1

Republic of MaliOne People – One Purpose – One Faith

------------------------ Ministry of Health

FINANCIAL SUSTAINABILITY PLANFINANCIAL SUSTAINABILITY PLANFINANCIAL SUSTAINABILITY PLANFINANCIAL SUSTAINABILITY PLANEXPANDED PROGRAM OF IMMUNIZATIONEXPANDED PROGRAM OF IMMUNIZATIONEXPANDED PROGRAM OF IMMUNIZATIONEXPANDED PROGRAM OF IMMUNIZATION

2003-20102003-20102003-20102003-2010

MALIMALIMALIMALI

Date of submission: 20 November 2002

2

TABLE OF CONTENTSTABLE OF CONTENTSTABLE OF CONTENTSTABLE OF CONTENTS

Executive summary 4

Introduction 7

PART 1: DIAGNOSIS

I General situation of Mali and the health sector 101.1 Geographical and demographic situation 101.2 Economic data 111.3 Political, global and sectoral orientations 12

II Financial management 13

2.1 Budgetary process 132.2 Vaccine and consumables supply processes 132.3 Financial procedures 142.4 Financial information system 14

III Characteristics: program objectives and strategies 163.1 Program results and objectives 173.2 Current vaccination calendar 183.3 Injection safety 193.4 Cold chain 193.5 Vaccine management 193.6 Changes of objectives for financial reasons 203.7 Management of the program 213.8 Functions and remit of the partners of the EPI 21

IV Baseline and current cost and funding of the program 22 4.1 Cost of the immunization program in 2000 22

4.2 Cost of the immunization program for 2001 26

V Future needs and financing 30

PART 2: STRATEGIC PLAN

VI Strategic plan and indicators of financial sustainability 326.1 Strategies and measures to mobilise appropriate additional resources 326.2 Strategies and measures to increase the sustainability of resources 346.3 Strategies and measures to improve the efficient use of resources 346.4 Summary of strategies and measures to be implemented 356.5 Additional indicators 36

PART 3: COMMENTS BY PARTNERS

VII Comments by partners

3

ACRONYMS AND ABBREVIATIONSACRONYMS AND ABBREVIATIONSACRONYMS AND ABBREVIATIONSACRONYMS AND ABBREVIATIONS

BCG Bacillus Calmette and GuerinICC Inter-agency Coordinating CommitteeMEF Medium-term Expenditure FrameworkIUPMRI Implementation Unit of the Program of Medical Reinforcement and InfrastructureLA Local AuthorityPSU Planning and Statistics UnitRCOCESHP Regional Committees for the Orientation, Coordination and Evaluation of Social and

Health ProgramsCHC Community Health CentrePRSP Poverty Reduction Strategy PapersVC Vaccination coverageAFO Administrative and Financial OfficeGOPD General Office of Public DebtNHO National Health OfficeDTP Vaccine against the Diphtheria, Tetanus and Whooping coughFIC Fully Immunised ChildUNFPA United Nations Fund for Population ActivitiesGAVI Global Alliance for Vaccines and ImmunizationIDA International Development AssociationJICA Japanese International Cooperation AgencyNID National Immunization DayMEF Ministry of the Economy and FinanceMH Ministry of HealthWHO World Health OrganisationNGO Non-Governmental OrganisationIMCI Integrated Management of Childhood IllnessTPMSD Ten-Year Plan for Medical and Social DevelopmentEPI Expanded Program of ImmunizationGDP Gross Domestic ProductMPA Minimum Package of ActivitiesUNDP United Nations Development ProgramOP Operational ProgramHIPC Highly Indebted Poor CountriesFPMSD Five-year Plan of Medical and Social DevelopmentFSP Financial Sustainability PlanAD syringe Auto-destruct syringeAIDS Acquired Immuno-Deficiency SyndromeUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentAAV Yellow-fever vaccineMEAS Measles vaccineTT Tetanus vaccineHIV Human Immuno-deficiency VirusOPV Oral Polio VaccineHib Hepatitis B vaccineDTP Hb Tetravalent vaccine against Diphtheria, Tetanus, Whooping cough and Hepatitis B

4

Executive summary

Since its launch in 1986, the Expanded Program of Immunization (EPI) has had its ups and downsfrom the standpoint of its funding and as a result its performance record has been very uneven.

Moreover, the end of the 1990s and the beginning of the 2000s saw the emergence of other challengesthat the country’s vaccination programs have to meet. They include vaccination safety, the willingnessof States and the International Community to speed up the eradication, elimination and control ofcertain disabling and deadly diseases, the epidemiological situation, the requirement for equity inNorth-South relations, and the willingness of States and the International Community to fight povertyare all factors that argue for the introduction of new and more expensive vaccines in the Routine EPI.

The new challenges are exerting increasing pressure on the State’s internal resources and are makingit even more difficult to manage the balance between the various national and public health priorities.

The need to combine internal and external resources to meet the above challenges so as to ensureappropriate and sustainable funding of all vaccination activities is more clearly relevant than everbefore. It is the purpose of the Financial Sustainability Plan (FSP) to take up the challenge. Theobjectives of the Plan are:

• to determine the common priorities and responsibilities of the Government and theDevelopment Partners;

• to mobilise and use resources effectively;• to provide a framework for discussions and negotiation between the health and finance

Ministries on the one hand and between the Ministries and the Development Partners on theother hand;

A. The diagnosis made of the program environment produced the following main findings:

1. The current context is favourable for the drafting of such a plan:• economic growth was good between 1994 and 2000, and will remain so for the period 2002-

2006: 6.7% a year;• tax receipts are expected to grow by 12.8% a year over the same period;• the allocation of resources to the health sector will also be high: 10.77% over the period;• the fight against poverty and the debt relief initiative are making considerable budgetary

resources available, including resources for vaccination;• the potential for funding that can be mobilised in the context of devolution and giving

communities responsibility is considerable;• a Medium-Term Expenditure Framework (MTEF) is in preparation;• the sectoral approach is creating a unique context of coordination, planning, programming,

monitoring, and evaluation of activities;• a strong resurgence of interest in vaccination is perceptible among the International

Community;• the political situation of the country is stable, democracy is gaining strength and the medium-

term economic prospects are good;• there is strong political commitment at the highest level of the State to vaccination and to

improving the situation of the most needy;• the Government is agreeing to implement the principles of good governance, to pursue the

fight against corruption and to improve the management of the public purse;

2.. The results of vaccination coverage by DTP P3 for 2001, estimated to be 61%, are a significantimprovement of the figures for 1999 and 2000, which are 47% and 54% respectively, due on the onehand to the increase in medical coverage brought about by the creation of new CHCs, and on the other

5

hand to the larger number of people joining the vaccination program and the effective implementationof the FPMSD.

The objectives of the EPI were established on the basis of available resources and those expected fromthe State and from the various partners of the EPI, and from the improvement of overall managementof the EPI by:

• the drawing up of micro-plans by health area with the participation of the communities;• the general use of performance contracts;• the renovation of the cold chain at all levels;• the boosting of vaccination activities by the mobile teams of health cercles and areas to cover

populations within an area greater than 5 km. (60% of the population);• the re-launching of supervision activities;• the monitoring of vaccination activities by level taking into account wastage for all the

antigens of the Routine EPI;• innovation and technological progress.

The objectives relate to achieving coverage of 93% for DTP-Hb 3 in 2010.

3 .On the other aspects relating to the management of the program, the major constraint found stemsfrom the difficulties of mobilising and justifying funds in the context of the FPMSD.

4 In relation to the costs of the program in 2000 and 2001, it will be seen that:

• operational costs predominate and absorb 71% and 90% respectively of the cost total ofvaccination activities in 2000 and 2001. The proportions are two-thirds and one-third forroutine activities, and three-quarters and one-quarter for the 2000 polio NIDs;

• vaccines and injection supplies are the prime cost item, accounting for 49% of total programexpenditure in 2000 and 68% in 2001;

• annual vehicle depreciation charges and staff costs are next, at 16% and 13% of the totalexpenditure in 2000 respectively;

• The cost of the vaccination program more than doubled between 2000 and 2001. It rose fromabout $5 million in 2000 to almost $13 million in 2001. This sharp rise is explained by thelarge volume of supplementary activities, the introduction of monovalent vaccine againsthepatitis B, and the changeover to using auto-destruct syringes. It should be noted that theintroduction of the Hep vaccine and the changeover to AD syringes led to a doubling of thecost of the Routine EPI.

The main finding is that the funding available is sufficient to cover all requirements over the GAVIperiod. A funding surplus of about $3.6 million is even shown for the period.

However, there is a need to ensure that on the one hand all requirements have in fact been expressedand included in full, and that on the other hand there will be sufficient flexibility on the part of theState and the Partners to ensure that shortfalls in the funding of certain minor items (including socialmobilisation) are covered by redeployment of resources at the time of the annual programmingexercises.

B. The additional funding required for the post-GAVI period is $4.2 million. However, the gaprelative to assured funding is $7.8 million. That gap could be filled by a better mobilisation ofavailable and new resources. On that score, the strategic plan makes provision for the followingstrategies and measures:

6

1. In respect of the mobilisation of adequate additional resources, the State intends tocontinue its efforts in support of the EPI so as to contribute even more to the long-termfinancial sustainability of the program. To that end, efforts will be directed to:

• the improvement of the budgetary resources allocated to immunization activities: the share ofthe health budget allocated to the national vaccination program will increase from 2.12% in2002 to 4.23% in 2010;

• the allocation to vaccination activities of at least 1% of HIPC resources;• the effective application of texts on decentralisation: such application would mean that 7% of

local authority resources would be allocated to the health sector; 20% of those resources couldbe allocated to vaccination activities;

• the improvement of resources covered by the population as part of community managementof primary health establishments;

• the development of alternative funding (mutuals);• getting the private medical sector to make a greater contribution to vaccination activities by

the signature of framework contracts;• looking for new partners or joining/exploring new initiatives: Olympic Aid, the initiative

known as the “Millennium Development Goal”;• getting certain traditional Partners of the EPI to contribute to the mobilisation of additional

support in their traditional areas of activity: JICA and Luxembourg Cooperation for cold chainlogistics support and equipment; USAID is expecting to increase the volume of its directsupport to the EPI during the period of this FSP;

• the development of decentralised cooperation;• the utilisation of the facilities offered by budgetary support;• the assignment to the EPI of an A-grade manager with an economics/finance profile to help

improve financial programming and the analysis of program effectiveness;

2. To make program resources sustainable, the Government intends to remove the mainconstraints associated with the low take-up of credits. To that end, it is contemplatingtaking the following measures:

• the holding of a workshop specially devoted to the difficulties associated with the mobilisationand justification of the funds channelled to the devolved levels in the context of the FPMSD;the discussions that will take place will make it possible to identify bottlenecks, find anappropriate solution to them, and thus improve resource take-up;

• giving staff responsibilities, introducing criteria for assessing their performance, andconducting weekly monitoring;

• making decentralised State authorities responsible for monitoring;• sharing responsibilities between the State and the Communities at the level of the health

areas in the management of EPI activities;• in the medium-term, consideration will be given to the signature of framework agreements

with local authorities for channelling resources through their financial circuits;• in the longer-term, the possibility will be studied of decentralised budgetary support with an

obligation to report to the health and finance Ministries.

3. In order to improve the effectiveness of the use of resources, the following indicatorswill be systematically monitored:

• cost efficiency: cost per FIC and per dose administered;• reduction of the dropout rate;• monitoring of vaccine wastage.

7

Introduction

Retrospective studies have shown that vaccination is one of the most effective public healthactivities. It also has proven economic benefits in terms of growth generated because of theresulting increase in life expectancy.

It was therefore right for the Government, with the support of its Partners, to have launchedthe Expanded Program of Immunization in the 1980s. Since then, the fortunes of programfunding have been mixed:

• the 1980s were the decade of the “fat cattle”, marked by the mobilisation of considerable resourcesin support of a program that enjoyed at the time sustained backing and the highest priority on thepart of the donor community which, incidentally, provided most of the of the funding of theprogram: all the operational expenditure and investment essential to the carrying out of vaccinationactivities was provided by the international community, including UNDP, UNICEF, UNFPA andWHO; government funding was mainly a matter of in-kind contributions - staff, buildings, theservices of public utilities. Vaccination coverage was very high for certain antigens;

• the first half of the 1990s was marked by a steady dwindling of program funding by the traditional

partners. That even resulted in cold chain equipment and logistics not being replaced, and thus totheir ageing, to frequent shortages of vaccines, and to a slowing-down or even halting of activitiesin some cercles (districts); as a consequence, vaccination coverage stagnated: less than 50% forDTP 3;

• the second half of the 1990s has been a period of resumed program funding: average annualfunding actually disbursed rose from CFAF 1.5 billion in 1994-1995 to about CFAF 2 billionbetween 1996 and 1998. This major financial effort comes essentially from the State and relatesmainly to the funding of vaccines and consumables as part of the Vaccination IndependenceInitiative; vaccination coverage has not risen sharply, however, because the cold chain and logisticshad not been updated, and the requirements for operational expenditure necessary for theimplementation of the EPI in the field were not covered; DTP 3 coverage averaged 52% between1997 and 2000.

It is therefore very important to ensure on the one hand complete and adequate funding of the priorityneeds of the EPI and on the other hand the long-term financial sustainability of the program in order tocontinue to protect sustainably the most vulnerable sections of the population from the tribulations ofdisease and death.

Moreover, the end of the 1990s and the beginning of the 2000s saw the emergence of other challengesthat national vaccination programs have to meet. They include:

• vaccination safety: the HIV/AIDS epidemic and the risks of contamination by the hepatitis Bvirus led WHO and UNICEF to recommend the use of safer but more costly injectionequipment;

• the willingness of States and of the International Community to speed up the eradication,elimination and control of certain disabling and deadly diseases: the initiatives born in thatcontext are increasing sharply the need for funding for national vaccination programs;

• the epidemiological situation, the requirement for equity in North-South relations, and thewillingness of States and the International Community to fight poverty are factors that arguefor the introduction of new and more expensive vaccines in the Routine EPI;

8

• the need to ensure the long-term future of what was achieved with GAVI funding after 2007(date announced for the end of funding);

The new challenges are exerting increasing pressure on the State’s internal resources and are makingit even more difficult to manage the balance between the various national and public health priorities..

The need to combine internal and external resources to meet the above challenges so as to ensureappropriate and sustainable funding of all vaccination activities is more clearly relevant than everbefore.

It is the purpose of the Financial Sustainability Plan (FSP) to take up the challenge. The objectives ofthe Plan are:

• to determine the common priorities and responsibilities of the Government and theDevelopment Partners;

• to mobilise and use resources effectively;

• to provide a framework for discussions and negotiation between the health and financeMinistries on the one hand and between the Ministries and the Development Partners on theother hand;

The current context is favourable for the drafting of such a plan:

• the fight against poverty, to which vaccination makes a significant contribution, is at thecentre of the concerns of the International Community. The resulting initiative to relieve thedebt of the HIPCs is making considerable budgetary resources available, including resourcesfor vaccination;

• the potential for funding that can be mobilised in the context of devolution and giving thecommunities responsibility is considerable;

• a Medium-Term Expenditure Framework (MTEF) is in preparation;

• the sectoral approach is creating a unique context of coordination, planning, programming,monitoring, and evaluation of health activities, thus facilitating the coordination andstreamlining of the use of the resources made available to the health sector.

The FSP document is divided into three parts:

• the diagnosis,

• the strategic plan,

• the comments of the main financial partners of the EPI, who are members of the ICC.

9

PART: DIAGNOSIS

10

I - General situation of Mali and the health sector

1.1. Geographical and demographic situation

Mali is a vast continental country with an area of 1,241,238 km2 distributed between three climaticzones: the Saharan (50%), Sahelian (25%) and Sudano-Guinean (25%) zones.

The population was estimated to be 10,278,250 inhabitants in 2000 with a natural demographic growthrate of 3% a year and a net growth rate of 2.26% because of emigration (PRSP, 2002). Women are in amajority (51.2%) and about 80% of the total population lives in rural areas. The population is youngfor the most part: 49% are under 15 years old and children aged from 0 to 11 months account for 4%.The population is distributed unevenly: 58% of the population lives on 8% of the national territory.

The geographical and demographic situation has an influence on the cost of EPI activities.

1.2 Economic data

In 2001, GDP was CFAF 1,927.4 billion, 38% of which was accounted for by the primary sector, 24%by the secondary sector and 32% by the tertiary sector. Although GDP rose on average by 5.2% from1994 to 2000, there was 2.4% negative growth in 1993 and a more marked positive change after thedevaluation of the CFAF in 1994: 6.4% in 1995 and 5.8% in 1997, for example.

Public finance was marked by an improvement in revenues from 142% of GDP in 1994 to 15.5% ofGDP in 2000. For the same period, expenditure rose from 25.2% to 28.6% of GDP.

The State budget has increased regularly for more than 10 years. It rose from CFAF 255 billion toCFAF 610 billion between 1990 and 2002. The health budget rose from CFAF 10 billion in 1990 toCFAF 39.5 billion in 2002. The overall budget of the health sector shows a modest level ofmobilisation of resources (64%) and an average implementation rate (52%). However, the trend istowards an improvement of these rates because of improved mobilisation of resources by the partners.For example, for the World Bank, the mobilisation rate rose from 4% in 2000, and 11% in 2001, to anexpected 30% at the end of 2002.

11

PartnersCredits

MH budgetTotal

S1

64

11

82

61

0

20

40

60

80

100

Chart 1: Mobilisation rate of FPMSD funds from 1999 to 2002 in %

For the period 2002-2006, the Government has set itself the objective of promoting strong andsustainable economic growth (6.7% per year) and reducing the poverty index, which will fallfrom 64% in 2002 to 47% in 2006.

The Government is also forecasting growth of tax revenues of 12.8% a year over the sameperiod. The growth of tax revenues will be accompanied by the allocation of additionalresources to priority sectors including the health sector.

1.3 Political, global and sectoral orientations

Economic constraints and the difficulties associated with the mobilisation of resources haveprevented the State from providing the health sector with the means needed to satisfy thehealth needs of the population. To overcome those difficulties, it has instituted a policy ofalternative health funding. This involves the participation of the population in the health effortby, in particular, their making a financial contribution for access to services or medicines. TheState has also provided support for the development of mutual arrangements: there were 52mutuals in 2002, 25 of which are working in the health sector, with 12,527 members. Inaddition, the decentralisation policy being pursued in the country is producing an effort tomobilise the resources of the decentralised local authorities themselves to benefit the healthsector. This effort is demonstrated specifically by the commitment of the local cercledevelopment committees to devote at least 7% of the income from the local development taxto health.

To this it should be added that the State has committed itself, through the HIPC (HighlyIndebted Poor Countries) initiative, to increasing its contribution to health funding. Accordingto the General Office of Public Debt total resources expected under the HIPC initiative isestimated to be almost CFAF 75 billion between 2002 and 2004. Fifteen percent (15%) ofthose funds are intended for the health sector. Initially, the HIPC resources of the health sectorwere used in the context of an intensification of the battle against HIV - AIDS and malariaand the development of human resources. In the FPMSD, however, action to combat diseaseis a priority where prevention by vaccination plays a major role. Vaccination is offered in allcommunity health centres that offer by definition the minimum package of activities. It is

12

therefore hoped that provision will be made in HIPC resources for funds for vaccination aspart of the funding of financial sustainability plans. This will make it possible to honour thecommitment by the Heads of African States, made at Abuja in 2001, to allocate 15% of theState budget to the health sector.

These new opportunities for funding health are part of an economic and social context markedby the fight against poverty and by institutional reforms intended to boost decentralisation anddevolution. The EPI is participating in the fight against poverty by helping to maintain theoutput and productivity of the individuals and families that are the decisive factors for theeconomic growth of a country. In Mali, the eradication of the polio made possible by theNIDs in Mali will have made it possible to avoid thousands of children suffering majorhandicaps that would harm the economic and social development of the country. Furthermore,retrospective studies have shown that about 8% of the increase in revenues could be explainedby improved life expectancy and that improved life expectancy could translate into a rise of1% of GNP within 15 years. Assessments of the economic impact of vaccination have shownthat the effects of investments in vaccination were positive both for new vaccines and for thetraditional vaccines of the EPI. In the case of the latter, most of the studies assessed theireconomic return at three to ten times the cost of the program. It should be noted that on the subject of the orientation of health policy, the Government ofMali defined its sectoral health policy in 1990 on the basis of the components and principlesof primary health care. In June 1998, a ten-year plan for medical and social development(TPMSD) for 1998-2007 was drawn up. The Program for Medical and Social Development(FPMSD) for 1998-2002 constitutes the first five years of that plan. The State was thusmarking the end of the project approach and the start of the program approach. Since then,the planning of EPI activities has been carried out in this overall framework.

When it comes to the supply of services and above all in a spirit of equity, outreach andmobile strategies are systematically organised, with a minimum package of activities beingmade available to the population. The minimum package includes the vaccination of womenand children, the provision of micro-nutrient supplements, pre-natal consultation, familyplanning, and the promotion of the use of impregnated mosquito nets.

As part of the institutional reforms, the adoption in the very near future of the plannedregulations for the staff of local authorities and the drafting of a convention for the staff ofCommunity Health Centres will make it possible to provide a solution to the uncertainty andshortage of the human resources of the health sector. The contractual approach alreadyembarked on will make it possible to provide solutions to these human resource problems andshould be contemplated in the context of vaccination activities.

For better coordination and monitoring of all activity in the context of the FPMSD, twobodies have been set up: the monitoring committee and the technical committee. For the EPI,coordination and monitoring are provided by the Inter-Agency Coordinating Committee(ICC).

13

II- Financial management

2.1. Budgetary process

The process of budgeting for the FPMSD starts at the level of the cercle/Commune with theoperational program (OP). The cercle operational program is drafted by the managers of theexecution structures at the cercle level working together with the local authorities. It assessesthe costs of the activities included, specifies how action is to be funded and also serves as aprogram budget. The set of cercle plans, confirmed at the regional level during the RegionalCommittees for the Orientation, Coordination and Evaluation of Social and Health Programs(RCOCESHP), constitute the OP for the region. The national OP is the consolidation of theOPs of the various regions confirmed by the technical committee.

The managers of the execution structures at the level of the Administrative and FinancialOffice and of the Planning and Statistics Unit are the actors responsible for the consolidationof the forecasts. They participate in the regional discussion on the budgets.

Activities financed by the State are budgetised starting in May to meet the requirements of theState budget preparation procedure, and an indicative ceiling is set in advance by the Ministryof Finance.

The department budget financed from the State budget is approved according to governmentalprocedures.

The Ministry of Health, in agreement with the partners, drew up an initial strategic multi-yearplan after 1998, the objectives and strategies of which were incorporated into the FPMSD. In2002, the multi-year plan was updated for the period 2002-2005. The strategic multi-year planis translated each year into an operational program included in the overall operationalprogram of the FPMSD.

Although this planning process may be regarded as satisfactory, there is nevertheless a need tospeed up the process of consolidation at the national level so as to mobilise resources in timefor OP implementation.

2.2. Vaccine and consumables supply processes

Under the Vaccination Independence Initiative in Sahelian Africa, Mali has signed aconvention with UNICEF for the supply of EPI vaccines and consumables through theCopenhagen Purchasing Centre.

In the convention, Mali has opted for the purchase assistance procedure. This means that, afterrequirements have been assessed, the amount of the UNICEF pro-forma invoice is the subjectof a payment order decision that enables resources to be transferred to the UNICEF account.

While the convention allows a supply of high-quality vaccines, it must be pointed out thatthere have been implementation difficulties due to late expressions of requirements andfailure to respect delivery dates.

14

2.3. Financial procedures

Financial procedures are the subject of a procedures manual that describes the procedures formanagement of the financial, human and material resources used for the production of thedocuments described in para. 2.4.

The FPMSD procedures manual provides for three different ways to make funds available. Itcovers the mobilisation of resources through the A, B and C accounts respectively for thecentral, regional and cercle levels. Those three accounts are the program accounts that receivefunds from the State and Netherlands funds. In addition to these accounts, there is the IDAspecial account that allows funds to be paid into the "A" account on the basis of vouchers.

According to the process, the "A" account feeds the "B" accounts, which in turn feed the "C"accounts.

Funds are disbursed as advances by the AFO to fund the OPs of the regions. The advances aresupported by programming the activities to be implemented and are paid out in a pyramidalfashion along the same lines as the preparation of the budget.

In addition, the partners may request the opening of specific accounts for the funding of theiractivities or may make funds directly available to the operational level. In all cases, they mustinform the central level for the purposes of accounting and financial monitoring.

The financial management process is global and does not allow targeted management of thevaccination program, which may be an adverse factor in a context of public finance difficulty.It would be desirable to give priority to the funding of EPI activities regardless of thedifficulties.

2.4. Financial information system

The financial information system is based on the TOMPRO software package

The TOMPRO software used in projects and similar programs was chosen for use as a supportfor the accounting information system of the FPMSD.The software is an integrated project management package providing real-time:

- General accounting;- Analytical accounting;- Budgetary accounting;- Financial accounting (management of donor financing);- Inventory management (equipment and stocks);- Contract and transaction management;- Staff management.

The principle on which it operates is single entry / multiple breakdown, which enables instantupdating of general, analytical, budgetary and financial accounts.

The software program is currently available in all the regional health offices to produce thevarious accounting and financial reports required.

15

Each partner must be informed of the situation of its account on the 15th of each month.

An analysis of this information should make it possible to anticipate and improve programmanagement. Partial use of the procedures manual does not allow the collection of relevantinformation that is of use to the decision makers. It should also be mentioned that many of thedifficulties encountered in the implementation of the FPMSD could be the result of failure touse the manual.

The financial operations of the FPMSD, for all types of all funding, are examined annually bythe independent auditors in accordance with generally accepted international auditingstandards.

The content of the checks to be carried out is specified in the terms of reference of the auditmission of the FPMSD accounts.

The audit of the accounts is generally carried out under the responsibility of the Ministry ofHealth. The audit is conducted in two visits a year and is certified by a general report of theaccounts of the FPMSD covering the budget year.

In addition, each partner may carry out an audit of its funding under the FPMSD.

16

III. Characteristics: program objectives and strategies.

The implementation of the EPI has gone through several successive phases:- the "sweep" phase (1986-1990): the target population consisted of children from 0 to 6

years of age and pregnant women. The diseases targeted by the program weretuberculosis, diphtheria, whooping cough, tetanus, measles, and poliomyelitis.

- The maintenance phase (1991-1994): this consisted mainly of the consolidation of whathad been achieved and the continuity of vaccination services. It addressed children in the0 to 23 month age group and women of child-bearing age.

- The phase of integration of the EPI into the MPA: with the extension of medical coverageby the creation of new health structures (CHCs). It consisted of making vaccinationservices permanent and continuous at all levels of the health system by emphasisingparticularly the needs of children under one year of age and women of child-bearing age.This phase has seen the general spread of vaccination against yellow fever and theintroduction of the vaccine against hepatitis B in 2002 into the Routine EPI.

The Health Department is supported in this enterprise by the technical and financial partners,the main ones being: UNICEF, WHO, GAVI, the European Union, USAID, Netherlands,Japanese and Luxembourg cooperation, and also the local authorities.

17

3.1. Program results and objectives:

3.1.1. Changes in vaccination coverage from 1995 to 2001(children aged 0 to 11 months)

Table 1: Changes in vaccination coverage from 1995 to 2001

Years

Antigens

1995 1996 1997 1998 1999 2000 2001

BCG 80% 79% 76% 78% 64% 75% 81%DTP 3 49% 53% 52% 56% 47% 54% 61%OPV3 49% 53% 52% 56% 47% 54% 61%MEAS 52% 57% 56% 60% 46% 55% 61%AAV 4% 8% 9% 10% 13% 17% 10%TT2+ Pregnant women 16% 16% 15% 15% 14% 19% 31%

Source: routine data

3.1.2. Objectives for the period from 2002 to 2009Children aged from 0 to 11 months and pregnant women

Table 2: Objectives for coverage by antigen from 2002 to 2009

Years

Antigens

2002 2003 2004 2005 2006 2007 2008 2009 2010

BCG 83% 85% 88% 90% 92% 95% 96% 97% 97%OPV3 65% 70% 75% 80% 85% 90% 92% 93% 93%DTP 1 * 75% - - - - - - - -DTP 3 * 65% - - - - - - - -MEAS 65% 75% 80% 85% 90% 92% 93% 94% 94%AAV 55% 60% 65% 70% 75% 80% 85 90% 90%TT2+ 65% 70% 80% 85% 90% 95% 96% 97% 97%VHB3 72% - - - - - - - -DTP Hb3 - 70% 75% 80% 85% 90% 92% 93% 93%

Sources: Multi-year strategic plan for the EPI (2002 – 2005) and projections for subsequent years* From 2003, Mali will introduce tetravalent DTP Hb vaccine which contains DTP and VHb

The results for DTP P3 vaccination coverage in 2001, estimated to be 61%, show a significantimprovement over the figures for 1999 and 2000, which are 47% and 54% respectively, dueon the one hand to the increased medical coverage by the creation of new CHCs, and on theother hand to greater participation by the population in the vaccination program and theeffective implementation of the FPMSD.

The objectives were set based on available resources and those expected from the State andfrom the various partners of the EPI, and the improvement of overall management of the EPIby:

18

• the drawing up of micro-plans by health areas and cercles with the participation of thecommunities,

• the general use of performance contracts,

• the renovation of the cold chain at all levels,

• the boosting of vaccination activities by the mobile teams of health cercles and areasto cover populations within an area greater than 5 km. (60% of the population),

• innovation and technological progress.

The national strategy to combat poverty drawn up by the Government of Mali is helping toimprove access to vaccination services, particularly for the populations of peripheral areas bythe creation of the community health centres.

3.2. Current vaccination calendar

Table 3: Vaccination calendar for children aged 0-11 months

Antigen Diseases targeted Age group Age for administration

OPV 0 Poliomyelitis 0-11 months At birth up to 2 weeks

BCG Tuberculosis 0-11 months At birth

DTP /P1 +Hep1

Diphtheria, tetanus,whooping cough,poliomyelitis, hepatitis B

0-11 months From one and a half months (6 weeks)

DTP P/P2 +Hep2

" " 0-11 months From two and a half months (10 weeks)

DTP P/P3 +Hep3

" " 0-11 months From three and a half months (14 weeks )

MEAS Measles 0-11 months From 9 months

AAV Yellow fever 0-11 months From months

Table 4: Calendar for vaccination against tetanus

Dose to beadministered

Preferred date of administration

TT1 As soon as possible from 15 yearsTT2* As soon as possible, ensuring that administration is at least 4 weeks after that of TT1.

TT3 Maintaining an interval of at least 6 months after administration of TT2.TT4 Maintaining an interval of at least 12 months at least after administration of TT3.TT5 Maintaining an interval of at least 12 months at least after administration of TT4.* For pregnant women, TT2 should be administered at least 2 weeks before delivery for protection to betransferred to the child at birth.

19

3.3. Injection safety.

A study on injection safety was made in Mali in 2000. The main findings of the study are:

• injections are not safe because there are risks to the patient: 10% of therapeuticinjections are still being made with sterilizable syringes;

• certain injection practices are hazardous for health staff: 66% of workers re-capneedles after therapeutic injections;

• injection wastes are a hazard to the community: 45% of the syringes and needles usedare not collected in safety boxes.

Mali has adopted the WHO and UNICEF guidelines on injection safety and drew up its planof action for vaccination injection safety in September 2002.

Mali, with the support of its technical and financial partners, has instituted the general use ofauto-destruct syringes and safety boxes at all levels and the construction of incinerators atcercle health centres.

3.4. Cold chain.

A recent survey on the replacement of EPI cold chain equipment carried out in January 2001shows that:

• the present cold chain is unable to ensure vaccine quality in two-thirds ofcases;

• 51% of centres have at least one defective appliance;

• 82% of centres have no stocks of spare parts;

• 13% of refrigerators are running at a temperature above 8° C.

The effect of this situation is high wastage everywhere.

The reduction of vaccine wastage is a national imperative that can be achieved by a completerenovation of the cold chain. In 2002, a partial renovation took place thanks to the support ofcertain partners (Luxembourg, Japan). That support enabled the renovation of almost 90% ofcold chain appliances at the various levels of the medical pyramid.

3.5. Vaccine management

The country gets supplies of vaccines and consumables through UNICEF. UNICEF will bethe preferred source in the coming years because of its reliability. However, it has been foundthat the administrative and financial procedures of the national financial services and thepartner (UNICEF) for orders and deliveries of vaccines are still cumbersome and slow.

Constant availability of vaccines and regular supplies to the health structures still poseenormous problems because of the size of the territory, the isolation of certain localities, the

20

shortage of logistics, and the low level of staff skills in the overall management of the EPI andmore particularly the management of vaccines.

Resolving these problems will require the introduction of the following strategies:

• keeping to the supply schedule,

• continuous monitoring of procedures for orders and deliveries of vaccines andequipment at all levels,

• boosting abilities to estimate vaccine requirements, and to manage stocks andequipment at all levels

An analysis of the vaccination reports of the Routine EPI of certain cercles reveals wastage ofantigens varying from 16% to 46% (1999 study) during vaccination sessions.

To counter this, measures will be taken to minimise such wastage by reducing it to 15% in2002 and 2003 and 10% in subsequent years, in accordance with reduction projections. Thiswill mean:

• more effective application of the policy on opened vials;

• monitoring of vaccination activities by level, taking into account wastage forall the antigens of the Routine EPI,

• reorganisation of vaccination activities at stationary centres, in the outreachstrategy and by mobile teams: stepping up the dialogue with communities,drafting of and compliance with the vaccination program, sharing ofresponsibilities between the State and the local authorities in the vaccinationservices on offer,

• resumption of supervision activities specific to the program with the aim ofproper management at all levels,

• continuation of micro-planning activities and the institution of performancecontracts at the level of all functional health areas,

• stepping up social community-based communication/social mobilisation withthe aim of improving the use of vaccination services.

3.6. Changes of objectives for financial reasons.

Since 2001, Mali has enjoyed the financial and technical support of GAVI in addition to thesupport from other partners. The GAVI support will end in a context where it is supposed thatthe State will already be prepared to ensure the continuity of vaccination services because ofthe substantial reduction of vaccine wastage and by additional appropriations in the Statebudget.

Since Mali’s economy depends partly on climatic ups and downs, any shortfall inprecipitation could possibly reduce agricultural and animal production and the country might

21

be faced with difficulties in mobilising resources to cover health expenditure, including theEPI.

3.7. Management of the program

The recent restructuring of the NHD, the underlying objective of which is to integrate healthprograms to make them more effective and efficient, is an opportunity for the ImmunizationSection responsible for the EPI to expand its services by relying on the strategies developedby other programs like the Integrated Management of Childhood Illness (IMCI).

Although the restructuring reduces the structural visibility of the program, the creation of theICC is an asset that helps to enhance further the priority given by the State and the partners tothe EPI.

3.8. Functions and remit of the partners of the EPI

The main partners of the EPI are members of a coordination and steering body - the Inter-agency Coordinating Committee to strengthen the Routine EPI. The Committee examines allthe reports and plans of operations of the EPI submitted to it by the program managers andrules on the funding of activities.

The private, community and NGO sectors, in the context of decentralisation, work at the mostperipheral level (village, health areas) of vaccination activities.

The dynamism of the State - private sector - NGO and community partnership will beensured: performance contracts, stepped up community participation in the preparation ofmicro-plans, and the sharing of responsibilities in the overall management of the Routine EPI.

A vaccination observation unit will be set up to monitor the country’s immunization effortsrelating to the targets of the program.

22

IV. Baseline and current cost and funding of the program

4.1 Cost of the immunization program in 2000

a. Volume and structure

The table below shows the aggregated costs of routine services and supplementary activitiesand their structure.

The following salient points will be noted:

• the predominance of operational costs, which absorb 72% of the total cost ofimmunization activities, as against a quarter for annual investment costs; theproportions are two-thirds and one-third for routine activities, and three-quarters andone-quarter for polio NIDs;

• vaccines are the prime cost item, accounting for 33% of total expenditure of theimmunization program: the proportion is 39% and 30% respectively for routineactivities and polio NIDs;

• annual vehicle depreciation charges are next, with 16% of total expenditure, 19% ofpolio NIDs expenditure and 13% of expenditure on routine activities;

• staff costs follow with 13% of the total cost of the Program, but 22% of the cost of thepolio NIDs and 12% of the cost of routine activities.

23

Table 5: Specific costs and funding of the program of vaccination for the base year 2000

Item No. Component Routine Services Structure Polio NIDs Structure Total Structure[A] Operational cost US$ US$ US$

Required information 1 Vaccines 1.1 Vaccines (6 traditional antigens) 808,472 33 820,968 30 1,629,474 321.2 Vaccines (New and under-used)2 Injection supplies 390,462 16 57,512 2 447,990 93 Staff 36,688 1 581,619 22 618,309 124 Transport and travel costs 94,787 4 42,793 2 137,583 35 Maintenance and overheads 36,818 2 36,819 16 Short-term training 18,271 1 325,731 12 344,003 77 Social mobilization /IEC 3,047 68,256 3 71,303 18 Control and surveillance 107,133 4 105,476 4 212,614 49 Other (specify) 7,361 7,3619.1 Operational costs not detailed 185,107 7 185,107 4

Optional information 10 Shared-use staff10.1 -Payroll 255,876 10 255,886 510.2 -Incentives/per diems11 Other (specify)

Sub-total of operational costs 1,758,915 72 2,187,462 81 3,946,377 77

[B] Capital costsRequired information

13 Purchase of vehicles 277,646 11 500,000 19 777,657 1514 Purchase of cold chain equipment 249,751 10 9,039 258,800 5

Optional information 15 Buildings 160,477 7 160,477 316 Other capital goods 792 79217 Long-term training18 Other (specify)

Sub-total of capital costs 688,666 28 509,039 19 1,197,705 23

[C] Miscellaneous19 Miscellaneous (funding not detailed)20 Miscellaneous (funding not detailed)

Sub-total of miscellaneous costs TOTAL 2,447,581 100 2,696,500 100 5,144,082 100

* Other supplementary vaccination activitiesExchange rates 2000: 1 US $ = CFAF 715 1 Euro = CFAF 655.,957 1 Yen = CFAF 6.31

24

b. Distribution of cost by source of funding

The following table shows the distribution of cost by source of funding. The following mainpoints will be noted:

• the State, UNICEF and WHO are the main financial partners of the immunizationprogram with 36%, 22% and 14% respectively of total funding, or almost three-quarters of the funding;

• the relative importance of participation by the private sector and NGOs in the fundingof the program: about 11.5%;

• figures for community participation are not available. However, the communitiesparticipate in funding the operation of the cold chain, social mobilization and theactivities of the outreach strategy. This explains the small share of the Communities(1.4%) in funding;

• the absence of funding from the Territorial Public Authorities;

• finally, the charges for the annual amortisation of capital costs have not been assignedto any particular source of funding.

NB: investment-related financing appears as annual amortisation charges.

25

Table 6: Distribution of the cost total of the program by source of funding in 2000

Component STATE WHO UNICEF (EU) CATR Community Private NGO Total %[A] Operational cost US$ US$ US$ US$ US$ US$ US$ US$

Required information

1 Vaccines 1.1 Vaccines (6 traditional antigens) 808,472 820,968 1,629,441 31.68%1.2 Vaccines (New and under-used) 2 Injection supplies 279,147 19,344 38,168 111,315 447,974 8.71%3 Staff 245,889 372,418 618,307 12.02%4 Transport and travel costs 20,594 39,036 77,950 137,580 2.67%5 Maintenance and overheads 33,587 3,231 36,818 0.72%6 Short-term training 128,410 197,321 18,271 344,002 6.69%7 Social mobilization /IEC 13,945 54,973 2,385 71,303 1.39%8 Control and surveillance 24,880 116,673 16,783 54,273 212,609 4.13%9 Other (specify) Office supplies 7,361 7,361 0.14% Other operational costs not detailed 84,323 72,045, 28,739, 185,107, 3.60

Optional information

10 Shared-use staff 10.1 -Payroll 136,026 119,8500 255,876 4.97%10.2 -Incentives/per diems 11 Other (specify)

Sub-total of operational costs 1,569,902 734,084 1,134,407 35,055 303,210 83,012 2,385 3,946,377 76.72%[B] Capital costs

Required information

13 Vehicles * 223,636 276,364 777,646 15.12%14 Cold chain * 9,039 258,790 5.03%

Optional information

15 Buildings * 160,477 3.12%16 Other equipment 792 792 0.02%17 Long-term training 0.00%18 Other (specify)

Sub-total of capital costs 232,675 792 276,364 1,197,705 23.28%[C] Miscellaneous 19 Miscellaneous (funding not detailed)

Sub-total of miscellaneous costsTOTAL 1,886,900 734,876 1,134,407 35,055 303,210 83,012 278,748 5,144,082 100%As % 36.68% 14.29% 22.05% 0.68% 5.89% 1.61% 5.42% 100.00%

Exchange rates 2000: 1 US $ = CFAF 715 1 Euro = CFAF 655.957 1 Yen = CFAF 6.31

26

4.2 Cost of the immunization program in 2001

c. Cost volume and structure

The cost of the immunization program more than doubled between 2000 and 2001. It rosefrom about $ 5 million in 2000 to almost $ 13 million in 2001. This sharp rise is explained bythe volume of supplementary activities (measles, meningitis, polio), by the introduction ofmonovalent vaccine against hepatitis B, and the changeover to auto-destruct syringes. Itshould be noted that the introduction of the Hep vaccine and the changeover to AD syringes,led to a doubling of the cost of the Routine EPI.

In addition,

• operational expenditure accounts for most of the cost of the program; it accounts for90% of the cost as against 10% for capital costs; this predominance applies in the caseof the Routine EPI as well as for supplementary activities;

• vaccines and injection supplies account for 60% of the total cost. The proportion is68% for routine activities.

27

Table 7: Specific costs and funding of the program of vaccination for the base year 2001

Item No. Component RoutineServices Structure Polio

NIDs Structure MeaslesCampaign Structure Other SVAs*

(Meningitis) Structure Total Structure

[A] Operational cost US$ US$ US$ US$ US$ Required information

1 Vaccines 1.1 Vaccines (6 traditional antigens) 2,567,662 49.6 572,18 23.43 904,233 30.9 1,348,571 56.8 5,392,65 41.71.2 Vaccines (New and under-used)2 Injection supplies 975,515 18.8 817,053 27.9 649,350 27.3 2,441,91 18.93 Staff 49,807 1.0 406,42 16.64 304,216 10.4 201,552 8.5 962,00 7.44 Transport and travel costs 81,429 1.6 98,02 4.01 246,234 8.4 127,253 5.4 552,94 4.35 Maintenance and overheads 21,906 0.4 21,90 0.26 Short-term training 136,728 2.6 138,94 5.69 107,413 3.7 438 383,52 3.07 Social mobilization /IEC 20,933 0.4 128,39 5.26 174,183 5.9 13,500 0.6 337,01 2.68 Control and surveillance 158,525 3.1 99,45 4.07 216,665 7.4 13,417 0.6 488,06 3.89 Micro-planning 65,446 1.3 65,44 0.5

Office supplies 8,684 0.2 31,61 1.29 40,29 0.3 Other operational costs 0 0.0 457,55 18.74 146,927 5.0 16,712 0.7 621,18 4.8

Optional information 10 Shared-use staff10.1 -Payroll 274,488 5.3 274,48 2.110.2 -Incentives/per diems11 Other (specify) 81,157 1.6 81,15 0.6 Sub-total of operational costs 4,442,279 85.8 1,932,60 79.14 2,916,925 99.6 2,370,794 99.8 11,662,59 90.2

[B] Capital costsRequired information

13 Purchase of vehicles 305,684 5.9 500,00 20.48 805,68 6.214 Purchase of cold chain equipment 246,398 4.8 9,25 0.38 11,259 0.4 4,626 0.2 271,53 2.1

Optional information 15 Buildings 179,769 3.5 179,76 1.416 Other capital goods17 Long-term training18 Other (specify) 5,395 0.1 5,39 Sub-total of capital costs 737,246 14.2 509,25 20.86 11,259 0.4 4,626 0.2 1,262,38 9.8

[C] Miscellaneous19 Miscellaneous (funding not detailed)20 Miscellaneous (funding not detailed) Sub-total of miscellaneous costs TOTAL 5,179,524 100.0 2,441,85 100.00 2,928,183 100.0 2,375,420 100.0 12,924,98 100.0

* Other supplementary vaccination activities Exchange rates 2001: 1 US $ = CFAF 700 1 Yen = CFAF 6.31 1 Euro = CFAF 655.957

28

d. Distribution of cost by source of funding

It can be seen from the table below that the volume of supplementary activities, financedmainly by the Partners, has reduced the State’s share of funding of immunization activities to15% as against 36% in 2000. It will be noted that two partners, UNICEF and IDA, have alarger relative share of funding than the State: 20% and 18% respectively. Another point tonote is the volume of funding by IDA, which did not appear as a partner in 2000 and whichbecomes the second largest contributor in 2001.

The trend for the other partners does not change relative to 2000. It should however be notedthat JICA and Luxembourg Cooperation financed a major renovation of cold chain equipmentand logistics in 2001. That major financial support does not appear because of the way costsare booked - as annual depreciation charges and not as funding disbursed;

29

Table 8: Distribution of the cost of the 2001 program by source

Component STATE WHO GAVI Japan UNICEF CATR IDA &NL USAID Community

Private NGO* ND Total %

Operational cost Required information

Vaccines Vaccines (6 tradl. antigens) 1,053,038 1,476,422 1,348,571 5,392,656Vaccines (New and under-used) 1,514,624 1,514,624

Injection supplies 181,203 43,752 3,045 791,267 773,301 649,350 2,441,918Staff 47,693 699,482 13,277 201,552 962,003Transport and travel costs 5,947 365,578 13,688 40,479 127,253 552,945Maintenance and overheads 16,000 5,906 21,906Short-term training 151,832 5,609 107,356 438 118,289 383,524Social mobilization /IEC 9,354 135,032 1,776 61,367 13,500 19,156 96,826 337,012Control and surveillance 12,218 400,615 6,959 22,32 13,417 32,525 488,061Micro-planning 65,446 65,446Office supplies 40,294 40,294Other operational costs 292,763 56,073 146,927 16,712 33,429 15,285 60,000 621,189Optional informationShared-use staff

-Payroll 117,414 157,074 274,488 -Incentives/per diems

Administration of vitamin A 81,157 81,157Sub-total of operational costs 1,759,924 2,014,966 50,258 2,305,892 2,605,853 22,322,370,794 203,399 157,074 15,285 156,826 11,662,599

Capital costsRequired informationVehicles 223,636 276,364 805,684Cold chain 18,514 6,621 271,533Optional informationBuildings 179,769Other equipmentLong-term trainingComputers and software 1,948 3,447 5,395

Sub-total of investments 242,150 8,570 3,447 276,364 1,262,381 MiscellaneousMiscellaneous (funding not detailed)Miscellaneous (funding not detailed)Sub-total of miscellaneous costs Total 2,002,074 2,023,536 50,258 2,309,338 2,605,853 22,322,370,794 203,399 157,074 15,285 433,190 731,85112,924,980 1As % 15.5 15.7 0.4 17.9 20.2 18.3 1 1 0 3 5 100.0

30

V. Future needs and financing

The following tables summarise funding requirements for the period covered by the FSP,available financing and the shortfalls over the GAVI period and the post-GAVI period.

The main finding is that assured funding does not cover resource requirements for the period.However, if probable and possible funding is considered, needs will be met.

Approaches will be made to the various partners to confirm probable funding as assuredfunding.

There is therefore no need to build scenarios, particularly since:

• the wastage level used, 15%, is already very ambitious; it could not be lowered anyfurther without destroying the credibility of the exercise;

• a revision of the coverage objectives is not something the Ministry of Health couldcontemplate;

• resources are available, including resources to cover the main expenditure items:vaccines, injection equipment, staff, and investment.

However, there is a need to ensure that on the one hand all requirements have in fact beenexpressed and included in full, and that on the other hand there will be sufficient flexibility onthe part of the State and the Partners to ensure that shortfalls in the funding of certain minoritems (including social mobilisation) are covered by redeployment of resources at the time ofthe annual programming exercises.

The additional funding required for the post-GAVI period is $4.2 million. However, the gaprelative to assured funding is $7.8 million. That gap could be filled by a better mobilisation ofavailable and new resources.

The following section makes specific proposals on the subject.

31

PART 2: STRATEGIC PLAN

32

VI. Strategic plan and indicators of financial sustainability

6.1 Strategies and measures to mobilise appropriate additional resources

a. Mobilisation of additional domestic resources

The Government has already shown its full determination to translate into specific action thepriority assigned to the fight against disease by prevention, including vaccination activities. Inparticular, in addition to expenditure on staff, buildings and public utility services, the State:

• has assumed responsibility since 1996 for the funding of the vaccines andconsumables of the Routine EPI for traditional antigens;

• is participating increasingly actively in taking responsibility for expenditure relating tosupplementary activities: polio NIDs, measles, yellow fever, anti-tetanus, meningitiscampaigns, etc.;

• is committed to take over progressively GAVI funding for the introduction of newvaccines, thus ensuring the long-term future of the operation in the same way as fortraditional vaccines.

All in all, funding by the State is already considerable in relation to that of the ExternalPartners. However, the State intends to continue its efforts in support of the EPI so as tocontribute even more to the long-term financial sustainability of the program. To that end,efforts will be focussed on:

• the improvement of budgetary resources allocated to immunization activities: thisimprovement is made possible by the projected growth of the budget of the healthsector: 10.77% for the period 2002-2006. The health budget will thus rise from CFAF39.5 billion in 2002 to CFAF 64.3 billion in 2010. It is planned to increase the nationalvaccination program’s share of the health budget from 2.12% in 2002 to 4.23% in2010, or an average of 3.72% for the period;

• the use of HIPC resources to fund the requirements of the immunization program. Theresources that will be released as part of this initiative relate to an amount of $ US 870million over 20 years for the Bretton Woods institutions. Those resources will beboosted by the inputs from bilateral donors from the end of 2002; the country has towait for the completion point at that date. It is therefore expected that there will be anincrease in the resources allocated in that context to the health sector, andconsequently to the EPI. The expected allocation to vaccination activities will relate toat least 1% of HIPC resources. It should be noted that Mali’s partners, particularly theWorld Bank, have registered their agreement to make immunization activities eligible;

• the effective application of the texts on decentralisation: such application would meanthat 7% of the local authorities’ own resources would be allocated to the health sector;20% of those resources could to be allocated to vaccination activities;

• the improvement of the resources covered by the population as part of communitymanagement of primary health establishments: that improvement will be obtained bythe expected improvement in the earnings of the population in the context of the

33

program to combat poverty, and of two-pronged action on the productivity of theCHCs and increasing their number;

• the development of alternative funding (mutuals): this development, planned as part ofthe FPMSD, will make it possible to mobilise more resources for vaccination;

• making the private medical sector contribute more to vaccination activities: to thisend, framework contracts will be concluded with existing and future structures for theprovision of services for the account of the health Ministry, and also for the promotionof vaccination among their customers.

b. Mobilisation of external resources

The current situation of the country favours the mobilisation of external resources:

• after the period of dwindling finance in the second half of the 1990s, a strongresurgence of interest in vaccination is perceptible among the InternationalCommunity; initiatives in support of vaccination are growing in number, thus makingresources available to the country;

• the political situation of the country is stable, democracy is gaining strength and themedium-term economic prospects are good;

• there is strong political commitment at the highest level of the State to vaccination andto improving the situation of the most needy;

• in health matters, interest is being shown in helping the CHCs and the poorestCommunes;

• the Government is agreeing to implement the principles of good governance, to pursuethe fight against corruption and to improve the management of the public purse;

These governmental measures favour the implementation of the following strategies for bettermobilisation of external resources :

• looking for new partners or joining/exploring new initiatives: Olympic Aid is inpreliminary contact with certain partners for possible action in the country; similarly,the initiative called the “Millennium Development Goal”, created under the auspicesof the G8 and the United Nations and the objectives of which include the fight againstdisease, looks interesting in many ways;

• making full use of certain traditional Partners of the EPI for the mobilisation ofsupport in their traditional areas of activity: JICA and Luxembourg Cooperation forcold chain logistics support and equipment;

• the development of decentralised cooperation: the current and future prospects fordecentralisation in and outside the country are an asset;

• the utilisation of the facilities offered by budgetary support, the form of fundingcurrently preferred by certain primary bilateral and multilateral partners: World Bank,

34

Netherlands Cooperation, USAID, etc. Major funding is channelled through budgetarysupport, from which vaccination receives little benefit; this will happen even more inthe future. Some of the funding of the Partners concerned could be directed towardsimmunization activities, particularly for the Routine EPI;

• the assignment to the EPI of an A-grade manager with an economics/finance profile tohelp improve financial programming, the preparation of dossiers for seeking funding ,financial monitoring including monitoring of the implementation of conventions withPartners and domestic funding, and the analysis of program effectiveness.

6.2 Strategies and measures to increase the sustainability of resources

On this point, the aim will be to remove the main constraints associated with the low take-upof credits. To this end, the Government is contemplating taking the following measures:

• the holding of a workshop specially devoted to the difficulties associated with themobilisation and justification of the funds channelled to the devolved levels in thecontext of the FPMSD. The workshop will bring together the staff involved in themanagement of funds at all levels of the medical pyramid; the discussions that willtake place will make it possible to identify bottlenecks, find an appropriate solution tothem, and thus improve resource take-up;

• giving staff involved at all levels of the medical pyramid responsibilities on the basisof a performance contract. To that end, criteria for assessing staff performance will beadopted and there will be weekly monitoring by immediate hierarchical managers withthe possibility of penalties for poor performance;

• making devolved State authorities responsible for monitoring;

• sharing responsibilities between the State and the local authorities at the level of thehealth areas in the management of EPI activities: target population, funding, socialmobilization;

• in the medium-term, consideration will be given to the signature of frameworkagreements with local authorities for channelling resources through their financialcircuits;

• finally, in the longer-term, the possibility will be studied of decentralised budgetarysupport with an obligation to report to the Health and finance Ministries.

6.3 Strategies and measures to improve the efficient use of resources

Ways to make efficient use of resources will be systematically sought from now on. One ofthe reasons behind this measure is the Government’s decision to increase markedly thegeographical accessibility of the population, which will increase progressively until 2007,thus giving a boost to the stationary strategy, which is in principle more efficient. It istherefore important to keep track of the impact of the extension of medical coverage on thecost per FIC and per dose administered. In this context, account will continue to be taken of cost-effectiveness as a monitoring EPIindicator. The economist mentioned in paragraph 1 of this section will be given the job of

35

introducing an appropriate tool to perform this monitoring that will result in an annual reportthat will also cover the other aspects of funding mentioned in the same paragraph; the reportwill be examined by the ICC and submitted to the health and finance Ministries.

Moreover, the following measures will also be taken:

• reduction of the dropout rate;

• reduction of vaccine wastage.

6.4 Summary of strategies and measures to be implemented

Activities Period Responsible Monitoring indicators

1The State allocates 3.72% of the healthbudget to vaccination

2003-2010 MHMEF

Proportion of the healthbudget allocated tovaccination

2 The State allocates at least 1% of HIPCresources to vaccination

2003-2010 MHMEFPartners

Proportion of HIPCresources allocated tovaccination

3 The Local Authorities (LA) allocate 7%of their resources to health, of which20% to vaccination

2003-2010 Ministry ofDecentralisationMEF

Proportion of LAresources allocated tovaccination

4 Improvement of cost-recovery and betterallocation of resources to supportvaccination

2003-2010 MH Share of the resourcesof communitiesallocated to vaccination

5 Development of alternative funding 2003-2010 MHMEF

Amount of fundingmobilised

6 Greater contribution by the private sectorto vaccination

2003-2010 MH Number of contractssigned and contributionby the sector to thenational CV

7 Search for new partners and joining newinitiatives

2003-2010

MHMEF

Number of newpartners and volume oftheir funding

8 Better utilisation of the possibilitiesoffered by some traditional partners(JICA, Luxembourg, etc.)

2003-2010 MH (EPI)MEF

Volume of fundingmobilised from suchpartners

9 Development of decentralisedcooperation

2003-2010 MHMinistry ofCooperation

Number of agreementssigned and volume ofEPI funding

10 Better utilisation of the possibilities ofbudgetary support

2003-2010 MH (AFO)EPI- MEF

Volume of this type offunding

11 Assignment of a managerwith aneconomics/ financial profile to the EPI

January2003

MH Presence of themanager

Measures and strategies to make funding more sustainable1 Organisation of the workshop on the

mobilisation and justification of FPMSDfunds

January2003

MH (AFO) Workshop organised

2 Introduction of performance criteria infinancial management

February2003

MH (AFO) Volume of fundingdisbursed

3 Giving devolved authoritiesresponsibilities

February2003

MH - MEFMI

Administrative act

36

4 Signature of framework agreements withLAs

2005-2010 MHM/Decentralisation

Number of frameworkagreements signed

5 Development of budgetary support forthe LAs

2007 MH – MEFPartners

Volume of fundingmobilised inaccordance with thisformula

Measures and strategies to improve the effective use of resources1 Introduction of a system for monitoring

effectiveness indicatorsMarch2003

MHICC

Monitoring of the costper FIC and per doseadministered

2 Reduction of the dropout rate 2003-2010 MHICC

Dropout rate for theantigens

3 Reduction of vaccine wastage 2003-2010 MHICC

Vaccine wastage

4 Resumption of supervision activities 2003- 2010 MH Number of supervisionvisits made

5 Stepping up monitoring of vaccinationactivities

2003-2010 MH Number of monitoringsessions held

6.5. Additional indicators for monitoring the FSP – Mali

Indicators Unit Responsible formonitoring

Comments

1 Specific operatingexpenditure/GDP-Debt Servicing

%MH - MEF

2 Specific investmentexpenditure/GDP- DebtServicing

%MH - MEF

3 Accessibility 0-5 km % MH4 Implementation rate of the

program budget% MH

5 Implementation rate of theprojected budget for domesticresources

% MH

6 Implementation rate of theprojected budget for externalresources

% MH

37

PART 3: COMMENTS BY PARTNERS

38

The Minister for Health The Minister for the Economyand Finance

Mrs Kéita Rokiatou NE Diaye Mr. Bassari Touré

39

ANNEX 1Methods used to evaluate costs: base and current years, and projections for 2003-2010

40

Methods used for the evaluation of costs: base and current years, and projectionsfor 2003-2007

A. Routine EPI

1. Operational costs

VaccinesFor 2000 and 2001, the actual payments made by the Government on the basis of pro-formainvoices were used. The payments are made in advance as required by the assistance purchaseprocedure.

For the 2002-2009 projections, the estimates were made based on the target populations,coverage objectives and wastage of the various antigens. Wastage was determined from thefollowing wastage figures appearing in the strategic multi-annual plan document: 15% for allantigens in 2003 and 10% for subsequent years. It will be noted that wastage as given by thestudy made for the 1997 to 1999 is distinctly higher: 46% for BCG, 21% for DTP, 16% forOPV, 30% for MEAS and 23% for TT. The reduction objectives therefore seem to beparticularly ambitious for BCG and MEAS.

It should also be noted that the estimates of requirements made for AAV are distinctly lowerthan the funding announced by GAVI.

Injection suppliesThe budget line that finances the purchase of injection equipment also authorises theacquisition of cold chain consumables and other supplies from the health Ministry. Theexisting financial data are therefore not fully disaggregated and the invoices relating toinjection equipment could not be made available to the team responsible for drawing up theFSP. Costs were therefore estimated from the quantities of vaccines administered for allantigens other than OPV in accordance with the outline contained in the guidelines. Theestimates were increased by 10% to allow for wastage.

StaffThe staff costs of the Immunization Section of the Division to combat disease (central level)have been classified as specific costs.

Staff costs at the other devolved levels were estimated using the standards provided by theImmunization Section for the regional, cercle and Community Health Centre (CHC) levels,and the average salaries provided by the AFO. These staff are shared with the otherprograms/activities, hence the estimate of the time devoted to vaccination activities based, forthe CHC level, on the number of vaccination sessions in the stationary and outreachstrategies, the time spent in preparation for sessions and the time spent on preparing thereports. For the other levels, the assessment of the EPI manager was used as the basis for theestimate.

41

Transport and travel costsExpenditure on fuel and travel costs was booked as supplied by the various sources. Servicingcosts were estimated on the basis of 5% of the annualised costs of vehicles and motorcycles.

Short-term training, social mobilization, control and surveillance, otheroperational costsThe data collected from the various sources of funding were used.

Maintenance and overheadsThe general costs of buildings and maintenance of cold chain equipment were estimated onthe basis of 5% of the annualised capital cost.

2. Capital cost

Vehicle and motorcycle costsThe annual cost was estimated on the basis of the hypothetical use of one vehicle per cercleand per region for mobile and supervision activities, the running time of the vehicles and theaverage cost of the Hilux 106 vehicle, the most representative of the fleet. The service lifeused is 10 years.

The running time was estimated from the number of supervision visits per year and thenumber of mobile strategy journeys.

For motorcycles, the standards used are one motorcycle per CHC, one per cercle and one perregion. A service life of 4 years was used and the unit cost used is that of the latestacquisitions made by WHO, or CFAF 1.350 million.

Cold chain costsThe inventory taken during the study on renovation and the introduction of a maintenancesystem for EPI cold chain equipment was used as the basis for the estimate of the cost ofheavy equipment.

The cost of light equipment (cool boxes, vaccine carriers, accumulators, etc.) was estimatedfrom the standards provided by the Immunization Section.

BuildingsThe annual cost was estimated as follows:

� Inventory of the number of buildings based on the number of CHCs and CSCs, sinceboth types of structure offer vaccination services;

� Evaluation of the cost of the CHCs according to the standard plan type supplied byIUPMRI;

� A service life of 20 years was used;

� Determination of the cost imputable to the EPI by application of the working hoursdevoted to the EPI by staff;

42

� Application of the same cost to the CSCs based on the fact that, in terms of spaceallocated to vaccination services, there is no difference between the two types ofstructure.

B. Supplementary activities

1. Operational costs

The costs shown in the campaign reports were used.

2. Capital costs

Estimate of the costs of vehicle useThe number of vehicles used during the 2000 and 2001 polio NIDs was estimated as follows:

� For the costs for the 5 regions of the South (Mopti, Koulikoro, Kayes, Sikasso,Segou), an extrapolation was made of the number of vehicles counted in the Moptiregion. The Mopti region is average from the point of view of area and demographicweight but, like Kayes, is one of the regions where access to the population is difficult(hilly relief and marshes);

� For the regions of the North (Tombouctou, Kidal and Gao), the extrapolation wasmade from the data collected for Tombouctou;

� The District of Bamako and the central level were given separate treatment;

� The number of days that vehicles are used was estimated at 10 per journey, or 20 daysfor both journeys (preparation, setting up vaccines and consumables, activity andevaluation);

� An average vehicle cost of CFAF 65,000 per day (excluding fuel) was used.

The rationale for using this estimation method was that there is no data available for the otherregions. The use of motorcycles was noted but the cost could not be estimated for lack ofdata; similarly, gifts in kind were recorded but could not be taken into account for lack ofexhaustive data.

The annual vehicle cost could not be calculated for the measles and meningitis campaign forlack of data.

Finally, the annual cost of vehicles for 2000 for the polio NIDs has been re-used for 2001,because no data was available on the number of vehicles used.

Estimate of the costs of the cold chainThe following method was used:

� The annual amortisation cost of the cold chain was split into 2: cost of the central levelcold chambers, and other cold chain costs at the devolved levels;

43

� The cost of cold chambers imputed to the campaign was determined on the basis of thenumber of days vaccines are kept in the cold chambers between delivery and theirsupply to the field. That time was estimated at one month per journey;

� The other costs of the cold chain imputed to the campaign were estimated based on theaverage time that vaccines are kept at the levels of the regions, the cercles and theCHCs. The average time was estimated at 6.3 days per journey;

� The total cost of the cold chain imputed to the campaign is the sum of the costs of thecold chambers and of the other costs of the cold chain imputed to the EPI.

C. Funding available

1. GAVI / yellow fever and injection equipmentThe amounts communicated by GAVI do not correspond to the estimate made using theprices supplied by GAVI. It was therefore decided to split the funding announced by GAVIinto funding available for new vaccines and funding for injection supplies in a proportion of82% to 18%, in accordance with the proportions given in the estimates made.

The period covered by this funding was therefore extended so that the funding surplus couldbe used after 2005. The funding outline used is therefore as follows:

� 2002: 100%� 2003: 100%� 2004: 90%� 2005: 80%� 2006: GAVI 75% of funding� 2007: GAVI 70% of funding� 2008: GAVI 8.7% of funding� 2009 and 2010: 0%

The calculations were made on the basis of the amounts of funding announced by GAVI until2006. From 2007 onwards, projected requirements were used as the basis for sharing fundingbetween the State and GAVI.

The sustainability plan was applied as defined in the request submitted to GAVI. The planenvisages progressive disengagement by GAVI according to the following calendar:

� 2003: 100%� 2004: 90%� 2005: 60%� 2006: 50%� 2007: 10%� 2008: 0%

The calculations were made on the basis of projected requirements.

44

2 Funding from the European UnionThe funding announced - € 1 million - has been distributed over 5 years, from 2003 to 2007.UE funding for cold chain equipment and maintenance: an exchange rate of € 1 = $ 1 wasused.

3 USAID fundingUSAID will deploy long-term support (12 years from 2003) of $ 13 million per year for thehealth sector. Part of this funding will be directed to the EPI, including the followingdomains:

� boosting institutional capabilities: training;� supervision;� micro-planning� Commodities: acquisition of equipment and materials according to needs and

priorities;� Vitamin A in the Routine EPI;� Integrated communication plan for the EPI;� Support for the introduction of new vaccines according to GAVI recommendations.

Taking into account the impossibility of determining the amounts allocated to the EPI at thisstage of programming activities, the indications of the Partner that the annual fundingallocated to the EPI will be at least equal to that provided in 2001 were used for 2003 to2010.

45

ANNEX 2

1. Cost and Funding 2002 and by source

ANNEX 3

1. Estimate of vaccine and injection safety requirements2. Estimate of staff requirements3. Estimate of fuel requirements for the outreach strategy4. Estimate of cold chain requirements5. Estimate of vehicle requirements6. Estimate of short-term training requirements7. Estimate of transport and travel requirements8. Estimate of servicing, maintenance & fuel requirements for the cold chain9. Estimate of requirements: control and supervision10. Estimate of requirements: social mobilization11. Estimate of requirements: vehicle servicing and fuel

ANNEX 4

Detailed tables 2003 – 2010 of annual resources and funding requirementsanalysed by risk

46

ANNEX 5Documents used

Lists of the documents used and data sources

1. Strategic Framework to Combat Poverty2. Guidelines for the preparation of a plan to ensure the sustainability of an EPI. GAVI, April

20023. GAVI submission document,4. Changes in the State Budget allocated to the Ministry of Health from 1996 to 20025. Manual of procedures of the FPMSD6. Note of an exchange between the Government of Mali and Japan concerning support for

the EPI, February 20017. Plan of action for vaccination injection safety, September 20028. Plan of action, US AID, 20019. Plan for the introduction of hepatitis B vaccine10. Ten-year Plan for Medical and Social Development (TPMSD)11. Sectoral plan of operations: Infant survival and development program (2003 – 2007),

UNICEF (draft), July 200212. Multi-year Strategic Plan of the EPI (2002 – 2005), September 200213. Five-year Program of Medical and Social Development (FPMSD)14. Draft Budget of the Ministry of Health 2003 and Projections for 2003 – 200515. Protocol between the Government of Mali and the Grand-Duchy of Luxembourg

concerning support, May 200016. SIS annual report17. Report on the Campaign of Vaccination against Measles and Meningitis, CNI, March 200218. Technical and financial report on the NIDs in Mali 1999, CNI19. Technical and financial report on the NIDs in Mali 2000, CNI20. Technical and financial report on the NIDs in Mali 2001, CNI21. Equipment assessment report, CNI, January 2002