new “ring fenced” national immunization funds. · programme on immunization (kepi) and to...

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VOL. 5, ISS 2, JULY 2013

A milestone was reached when peers from 17 countries met in Dakar, Senegal on August 5-6, 2013 for the Second Sustainable Immunization Financing Colloquium. More than 100 participants, including delegates from ministries of health, ministries of finance and parliamentarians, exchanged advocacy strategies and best practices and charted progress toward ownership of their national immunisation programs.

Since the first colloquium, held in Addis Ababa, Ethiopia in 2011, countries involved in Sabin’s Sustainable Immunization Financing Program have been working to increase their commitments to immunisation through two pathways: legislation and innovative financing.

The second colloquium, in Dakar, revealed that all but one country have drafted new, or are amending existing, laws relating to immunisation. Countries discussed their legislative work and brainstormed ways to accelerate their respective legislative processes. The emerging role of parliaments in crafting and championing the bills was noted. In several countries, MPs have formed immunization forums, or caucuses, to facilitate the legislative process.

Innovations in immunization financing and budgeting were also shared. Among the key innovations in the countries are efforts to create new “ring-fenced” national immunization funds. In one case, government is matching private sector donations to the fund. Countries are also identifying new revenue sources, such as excise taxes on cellular phone calls, as a way to increase their immunization investments.

In recent years, the countries as a whole have steadily increased their immunization spending. However, development partners (such as GAVI Alliance, UNICEF, and others in civil society) continue to finance more than 50 percent of routine immunization budgets in many of the

J VOL. 5, ISS 3, SEPTEMBER 2013

http://www.sabin.org/updates/events/first-sabin-vaccine-institute-colloquium-sustainable-immunization-financing-sif

http://www.sabin.org/updates/pressreleases/dakar-conference-countries-showcase-increased-efforts-fund-their-own



countries. Achieving country ownership and meeting the six strategic objectives of the Global Vaccine Action Plan will require nothing less than a paradigm shift, remarked Sabin Executive Vice President Ciro de Quadros. Countries must increase their financial contributions to the immunization programs that protect their citizens and ensure the health of the next generation. They must reduce their dependence on external funding.

The full report from the Second Sabin Colloquium on Sustainable Immunization Financing can be downloaded here.

Recent elections and a new constitution have opened the doors for renewed immunization advocacy work in Kenya. A briefing held on 12 July brought together representatives from Kenya’s National Assembly, Kenyan Pediatric Association, Ministry of Health, Ministry of Finance and the Ministry of Devolution and Planning. They were joined by UNICEF, WHO, USAID and Sabin counterparts. A Sabin-sponsored peer exchanger from Uganda also attended.

The purpose of the briefing was to inform parliamentarians, key government counterparts

and other immunization stakeholders on the challenges facing Kenya’s Expanded Programme on Immunization (KEPI) and to brainstorm ways to ensure sustainable immunization financing. The expected

outcomes were to develop a set of follow‐up activities for upstream (high level advocacy) and downstream (district and point of service delivery) advocacy.

KEPI Manager, Dr Tatu Kamau, presented the major issues and challenges facing the Program. Reviewing the financial situation, Dr. Kamau pointed out that the Government of Kenya (GoK) has for years funded all of its immunization delivery system, 90% of its cold chain and all of its traditional vaccines. Kenya has kept up with its GAVI co-payments for pentavalent, yellow fever and PCV-10 vaccines. To avoid onerous importation duties, the program purchases its syringes domestically. The program, however, still depends on external partners for most of the new vaccines and about 50% of its supervisory and 90% of its training costs. Program funding is limited by the Government’s Medium Term Expenditure Framework (MTEF) and the Ministry’s Sector wide Approach (SWAP), through which a capped budget is distributed annually among the various health programs. Though there is a budget line item for vaccines, the immunization budget is not ring-fenced.

According to its 2011-2015 comprehensive Multi-Year Plan (cMYP) for immunization, Kenya’s direct, recurrent routine immunization program costs came to about US$23m in 2010, of which the GoK paid $6.6m. Adding in shared health system costs brought total expenditures to about $134.8m. Of this total, the GoK financed about $67m. Like other countries, Kenya likely underreports its immunization expenditures. Dr. Kamau presented the 2013 budget shown on the next page:

http://www.who.int/immunization/global_vaccine_action_plan/en/

http://www.sabin.org/updates/events/second-sabin-vaccine-institute-colloquium-sustainable-immunization-financing



Not included in the table are the shared health system costs for 2013. To summarize, the GoK’s direct, central-level immunization budget has increased, however, Kenya’s immunization program remains dependent on external financing.

Another challenge lies in the decentralization of vaccine procurement. With the new Constitution and devolution plan, Kenya’s 47 counties are expected to assume responsibility for routine immunization delivery within the coming three years. Some counties will have their own revenues. Others will receive direct external partner funding “off budget”. Most of the counties will depend on annual federal transfers to pay immunization and other health service delivery costs. Annual transfers will be on the order of KSh 210b. The central MoH will provide normative, technical and quality assurance support to the counties.

Dr. Kamau displayed county by county 2013 routine immunization budgets which she and her team prepared in anticipation of the devolution process. In total, the counties will need about KSh 800m (~US$10m) in federal transfers and about KSh 2.6b (~US$30m) more in additional funding per year to maintain current vaccine coverage levels.

*(The latter figure includes vaccines and syringes. It remains unclear which government level will pick up cold chain equipment costs.) She expressed concern that the Treasury may have already made the transfers and that counties intend to use the funds to independently procure their own vaccines and vaccination supplies. Participants shared her

concern that this would greatly increase risks of vaccine stockouts and would be relatively more expensive. Experience elsewhere has shown that these commodities are best procured centrally.

Dr. Kamau felt that a legal framework is urgently needed, particularly to spell out the immunization program financing, vaccine procurement and other rules the federal and county governments will follow. She recalled that this was one of the action points that she, Hon. David Eseli and the other Kenyan delegates identified in the 2011 SIF Colloquium in Addis. In fact, two draft immunization laws were prepared by members of the National Assembly Health Committee in 2011-12. In the last Sabin Kenyan briefing (February 2012), participants decided not to push the bill until after the 2013 elections.

Ugandan MP, Hon. Mathias Kasamba, described the SIF advocacy work underway in his country, highlighting the formation of the Uganda Parliamentary Forum on Immunisation (UPFI) and its achievements in the areas of legislation and budgetary oversight.

Representing the newly created Ministry of Devolution and Planning, Mr. James Mwanzia gave his views of the health devolution process. Above all, public health should not be compromised at any point in the process, he stated. Mr. Mwanzia listed several of the key policy documents his group is using to define the constitutional changes and devolution modalities (e.g., Urban Areas and Cities Act, Public Financial Management Act 2012, Government Relations Act). One useful conduit through which his ministry works is the Governors’ Summit. The counties will need to meet some strict technical and managerial tests before the government actually sends the health sector transfers, he commented. No transfers have yet been sent for health, he assured the group.



In the third session, participants summarized their observations and began charting a way forward. What is urgently needed, suggested Mr. Mwanzia, is a policy paper spelling out these specific benchmarks and technical criteria for immunization in Kenya. Specific recommendations need to be formulated on vaccine procurement, resource tracking, reporting by the counties locally and to and from the respective federal ministries and other issues identified.

Mr. Mwanzia also agreed that up-to-date immunization legislation is needed, not only to accommodate the structural changes in how services are delivered but also specifying how they are to be publicly financed. He endorsed the suggestion made by Hon. Kasamba that parliament and government jointly write the legislation but, he added, government must lead and not just wait to be summoned by Parliament to act.

On 4 September, a second SIF parliamentary briefing took place in Nairobi. Attending were 24 MPs, representatives from the Ministries of Health and Finance and partner organization counterparts.

Kenyan MPs discussing sustainable immunization financing in September 2013.

The introductory remarks were led by the KEPI Deputy Director Dr Dominic Mutie, who highlighted the challenges implicit in the sustainable financing objective and called for more collective action by the executive,

legislators and stakeholders in order to address these concerns. He mentioned several challenges faced by the National Immunization Program, such as the introduction of the new Railway Development Levy which is causing a delay on clearance of vaccines and injection equipment from the entry ports. Clearance requires numerous exemption letters from various government ministries and institutions, among them Treasury, Kenya Revenue Authority, Kenya Bureau of Standards, and Kenya Medical Supplies Agency (KEMSA). Mutie also brought up the issue of co-financing of the country’s GAVI new vaccine grants. Co-financing payments are supposed to be made directly by Treasury but they are often delayed because no money is designated in the budget specifically for this purpose. Dr Mutie hoped that the parliamentary committee will support the Ministry of Health in ensuring timely disbursement of these previously approved funds. *Addressing the issue of establishing Kenya’s National Immunization Technical Advisory Group (NITAG), Mutie emphasized that parliament should make necessary legal provisions. Progress has been hampered in their absence. Honorable Dr. David Eseli from Kenya’s National Assembly took the floor next and applauded the presentations which, in his view, enabled the MPs to fully appreciate the importance and challenges involved in vaccinating Kenya’s children. These issues, commented Eseli, can be addressed by the MPs at various levels through legislation, oversight, budget appropriation and advocacy. The MPs in attendance represented various committees. Eseli urged them to consolidate their efforts to ensure their advocacy work has far reaching, long lasting effects. Also represented was the Kenya Women’s Parliamentary Association (KEWOPA). This group includes MPs from all 48 counties in



Kenya. Engaging KEWOPA in the action would assure that immunization advocacy efforts have nationwide reach. Hon. Eseli emphasized the need to correctly frame the immunization financing challenge. In the past KEPI was funded mainly by development partners, making the Program dependent on their goodwill. The success of immunization is its largest downfall, he remarked. Once government feels that the partners will provide the funds needed and disease outbreaks are no longer occurring, public funding begins to fall.

Legislation is one tool for addressing sustainable financing. The Kenyan Public Health Act, pointed out Eseli, is outdated in that it only mentions smallpox. The law does not mention that the onus is on the government and parents to ensure full immunization of each child. New legislation on immunization is needed to address these issues. If we do this, and organize a forum within parliament, added Eseli, “We will be able to safeguard vaccines, safeguard vaccination coverage and vaccination financing”.

The Chairperson of the Health Committee, Hon. Dr Rachael Nyamai, noted that MPs self-select the committees to which they belong.”We therefore have a group of interested and influential members willing to move forward on addressing challenges of vaccine and immunization financing”. She acknowledged that donor dependency alarms have already been raised at cabinet meetings, so this immunization financing advocacy is a timely intervention. However, she stressed to government counterparts, when it comes to matters of legislation, the committee must be kept well informed to avoid complications, particularly in the later legislative stages. Such complications were experienced in developing a recent health bill. The Ministry of Health and WHO are in positions to share accurate, updated information with the Health Committee. Its members can then make appropriate,

informed decisions. The Chair then thanked the team that attended the SIF Dakar colloquium and reiterated that her Committee is ready to take action- by reaching out to other parliamentary committees and forming a parliamentary forum for immunization and formulating arguments to support the KEPI budget.

Participants went on to discuss and formulate action points each institution would subsequently lead. These included the elaboration of immunisation legislation, formation of Parliamentary Lobby Group (forum) on Immunization and a series of advocacy activities to be carried out in support of sustainable immunization financing.

It has been an eventful quarter for immunization in DRC. Throughout July, Kinshasa-based Senior Program Officer Helene Mambu-Ma-Disu worked with her counterparts to prepare for the Dakar SIF Colloquium, which took place on 5-6 August. Their efforts paid off. In a peer-reviewed poster session, DRC was scored in the top third of SIF projects in terms of innovativeness of the work. [See related article in this issue].

On the legislative front, Mambu-Ma-Disu reported attending four meetings with Members of Parliament, legal advisors from the Ministry of Health and the National Assembly, the national EPI Manager and counterparts from the Ministry of Budget, UNICEF and WHO. All are helping to refine a draft immunization law prior to depositing it for formal consideration by the National Assembly.

On 22-23 July, Mambu-Ma-Disu joined a visiting GAVI mission in Kinshasa. The purpose was to develop a country-tailored approach for



GAVI support to the national immunization program.

On 29-31 July, Mambu-Ma-Disu facilitated a workshop in Kinshasa organized by the Agence de Medecine Preventive (AMP). The workshop trained immunization managers from all 11 provinces to use a costing tool for better management of resources at the delivery level. Other topics addressed included budgeting, resource mobilization, data analysis and reporting. The workshop built on resource tracking work started last year by the Ministry of Health.

During the workshop, EPI Financial Officer Mr. Benjamin Matata presented a table the Program uses to track immunization resource flows. The table summarizes commitments and disbursements from all sources for the years 2010-2013.

“It was a true peer-to-peer learning experience. The EPI team will follow up with the participants to make sure they prepare their budgets for 2014 and present them to their provincial governments so that they are included in their 2014 provincial budgets”, reported Mambu-Ma-Disu.

The EPI team subsequently updated its resource tracking table (see below) and presented it on 4 September in a meeting of the Technical Inter-Agency Coordinating Committee for immunization. The team used the Sabin budget flow analysis sheet to prepare their report. The table shows that the government’s contributions have increased in absolute terms and as a percentage of total financing. The table also shows that the disbursement of budgets is not always complete for any given source or year, however, the government’s disbursement rate has been steadily improving.

“We expect the Government to disburse the GAVI co-financing payments any day. That will bring the disbursement rate for EPI close to 100% by the end of the year”, commented Mambu-Ma-Disu, who attended the meeting. [Editor’s note: The Government of DRC subsequently made the disbursements for co-financing and for vaccine procurement.]



On 25 September, EPI team members and members of the Parliamentary Forum on Immunization (Réseau des Parlementaires Congolais pour l'Appui à la Vaccination) met to discuss the details of the proposed 2014 immunization budget. Such meetings have become routine in DRC. “They exemplify the kind of institutional innovations countries are developing to reach the sustainable immunization financing objective”, observed SIF Program Director Mike McQuestion.



It is not clear whether government immunization investments truly dropped in 2012 or whether the drop reflects poor reporting. Governments report their routine immunization expenditures annually through WHO/UNICEF Joint Reporting Form (JRF) Indicator 6500. They report their vaccine expenditures through JRF Indicator 6470. As shown in the table below, only 66% of countries reported any expenditures at all in 2012. This compares to an average reporting rate of 75% for 2006-2011. By definition, vaccine expenditures any given year should be less than total immunization program expenditures. Of 45 countries reporting any expenditure information in 2012, 8 (18%) reported greater vaccine than total expenditures. For prior country-years, 23% misreported expenditures in similar fashion.

According to the Global Vaccine Action Plan Monitoring & Evaluation/Accountability Framework, governments are to begin reporting their annual immunization expenditures in the May 2014 World Health Assembly, using JRF Indicator 6500. Reported JRF immunization expenditures are reported for each SIF country here. Table 2 shows the 2010-12 JRF government expenditures for reporting SIF countries. Also shown are unofficial annual routine immunization budget estimates for the same countries. The unofficial data were generated by the Sabin Senior Program Officers and their national counterparts using a standard Sabin budget flow analysis tool. The results show that 2012 government routine immunization expenditures declined in this sample of SIF countries as well. Although higher, the government expenditures tracked using the Sabin flow sheet also declined, from US$12 in 2011 to $7 in 2012.

http://www.sabin.org/programs/vaccine-advocacy-education/sustainable-immunization-financing-sif-program



On 14-18 July 2013, a joint GAVI-WHO-Sabin mission took place in Jakarta, Indonesia. Representing GAVI was Director of Immunization Financing, Santiago Cornejo. National Immunization Officer Asmaniar Saleh represented WHO/Jakarta. Senior Program Officer Khongorzul Dari and SIF Program Director Mike McQuestion represented Sabin. Dr. Theresia Sandra Diah Ratih, Chief of the Ministry of Health’s Immunization Sub-Directorate, prepared the agenda and accompanied the team throughout the visit.

The first objective of the mission was to assess prospects for Indonesia graduating from GAVI grant eligibility. The second was to invite Indonesia to join the SIF Program.



With an annual birth cohort of 4.8m, Indonesia is the world’s fourth most populous country. Over the period 2006-2011, Indonesia’s per capita gross national income grew from US$1,370 to $2,940, qualifying it a GAVI graduating country. In the political sphere, the country has moved steadily from an authoritarian to democratic form of government. The first direct local elections took place in 2004. Since 2009, all 560 members of the People’s Representative Council (parliament) have been popularly elected. A decade ago, Indonesia implemented a “big bang” devolution program. The result is that 34 provinces and 497 districts prepare and manage their own immunization delivery operations.

Indonesia launched its national immunization program in 1977. The program has progressed steadily. Polio transmission was interrupted in 2006. Maternal and neonatal tetanus has been eliminated from 87% of the country. Measles is targeted for elimination by 2018, rubella control by 2020. According to WHO/UNICEF estimates, 64% of Indonesian children were getting DTP3 in 2012. Due to the country’s size, the remaining 36% constitute the world’s third highest number of unimmunized and partially immunized children.

Indonesia is well on the way to GAVI graduation. The country is financing all of its traditional vaccines. Laws enacted in 2002 and 2009 guarantee the right to childhood vaccination. There is a well functioning national regulatory agency, a committee monitoring acute events following immunization (down to district level) and an independent expert advisory committee.

The mission revealed two areas where added advocacy strategies could help strengthen Indonesia’s immunization program.

The first is improving program performance in the provinces, districts and where pockets of low vaccine coverage persist. The problem is not financing, explained Ministry of Finance

counterparts, but absorptive capacity: not all jurisdictions prepare and request their immunization budgets on time. Experience elsewhere has shown that bringing together sub national health authorities and local elected officials can sometimes induce action to quickly improve program performance.

“This works wherever we manage to involve sub national counterparts in larger collective action processes”, commented McQuestion. “It often leads to healthy competition among peers. Counterparts learn from each other and no one wants their place to be last”.

The second proposed advocacy area is the introduction of new vaccines. Hib and Hepatitis B vaccines (pentavalent) came into nationwide use just this year through GAVI’s first vaccine grant to the country. Indonesia produces its own vaccines through Bio Farma, a parastatal company. To introduce the more advanced conjugate pneumococcal and rotavirus vaccines while maintaining a policy of vaccine self reliance will require the government to considerably increase its immunization investments. Manufacturing technological transfer agreements will need to be worked out. In the meantime, if the new vaccines are introduced, Indonesia stands to achieve Millennium Development Goal #4 (reduce child mortality by two-thirds by 2015) and will have partially achieved Strategic objective #5 of the Global Vaccine Action Plan (Immunization programs have sustainable access to predictable funding, quality supply and innovative technologies).

Indonesia’s People’s Consultative Assembly (parliament), counterparts agreed, must be sensitized to these issues and asked to play an active role in the immunization program. During a parliamentary visit, the Vice President of Commission IX (Demographic affairs, health, manpower and transmigration), Hon. Dr.Nova Riyanti Yusuf, agreed and pledged to work with the national EPI team.



The mission resulted in a consensus for Indonesia to join the SIF Program. Dari, who manages SIF activities in Vietnam and her native Mongolia, will assume responsibilities for the Indonesia SIF project.

The Indonesians wasted no time in developing a first round of sustainable immunization financing advocacy activities. The proposals were presented by a five-person delegation of government counterparts and parliamentarians who attended the second Sabin SIF Colloquium in Dakar, Senegal on 5-6 August. In the coming months, government counterparts will concentrate on resource tracking and improved data management, targeting low-performing districts and provinces. MPs will study the proposed immunization budget and will join government and provincial MPs in selected field activities. Government and parliamentary counterparts will review existing laws and regulations and proposed needed updates. Sabin will assist by organizing periodic briefings for parliament and local health and elected officials.

On 22-25 July, a novel inter-ministerial workshop took place in Yaoundé, Cameroon to consider pending legislation on immunization financing. Chaired by the Minister of Health, Hon. Dr. Andre Mama Fouda, the first meeting of the Inter-ministerial Committee on Sustainable Immunization Financing drew 49 governmental, parliamentary and external partner agency counterparts. Established in 2012 at the request of Minister Mama Fouda, the Committee implements a recommendation put forth in a May 2012 parliamentary briefing on sustainable immunization financing. Its charter is to review and approve public financing proposals for the country’s immunization program. Yaoundé-based Sabin

Senior Program Officer Jonas Mbwangue attended both events and has been part of the institutional innovation process.

“This was the first time all the ministries were briefed on immunization financing options”, remarked Mbwangue. “The original idea was to create a single, ring-fenced immunization fund. But the idea of such a fund caught on with other program managers. Now we are discussing a fund to finance all of the Ministry of Health’s priority health programs”.

In the workshop, the EPI Program team shared the working draft of a proposed immunization law and presented a recently completed budget flow chart for the Program. Impressed, Committee members agreed to take up the draft immunization law and to ensure that the final bill contains a provision establishing the Health Support Fund. The Fund will have a special immunization financing window. Committee members agreed to convene again in late October to review their work. \

SIF SPO, Clifford Kamara attended the official launch of “A Promise Renewed: Committing to Child Survival in Liberia” opened by President Mrs. Ellen Johnson Sirleaf, in Tubmanburg, Bomi County. Remarks were made by Dr. Bernice Dahn, Deputy Minister/ Chief Medical Officer, WHO Representative Dr. Nestor Ndayimirije, UNICEF Representative Mr. Sheldon Yett, Deputy Asst. Administrator, Bureau for Global Health/ USAID, Hon. Minister of Health and Social Welfare Dr. Walter T. Gwenigale, Hon. Deputy Chair of Senate Committee on Health and Social Welfare, Geraldine Sheriff. This was a successfully implemented, well-attended activity during which Kamara met with representatives from the Ministry of Health and Social Welfare and other Ministries, Departments and Agencies. In addition in July the Terms of Reference for the Liberian Parliamentary Forum has been



finalized and progress was made on the draft amendments on Immunization that have been submitted to the Senate.

SPO Clifford Kamara in discussions with the WHO Representative, Dr. Nestor Ndiamirije ; Deputy Chairman of the House Standing Committee on Health and Social Welfare, Representative Hon. Johnson Chea ; and Deputy EPI Manager, Adolphus Clarke, during the launch of ‘A Promise Renewed’ in Tubmanburg, Bomi County.

11 July, Washington, D.C. USA: Launch of SIF mini-course online

12 July, Nairobi, Kenya: SIF Parliamentary Briefing

16-17 July, Dakar, Senegal: SIF Parliamentary Briefing

13-18 July, Jakarta, Idonesia: Joint GAVI-Sabin-WHO mission22-23 July, Kinshasa, DRC: Tailored approach meeting

22-24 July, NYC, USA: IF&STT meeting, UNICEF

22-25 July, Yaounde, Cameroon: Inter-ministerial workshop29-31 July, Kinshasa, DRC: National immunization financing workshop (HM with AMP)

5-6 August, Dakar, Senegal: Sabin SIF Colloquium II

26 August, Kampala, Uganda: UPFI and Partner planning meeting

16-21 August, Bamako, Mali: National EPI conference

26-30 August, Bamako, Mali: National EPI review

18 August, Washington, D.C: IAIM launch

4 September, Nairobi, Kenya: SIF parliamentary briefing



Milestone/Activity (1.IV.13 - 30.VI.13)

Achieved this quarter

Cumulative (1.IX.09– 30.VI.13)

Details:

Visits to field countries

9 141

Congo Brazzaville (July), Kenya (July, Sept), Liberia (July), Mali (July), Senegal (July, 2), Sri Lanka (Sept), Indonesia (Sept), Vietnam (Sept)

National briefing 4 95 Cameroon (July), Kenya (July, Sept), Senegal (July)

Sub-regional briefing 0 14 None reported this period

International Partners Meetings

1 73 22-24 July: IF&STT meeting, UNICEF

Workshops/capacity building meetings

4 None reported this period

Peer exchanges involving SIF target countries

1 58 Ugandan peer exchangers attended Kenyan briefing (July)

Number of ICC meetings (measured since Jan 2013)

7 13

Cameroon (July, Sept), Mali (July, Aug), Sierra Leone (July), Uganda (August), Nepal (Sept)

Sustainable Immunization Financing is an initiative of the Sabin Vaccine Institute. SIF is funded by generous grants from the Bill & Melinda Gates Foundation and GAVI. 2000 Pennsylvania Avenue NW, Suite 7100 Washington, DC, USA 20006 www.sabin.org/sif www.sabin.org/fr (en français) [email protected]

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new “ring fenced” national immunization funds. · programme on immunization (kepi) and to...

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