP-HepB-Hib

DTP-HepB

DTP-Hib

Vaccine 0.04 0.46 0.17 0.41

Treatment 0.68 0.17 0.17 0.67

Total 0.72 0.63 0.35 1.08

Impact on disease burden

DTP DTP-HepB-

Hib

DTP-HepB

DTP-Hib

Illness episodes averted

0 32,117 29,149 3,180

Deaths averted 0 27,440 26,763 725

EPI expenditures in perspective2000/01 2001/02 2002/03

Cost per capita $.31 $.33 $.73

Cost per FIC $17.36 $16.89 $32.50

Vaccine cost to total EPI cost

18% 30% 73%

EPI cost to total health expenditure

11% 8% 16%

EPI allocation to total health expenditure

2.7% 2.2% 1.8%

STRATEGIES TO ENSURE FINANCIAL

SUSTAINABILITY OF THE PROGRAMME

Key strategies

Mobilize additional internal resources

Mobilize additional external resources

Increase reliability of resources Increase program efficiency

Mobilizing additional internal resources

Strategy for mobilizing public resources

Health Financing Strategy allocates 4% of health budget recurrent costs for vaccines

Allocation been reducing annually to under 2% at present

Need to halt slide on proportion of health expenditure on vaccines/EPI

Strategy for mobilizing public resources

Govt to continue funding the full cost of traditional 6 antigens including the DPT cost and injection supplies.

Propose an increase in proportion of health expenditure for vaccines/EPI (1% increase in real terms annually starting 2004/05)

Govt budget not expected to fund 100% of vaccine costs in the medium term

Impact of 1% annual increase in EPI allocation

31,44935,6129,91411,2570.305%2006/07

35,03439,66820,80023,6180.648%2009/10

33,78638,25717,00819,3120.527%2008/09

32,59236,81513,38115,1940.416%2007/08

30,35434,3726,6717,5740.204%2005/06

29,30433,1853,5083,9830.113%2004/05

28,29932,0464124670.012%2003/04

Deaths averted

Illness episodes averted

Deaths averted

Illness episodes averted

TotalGoU contributionPropn of penta costs covered (bn. shs)

Propn of health budget

YR

Mobilization of other local resources

Immunization activities to be integrated into Local Government activities funded by local resources

Local Govts to mobilize resources for selected cost items, such as IEC and social mobilization

Mobilizing additional external resources

Strategies to seek external resources

Significant donor support for SIAs imply high confidence among donors in immunization as a disease prevention strategy

Advocate for routine vs SIAs support (e.g. rotary, red cross) design a menu for civil society partners and private sector

Negotiate with World Bank for buy-down: performance related external support

Private sector: corporate partners, lottery, e.g. advertising

Increasing reliability of resources

Strategies to increase reliability Taper off vaccine fund support beyond 5

years (use performance grants from GAVI) Protection of vaccine commitment in prog. 9 Cost savings from donors to be maintained

within programme, as opposed to remitting back

Incorporate FSP financial forecasts in govt planning and budgeting processes e.g. MTEF/LTEF

Improve district financial mgt. capacity Advocate for sustainability of SWAp

partnership

Increase programme efficiency

Strategies to improve efficiency Reduce vaccine wastage

– Vaccine management monitoring system & MDVP– Create immunisation logistics manager position– Maintain and upgrade cold chain

NB. Most strategies to reduce wastage may also reduce immunisation coverage

Reduce operational costs– Reduce distribution cost…Switch from gas to

electric/gas Rationalise outreach services/ intensify social

mobilisation

Summary Immunisation is most Cost Effective use of

scarce resources, preventing disease, death and disability, & unnecessary treatment costs

UNEPI to continue providing the current 8 antigens

EPI programme costs shall continue to raise as newer vaccines are developed

Cost implications manageable if phased over time

Are many funding partners besides GoU budget, though this is expected to remain main source of funds (in line with SWAp strategy)

Inability to cover vaccine costs beyond GAVI support implies higher costs to the system

Discussion points

Rising costs of vaccination programme due to popn increase and better coverage.

GoU allocation for immunization activities.

Long-term vision to enable increased adaptation of newer vaccines over time: yellow fever, pneumococcal vaccine, malaria, HIV, etc.

Next Steps

READ the FSP Submit comments on strategy to UNEPI

for inclusion in FSP (is a full section on stakeholder comments for inclusion in final FSP)

Present strategy to Health Sector Working Group

FSP chapters Section 1: Impact of country and health

system context. Section 2: Program characteristics, objectives

and strategies. Section 3: Baseline and current program

costs and financing Section 4: Future resource requirements,

financing gap analysis Section 5: Sustainable financing strategy,

actions, indicators Section 6: Stakeholder comments!!!!!

Vision of UNEPI

To have a society free of vaccine preventable

diseases and disabilities. Immunization expenditures are not

mere costs but investments in health and development