rwanda – expanded program of …...1 rwanda – expanded program of immunization financial...

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RWANDA – EXPANDED PROGRAM OF IMMUNIZATION

FINANCIAL SUSTAINABILITY PLAN 2002 - 2008

SUMMARY

A. Description of the key objectives for the improvement and expansion of theprogram:

- More energetic advocacy of and social mobilization for the program- Strengthening program logistics and equipment maintenance- Continuing the introduction of new technologies into the program- Improving the monitoring and tracking system with the aim of reducing the dropout rate- Developing the capabilities of staff involved in program activities- Taking control of waste management and disposal system in the context of injection safety.

B. List of current program costs and sources of funding:

1. Reference year (2000):

- Total cost: 2,219,108 USD- Financial coverage:

a) Government of Rwanda: 1,364,562 USDb) GAVI: 0c) WHO: 299,236 USDd) UNICEF: 542,725 USDe) Rotary: 7,097 USDf) Belgian Cooperation: 5,424 USDg) Other funding: 64 USD

2. Current year (2001):

- Total cost: 2.616.980 USD- Financial coverage:

a) Government of Rwanda: 1,481,818 USDb) GAVI: 269,404 USDc) WHO: 160,661 USDd) UNICEF: 685,567 USDe) Rotary: 14,043 USDf) Belgian Cooperation: 5,424 USDg) Other funding: 64 USD

Rwanda – Financial sustainability plan 2002 - 2008 2

C. Forecast of resource shortfalls during the remainder of the period covered by thesupport given by the Global Alliance for Vaccines and Immunization andsubsequently:

1. Period covered by the support given by the Global Alliance for Vaccines and Immunization(2002-2005):


a) Government of Rwanda: 8,607,370 USD (30%)b) GAVI: 16,847,438 USD (58%)c) WHO: 426,437 USD (1%)d) UNICEF: 3,173,776 USD (11%)e) Rotary and Belgian Cooperation: 35,646 USD

All of this funding is certain or probable.

2. Period after the period covered by the support given by the Global Alliance for Vaccines andImmunization (2006-2008):


a) Government of Rwanda: 7,313,114 USD (33%)b) GAVI: 4,704,077 USD (21%)c) WHO: 259,673 USD (1%)d) UNICEF: 573,951 USD (3%)e) Rotary and Cooperation Belgian: 30,222 USD

Uncovered balance: 9,258,593 USD

D. List of strategic priorities of the financial sustainability plan. The list should bebased on the diagnosis of the main financial challenges:

There are 4 main objectives, each of which involves strategies to be implemented.

Objective 1:

To bring about an increase in the Government ‘s financial contribution to the EPI by constantlypresenting the case for the importance of the EPI in terms of general policy

Objective 2:

To increase the contribution from other donors (bilateral and multilateral cooperation) with the aimof closing the gap between needs and acquired resources and to reduce dependence on thosedonors by a greater diversification of sources of funding.

Objective 3:To increase the sustainability of funding:

Objective 4:

To increase the efficiency of the program so as to improve the cost–benefit ratio.


E. List of measures taken in the short and medium term to ensure financial sustainability:

1.1.1 Prepare general information brochures on the EPI and distribute them to all governmentalinstances (Government and Ministries concerned, provincial and district authorities).

1.1.2 Step up the information and awareness-building tours in the health districts (1 x / quarter).

1.1.3 Launch of awareness-building campaigns in the press (TV, radio and newspapers).

1.1.4 Organise a National Immunization Day.

1.2.1 Establish an objective for the budgetary commitment by the State.

1.2.2 Incorporate the FSP1 of the EPI into the national health plan.

1.2.3 Publish a weekly review of information on the EPI for distribution to the members of theGovernment, to the ministries most concerned, to the members of the ICC, and to theinternational partners.

1.2.4 Organise an annual symposium on the EPI.

2.1.1 Try to expand the composition of the ICC by bringing in new members.

2.1.2 Distribute the general information brochures on the EPI to the members of the ICC and toother potential donors.

2.1.3 Distribute the weekly reviews of information on the EPI to the members of the ICC and toother potential donors.

2.1.4 Invite potential donors to the annual symposium on the EPI.

2.1.5 Make funding proposals to potential donors.

3.1.1 Involve donors to a greater extent in the medium- and long-term planning of EPI budgetaryneeds.

3.1.2 Try to obtain financial commitments of more than 5 years.

3.2.1 Set up coordination between the financial managers in the Ministry of the Health, theMinistry of Finance and the Ministry of Local Administration with the aim of improving theprocedures for transfers of funds.

3.2.2 Help administrators and managers of health districts to anticipate and prepare the requestsfor funds they send to the central level better.

4.1.1 Improve the completeness and promptness of vaccination reports sent in by the districts.

4.1.2 Organise seminars for the supervisors of health districts with the aim of improving theirskills in the collection, processing and analysis of data.

4.1.3 Upgrade the computing hardware for data processing at the central level.

4.2.1 Strengthen the WHO strategy on the policy for opened vials.

1 FSP: Financial sustainability plan


4.2.2 Verify the implementation of the new guidelines that have just been issued on stockmanagement.

4.2.3 Ensure that auxiliary cold-chain technicians apply correctly the guidelines they were givenat the time of the May 2002 seminar on cold-chain maintenance.

4.3.1 Make proposals concerning a strategy to motivate health staff with the aim of reducing staffchurn.

4.3.2 Improve financial monitoring including monitoring at the time of the quarterly and half-yearlyreviews of data: develop a financial component of monitoring alongside the technicalcomponent.

4.3.3 Ensure the effective establishment in the health districts of the maintenance units createdafter the seminar for auxiliary cold-chain technicians; introduce the control and monitoringsystem for these maintenance units.

4.3.4 Ensure the proper establishment of the decentralisation of stocks of spare parts.

4.4.1 Mobilise health promoters to a greater extent.

4.4.2 Raise the awareness of the grassroots political and administrative authorities.

4.4.3 Raise the awareness of other opinion leaders at the community level.

4.4.4 Raise the awareness of the “IEC Focal Points”2 of the Ministries concerned.

F. List of the indicators used to track progress made towards achieving the objectives offinancial sustainability:

1.1.1 The general information brochures on the EPI exist and have been distributed to allgovernmental instances (Government and Ministries concerned, provincial and districtauthorities).

1.1.2 The reports of the quarterly awareness-building tours of the health districts exist and areavailable.

1.1.3 There is at least 1 annual press campaign involving the 3 media.

1.1.4 A National Immunization Day has been organised; the report exists and is available.

1.2.1 There is an objective for budgetary commitment by the State.

1.2.2 The FSP of the EPI has been incorporated into the national health plan.

1.2.3 A weekly review of information is being published and distributed.

1.2.4 The report of the annual symposium exists and is available.

2.1.1 There is at least one new member of the ICC each year.

2 IEC (Information – Education – Communication) focal points are resource persons for information, education andcommunication in the social ministries.


2.1.2 The general information brochures exist and have been distributed (cf distribution list).

2.1.3 The weekly reviews of information exist and have been distributed (cf distribution list).

2.1.4 Donors have been invited to the annual symposium (cf list of invitations and report of thesymposium).

2.1.5 Funding proposals have been sent out.

3.1.1 Donors are participating in the preparation of budgetary requirements planning includingwork done at the quarterly meetings of the ICC

3.1.2 The funding proposals relate to funding periods longer than 5 years

3.2.1 A written document laying down the procedures for transfers of funds has been producedfollowing the coordination meetings organised with the Ministries concerned.

3.2.2 A workshop for health district administrators and managers is being organised once a yearand includes a component on the management of decentralised funds.

4.1.1 Reports are more complete and deadlines are met: they reach the central level no laterthan the 15th of the following month.

4.1.2 The seminars on the SIS (Health Information System) for health district supervisors areheld once a year.

4.1.3 New equipment has been purchased and is operational; ad hoc training courses have beengiven.

4.2.1 Written instructions relating to the policy on opened vials exist and have been sent out to allthe districts.

4.2.1 (bis) A ‘Monitoring of the policy on opened vials’ component has been included in theguidelines for supervision.

4.2.2 The ‘Verification of stock management’ component has been strengthened in the guidelinesfor supervision missions of health districts.

4.2.3 The ‘Verification of cold-chain maintenance component of the has been strengthened in theguidelines for supervision missions of health districts.

4.3.1 A document containing proposals on a strategy to motivate health staff has been producedin the Ministry of Health.

4.3.2 The content of the ‘financial information’ section of the periodic reviews of EPI data hasbeen strengthened.

4.3.3 The creation of ‘Cold-chain maintenance units’ is verified during the supervision missions ofthe health districts.

4.3.3 (bis) A complete inventory is prepared at least once a year.

4.3.4 There are decentralised stocks in each health district.

4.4.1 A meeting monthly with health promoters is held in each medical establishment (Healthcentre and health district hospitals).


4.4.2 A quarterly meeting, financially supported by the EPI, is held in each health district with thegrassroots political and administrative authorities.

4.5.1 A meeting with all the focal points of the ministries concerned is held at least once aquarter.


Section 1: General situation of the country and itshealth system

1.1 General context of Rwanda:

Rwanda, a landlocked country, lies in the centre of Africa, or more precisely in the centre of theGreat Lakes region. Bounded to the North by Uganda, to the West by the Democratic Republic ofthe Congo, to the South by Burundi and to the East by Tanzania, Rwanda has an area of 26,338km², 17,758 km² of which is arable land. Essentially mountainous, Rwanda has a temperateclimate; the average temperature is 18°C. Two rainy seasons (the major and the minor) and twodry seasons (the major and the minor) cover the crop year. Rainfall varies from 700 to 2,000 mm ofwater depending on the region.

The country has 11 Provinces and the City of Kigali and is subdivided into 106 administrativedistricts. Each administrative district is in turn divided into sectors and the sectors into units.

The total population of the country in 1999 was estimated to be 8.1 million inhabitants with adensity of 307 inhabitants per km2. The degree of urbanisation is still very low. With currentreproduction rates, the women of Rwanda will give birth to 5.8 children during their reproductivelife. However, despite the major upheavals that led to the population movements during and afterthe genocide, the total population in 1997 has exceeded that of after 1994.

The genocide affected the demographic structure: 49% of the population is under 15, and thereare more women than men (54% against 46%).

With a high reproduction rate, a young population and a natural growth rate estimated at2.8%, Rwanda will have more than 11 million inhabitants by 2012. This high population densityexerts considerable pressure on the occupation of arable land, and the fall in incomes iscontributing to an increase in impoverishment.

Rwanda has one of the highest rates of infantile mortality: 107 children per 1,000 live birthsdie after reaching their first birthday. Maternal mortality is still very high, 1,071 deaths per 100,000births for the period 1995-2000.

The country is in a difficult economic situation3. The indicator of this state of affairs is therelatively high proportion of people living below the poverty line. In 1997, the figure was 70% whileit was only 40% and 53% respectively in 1985 and 1993. The decline in agricultural production andthe global economic environment (including coffee prices) and also the consequences of the 1994Genocide are probably among the root causes of this phenomenon.

Gross national product (GNP) was 237 USD in 1999 (IPRSP, 2000). Agriculture contributes47% of GNP, 91% of employment and 72% of exports. The industrial sector accounts for only 19%of GNP and employs less than 2% of the active population.

The manufacturing and construction sectors account for 10% and 9% of GNP respectively.After a drop of 50% in 1994, GNP recovered progressively after the war (37% in 1995, about 10%a year between 1996 and 1998, and 6% in 1999), particularly after the considerable amounts ofmoney injected into Rwanda by the international community immediately after the war.

3 This section of the text is based largely on the Interim Poverty Reduction Strategy Paper (2000), Ministry of Finance and Economic

Planning, Kigali.


Expected growth is estimated at 8% per year for the next 15 years. Inflation has beencontained during recent years (6.8% in 1998 and 2.4% in 1999).

Low and only slightly diversified agricultural production, the cyclical droughts and faminesthat affect the country, growing unemployment, high transport costs, and environmental decline areall structural problems that have as their corollary dependence on the two main export products(coffee and tea), substantial export deficits (16 USD per capita on average, compared with 100USD per capita in sub-Saharan Africa), an imbalance between income and expenditure, and lowprivate investment (8% of GNP in 1999).

The Genocide of 1994 has also left a major heritage of difficulties that include: aconsiderable reduction in the number of adult men (34% of households are headed by women), ahigh proportion of orphans, many households without a solid abode, a reduction of small familyfarms, an increase in the prevalence of AIDS (violence, population movements, etc.), anddisappearing human resources.

1.2 Health context:

Since the 1980s, the Government of Rwanda has subscribed to the policy of primary healthcare as defined at Alma Ata. From 1985 onwards, taking on board the policy of decentralisationadvocated at Lusaka, Rwanda stared its own thinking on the decentralisation strategies applicableto its health system. The process implemented will be limited to the health regions, which, becauseof their size, will never be totally operational.

In February 1995, just after the genocide, the Ministry of Health, with the support of WHO,started on a health reform that would be adopted by the Government of National Union in March1996. The declared objective of the new policy is to contribute to the well-being of the populationby providing quality services that are acceptable and accessible to the majority of the population,and implemented with its full participation.

To achieve these objectives, the reform is based on 3 main strategies: (1) use of the healthdistrict as the basic operational unit of the system, (2) the development of primary health carethrough its eight fundamental components, and (3) enhanced community participation in themanagement and funding of the services.

After 5 years of implementation of this policy, 39 health districts are now functional to amore or less advanced degree. Most of the health infrastructure has been restored and equipped.63% of the minimum package of activities developed from the components of primary health carehas been achieved in all grassroots medical establishments. Thirty one (31) districts of the 39 inexistence now have a functional hospital, and 90% of the complementary package of activities hasnow been achieved4.

Community participation is effective in 100% of the medical establishments of the primaryand secondary levels, albeit with variable degrees of performance. To strengthen the commitmentof the local communities, a vast network of health promoters has been set up throughout thecountry.


1.3 Organisational structure of the health system:

The health system in Rwanda has a pyramidal structure with 3 levels: central, intermediateand peripheral. The central level includes the management offices of the Ministry of Health and thenational referral hospitals. The intermediate level consists of the Provincial Management Office thatincludes health as part of its remit but has no care units. The peripheral level is represented by thehealth district, which consists of an administrative base, a primary referral hospital and healthcentres providing primary health care.

The role of the central level is to draft the national health policy and also the strategies andplans for its implementation. It organises, coordinates and supports the intermediate and peripherallevels of the national health system in administrative, technical and logistical matters. Its role isalso to monitor and evaluate the medical situation and to coordinate resources at the national level.

The task of the intermediate level, which corresponds to the provinces, is to facilitate andguide the process of development of the operational level (health district), for which it providesadministrative, logistics, technical, and policy supervision.

The peripheral level is the operational unit of the district, consisting of an administrativebase, a district hospital and the primary medical establishments, mainly the health centres. It dealswith all the health problems of a well-defined population. With the participation of that population, itplans, coordinates and implements the health activities of its geographical area.

At the level of the district structures, decisions are made collegially by a number ofcommittees. The management structures of the district are the district health committee, the districtfoundation team, the hospital health committee, and the health committees of the health centres.The composition, role and remit of these committees have been defined.

In order to provide clients with the best care possible, a referral-against-referral system isstaged on 3 levels according to the technical skills required and the rational use of resources.

1.4 Decentralisation of the health services:

As in most African countries, the process of internal reorganisation of the health system inRwanda has been overtaken by administrative and policy decentralisation reforms that are causingupheavals in the institutional environment, leading to new relations with administrative authoritiesand political actors, and forcing the health sector to make considerable readjustments.

As a prelude to the application of the decentralisation policy, the Government of Rwandaembarked on the implementation, starting in 2000, of measures to decentralise the budgets ofperipheral services. This means that the credits of the decentralised services are managed by theprovince, which, in collaboration with those in charge of the services, should be able to ensure theyare used properly. Since the decentralised services of the Ministry of Health, unlike those of theother ministries, already enjoy considerable management autonomy the context of the healthsystem, the usefulness of considering the implementation of this measure is understandable.

Consideration of measures to decentralise budgets is followed by an analysis of theadministrative and policy decentralisation reforms from the point of view of their implications for thehealth sector. The analysis consists mainly of highlighting the issues of the expectations of the


various actors in the new context, and the identification of the challenges and opportunitiesaccompanying the reforms. This is the framework within which the specific case of the mutualisthealth system will be examined to see where opportunities can be found in the decentralisationreforms to solve some of the problems arising from its development.

The interest that the Ministry of Health and the various partners are showing in the questionof decentralisation reforms is thus justified by a legitimate need to put the health sector in acomfortable situation that will enable it to take on board the various reforms in a stance favourableto the preservation of what it has achieved and the achievement of its objectives.


Section 2: Financial management

The State’s contribution to the operations of the Ministry of the Health is limited, remainingbelow the level of 4% of the national budget, which corresponds to about 1.25 USD per capita peryear. According to the 1999 review of public expenditure, 60% of these funds go to the peripheralhealth services, 15% are allocated to the referral hospitals and 26% to the central and provincialservices. Three quarters of the budget are devoted to providing services and no more than onequarter to administration. 80% of expenditure is made at the level of the health districts.

It should however be noted that donors largely support the referral hospitals and the operationof the central level services.

The population’s average contribution to the operation of the public structures is 0.5 USDper year per capita2. All in all, according to the estimates made in the context of the national healthaccounts, total contributions by the population (public and private services, traditional medicine)would be 1.5 USD to 2 USD per year per capita, which is a long way from the 5 USD per year percapita observed in sub-Saharan Africa.

The dependence of the Ministry of Health on external aid is considerable, because some 50to 60% of the sector’s financial envelope comes from international cooperation, compared with20% for the Government and 30% for the population (1998 data). This dependence is tending todiminish, but to the detriment of the total envelope, which is due to fall from a little under 20 milliondollars in 1998 to less than 10 million dollars in 2002.

During the 1999 spending review, one study estimated that 8 USD per capita per yearwould be necessary to fund a capable district-based system while currently, adding up all thepossible sources of funding, we arrive at a figure of only 3 to 4 USD per capita per year. Thequestion of the long-term funding of the decentralisation policy is particularly acute today.

The funds allocated by donors to the vaccination program are deposited directly intoseparate Ministry of Health accounts opened with the National Bank of Rwanda. Official signatoriesto these accounts are appointed by the Ministry of Health so that a withdrawal of funds requires atleast two or three authorised signatures.

Where the financial management of the funds allocated to the program is concerned, it canbe seen, thanks to the advocacy and awareness-building efforts directed at the decision makers,that there has been some improvement in the process of budgetary decisions. However, there arestill delays due mainly to administrative sluggishness; the problem becomes more acute wheretransfers to the peripheral structures are concerned.

Management of the funds allocated by the Government and donors is transparent as far aspossible. Use of the funds is justified in accordance with the accounting methods defined by theMinistry of Finance and is monitored by the auditors mandated by the Government (Office of theAuditor General).

The financial partners of the program have a right of scrutiny in relation to the managementof the funds allocated, and the Ministry of Health keeps them informed of the use of the funds,including by regular financial reports.

When necessary, changes people want to make in the mechanisms for managing the fundsare the subject of exchanges between the Ministry and its partners at the time of the half-yearly or

2 Partnerships for Health Reform & World Health Organization (2000) 1998 National health Accounts in Rwanda,Ministry of Health, Kigali.


yearly review meetings. The EPI Inter-agency Coordinating Committee is the preferred venue forthis type of exchange.

Purchases of equipment and other supplies for the program are made in accordance withthe rules defined by the National Tender Board. For all purchases of an amount not exceeding 3million Rwandan francs (about 6,000 USD), an internal commission of the Ministry of Health meetsand, using clear and transparent procedures, examines the various offers. If the transaction is inexcess of 3 million Rwandan francs, the transaction must be put out to public tender through theNational Tender Board.

Section 3: Characteristics, objectives and strategiesof the Program

3.1 Brief background of the EPI in Rwanda :

The Government of Rwanda has made the fight against childhood diseases, particularlyby prevention, one of its priorities. That is the context in which the Expanded Program ofImmunization was created in 1978 to combat six vaccination-preventable diseases:tuberculosis, poliomyelitis, diphtheria, tetanus, whooping cough, and measles. The programhad achieved major successes in vaccination coverage until just before the genocide thatplunged Rwanda into mourning in 1994. From April 1994 to August 1994, practically all theactivities of the EPI were halted throughout the national territory. The assets of the programwere plundered and skilled human resources became very scarce.

The program was re-launched in September 1994 by the Ministry of Health with thesupport of its traditional partners. The cold chain was restored and staff progressivelyestablished. The EPI is currently operational in all the medical establishments of the country.The results achieved during the past 5 years are by and large satisfactory.

3.2 Overall mission of the EPI:

To improve the health of children by reducing infant and juvenile morbidity and mortalitydue to vaccination-preventable diseases.

3.3 General objectives:

- To boost the services provided by the vaccination services so that they are of highquality and sustainable

- To accelerate efforts to achieve the eradication of poliomyelitis, and the control andelimination of measles and neonatal tetanus

- To introduce sustainably new vaccines and appropriate technologies into thenational vaccination program.

3.4 Specific objectives:

- To strengthen the national vaccination system so as to achieve by 2005 95%vaccination coverage for all antigens, in all the health districts of the country, and tokeep it above that level for subsequent years

- To eradicate poliomyelitis by 2005- To eliminate maternal and neonatal tetanus by 2005- To bring about a reduction of morbidity and mortality due to measles to less than

0.01% per birth cohort by 2006- To make vitamin A supplement part of routine vaccination services in 100% of

health districts by 2006- To ensure that medical establishments are in control of the aspects of injection

safety management, including safe waste disposal, by 2004

- To ensure the integration of active surveillance of the diseases targeted by theprogram and especially those targeted for eradication, control or elimination in 100%of health districts.

.

3.5 Strategies adopted to achieve the objectives:

- Planning of action at both the national level and at that of the health districts- Development of the capabilities and continuous training of staff- Intensified advocacy, social mobilization and communication to change behaviour in

favour of the program- Lobbying for political commitment at the highest level for the program- Strengthening of logistics, the supply system and quality of vaccines, and also of

equipment maintenance- Management of the program: quarterly reviews, supervision visits, monitoring and

evaluation.

3.6 Partnership:

The program has had an operational Inter-agency Coordinating Committee (ICC)since 1996. The Committee is made up of the senior officers of the Ministry of Health, thefunding partners of the EPI (WHO, UNICEF, USAID, Rotary International, ) and other partiesinterested in being part of the Committee. The ICC plays a technical role and one ofadvocacy in favour of the program. Its meetings are held regularly and are documented byminutes. The Committee is open to new members who demonstrate the intention of joining.

The Ministry maintains regular and excellent relations with the representatives of thechurches that manage almost 40% of the medical establishments in the country. Aconvention between the Government and the accepted parties is about to be made official.The various parties involved are regularly brought into strategic thinking either at the locallevel (where they form an integral part of the district foundation teams or the communitymanagement committees) or at the central level, at the time of coordination meetings or ofthe strategic workshops to which they are regularly invited. There is however no formalisedcoordination framework yet at the central level. Relations with the private and traditionalsectors are very little developed. As to vaccination activities, the EPI has just establishedclose relations with the private medical establishments of the city of KIGALI, by providingthem in particular with vaccines and vaccination equipment free of charge whenever cold-chain conditions so allow.

The EPI is working in close collaboration with the other programs and divisions of theMinistry of Health, and also with the provinces and health districts. The program is alsobuilding up a partnership with the various ministries by requesting their support, especially atthe time of national or local immunization days. Within the grassroots community, theprogram relies on the health promoters, whose assistance is increasingly appreciated,including help in reducing vaccination dropout rates.

3.7 The provision of vaccination services:

3.7.1 Routine vaccination:

Routine vaccination applies to children between 0 and 11 months of age. It also includesin its program the vaccination of pregnant women. As previously mentioned, the nationalvaccination program was disrupted by the war of 1994. However, the Government ofNational Union, in its efforts to reconstruct the country, has made the program one of its mainpriorities. The assessment of vaccination coverage carried out two years after the warshowed that the rate of participation in initial vaccination was around 91%, but that theproportion of children who completed the recommended series of vaccinations (traditionalvaccination calendar) was little more than 60% of the target. It goes without saying that toachieve the post-war level, enormous efforts and means had to be applied.

According to an assessment of program performance carried out in September 1998, themajor problems identified as obstacles to the proper operation of the program are thefollowing:

� A reduction in the efforts to monitor and supervise the activities of the EPI at all levels� A fall in the efforts to increase the awareness of parents of the need for several

vaccination visits, resulting in a high dropout rate� The use of sterilizable syringes for injections, which caused parents to lose

confidence (problems associated with injection safety)� Insufficient training of staff in EPI management at all levels and particularly at the

peripheral level� Weaknesses in the system of medical information� Failure to control the “target population” variable, resulting in under- or over-estimates

of the denominator� A halting of outreach strategy activities, resulting in vaccination services becoming

physically inaccessible in several parts of the country� Failure to match the supply system to demand, resulting in frequent shortages of

vaccines, vaccination equipment and fuel� Inadequacy of the cold-chain maintenance service.

Two years after these findings, the program has entered a phase of redynamisationthanks to the support of GAVI and the Global Fund for Children’s Vaccines and also to theefforts made by the Government, especially in the purchase of vaccination equipment (auto-destruct syringes and safety boxes) for all vaccination injections with the aim of protectingthem.

The GAVI funds have made it possible to re-launch the activities identified by the districtsas likely to increase vaccination coverage rapidly. These include:

� The training of health workers in EPI management� The holding of quarterly meetings to evaluate vaccination activities between district

foundation teams and the holders of health centres� Support for vaccination activities using the outreach strategy� Support for supervision activities at all levels� Support for monitoring activities based on the determinants of vaccination coverage� The purchase of schedulers for the active search for dropouts

� Support for updating the EPI target population by strengthening the work of healthpromoters in the field

� Involvement of the private sector in routine vaccination activities.

Source:MinistryofHealth/StatisticsDivision

3.7.1.1Availabilityanduseofvaccinationservic

es:

Vaccination services are completely integrated with the routine activities of themedical establishments. Over 90% of vaccinations are given under the stationary strategy.According to the survey of vaccination coverage carried out in 1999, the degree ofaccessibility of vaccination services, which shows up as the number of children that hadreceived the first dose of DTP, was 93%. The survey showed the existence of dropout ratesof 9% between DTP 1 and DTP 3 and 16% between DTP 1 and MEAS.

With the support of the GAVI funds intended to strengthen the vaccination services,the Ministry of Health has put in place strategies aimed at reducing dropout rates, including:

- An active search for dropouts through the health promoters- A monitoring system introduced at the level of the health districts. The system

consists of:o correctly determining the denominator by monitored activity (reliable estimate

of the target population)o estimating the availability of the resources necessary for the performance of

vaccination activitieso measuring geographical accessibility so as to be more familiar with people

who have difficulties in attending vaccination services easily (planning ofoutreach strategies)

o measuring the use of serviceso calculating the appropriate and actual coverage of the measures developed.

3.7.1.2 Introduction of new vaccines into the routine EPI:

Changes in vaccination coverage 1997-2001

0%10%20%30%40%50%60%70%80%90%

BCG DTP3 OPV3 MEAS TT2+Antigens

Cov

erag

e 1998199920002001

Rwanda took the initiative, with the support of GAVI, of introducing new vaccines intoits vaccination program starting in January 2002. The vaccination calendar has beensupplemented by vaccination against hepatitis B and type B hæmophylus Influenzæ. Thesetwo new antigens have been associated with traditional DTP and are administered in theform of a pentavalent vaccine: DTP-HepB/Hib. This combined form has the advantage oflimiting the number of injections per child and its incorporation into the program has notencountered any difficulties, since it has not disturbed the usual vaccination calendar.

The vaccination calendar in effect in the country is as follows:

Antigen Age at first dose Minimum interval betweentwo doses

Number ofdoses

BCG At birth - 1Polio At birth 4 weeks 4DTP -HepB/Hib At 6 weeks 4 weeks 3MEAS At 9 month/s - 1TT First contact with the

pregnant woman- 4 weeks between TT1 and TT2- 6 months between TT2 and TT3- 1 year between TT3 and TT4- 1 year between TT4 and TT5

5

3.7.1.3 The cold chain:

At the central level, cold-chain equipment consists of a positive cold chamber andalso freezers and refrigerators.

Current storage capacity is estimated to be insufficient to be able to store thevaccines required for a 6 months period, including the stock of new vaccines. The coldchamber, which survived the pillaging of the 1994 war and the fire of July 1998, is causingenormous maintenance problems and has to be replaced. The sustainability of the programrequires continuous renewal of the cold-chain equipment not only in the EPI centralwarehouse but also at the level of the districts and health centres.

An inventory of cold-chain equipment was brought up to date in November 2001 andprovided important information on the type, age, operational status, and capabilities of thecold chain at various levels. After the operation, the following recommendations were made:

� Renovate the central level cold chamber� Install fire-fighting equipment at the central EPI� Renovate the electrical installations and the emergency generator of the central EPI� Replace freezers and refrigerators more than 5 years old at each level� Replace domestic freezers and refrigerators with appliances that are appropriate for

vaccine storage (without CFC)� Make spare parts available for the cold appliances available at each level

Action taken:

- A contract for the renovation of the cold chamber has just been awarded to a localcompany after a tender put out by the National Tender Board. This will entail therenovation of the existing cold chamber, the installation of a new 30m3 mixed(positive/negative) chamber, the installation of a fire-prevention system(extinguishers, lightning conductors, etc) and an emergency generator

- Rotary International has just made a donation to the EPI consisting of cold-chainequipment (2 freezers, 5 large refrigerators, 15 small refrigerators, cool boxes, andspare parts for this equipment)

- A plan for the renovation of peripheral level equipment is being finalised in line withthe recommendations stemming from the inventory carried out in November 2001.

3.7.1.4 The supply of vaccines and other supplies:

Until now, UNICEF has been the exclusive supplier of the vaccines used in routineactivities with the exception of the new vaccines provided by GAVI.

The large increase expected in the budget allocated to the national vaccinationprogram for 2003 will mean that routine vaccine requirements (with the exception of newvaccines) will soon be paid for entirely by the Government. It should be noted that theGovernment contributes to the purchase of vaccination equipment and has already releasedabout 400,000 USD, thereby covering requirements for auto-destruct syringes for 2001-2002.

3.7.1.5 Injection safety

The Government of Rwanda has adopted since 2001 the systematic and exclusiveuse of auto-destruct syringes and safety boxes both for routine vaccination and for all massvaccination campaigns. An assessment of injection practices in the country was made onlyrecently (August 2002).

The results of that assessment enabled the drafting of a five-year plan of action toimprove injection safety and risk-free disposal of injection waste in Rwanda. The activitiesscheduled in the plan include the training of health technicians in both the public and privatesectors, the mobilisation of the community in injection safety matters, supplies of injectionequipment and safety boxes, the construction of modern incinerators for each medicalestablishment, the construction of an equipment storage depot at the central level,monitoring and evaluation of activities, etc.

The overall objective of the Ministry of Health in this area is thus to ensure that by2003 all injections given are free of risk for the beneficiary, the care provider and theenvironment.

The strategies for achieving that objective range from the choice of injectionequipment, via the calculation of the necessary supplies, to methods for the safe destructionof sharps. Obviously the implementation of the plan requires the combined efforts of theGovernment and of the financial partners of the program.

3.7.2 Supplementary immunisation activities

3.7.2.1 NIDs to combat poliomyelitis:

Rwanda has been participating since 1996 in the global effort to eradicatepoliomyelitis. From 1996 to 2002 the country ran successfully five rounds of NationalImmunization Days (NIDs) and two rounds of Local Immunization Days (LIDs). As can beseen from the graph below, coverage during those campaigns has grown progressively andhas been kept above 95% in the last four years. This success is due mainly to the followingfactors:

- social mobilisation supported at the highest political level- a multi-sectoral partnership- cumulative experience in the organisation of NIDs

As part of inter-country medical cooperation, the mass vaccination campaigns wereoften organised in synchronisation with the countries of the sub-region.

Rwanda can now rely on good routine vaccination coverage, the fairly high number ofNIDs/LIDs organised successfully, and the high standard of surveillance of acute flaccidparalysis (AFP) to be ready for 2005, the year for certification that poliomyelitis has beeneradicated. If the epidemiological situation in the neighbouring countries does notcompromise what has been achieved, Rwanda will not need to organise any more NIDs untiljust before the year of certification, i.e. in 2004.

3.7.2.2 Strategies to combat measles:

As part of the acceleration of efforts to control measles in Rwanda, a strategic five-year plan (2000 -2004) has been drawn up. The plan has been revised (2002-2006) so as tobring it into line with current epidemiological realities and thus to take account of regional

Changes in vaccination coverage of NIDs/LIDs/Polio, 1996-2002

53

73

89

104 10196

104

62

75

92

106100 99

105

58

74

90

105100 97

104

0

20

40

60

80

100

120

1996 1997 1998 1999 2000(NID) 2001 2002(LID)

Period

Cov

erag

e

Coverage 1st round

Coverage 2nd round

Coverage Average

orientations in the fight against measles. In addition to the strategies to step up routinevaccination activities, the country has always taken the opportunity offered by the NIDs toassociate with them vaccination against measles and the administration of vitamin A. Thecampaigns of 1999, 2000 and 2001 targeted children between 9 and 59 months old.

The plan is based on the following strategic components:

- Running a nation-wide campaign in the first quarter of 2003 for all children from 9months to 14 years of age

- Increasing the coverage of routine vaccination against measles among childrenunder one year of age in successive birth cohorts

- Providing active surveillance based on cases- Providing proper care of all children with measles so as to minimise measles

mortality.

The strategies for implementing the plan will be based on stepping up advocacy andsocial mobilization, training of staff, communication to change behaviour, strengthening oflogistics (transport and cold chain), multi-sectoral partnership, and community participation.

3.7.2.3 Strategy of the fight against NMT:

The fight against maternal and neo-natal tetanus in Rwanda is centred around fourmajor strategies:

� Strengthening of routine vaccination (TT)� Identification of the areas at high risk from tetanus� Organisation of mass vaccination campaigns for women of child-bearing age in high

risk areas� Stepping up active surveillance

3.8 Surveillance of diseases:

Surveillance of the diseases targeted by the EPI is entirely integrated with generalsurveillance by the Ministry of Health. Three EPI diseases are on the list of alert diseases:measles, maternal and neo-natal tetanus, and poliomyelitis (AFP). Very recently, paediatricbacterial meningitis was added to the list with the aim of measuring the impact of the newvaccines on morbidity and the mortality attributable to haemophilus influenzae.

Number of cases of diseases targeted by the EPI recorded inmedical establishments, from 1997 to 2001

Year

Disease

1997 1998 1999 2000 2001

Measles 1019 1308 4436 2555 841MNT 0 0 24 12 27AFP 3 26 38 46 70

Source: Annual report of the Ministry of Health 2001

3.8.1 Measles

During 1998 and 1999, the incidence of measles was high not only among the infant andjuvenile populations, but also among adults. The majority of cases were reported in the areasof the West of the country, where insecurity was rampant during that period. It was alsoduring that period that a fall in vaccination coverage was observed.

It should however be stressed that the introduction of the EPI has brought about aremarkable drop in the incidence of measles throughout the country as compared with thepre-EPI period. In fact, the country experienced less than 1,000 cases in 2001, or a reductionof more than 95%.

Case-based surveillance was introduced in the health districts in 2001 but is still verylimited. A national public health laboratory that has been functioning for almost two yearsprovides the analysis of samples and enables accurate confirmation of measles diagnoses.The collection of samples at the medical establishment level needs to be improved andstrengthened. Priority activities include the training of staff, the supply of the necessaryequipment and the introduction of a system for transporting samples.

3.8.2 Acute flaccid paralysis (AFP)

Active surveillance of AFP started in May 1998 and has been established successfully inall the health districts of the country. Efforts will continue in this area to improve performance,particularly in health districts with a low rate of detection. Awareness-building meetings areorganised at the district level with the aim of involving the community in active surveillance ofAFP through the health promoters.

Rwanda – financial sustainability plan of the EPI - 2002 – 2008 - Section 6 29.11.02 22

Section 6: Strategic plan and indicators of the financialsustainability of the EPI:

6.1 General overview of the financial sustainability of the EPI:

6.1.1 General structure of the costs of the EPI:

6.1.1.1 Period 2000 – 2001:

From 2000 to 2001, total expenditure rose by about 400,000 USD to reach 2.6 million USD - agrowth rate of 18%. Over half of the increase was related to the purchase of vaccines and injectionsupplies. That was because of:

- the growth of the population- the improvement in vaccination coverage.- the organisation of the National Immunization Days (in 2000, only Local Immunization

Days took place; they relate to only certain of the health districts).

Staff costs increased by 50,000 USD (+ 8%); this is partly explained by:

- the ‘automatic’ increase in salaries because of seniority and of incumbents’ regularperformance in their posts

- the raising of the level of skills of national staff, which has led to scale increases.

6.1.1.2 Period 2002 – 2005:

In comparison with the previous year, there has mainly been an ‘explosion’ of the costs ofvaccines, particularly Pentavalent, the average annual cost of which is 3.9 million USD. Thataverage annual cost accounts in itself for 1.5 times all vaccination costs in 2001 and is more than½ of the costs for the period 2002 – 2005. In total, the average annual costs of the EPI are thusmultiplied by a factor of 2.8 as compared with the current year.

If the cost of Pentavalent5 is factored out, however, the total average annual cost is about 3.3million USD - an increase of 27% over the total cost in 2001, which is a year without Pentavalent.And if it is assumed that the growth of expenditure is linear over the whole period, the annual rateof increase is about 9.5% a year, which can easily be explained by the rate of population growth,the improvement in vaccination coverage and the inflation rate.

6.1.1.3 Period 2006 – 2008:

The findings are similar to those of the previous year: Pentavalent “consumes” a large part of theannual budget (more than 54%). But if Pentavalent is disregarded, the average annual cost ofvaccination is about 3 million USD - a fall compared with the pervious period. This is explained bythe fact that in 2003 and 2004 two vaccination campaigns have been scheduled, one againstmeasles, the other against poliomyelitis, while for the period 2006 – 2008, other campaigns are

5 It might be objected to this reasoning that if Pentavalent is removed from the calculations, it should be replaced byanother product to enable a valid comparison of the two periods. That substitution product is in fact the DTP that wasused formerly and the cost of which is more than 10 x lower than that of Pentavalent; so ignoring this in the reasoningdoes not change matters fundamentally.


also planned, but their costs have not yet been determined. They are therefore not included in thebudgets at this stage.

6.1.2 General structure of funding of the EPI and prospects during the period covered by theGlobal Alliance for Vaccines and Immunization and for the subsequent period:

For the period 2000 and 2001, the Government of Rwanda’s share of funding of all expenditure isabout 59% of total expenditure. For the period 2002 – 2005, it falls to 28%. As in the case of thesudden increase in expenditure from 2002, this sharp fall is explained by the by the introduction ofPentavalent, the cost of which is covered in its entirety by the Global Alliance for Vaccines andImmunization. In reality, although the Government’s relative share decreases, its contribution inabsolute value increases: it is 2 million USD a year on average over the period 2002-2005,compared with its contribution for 2001, which is 1.5 million USD. In other words, if it is assumedthat the growth of the Government contribution is linear, that would mean a rate of growth of morethan 13% a year for 4 years, compared with 2001.

For the period 2006-2008, its average annual contribution will continue to increase: it will be 2.4million USD a year, which is almost double that of the reference year.

It may therefore be stated that the Government’s efforts to increase its contribution to paying forthe costs of the vaccination programs are very considerable even though, in the tables, thoseefforts are somehow obscured by the overwhelming and new share represented by the purchaseof Pentavalent and its funding by the Global Alliance for Vaccines and Immunization. Thismoreover poses a problem for future funding: who, in fact, will take over once the Global Alliancefor Vaccines and Immunization ends its support? Given the high cost of Pentavalent, it would seemdifficult to contemplate the Government’s taking over from GAVI, and in any case not immediately.Indeed, if it wished to do so, it would have to increase by a factor of over 2.5 from 2007 the amountof its annual contribution to the costs of the EPI for that year. It seems difficult to envisage that atpresent. And there is nothing to suggest that other donors will take over for such high amounts.There is therefore a risk of finishing up in a blind alley. At worst, one could imagine droppingPentavalent and going back to the “old” DTP . But that would of course mean a major loss ofquality in therapeutic terms and in terms of ease of vaccination. Furthermore, it is not certain thatDTP will still be available on the market in a few years time.

To wind up this general overview, it may be said that, without Pentavalent, the financialsustainability of the vaccination program would have been almost completely ensured by theGovernment. Indeed, for the period 2006 – 2008, the average annual shortfall to be funded byother donors, disregarding Pentavalent and in a worst-case scenario (no contribution from UNICEFor WHO to operating costs), would have been ‘only’ about 400,000 USD a year, or 13% of annualcosts. One could be reasonably sure of being able to cover the deficit. The use of Pentavalentturns these prospects on their head and makes them much more gloomy.


6.1.3 Graphs:

The graphs reproduced in annexe IV, the basic calculations for which are in annex V, illustrate theforegoing. In particular,

a) Graphs 1 and 2 show, regardless of the scenario:

- The growth of total expenditure from 2001 with a peak in 2003 (measles campaign) andanother smaller one in 2004 (poliomyelitis campaign).

- The gap that is created from 2006 onwards between requirements and sources offunding.

b) Graph 5 shows the sources of funds in average annual values: one can see

- The strong growth of annual expenditure from the period 2002-2005.- The very major contribution of the Global Alliance for Vaccines and Immunization during

the same period- The growing contribution of the Government of Rwanda during the 3 periods.

c) Graph 7 also shows the sources of funds in average annual values, but this time factoring outthe purchase of Pentavalent: it shows even more clearly the Government’s growing share inthe funding of the EPI (excluding Pentavalent)


6.2 Opportunities and challenges relating to the financial sustainability of the EPI:

6.2.1 Opportunities:

6.2.1.1 Major economic growth:

Economic growth has been of the order of 6 to 8% a year for more than 5 years.6 This major andcontinuous increase in GNP implies on the one hand increasing average per capita income andhence greater accessibility for the population to care in general and to the health structures inparticular; and it is in those structures that vaccinations are given. On the other hand it implies anincrease in Government revenues. It would therefore be reasonable to expect an increase in thebudget for the health sector from which the vaccination programs should benefit (see alsoparagraph 6.2.1.3 below).

6.2.1.2 Very substantial qualitative leap in the skills of health staff at the district level:

The comparison of the health manning tables in the districts between 1997 and 2001 is given bythe following figures7:

1997 2001Number % Number %

Doctors 181 4% 144 4%Nurses andparamedical staff 1,068 22% 1966 60%

Unqualified medicalstaff 1,377 28% 820 25%

Non-medical supportstaff 2,274 46% 349 11%

Total 4,900 100% 3,279 100%

The significant drop in the total number of staff is compensated for by a very considerable increasein the number of staff belonging to the second category (nurses and paramedical staff): thatnumber has almost doubled and as a proportion of all health staff has almost tripled 8; this has animmediate impact on vaccination because vaccinations will be given with many more staff havingthe required skills.

6.2.1.3 The growing involvement of the Government in the domain of health in general and ofprevention in particular:

The proportion of the health budget in the regular budget of the State9 rose from less than 3% in1997 to more than 4% in 2000. Despite a slight drop in 2001, it resumed its upward trend this year.Furthermore, the Government’s contribution to health expenditure10 increased steadily between

6 Cf Section 17 Ministry of Health: “Analysis of the health situation in Rwanda – 1997-2001” - September 20028 This corresponds to the period during which the first batches of graduates came out of medical school when they

reopened after the events of 1994.9 cf graph p. 50 of the 2001 report by the Ministry of Health10 cf graph p. 49 of the 2001 report by the Ministry of Health


1996 and 2000, at the same time as a there was a drastic fall in the inputs from bilateral andmultilateral partners.

In addition to the willingness of the State to involve itself to a greater extent in the health sector, itis important to remember also that it has made prevention and vaccination one of the five majorhealth priorities11 for the coming years.12 It has, for example, included in its budget for 2003 anamount of 550,000 USD (270 million Frw) for the purchase of vaccines and syringes, or 3 timesmore than in the previous year.

6.2.1.4 The constant improvement of the country’s infrastructure:

This desire to improve the country’s infrastructure is expressed by, among other things, thebuilding or repair of roads, the development of means of transport and the increase in the numberof health centres. This means greater accessibility to those centres and lower vaccination costs(less wear and tear on vehicles, shorter times required to reach health centres, shorter distances totravel, better conditions for cold-chain maintenance, etc.).13

6.2.1.5 Decentralisation policy:

The decentralisation policy that was initiated in 2001 and implementation of which started in 2002is raising great hopes from the point of view, among other things, of the allocation and use of theresources available.

6.2.1.6 The creation of the health mutuals:

Over the last 3 years, the Government has strongly encouraged the development of a system ofboth public and association health mutuals. There has been a great upsurge of these. It is obviousthat greater community financial responsibility for health costs means greater accessibility to healthcare. People visit the health centres more frequently and this gives everyone an opportunity to bemade more aware of the advantages of prevention and vaccination. It is also an opportunity forthem to have their children vaccinated. Evidence of this includes the fact that BCG vaccinationcoverage was 97% in 2000 and that the dropout rate is below the 10% limit advocated by WHO14.

This encouragement to set up mutuals has also made it possible – and this incidentally was one ofits main objectives - to compensate for the opposite effects of the institution of a system of costrecovery (“cost sharing”) from 1998 onwards.15.

11 The other priorities are the fight against AIDS and malaria, the development of the mutuals, and the reassessment of

the status of doctors.12 In the tables in sections 4 and 5, this is shown by the Government taking financial responsibility for syringes (from

2001) and traditional vaccines (from 2003).13 It must be remembered that over 90% of vaccinations are given under the stationary strategy.14 Source: Demographic and Health Study (DHS) carried out by ONAPO (National Population Office of the Ministry

of Health).15 It should be noted that the cost recovery system does not apply to the prevention and vaccination sector.


6.2.2 Challenges:

First, a preliminary remark will be in order: in the following account of the risk factors, a distinctionmust be made between, on the one hand, external factors over which neither the EPI nor theMinistry of Health has any control and, on the other hand, factors that they can influence. For thelatter, there is a summary in paragraph 6.3 of the various actions that the EPI is proposing to takewith the aim of eliminating them or reducing their impact.

The main risk factors identified are the following:

6.2.2.1 Prevention policy as a government priority:

Although vaccination is one of the Government’s priorities at present (cf paragraph 6.2.1.3 above),it will be necessary to be very vigilant to ensure that in the future prevention remains a cornerstoneof government health policy. Furthermore, it must also be ensured that this priority is correctlyappropriate at the provincial and district level.

6.2.2.2 The cost of vaccination programs:

Despite its advantages from a practical point of view and in terms of prevention, the institution ofPentavalent has resulted in an “explosion” of the costs of vaccination programs16. It is trulysomewhat paradoxical to observe that the new use of Pentavalent - strongly recommended bydonors - will compromise the financial independence so much desired by those same donors (cfparagraph 6.1 above).

6.2.2.3 The increased dependence of the Ministry of Health on outside donors:

Because of the sudden and sharp rise in the costs of vaccination programs, the longer-term risksof a major gap between budgetary requirements on the one hand and available or probableresources on the other hand have increased sharply. There are legitimate grounds to fear whatmay happen at the end of the current funding periods: a sustainable demand by the population isbeing created or at least strongly encouraged, while the donors’ commitment is only short term.The question is what will happen at the end of that period, knowing that it is difficult to contemplatehaving to interrupt these vaccination programs when current funding comes to an end.

6.2.2.4 The decentralisation policy:

As has already been seen, the Government has instituted a policy of decentralisation. Alongsidethe beneficial effects already mentioned previously, it is to be feared that, as in any countryembarking on such major reform, it may also create additional organisational problems initiallybecause:

- Its launch will undoubtedly still cause a certain amount of hesitation and uncertainties ;

16 One dose of traditional vaccine (DTP) costs about 0.3 $; Pentavalent (which includes DTP + hepatitis B + Hib) costsabout 3.45 $; the ratio is thus 1 : 11.


- There are still some “grey areas” between the greater autonomy of the provinces anddistricts on the one hand and the need to preserve the consistency of a national policyon the other hand;

- Because of their greater autonomy, the provinces and districts have the authority, in theevent of an emergency, for example, to reassign funds temporarily to suchemergencies; this could have the effect of causing delays in the implementation of theactivities normally covered by those funds; alternatively, prevention programs may fallvictim to such temporary reallocations;

- Since decentralisation means that more funds are made directly available to theprovinces and districts, there will be a need to be all the more vigilant over thechannelling of the funds to the periphery at the proper time.

6.2.2.5 Vaccine wastage:

It is known that vaccine wastage is high, but the exact figures are not yet known because thewastage monitoring system was set up only from the end of 2001. The factors influencing wastageare the following:

- Inadequate maintenance of cold-chain equipment.- In some cases, failure to comply with the “opened vial policy” advocated by WHO.- Rules for stock management are not always respected (rotation too slow and

overstocking).

6.2.2.6 Other inefficiencies observed relating to:

- Funds pledged by donors sometimes arrive late because the requests themselves weremade late.

- Shortcomings in the system for collecting and processing information relating to theimplementation of the prevention policy17.

- Shortages of spare parts at times, e.g. in the case of refrigerators funded by a donor:the need to purchase spare parts was not properly understood at the time of purchase,hence the shortage.

- Churning in rural areas of qualified staff who, for reasons including pay, prefer to workin the city.

17 Cf Report on the Data Quality Audit (DQA) for 2001 (PriceWaterhouseCoopers).

Rwanda – financial sustainability plan of the EPI - 2002 – 2008 - Section 6 28.11.02

6.3 Objectives, strategies and corresponding action to be taken with the aim of improving the financial sustainability of the EPI – monitoringindicators:

OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS- Draw up general information

brochures on the EPI anddistribute them to the authorities.

Brochures exist and are distributed.

- Step up the information andawareness-building tours of thehealth districts (1 x / quarter).

The reports of the quarterlyawareness-building tours of thehealth districts exist and areavailable.

- Launch the awareness-buildingcampaign in the press (TV, radioand papers).

There is at least 1 annual presscampaign involving the 3 media.

� Strategy 1.1:

Continuous building of theawareness of all governmentagencies (Government and theMinistries concerned, provincialand district authorities) of theadvantages of the EPI both interms of health aspects per se andfrom the of the point of view of theeconomic effects.

- Organise a NationalImmunization Day.

A National Immunization Day hasbeen organised, the report existsand is available.

- Establish an objective forbudgetary commitment by theState.

There is an objective for budgetarycommitment by the State.

Objective 1:

To bring about an increase in theGovernment ‘s financialcontribution to the EPI byconstantly presenting the case forthe importance of the EPI in termsof general policy:

� Strategy 1.2:

Step up ICC18 lobbying of theGovernment (Prime Minister,Minister for Finance and EconomicPlanning, etc. ) with the aim ofincreasing the budget of the EPI:

- Incorporate the FSP19 of the EPIinto the national health plan.

The FSP of the EPI has beenincorporated into the nationalhealth plan.

18 ICC: Inter-agency Coordinating Committee19 FSP: Financial Sustainability Plan


OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS- Publish a weekly review of

information on the EPI fordistribution to the members of theGovernment, to the ministriesmost concerned, to the membersof the ICC and to the internationalpartners.

A weekly review of information isbeing published and distributed.

- Organise an annual symposiumon the EPI.

The report of the annualsymposium exists and is available.

� Strategy 1.3:

Explore other government sourcesof revenue (e.g.: PRSP 20: funds forthe reduction of the debt of theHIPCs 21 22)

- Contact the Ministry of Finance toinclude the EPI in the priorities ofthe PRSP

Written commitment from theMinistry of Finance

- Try to expand the composition ofthe ICC by bringing in newmembers.

There is at least one new memberof the ICC each year.

- Distribute the general informationbrochures on the EPI to themembers of the ICC and to otherpotential donors.

The general information brochuresexist and have been distributed (cfdistribution list).

Objective 2:

To increase the contribution fromother donors (bilateral andmultilateral cooperation) with theaim of closing the gap betweenneeds and acquired resources andto reduce dependence on thosedonors by a greater diversificationof sources of funding

� Strategy 2.1:

Acquaint potential donors with theEPI and ask for their support:

- Distribute the weekly reviews ofinformation on the EPI to themembers of the ICC and to otherpotential donors.

The weekly reviews of informationexist and have been distributed (cfdistribution list).

20 PRSP: Poverty Reduction Strategy Paper21 HIPCs: Highly-Indebted Poor Countries.22 Cf particularly the European Union funds made available (on certain conditions) to the Ministries of Health, Justice and Education.


OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS- Invite potential donors to the

annual symposium on the EPI.Donors have been invited to theannual symposium (cf list ofinvitations and report of thesymposium).

- Make funding proposals topotential donors.

Funding proposals were sent out.

- Involve donors to a greater extentin the medium- and long-termplanning of EPI budgetary needs.

Donors are participating in thepreparation of budgetaryrequirements planning includingwork done at the quarterlymeetings of the ICC.

� Strategy 3.1:

Try to obtain long-term financialcommitments from donors:

- Try to obtain financialcommitments of more than 5years.

Funding proposals relate to fundingperiods longer than 5 years.

- Set up coordination between thefinancial managers in the Ministryof the Health, the Ministry ofFinance and the Ministry of LocalAdministration with the aim ofimproving the procedures fortransfers of funds.

A written document laying downthe procedures for transfers offunds has been produced followingthe coordination meetingsorganised with the Ministriesconcerned.

Objective 3:

To increase the sustainability offunding:

� Strategy 3.2:

Improve the procedures fortransferring funds from the capitalto the periphery so as to avoid therisks of fund shortfalls:

- Help administrators andmanagers of health districts toanticipate and prepare therequests for funds they send tothe central level better.

A workshop for health districtadministrators and managers isbeing organised once a year andincludes a component on themanagement of decentralisedfunds.

Objective 4:

To increase the efficiency of theprogram so as to improve the cost–benefit ratio:

� Strategy 4.1:

Improve the system of healthinformation:

- Improve the completeness andpromptness of vaccinationreports sent in by the districts.

Reports are more complete anddeadlines are met: they reach thecentral level no later than the 15thof the following month.


OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS- Organise seminars for the

supervisors of health districts withthe aim of improving their skills inthe collection, processing andanalysis of data.

The seminars on the SIS (HealthInformation System) for healthdistrict supervisors are being heldonce a year.

- Upgrade the computing hardwarefor data processing at the centrallevel.

New equipment has beenpurchased and is operational; adhoc training courses have beengiven.Written instructions relating to thepolicy on opened vials exist andhave been sent out to all thedistricts.

- Strengthen the WHO strategy onthe policy for opened vials.

A ‘Monitoring of the policy onopened vials’ component has beenincluded in the guidelines forsupervision.

- Verify the implementation of thenew guidelines that have justbeen issued on stockmanagement.

The ‘Verification of stockmanagement’ component has beenstrengthened in the guidelines forsupervision missions of healthdistricts.

� Strategy 4.2:

Reduce vaccine wastage:

- Ensure that auxiliary cold-chaintechnicians apply correctly theguidelines they were given at thetime of the May 2002 seminar oncold-chain maintenance

The ‘Verification of cold-chainmaintenance component of the hasbeen strengthened in theguidelines for supervision missionsof health districts.

� Strategy 4.3:

Improve in general the allocationand use of the human, financialand material resources

- Make proposals concerning astrategy to motivate health staffwith the aim of reducing staffchurn.

A document containing proposalson a strategy to motivate healthstaff has been produced in theMinistry of Health.


OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS- Improve financial monitoring

including monitoring at the time ofthe quarterly and half-yearlyreviews of data: develop afinancial component of monitoringalongside the technicalcomponent.

The content of the ‘financialinformation’ section of the periodicreviews of EPI data has beenstrengthened.

The creation of ‘Cold-chainmaintenance units’ is being verifiedduring the supervision missions ofthe health districts.

- Ensure the effectiveestablishment in the healthdistricts of the maintenance unitscreated after the seminar forauxiliary cold-chain technicians;introduce the control andmonitoring system for thesemaintenance units.

A complete inventory is prepared atleast once a year.

- Ensure the proper establishmentof the decentralisation of stocksof spare parts.

There are decentralised stocks ineach health district.

- Mobilise health promoters to agreater extent.

A monthly meeting with healthpromoters is being held in eachmedical establishment (Healthcentre and health district hospitals).

- Raise the awareness of thegrassroots political andadministrative authorities.

A quarterly meeting, financiallysupported by the EPI, is being heldin each health district with thegrassroots political andadministrative authorities.

� Strategy 4.4:

Improve social mobilisation so asto increase vaccination coverage ingeneral and increase thevaccination of children who cannotbe reached except by an outreachstrategy in particular:

- Raise the awareness of otheropinion leaders at the communitylevel.


OBJECTIVES STRATEGIES ACTION MONITORING INDICATORS� Strategy 4.5:

Develop an operational partnershipwith the other Ministries on socialmobilisation :

- Raise the awareness of the “IEC Focal Points”23 of the Ministriesconcerned.

A meeting with all the focal pointsof the ministries concerned is beingheld at least once a quarter.

23 IEC (Information – Education – Communication) focal points are resource persons for information, education and communication in the social ministries.


Section 7: Comments by the parties

1) WHO

2) UNICEF

3) Rotary


For the Ministry of Health,

Prof. Abel DUSHIMIMANA

Minister for Health

For the Ministry of Financeand Economic Planning,

Dr Donald KABERUKA

Minister for Finance andEconomic Planning

rwanda – expanded program of …...1 rwanda – expanded program of immunization financial...

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