Immunization Financing News | Volume 6, 2014
Volume 6.4, February 2015
This quarter, Nepal advanced further toward its sustainable immunization financing goal. New immunization legislation is nearing passage, inaugurating a public-private immunization financing arrangement. Four years in the making, the project recently received a boost from Nepal’s President, the Honorable Dr. Ram Baran Yadav, who announced he was joining the growing network of supporters working on immunization financing solutions for the country.
Like many lower income countries, Nepal’s economy is growing and revenues are increasing. But vaccine and delivery costs are rising faster. The country has already introduced inactivated polio vaccines in September 2014 and is on track to introduce pneumococcal and human papillomavirus in 2015, which will push immunization costs to well over US$30 per child- far more than the government can currently allocate to the program. The solution: establish two immunization funds, one governmental, and the other private. Backed by a new vaccine law, the public fund will guarantee a minimal vaccine budget safeguarded from budgetary shocks. It will be matched by a private fund, dubbed the Sustainable Immunization Financing Support Fund, which was launched by the country’s Rotary and Lions clubs in October 2012 [see related stories: Summary Digest, Vol 5, Issue 1, Immunization Financing News, Vol 6, Issue 1]. Government officials are currently working on a provision granting tax benefits to induce domestic firms to contribute to the private fund.
These efforts to achieve sustainable immunization financing caught the attention of Nepal’s President, Hon. Dr. Ram Baran Yadav. On 31 October, President Yadav hosted a briefing in his office to learn more about this work. Attending were Sabin Senior Program Officer Dr. Devendra Gnawali and, representing Rotary International/Nepal, Rotarians Ram Prasad Bhandari, Rabindra Jang Thapa, Gopal Pokhrel and Rishi Raj Adhikari.
The group discussed how new legislation will establish the funds and guide their administration. The Ministry of Health and Population (MOHP) began the project in May 2011. In April 2014, the Ministry of Finance allocated an initial NPR 10 million (around US$100,000) for the new fund. The prospects of enacting the supporting legislation dimmed when a constitutional crisis led to the dissolution of Parliament in July 2012. Undaunted, officials in the Ministries of Finance and Law and Justice turned to crafting regulations for the funds. Local governments and a range of non-governmental organizations, as well as WHO and UNICEF experts were consulted during this process.
The launching of the private fund by Rotarians and Lions Clubs in October 2012 added impetus to the government’s efforts. Former Minister of Health Hon. Vidyadhar Mallik guided the final government approval process, culminating in January 2014 with the publication of the fund regulations in the Nepal Gazette.
At the request of Hon. Ranju Kumari Jha, Chairperson of the Women, Children, Senior Citizens & Social Welfare Committee, the Ministry of Health and Population, WHO and SIF/Sabin jointly organized a "Symposium on Shared Responsibility for a Sustainable Immunization Program" for parliamentarians in Kathmandu, Nepal. The Symposium was chaired by Mr. Shanta Bahadur Shrestha, MOHP Secretary. The Chief Guest was Hon. Khag Raj Adhikari, Minister of Health and Population, and the Special Guest was Hon. Ranju Kumari Jha. Also attending were reporters, more than twenty MPs from the Women, Children, Senior Citizens & Social Welfare Committee, and officials from the MOHP, EPI team, WHO, UNICEF, and Sabin. Using the appreciative inquiry method, discussants analyzed technical issues of the national immunization program, the immunization law and the immunization fund in detail. The Health Minister, H.E. Khag Raj Adhikari, disclosed that the draft would be registered into the parliament very soon, and the MPs committed to pass the immunization bill.
At this writing, the National Immunization Law is now on the docket of the recently re-established Parliament and could be passed as early as March 2015.
“Now H.E. Khag Raj Adhikari, Minister of Health and Population, is calling for the immunization law”, reported Gnawali. “We are very close to the goal”, he concluded. Following Nigeria, Nepal now stands to be the second SIF country to enact legislation guaranteeing public financing for immunization.
Since 2009, the SIF Program has been working with an array of countries to build the capacity of governmental and domestic non-governmental counterparts to develop and institutionalize their own innovative financing solutions. All but one of the original countries have remained with the SIF program to this day, and three more have joined since the program’s inception.
SIF has been operating on a unique international development frontier. The Program seeks to catalyze the transition of national immunization systems from financial precariousness and dependency to self-sustainability and country ownership.
Little documentation exists on transitions of this nature, whether in the field of global health or elsewhere in international development. With six years of documentation to work from, SIF Program Coordinator Mr. Andrew Carlson recently produced the “SIF Institutional Knowledge Catalogue”. The Catalogue contains a monthly time-log of SIF Senior Program Officer activities linked to steps a country has taken toward one of five dimensions of financial sustainability:
- Legislation protecting federal immunization budgets against institutional, political, or economic shocks
- An inter-institutional or parliamentary coalition to advocate for an increased immunization budget
- A financing mechanism which ensures adequate, predictable domestic funding to the EPI program, such as a trust fund or a national immunization fund
- The regular, independent use of resource tracking tools by the appropriate government entity
- The integration of GVAP Strategic Objectives #1 and #5 into national immunization work plans
The five dimensions were derived from country presentations at the second SIF Colloquium (Dakar, August 2013). The catalogue will be updated monthly and is already being used for qualitative and quantitative analyses. The catalogue will be available on the SIF website by April 2015.
DRC continues to increase immunization financing at the provincial level. In October and December 2014, government authorities from three more provinces made formal commitments to mobilize local funding and pass legislation to support their immunization programs. In all, six of DRC’s eleven provinces have begun developing such solutions. Driving the process is the Réseau des Parlementaires Congolais pour l’Appui à la Vaccination (Congolese Parliamentary Network for Immunization Support). Known as REPACAV, the Network includes parliamentarians and government officials working together at federal and provincial levels.
REPACAV’s President, Hon. Gregoire Lusenge, established the coalition in May 2012. The REPACAV Charter states that,
“In our country, children die every year from vaccine-preventable diseases…an action by parliament would allow the Democratic Republic of Congo to benefit from autonomy over its immunization financing efforts, and better organize its national immunization program.”
REPACAV was created to “support vaccine-related activities through advocacy on the parliamentary level and sensitization campaigns on the community level.”
Hon. Lusenge, Hon. Louis Kaswende, Hon. Celestin Bondomiso, and Hon. Richard Makuba of REPACAV and SIF Senior Program Officer Dr. Helene MambuMa-Disu embarked on the first advocacy mission, to Bas Congo Province, on 11 December 2013 (see related story, Immunization Financing News, 5(4)). This past December, three REPACAV members, Hon. Makuba, Hon. Yukula, and Mr. Muntuntete-Vanloy, paid a return visit to Bas Congo where they assisted the provincial EPI team in preparing the program’s budget for 2015.
On 5 & 7 May 2014, REPACAV members visited Oriental and Kasai-Occidental provinces (see related story, Immunization Financing News, 6(2)). Among the delegates were national immunization program counterparts Dr. Guillaume Ngoie Mwamba, Dr. Jacky Matondo and Mr. Benjamin Matata. Among the MPs were Hon. Gregoire Lusenge, Hon. Célestin Bondomiso, Hon. Louis Kaswende, and Hon. Mubikayi, who represents Kananga, the capital city of Kasai-Occidental. Ministerial and parliamentary authorities in both provinces agreed to begin mapping the way towards sustainably financing their local immunization programs, reported SIF Senior Program Officer Dr. Mambu-Ma-Disu, who accompanied the delegates. The provincial officials, in turn, asked REPACAV to facilitate the disbursement of funds from federal level to their provinces.
These missions were soon followed by more. After their parliamentary summer recess, REPACAV members visited Bandundu (2-5 December) and Maniema Provinces (23-27 December). The delegation was led by former MP Hon. Hubert Masala and current MPs Hon. Louis Kaswende, Hon. Lumeya and Hon. Koko. As in their previous forays, the REPACAV delegates met with the provincial immunization coordinators, health ministers, governors, provincial assemblies and civil society leaders.
Maniema Province, the country’s poorest, subsequently increased its proposed immunization budget by 66 percent.
To date, the Network has added six of DRC’s eleven provinces to the REPACAV network, creating subnational antennes for sustainable immunization financing:
- December 2013: Bas-Congo
- May 2014: Kasai-Oriental
- May 2014: Kasai-Occidental
- October 2014: Orientale
- December 2014: Bandundu
- December 2014: Maniema
Looking ahead, Hon. Lusenge and his colleagues are envisioning an advocacy network with representation from all eleven provinces.
An interesting event took place on 6-7 October in Ulaanbaatar, Mongolia. The Government and State Great Khural (parliament) of Mongolia, along with SIF, sponsored a peer exchange, the theme of which was Sustainable immunization financing: The legal landscape. Participating were parliamentarians and senior government officials from Mongolia, Vietnam and Uganda. The purpose of the exchange was to learn how Mongolia created its immunization law and national immunization fund.
For the Ugandans, the visit was an obligatory study tour on behalf of their National Assembly. Before taking up a similar bill, Uganda’s Speaker of the House had earlier asked members of the Parliamentary Forum for Immunization to learn from the experience of another country having had the same experience and to report that experience back to parliament. This added evidence would make it easier for parliament to approve Uganda’s immunization bill, now three years in the making. Ulaanbaatar-based Sabin Senior Program Officer Dr. Khongorzul Dari was already planning another peer exchange between Vietnam and Mongolia. Her parliamentary and government counterparts agreed to alter the plan and host a joint Ugandan- Vietnamese visit.
Representing Uganda were Hon. Henry Banyenzaki, MP and State Minister for Economic Monitoring, Office of the President. He was joined by two other MPs active in the Network, Hon. John Amos Okot and Hon. Anne Auru. The Vietnamese peer exchangers were Drs. Tran Hien Nguyen and Cong Luat Nguyen. Receiving the delegations were Hon. Enkhbold Zandaakhuu, Parliamentary Speaker, Hon. Battsogt Dogsom, Chairman of the Standing Committee on Social Policy, and Hon. Amarsanaa Jazaa, Vice Minister of Health.
Hon. Amarsanaa Jazaa moderated the inaugural session. Representatives from the Mongolian Ministry of Health, Ministry of Finance and Tax Department presented the history and structure of Mongolia’s immunization law and fund. The fund, which was launched in 2000, is largely financed with mining revenues. Immunization expenditures were meager in the early years but, with the addition of newer vaccines, the fund is now disbursing over US$40 per surviving infant.1 In the next session, the visiting peers presented their own innovations for sustainable immunization financing. Later, the peers visited the Tax Department, where another innovation has been developing. Dr. Dari and her Tax Department counterparts have been coaching local government officials to begin reporting their local immunization expenditures to their publics (see related story, Immunization Financing News, 6 (2)).
On the second day of the visit, the peers met with Mongolian Ministry of Health counterparts to compare their respective health systems and discuss immunization financing strategies. The final stop was the House of Parliament, where the peers were received by Speaker of the House Hon. Enkhbold Zandaakhuu and Hon. Battsogt Dogsom, two MPs with deep interest and experience in the health arena. The peers reviewed their observations and the recommendations they would take home to their own governments and parliaments. Decision makers would be urged to adopt or amend laws that make immunizations universal and sustainably financed. Secondly, subnational governments would be asked to dedicate a budget line item to cover operational costs of immunization. Thirdly, MPs and government counterparts will need to redouble their advocacy efforts for increased government expenditures on immunization. Hon. Henry Banyenzaki then proposed 1 Source: WHO/UNICEF Joint Reporting Form – Mongolia. forming global parliamentary network for immunization at the next International Parliamentary Union meeting in Geneva. Speaker Hon. Enkhbold Zandaakhuu agreed to support the proposal.
Reflecting on their experience, the Ugandan MPs praised the Mongolians for their immunization financing work and resolved to push their own immunization bill into law upon their return home.
Twenty-five parliamentarians and ministerial officials from six French-speaking African countries assembled at Hotel Framontel, Kribi, Cameroon on 4-6 December to subject their institutional work in immunization legislation, resource tracking, and budget advocacy to peer review.
The Francophone Africa Peer Review Workshop on Sustainable Immunization Financing was the second episode in a three-part sequel to the SIF Program’s Second Colloquium on Sustainable Immunization Financing, which took place in Dakar, Senegal on 5-6 August 2013. The first post-Dakar peer review workshop took place in Phnom Penh, Cambodia, on 21- 23 July, 2014 where delegations from Cambodia, Nepal, Sri Lanka, Mongolia, Indonesia, and Vietnam scrutinized their respective financing innovations (see Immunization Financing News, 6 (3)).
Joining the Kribi workshop from DRC were Mr. Jules Baganda, Ministry of Budget Department Director, Hon. Gregoire Lusenge, National Assembly, Mr. Benjamin Matata, EPI Financial Director and Dr. Audry Mulumba, EPI Manager, Ministry of Health. Representing Madagascar were Ms. Noeline Victoire Raveloarijao, Ministry of Finance and Budget, Dr. Aro Tafohasina Rajoelina, Health Projects Director, Ministry of Public Health, and Dr. Lova Herizo Rajaobelina, National Assembly Health Committee Chair. Representing the Republic of Congo were Dr. Hermann Boris Didi-Ngossaki, EPI Manager, Ministry of Health, and Mr. Jean Fenelon Kanda, Budget, & Public Portfolio, Ministry of Finance. Representing Senegal were Dr. Ousseynou Badiane, EPI Manager and Dr. Alimata Naco Diallo, both of the Ministry of Public Health & Hygiene, and Hon. Elene Tine, of the Parliamentary Health Committee. Representing Mali were: Mr. Mahamadou Sidibe, Health Focal Point, Directorate-General for Budget, Ministry of Economy, Finance, & Budget, and Hon. Abdoulaye Dembele, Health Committee Member, National Assembly. The Cameroon delegation included: Dr. Marie Kobela, EPI Manager, Ministry of Health; Mr. Cyrille Effila, Budget Department, Ministry of Finance; Hon. Gaston Komba, Finance & Budget Committee Member, National Assembly and; Dr. Ngwen Ngangue, Ministry of Economy & Finance. Also attending were representatives from UNICEF, Mr. Remy Mwamba, Christophe Mvondo, and Folefack Medard. Attending from Sabin were Senior Program Officers Mr. Jonas Mbwangue and Dr. Helene Mambu-Ma-Disu.
The workshop began with four rounds of small group work in which each delegation presented its institutional innovation- some new, creative approach or a new form of collaboration- within one of three thematic areas: budgeting and resource tracking, legislation, and advocacy strategies. The second half of the workshop featured a formal peer evaluation, where each delegate scored the other countries’ innovations. UNICEF and Sabin representatives served as facilitators.
“The delegates interacted intensely in the small groups, the plenary sessions and in the formal peer evaluation exercise”, reported SIF Senior Program Officer Mr. Jonas Mbwangue.
Workshop participants evaluated innovations in the other countries and received constructive feedback from their peers, which they will use to advance their own innovations.
Following the workshop, Senegalese delegate Hon. Elene Tine conferred with the Speaker of the National Assembly and the two announced the formation of a parliamentary network for immunization patterned on the DRC parliamentary network. In short order, the Senegalese parliamentary network numbered thirty MPs. Commented Hon. Tine:
“Next week, I plan to send a letter to the National Assembly President, calling for the official recognition of the network as well as a General Constituent Assembly session at the Parliament level. This network will be linked to an inclusive advocacy group soon to be established at the national level.”
The National Assembly of the Congo Republic has also begun to organize a parliamentary network for immunization, reports Dr. Helene Mambu-Ma-Disu.
The next SIF peer review workshop is in preparation. It will involve the six Anglophone African SIF countries: Uganda, Kenya, Ethiopia, Sierra Leone, Liberia, and Nigeria
Interested readers can find a number of Sustainable Immunization Financing Tools on our SIF Program website.
Two resource tracking tools, in English and French, are currently in use in several SIF countries. The Generic Annual Work Plan and the SIF Budget Flow Analysis tools both allow immunization managers to analyze their budget performance and identify any bottlenecks.
There are also tools for small group work using the nominal group technique. These guides are used in SIF workshops to identify and analyze key problems as well as best immunization financing practices.
Below are the names of individuals who participated in SIF-organized peer exchanges during 2014. Each has made, and continues to make, significant contributions to the cause of sustainable immunization financing in their countries.
The SIF team salutes them for their work.
- Dr. Otgontuya Dari, Public Health Institute
- Mrs. Otgon Majaa, Standing Committee on Social Policy, Education, Culture, and Science; Parliament of Mongolia
- Dr. Ganchimeg Ulziibayar, Ministry of Health
- Hon. Enkhbold Zandaakhuu, Parliamentary Speaker
- Hon. Battsogt Dogsom, MP, Chairman of the Standing Committee on Social Policy
- Hon. Amarsanaa Jazaa, Vice Health Minister
- Mr. Komal Prasad Acharya, Under-Secretary, Legal Department, Ministry of Health and Population
- Mr. Shambhu Prasad Jnawali, EPI Manager, Ministry of Health and Population
- Mr. Birendra Bahadur Karki, Secretary; Women, Children, Senior Citizen and Social Welfare Committee, Parliament of Nepal
- Dr. Nguyen Van Cuong, Deputy EPI Manager, National Immunization Program,
- Mr. Do Cong Thanh, Head of Budget Planning, Ministry of Finance
- Dr. Nguyen Tran Hien, EPI Manager, National Institute of Hygiene and Epidemiology, Ministry of Health
- Dr. Cong Luat Nguyen, National Institute of Hygiene and Epidemiology, Ministry of Health
- Dr. Paba Palihadawana, Chief Epidemiologist, Epidemiology Unit, Ministry of Health
- Ms. Nandini Ranawaka Appuhamillage, Health Committee Staff, Parliament of Sri Lanka
- Mr. W Arachchilage Don Dushantha Sameera Wickramasinghe, Director, Budget Department, Ministry of Finance and Planning
- Mr. Maliki Arif Budianto, Head of Planning and State Budget Subsection, Bureau of Planning & Budgeting, Ministry of Health
- Dr. Diany Litasari, Immunization Sub-Directorate, Ministry of Health
- Mr. Entos Zainal, Head of Health Promotion and Nutrition Community Sub-Directorate, National Development and Planning Agency
- H.E. Ouk Damry, Senior Advisor to the National Assembly; General Secretary of CAPPD
- H.E. Uy Visal, Director, International Relations Department, National Assembly of Cambodia
- Prof. Sann Chan Soeung, Advisor, National Immunization Program, Ministry of Health
- Dr. Chheng Morn, Deputy NIP Manager, Ministry of Health
- Mr. Hok Khiev, Director, Department of Legislation, Ministry of Health
- Mr. Kim Phalla, Deputy Director General, Department of Finance and Public Policy, Ministry of Economy and Finance
- Mr. Sok Khorn, Department of Public Finance and Policy, Ministry of Economy and Finance
- Ms. Bola Kan, Health Economist, Budget Department, Ministry of Economy and Finance
- Hon. Mr. Uk Bun Chhoeun, Chairman of Commission 8, Senator
- Hon. Mr. Yan Sen, Chairman of Commission 1, Senator
- Hon. Mr. Chhit Kim Yeat, Vice-Chairman of Commission 8, National Assembly
- Hon. Mrs. Pov Savoeun, Secretary of Commission 8, National Assembly
- Hon. Mrs. Krouch Sam An, Secretary, National Assembly
- H.E. Kob Maryas, National Assembly
- H.E. Khim Hi, Advisor to the National Assembly
- H.E. Mr. Kin Ratha, Advisor to the National Assembly
- Mr. Kal Ketnin, Advisor to the National Assembly
- Mr. Sur Sovanpheach, Advisor to the National Assembly
- Mr. Son Kakson, Advisor to the National Assembly
- Dr. Koam Sinoun, Deputy Director, Department of Legislation, MOH
- Dr. Enheng Morn, Ministry of Health
- Mr. Thiep Chanthan, Senior Program Officer, Ministry of Health
- Chhat C. Valthanak, Government of Cambodia
- Mr. Phar, Government of Cambodia
- Mr. Jules Baganda, Department Director, Ministry of Budget
- Hon. Gregoire Lusenge, Member of Parliament
- Mr. Benjamin Matata, EPI Financial Director
- Dr. Audry Mulumba, EPI Manager
- Ms. Noeline Victoire Raveloarijao, Health Projects Director, Ministry of Finance & Budget
- Dr. Aro Tafohasina Rajoelina, Ministry of Public Health
- Dr. Lova Herizo Rajaobelina, Health Committee Chair, National Assembly
- Dr. Hermann Boris Didi-Ngossaki, EPI Manager
- Mr. Jean Fenelon Kanda, Ministry of Finance, Budget, & Public Portfolio
- Hon. Elene Tine, MP, Parliamentary Health Committee Member
- Dr. Ousseynou Badiane, EPI Manager
- Mr. Mahamadou Sidibe, Health Focal Point, Directorate-General for Budget, Ministry of Economy, Finance, & Budget
- Hon. Abdoulaye Dembele, MP, National Assembly Health Committee Member
- Dr. Alimata Naco Diallo, Ministry of Health & Public Hygiene
- Dr. Marie Kobela, EPI Manager
- Mr. Cyrille Effila, Budget Department, Ministry of Finance
- Hon. Gaston Komba, MP, National Assembly Finance & Budget Committee Member
- Dr. Ngwen Ngangue, Ministry of Economy & Finance
- Maina Djoulde, Government of Cameroon
- Amougou Mezang, Government of Cameroon
- Marie Epee, Government of Cameroon
- Tina Sonia, Government of Cameroon
- Lambiu Adamu, Government of Cameroon
- Flore Ekoulle Government of Cameroon
- Hon. Henry Banyenzaki, Member of Parliament; Hon. John Amos Okot, Member of Parliament
- Hon. Anne Auru, Member of Parliament
- 21-31 October, Tibilisi. SIF SPO Dr. Eka Paatashvili assists in Georgia’s Gavi Graduation Assessment Mission.
- 7 & 14 November, Dakar and Bamako. SIF SPO Mr. Jonas Mbwangue organizes parliamentary briefings in Senegal and Mali.
- 12 November, Dalanzadgad City. The Mongolian Tax Department, Department of Health and Parliamentary Standing Committee on Health, with assistance from SIF SPO Dr. Khongorzul Dari, brief Umnugobi District health and tax officials on local immunization expenditures.
- 12 November, Abuja. SIF SPO Dr. Clifford Kamara in tandem with peers from Nigeria’s Senate Committee on Health, Ministry of Health, the NPHCDA and other international agency counterparts, moderates a panel at a conference marking World Pneumonia Day, Sustaining PCV Introduction in Nigeria.
- 13 November, Kampala. SIF Director Mike McQuestion and SPO Ms. Diana Kizza Mugenzi host a SIF/Uganda Alumni Dinner attended by past SIF peer exchangers.
- 15-17 November, Kinshasa. Representatives from the DRC’s EPI and Ministries of Finance, Budget and Planning, with assistance from SIF SPO Dr. Helene Mambu-Ma-Disu, integrate GVAP Objectives #1 and #5 into the country’s cMYP.
- 9 December, Abuja. Nigerian President H.E. Goodluck Jonathan signs the National Health Bill into law.
- 10-13 December, Kribi. Counterparts from the Cameroon Ministry of Health, the Clinton Health Access International (CHAI), WHO, UNICEF, Agence de Médecine Préventive (AMP), Gavi, and SIF co-organize a cMYP workshop.
Volume 6.3, December 2014
Nigeria, Africa’s most populous country, more than doubled its immunization budget from 2010-12 and the budget continues to grow. In February 2014, the country took another step toward country ownership by passing a new National Health Bill in the Senate and House of Representatives. The Bill includes a provision explicitly guaranteeing public immunization financing. This makes Nigeria the first of the original 15 SIF countries to pass such a bill.
The Bill was passed thanks to the efforts of a handful of dedicated individuals, reports SIF Senior Program Officer Clifford Kamara who has worked with the country since 2008. On the government side, the Honorable Minister of Health, the Executive Director of the National Primary Health Care Development Agency and their officials provided technical input to the bill. On the parliamentary side, the Senate and House of Representatives Health Committees played prominent roles in ensuring passage of the Bill. In the Senate, the arrowheads were the Chairman of the Health Committee, Senator Arthur Ifeanyi Okowa and Senator Sefiu Adegbenga Kaka who rallied support from their fellow senators as well as the House of Representatives for final passage. In addition, a coalition of NGOs working in the health sector under the leadership of HERFON (Health Reform Foundation of Nigeria) provided technical input and kept discussions on the health bill on the front burner of public discourse. Approval followed an arduous, two-year effort, as would be expected for such a wide-ranging bill. The First Reading took place in October 2012. In a presentation to the August 2013 Dakar SIF Colloquium, Sen. Kaka described the range of stakeholders who were vigorously debating how the government should deliver and finance curative as well as preventive services. The Senate Health Committee inserted the vaccine-specific language at the Third Reading.
Section 11(2)b of the law provides: 20 percent of the [Basic Health Care Provision Fund] shall be used to provide essential drugs, vaccines, and consumables for eligible primary health care facilities. The provision insulates the vaccine budget from political, economic or other shocks and ensures continuous vaccine financing.
With the passage of the 2014 National Health Bill, Nigeria joins a host of countries, principally in Latin America, that guarantee public vaccine financing.
Following passage, the Senate Health Committee Chairman, Senator Ifeanyi Okowa remarked: "We need to provide for vaccines…it will be a welcome affair that our people in the rural areas have somewhere they can call their own to attend when they have one ailment or the other, rather than going to the medicine vendors…”
Immunization financing arrangements are actually quite complex in highly decentralized Nigeria. The Bill establishes a Basic Health Care Provision Fund, to be co-financed by federal revenues and defined contributions from state and local governments. Kamara and the Nigerian SIF champions will now shift their advocacy efforts to the thirty-eight states whose participation in the fund will be crucial. And though the bill has been passed, President Goodluck Jonathan must provide his signature before it is enacted into law. “Well, this is political will,” commented Kamara.
By Jonas Mbwangue, Senior Program Officer, Sabin Vaccine Institute Sustainable Immunization Program
Recent developments in Cameroon illustrate how African countries are taking ownership of their immunization programs. Cameroon’s commitment to immunization continues to rise. On the legislative front, the Ministry of Health is developing new legislation which wills secure public financing for immunization. On the programmatic side, government and parliament have integrated the six strategic objectives of the Decade of Vaccines Global Vaccine Action Plan (GVAP) into the national immunization action plan.
From August 19th to the 23rd, I attended a national immunization planning workshop in Ebolowa, Cameroon. 40 delegates representing the government of Cameroon, the Parliament, the Association of Mayors and external immunization partners WHO, UNICEF, GAVI and AMP were in attendance. At this workshop, I saw our national institutions work together to generate a 5-year plan for the national immunization program. Sabin co-sponsored the workshop along with UNICEF, the World Health Organization (WHO) and Cameroon’s Ministry of Health.
The first order of business was to align Cameroon’s 2015-2020 Immunization Country Multi-Year Plan (cMYP) with the Global Vaccine Action Plan (GVAP), a framework adopted by the WHO in 2012 to improve health by extending the benefits of immunization to all people. The second objective was to define how Cameroon will fully finance the program in the coming years. Financing is an increasing concern as Cameroon will soon graduate from GAVI grant eligibility and will thereafter have to fully finance its new vaccines. The workshop was the latest in a series of Sabinsupported advocacy activities in Cameroon that began in 2009. Over the years, these advocacy efforts have given voice to a cadre of immunization champions, in government, parliament and civil society. The workshop again brought them together. Dr. Marie Kobela, Cameroon’s EPI Manager, opened the workshop by explaining how Cameroon’s EPI program is working towards increasing immunization financing and vaccination coverage through new legislation and advocacy work.
Cameroon’s draft legislation for sustainable immunization financing continues to advance despite domestic political difficulties, she noted. The program’s budget has also been increasing. The progress is due to the champions, who have been working through their respective institutions, principally the Ministry of Health, Ministry of Finance, Parliament and the Association of Mayors. In essence, Dr. Kobela now works with a team of supporters who are helping advance the legislation and advocate for program budget increases.
These champions see immunization as a valuable public good which benefits all levels of society, and their advocacy has reached the highest levels of government. At their insistence, Cameroon’s Prime Minister established an inter-ministerial committee earlier this year to review the draft immunization law before it is submitted to Parliament for approval. At the workshop, the champions renewed their call for action on the bill. Once submitted, Dr. Kobela explained, the champions will do what they can to get the law approved as soon as possible.
A key immunization champion is Hon. Gaston Komba, a member of Cameroon’s Parliamentarian Financial and Budget Committee who has been involved in the country’s sustainable immunization financing advocacy efforts since 2009. Last year, Hon. Komba and Dr. Kobela led the Cameroonian delegation in a Sabinorganized legislative workshop in Kinshasa, DRC. At the Ebolowa workshop, Hon. Komba urged government policymakers to view immunization as an investment rather than an operational cost.
The proposed law will establish a fund earmarked for immunization. However, each year, Dr. Kobila and her team will still need to prepare and defend steadily increasing EPI budget requests. One part of the investment case is to show how well the previous budget was executed. The EPI program team does this by tracking, analyzing and reporting immunization program allocations and expenditures. For the past three years, Dr. Kobela and her team have used a simple budget flow sheet, provided by Sabin, to do this resource tracking. Armed with this information, Parliament monitors the government’s level of commitment to the program. Dr. Kobela refers to these MPs as her EPI “watchdogs.” Their support has proved crucial. In 2012, the government significantly cut the EPI budget. Thanks to the watchdogs, the cuts were restored and the 2013 budget was increased by US$4 million.
The workshop also revealed how a new NGO-driven Immunization platform is promoting immunization throughout the country. The NGO Immunization Platform (PROVARESSC) is supported by grants from GAVI. In the workshop, a representative from this Platform shared details of their plan to bring immunization information and advocacy to all 14,000 villages of Cameroon. If this outreach activity is funded, the Platform will boost the GVAP strategy of “Reaching all households”.
The Ebolowa workshop convinced me that Cameroon is well on the way to owning its immunization program. Hearing from immunization champions within the government and NGO community, I strongly believe that long-term immunization financing will be secured through legislation. Continued monitoring and tracking of government expenditures will provide decision makers with the information they need to properly oversee the EPI program. Lastly, the NGO Immunization Platform will increase immunization demand. Together, all of these efforts will ultimately create a healthier Cameroon.
Senator Sefiu Adegbenga Kaka was one of the prime movers behind the drafting and passage of the Nigeria’s National Health Bill, passed in February 2014. An influential member of the Senate Health Committee, he has long been a proponent of publicly provided primary health care in Nigeria and his involvement in the passage of this law marks just another of the Nigerian Senator’s achievements.
Senator Kaka represents Ogun East Senatorial District in the National Assembly of Nigeria. He was last elected on 9 April 2011, took office on 6 June 2011, and his current term ends on 5 June 2015.
The Senator did not always envision himself in politics. He was a passive political supporter from his teens up until he earned his Bachelor of Science in Agriculture in 1978. In 1980, he began his career with Livestock Feeds PLC (of which he ultimately became Director from 2004-2011). He also worked in the agricultural development sector for the Ogun State government. It was during this time that the Sen. Kaka’s passion for an egalitarian society was shaped and this motivated him to run for election to the National Assembly of Nigeria.
Sen. Kaka, who represented Nigeria at SIF’s Second Colloquium on Sustainable Immunization Financing in August 2013 and at other SIF events, recognizes the need for public vaccination financing
He and Senate Health Committee Chairman Sen. Dr. Ifeanyi Okowa convinced their fellow legislators of this need and were able to consolidate a critical mass of support to ensure the bill’s passage through both parliamentary chambers from 2012-2014.
Although the Bill mandates a public vaccine budget, Sen. Kaka cautions that approved immunization budgets are not always disbursed in their entirety. He and his committee members will be monitoring the situation. In his words, “immunization is a holistic and continuous exercise that cannot be half-heartedly executed.”
The Sabin SIF Program team is proud to recognize Sen. Kaka as our newest SIF champion.
On 21-23 July, 2014, the National Assembly of Cambodia and Sabin’s Sustainable Immunization Financing (SIF) Program co-sponsored the Asia Peer Review Workshop on Sustainable Immunization Financing in Phnom Penh, Cambodia. Delegations from six Asian countries gathered to exchange and evaluate each other’s institutional work in the area of public financing for immunization.
Fifty-five peers attended in total, of whom eighteen were delegates named by the sending institutions in the six countries. Representing the Parliament of Cambodia were thirteen senators, deputies and staff members. Representing the Cambodian government were nine officials from the Ministry of Health (MoH), Ministry of Economy and Finance (MoEF), and the National Development and Planning Agency (NDPA). The visiting delegations represented the parliaments and governments of Indonesia, Mongolia, Nepal, Sri Lanka and Vietnam. The workshop was facilitated by counterparts from the Cambodian National Assembly, WHO (Cambodia and Indonesia), UNICEF (Cambodia, Nepal and Indonesia) and the Sabin Vaccine Institute.
The workshop began with two rounds of presentations by each delegation. The presentations highlighted each country’s efforts in the areas of financing, budgeting, resource tracking for their national immunization programs and legislation to make financing for those programs sustainable. Each was followed by a round of small group work. In the second part, peers were asked to assess each other’s’ work using a standard peer review guide. The delegates then came together to discuss Cambodia’s draft immunization law.
The full workshop report can be obtained here.
The workshop provided an enriching learning experience for the peers, reported Sabin Senior Program Officers Devendra GNAWALI (Nepal) and Khongorzul Dari (Mongolia), who organized the event with colleagues from Cambodia’s National Assembly. Several of the delegates had participated in a similar peer review which Sabin sponsored in Dakar, Senegal in August 2013. This was the first Sabin-organized workshop to bring together all six Asian SIF countries.
Back in their respective countries, report GNAWALI and DARI, delegates have been quick to follow up the workshop with new activities aimed at securing sustainable immunization financing. In Nepal and Sri Lanka, reports GNAWALI, new immunization financing legislation is nearing parliamentary passage and is expected to soon be signed into law. To speed up the process, Cambodia is developing a ministerial decree which will accelerate ongoing development of their national immunization law. The other three countries already have such laws on their books. DARI reports that the Indonesian delegates are nevertheless reviewing theirs and are contemplating updates to strengthen financing and update other provisions such as support for the Indonesian Technical Advisory Group on Immunization (ITAGI). On the implementation side, DARI is advising Vietnam’s National Institute of Epidemiology and Health as it organizes another series of advocacy activities with provincial officials aimed at increasing subnational immunization financing and improving expenditure reporting. Mongolia, adds DARI, already has specific legislation, dating back to 2000, which established a national immunization trust fund. Other SIF countries contemplating such funds include Cameroon, Nepal and Uganda. On 5-7 October, Sabin arranged a peer exchange by peers from Uganda and Vietnam to Ulaanbaatar to study how the Mongolian Parliament fashioned that legislation and how well the government-managed fund has performed.
The next Sabin peer review workshop will take place on 4-6 December, in Kribi, Cameroon. Delegates from the six Francophone African SIF countries will attend.
The recent outbreak of Ebola Viral Disease (EVD) in West Africa started in Guinea in late 2013, and gradually spread to neighboring Liberia and Sierra Leone in early 2014. The initial response was tardy and inadequate, primarily because this was the first EVD outbreak in a region where health staff had no previous experience on how to control it. With an estimated 1 doctor per 10,000 people, a compromised health infrastructure and the absence of epidemic preparedness, Sierra Leone’s health sector was illequipped to respond to the rapidly expanding epidemic of this highly contagious and deadly disease. As more government resources and attention are redirected from vaccination programs to Ebola control, the risk of a vaccine-preventable disease (VPD) outbreak is increasing. Such an outbreak could be devastating and perhaps irreversible
Many health facilities have been converted into “Holding Centres”, where suspected cases are admitted until laboratory tests confirm or clear the patient for Ebola infection. In addition, citizens are not attending the unconverted health clinics for fear of contracting the disease. There is widespread mistrust of health personnel, who some citizens perceive as responsible for introducing and spreading the disease.
Health facility attendance for reproductive and child health services decreased by 25 percent, from 490,393 soon after the outbreak in May, to 368,529 in July. The following graphs (administrative data) depict the sharp drop in vaccine coverage levels for BCG, Penta3 and Fully Immunized Children (FIC) since the outbreak erupted in May 2014. Vaccine coverage rose in only one district, Koinadugu, which was the only Ebola-free district at the time of this report.
All maternal and child health services in Sierra Leone are at risk. The normal sector-wide budgeting process divides the MCH budget across both curative and preventive services like immunizations, health education, water and sanitation and growth monitoring. Within these competing priorities, a dedicated budget line was established for immunizations- the result of sustained advocacy work by Sabin SPO Clifford Kamara and his national counterparts. Sierra Leone is also one of eight SIF countries where routine immunization budgets increased from 2006-2013.
Now, with the EVD emergency, funding for all health programs, including immunizations, has decreased substantially. The immunization program received Le 1,069M (US$220,000) for the period January – July 2013 but just Le255M (US$53,125) for the same period in 2014- a 76 percent drop. The budget cut, coupled with the sharp decrease in vaccine coverage and citizens’ mistrust of the health services, pose a daunting challenge to Sierra Leone. Preserving the immunization program may be vital to stopping the epidemic. The WHO reports that an Ebola vaccine may be piloted in Sierra Leone. 12
The immunization program team, within the context of the Ebola awareness campaign, continues to communicate the benefits of immunization to communities, whilst carrying out EVD control measures. Kamara and his colleagues are focusing their advocacy efforts on Parliamentarians and government officials in the ministries of Finance and Health. A SIF-assisted parliamentary briefing on immunization financing is planned for December.
- 21-23 SIF and the Kingdom of Cambodia sponsored the Asian Peer Review Workshop on Sustainable Immunization Financing in Phnom Penh, Cambodia. Here, the six SIF Asian countries shared their best innovations in legislation and resource tracking and provided each other quality feedback.
- 23-25 SIF and the Gavi alliance co-sponsored a face-to-face meeting of the Immunization Financing and Sustainability Task Team (IFSTT) at Sabin headquarters in Washington D.C., United States. Partners presented their progress over the past year and developed strategies to strengthen synergy within the IFSTT.
- Also in July, the Nepalese government contributed an additional deposit of US$105,263 to the growing public-private immunization fund. The government had already pledged US$575,000 to initiate the fund.
- 12, 18, 28 August & 7 September, Nepal’s draft law was finalized in four multi-institutional working meetings convened by SIF SPO Devendra Gnawali. 22 September, the Minister of Law & Justice approved it to be presented by the MOHP before the Council of Ministers.
- 14 August, SIF SPO Alice Abou Nader updated the WHO/UNICEF Joint Reporting Form (JRF) template to include alert messages that appear when data is misreported. The innovation makes it impossible for countries to report erroneous financial data. The new template was ultimately approved and adopted.
- 17-24 August, SIF SPO Jonas Mbwangue held the SIF/UNICEF/WHO/MOH-sponsored GVAP/cMYP Workshop in Cameroon. GVAP objectives were inserted into the EPI work plan and country-level participants mapped a way forward in resource tracking, legislation, and financing.
- In August, SIF SPO Clifford Kamara joined the National Ebola Task Force of Sierra Leone. Here he has established a firm group of supporters who will ensure immunization financing is preserved.
- 14-18 September, SIF SPO Diana Kizza Mugenzi participated in the Kenya Immunization Financing Situational Analysis. Diana, UVIS, and partners resolved to focus on fast-tracking the passage of the health bill.
- 15 September, SPO Mbwangue hosted another cMYP/GVAP Workshop in Cameroon where costing mechanisms were added to the cMYP. The final cMYP was then ready to present at the next ICC meeting.
- 30 September, the Ugandan parliamentary health committee and their fellow MPs met to feedback on the draft bill. Two critical provisions were suggested by the fellow MPs.
- In September, the new Cambodian Secretary of State for Health began mobilizing his peers to develop an immunization sub-decree to support the draft law. He was motivated to this end from the suggestions received at the Phnom Penh workshop in July.
- Also in September, the DRC EPI team completed the SIF-generated immunization program flow chart for 2014, despite disbursement difficulties this year from the federal government.
Volume 6.2, August 2014
On 29 April 2014, Sri Lanka inched closer to a national immunization bill which will assure sustainable immunization financing. The occasion was a ceremony at the Bandaranaike Memorial International Conference Hall, in Colombo, in which Chief Epidemiologist Dr. Paba Palihawadana delivered the country’s new National Immunization Policy to the health minister, Hon. Maithripala Sirisena. Over 150 guests attended, including members of parliament Hon. Dr. Sudarshini Fernandopulle and Hon. Dr. Ramesh Pathirana; Chief Minister of the southern province Hon. Shan Vijayalal de Silva, and; Health Ministers of North Western and Central provinces Hon. D.B. Herath and Hon. Bandula Yalegama. Other Ministry of Health officials in attendance included Dr. Palitha Mahipala, Director General of Health Services, Dr. Sarath Amunugama, Deputy Director General of Public Health Services, Dr. Ananda, Consultant Epidemiologist and EPI team. They were joined by officials from the Ministries of Finance and Planning, Education and Justice, all of whom participated in formulating the policy. The event was widely covered by the print and electronic media, reported Sabin Senior Program Officer Devendra Gnawali, who also attended. Minister Sirisena recognized the members of the National Immunization Policy Development Subcommittee and thanked them for their contributions to the effort.
A necessary step in the legislative process, the draft policy, was formulated over a one-year period with input from the public and a range of non-government stakeholders. The policy states that the Federal Government will provide sufficient funding for timely procurement and supply of quality vaccines and their delivery. It provides for a separate budget line item for the national immunization program. Secondly, the policy states that provincial governments shall co-finance immunization delivery. Thirdly, mechanisms will be put into place to monitor the financial sustainability of the immunization program.
Minister Sirisena will next pass the policy document to the Council of Ministers. From there it will go to Parliament where a corresponding Act of Parliament will be generated, translating the policy into law.
On 6 May, Mongolia unveiled a new advocacy strategy to consolidate immunization financing. The setting was a sunny plaza in western Hovd District (aimag) where approximately two-hundred citizens gathered to commemorate Tax Day. The ceremony was opened by parliamentarian Hon. Battsogt Dogsom, who represents this district in Mongolia’s Grand Hural, accompanied by Mike McQuestion, Director Sustainable Immunization Financing Program, and Director of the District Tax Department Ms. Khandtsetseg Galindev. Ms. Galindev called out the names of artisans and entrepreneurs, who received their plaques on stage, and commemorated them for the taxes they had paid. The ceremony continued with singing and dancing by children dressed in traditional attire.
The program then shifted to sustainable immunization financing. Leaflets were distributed to the crowd with a photo of a child being immunized and a list of bullet points about immunization. The leaflets included general information on immunization, in addition to financial data on local government expenditures for immunization and other health services in Hovd District the previous year.
In a briefing of health workers later that day, discussions focused on resource tracking at the local level and advocacy activities for sustainable immunization financing. During the briefing, district health workers were given a more detailed analysis of local health expenditures. Hon. Dogsom emphasized the fact that it would be very useful to have detailed budget and finance data on health to leverage funding for following year budgets. Dr. Enkhamgalan Agvaandash, District Health Officer, agreed, adding that she will make it a priority to include this type of financial reporting and analysis in future meetings.
Another important topic that was covered at the briefing was that of fuel and transportation costs needed for health officials to travel to households for vaccinations. Local vaccinators and health officers worked together to come up with ideas to make the programs more efficient.
Last year, Dr. Khongorzul Dari, Sabin Senior Program Officer, along with counterparts at the General Tax Department and Ministry of Health, developed a model to demonstrate how the government uses tax revenue for public health services. This work produced a national report, which was well received by government officials and the public. The next step is to work with the country’s remaining 22 districts, with the goal of delivering financial data on immunization.
On May 20, officials from the Ministry of Health, Ministry of Finance, National Institute of Hygiene and Epidemiology (NIHE), and provincial-level officials from the People's Committees Health Centers and Finance Departments, gathered in Vietnam’s Hai Duong province to discuss sustainable immunization financing at the provincial level.
Hai Duong province has a population of 1.7 million, encompassing 12 districts and 265 communes. At each level, there is a health committee responsible for immunization and other health programs. The budget for immunization is currently 680M VND, higher than other provinces.
Prof. Duong Nhu Tran, Deputy Director of NIHE, opened the briefing by welcoming all of the participants. He highlighted the importance of this sub-regional briefing, seeing that it marked the first time discussions were held regarding the importance of effective spending for immunization at the provincial and district levels. Prof. Duong commented on increasing contributions from provincial governments on immunization financing. He noted that in collaboration with the Sabin Vaccine Institute, NIHE has already demonstrated progress towards sustainable financing. In 2014, all healthrelated budgets, including immunization, were reduced by 40 percent as a result of a downturn in the economy. However, NIHE was able to increase its budget for immunization by closely working with the National Assembly.
Following, Dr. An, Deputy Director of Finance in Vietnam’s Ministry of Health, highlighted the success of the EPI program and its long history of high performance in sustainable financing practices. Dr. An challenged the Hai Duong province to step up its financial commitment to the program. He stated that the national government is committed to achieving sustainable financing; however, it still needs provincial support to reach the overall goals of the program.
Dr. Bui Huy Njanh, Director of the Hai Duong Provincial Center of Medicine, discussed provincial financing practices which was later followed by briefings led by district and commune officials.
This briefing emphasized the importance of sustainable immunization financing and resource tracking to local leaders at the subnational level. In light of the goals set forth by Dr. Khongorzul Dari, Senior Program Officer at the Sabin Vaccine Institute, a series of subnational briefings are planned in Vietnam.
On 7-9 April 2014, in Kinshasa, DRC, health officials sought to strengthen their immunization programs by scrutinizing each others’ financial reports. The WHO/UNICEF- organized peer review meeting drew around sixty participants representing ten Central African countries. Such peer review meetings, which date back to 2007 in this subregion, usually focus on preparing new grant proposals. This time, participants assessed how well they and their peers are tracking and reporting what their governments are spending on immunization.
Countries report this information annually through the WHO/UNICEF Joint Reporting Form for immunization (JRF). Getting the numbers right is increasingly important because government expenditures comprise the key indicator of country ownership in the Decade of Vaccines Global Vaccine Action Plan Monitoring and Evaluation/ Accountability Framework.
The peer review process was straightforward. First the delegations presented their figures, describing how they obtained and aggregated the data. Next they scrutinized each others’ reports, identifying logical inconsistent and missing values. Delegates corrected their reports and passed them to the WHO and UNICEF facilitators who later submitted them to the JRF system. The countries will have one more look at their reports before they become official.
Among the workshop facilitators were Remy Mwamba (UNICEF Regional Office for West and Central Africa, Dakar), Alexi Satoulou (WHO/AFRO Inter-country Support Team for West and Central Africa, Ouagadougou) and Helene Mambu-Ma-Disu (Sabin Senior Program Officer, Kinshasa). All three had attended the Central African EPI managers meeting in Bujumbura, Burundi last February where they presented detailed feedback reports to the countries highlighting the quality and completeness of their past JRF expenditure reports [see related article in IFN 6(1)].
Tracking resources at program level is no easy task. In a WHO-led survey earlier this year, 55 percent of respondents stated they had difficulties accessing any immunization program expenditure data. Most of what governments spend on immunization is in the form of shared health system expenditures for items such as salaries, transportation and maintenance. Different approaches are being developed to capture and include them along with the more easily observed direct program expenditures.
“The added attention to expenditure reporting is already paying off,” comments Sabin Senior Program Officer Alice Abou Nader, who regularly works with the JRF data. Nader and Mwamba developed the logical rules the Kinshasa participants used to clean their data. “The 2013 results show the Central African countries increased their immunization spending by 30 percent. We did not see an increase that big in any of the other subregions,” added Nader.
On 21 May, ministers of health took up the Global Vaccine Action Plan (GVAP) at the 67th World Health Assembly in Geneva. Ministers from 54 WHO Member Countries spoke about their countries’ immunization programs and what they are doing to achieve the six GVAP Strategic Objectives. Among them were ministers from six SIF countries: Congo Republic, Ethiopia, Indonesia, Kenya, Mongolia and Vietnam. Discussion focused on the 2013 GVAP Monitoring, Evaluation and Accountability Report, which was prepared for the session by the WHO Secretariat. Among other issues, the ministers recognized the need for countries to increase their immunization investments in order to achieve country ownership. The GVAP provides for similar monitoring and feedback sessions in each World Health Assembly through 2020. Read more on the 67th WHA GVAP session here.
In the Democratic Republic of Congo, the innovative Parliamentary Support Network for Immunization (Réseau des Parlementaires congolais pour l’Appui à la Vaccination) has expanded further with the recruitment of parliamentarians in two more provinces. The action took place on 4-11 May 2014 when four MPs from the National Assembly visited the provincial capitals Mbuji-Mayi, Kasai-Oriental and Kananga, Kasai-Occidental, to confer with local authorities about immunization financing and to challenge their provincial MP counterparts to get involved. The Réseau emissaries included President Honorable Gregoire LUSENGE, Rapporteur Honorable Célestin BONDOMISO and Members Honorable Louis KASWENDE and Honorable MUBIKAYI, who represents Kananga City. Accompanying the MPs were national immunization program counterparts Docteur Guillaume NGOIE MWAMBA, Docteur Jacky MATONDO and Monsieur Benjamin MATATA. Sabin Senior Program Officer Helene MAMBU-MA-DISU joined the mission and sent this report.
The visit to the Kasais followed a similar Réseau mission to Bas-Congo Province last December [see related story, IFN, volume 5 issue 4]. Team leader and Réseau President Hon. Gregoire LUSENGE has vowed to carry the crusade to the country’s remaining eight provinces over the next two years. The federal Ministry of Health has added a line item to its immunization budget to co-finance the Réseau’s advocacy work.
The MPs make two simple but compelling arguments. If a country does not fully finance its own immunization program, it may not claim sovereignty over its children. Secondly, immunization will save each province money by reducing hospital care costs. The MPs are urging each provincial government to create a separate budget line item for immunization delivery and to increase that budget every year as needed.
The mission kicked off on 5 May, in Mbuji-Mayi, where the MPs were briefed by the Provincial Health Department and explained the purpose of their visit. “Better late than never,” remarked the Provincial Health Minister. The MPs then proceeded to the Kasai-Oriental Provincial Assembly where they were warmly received by the Assembly President and the President of the Health Commission, Honorable NTEMBO NYERERE. That afternoon, the MPs joined a working session with the provincial immunization program team. The next day, the Réseau emissaries met with students at l’Institut Supérieur des Techniques Médicales, the provincial governor and a civil society association active in immunization. On 7 May, they met with the full Provincial Assembly, accompanied by the provincial health minister. The result: All Provincial Assembly members pledged to join the Réseau. Their final visit that day was to the mayor of Mbuji-Mayi and his council of advisors (Bourgmestres des Communes).
The team then proceeded to neighboring Kasai Occidental Province for a second round of intense advocacy work. Again the authorities agreed to create an immunization delivery budget line item and a new batch of parliamentary MPs joined the Réseau.
Over the past eight years WHO and UNICEF have gathered performance indicators that evaluate national immunization programs through the Joint Reporting Form (JRF). Government expenditures on routine immunization, JRF Indicator 6500, received particular attention at this year’s 67th World Health Assembly session, where health ministers reviewed the data [see related story, this issue]. Country ownership is one of the six GVAP guiding principles and can be measured by a country’s immunization expenditures. Dividing JRF Indicator 6500 by the total amount spent (from all sources) on the program (Indicator 6510) yields the percent of contributions made by the government.
The quality, consistency, and validity of the financing JRF data are also important. Recently Sabin developed a series of logical statements that check for data inconsistencies. Only 6 percent (12/193) of Member Countries have completely and consistently reported their government expenditures during 2006-13. Overall, reporting completeness has been decreasing for all but one financial indicator. On a positive note, the African Region countries became more complete reporters from 2012-13 for all six JRF financial indicators.
As a group, the 18 SIF countries improved their reporting as well. From 2012-13 the number of countries reporting Indicator 6500 increased by 36 percent. The magnitude of their government routine immunization expenditures also increased by 8 percent. The chart ranks the SIF countries according to their reported government expenditures per surviving infant. From 2011-13 Mongolia is the only country that was within the top echelon for JRF Indicator 6500. Notably, the ranks change from year to year, reflecting inconsistent government expenditures and/or inconsistent reporting. Reporting completeness has also varied. Sri Lanka, for example, has missing data for four out of the six years, making it hard to follow the country’s financial trend. Yet for years it did report, Sri Lanka consistently ranks high. Underreporting obscures Sri Lanka’s progress towards sustainable immunization financing.
The graph below shows average government routine immunization contributions for those SIF and other GAVI eligible countries that reported data. From 2008-2012, both groups follow similar trends. In 2013, the average government contribution of SIF countries decreased by 20 percent. This could be due to a number of factors. It could be a true decrease and/or a reporting artifact.
Ciro devoted his life to help others. His work was a well spring of commitment in which others could do their best. He didn't judge. He welcomed good will and drive to help in any way that it came. Politics came and went. Egos and insecurities sometimes held sway. Ciro worked in an existence that sustained and surpassed it. He worked, sometimes among adventure but often in tedium, and with those who had far less life experience, always with respect, always with a genuine drive and intent, simply to help others, and to help others to do the same. To work with Ciro was a celebration of goodness and progress.
-Marcia Rock, MPH (Program Officer, PolioPlus Program, Rotary Foundation, 1987-92)
We are pleased to welcome Dr. Eka Paatashvili to the SIF team. Based in Tbilisi, Georgia, Eka will be the Senior Program Officer responsible for SIF activities in Armenia, Georgia, Moldova and Uzbekistan. A physician by training, Eka worked in the Georgia Ministry of Labor, Health and Social Affairs in the areas of program management and procurement, finance and budget reform, and regulatory affairs. From there she earned an Executive Master of Public Administration degree from Syracuse University. Her research at Syracuse compared the Georgia and United States health care systems and developed effective paradigms of collaborative governance. “I am ready for another challenge- advising four GAVI-graduating countries on consolidating ownership of their national immunization programs”, says Eka, reflecting on her new role. She officially assumed her duties on 1 July
We are pleased to welcome Mr. Andrew Carlson to the SIF team. A Connecticut native and 2013 graduate of Lawrence University in Appleton, WI, Andrew has been working for six months as the Africa Region Intern with the Global Network for Neglected Tropical Diseases (NTDs), another of Sabin’s initiatives. In this capacity, Andrew helped shape the Global Network’s advocacy strategy to Nigeria. Before his time at Sabin, he worked with the Monitoring & Evaluation team at Search for Common Ground, where he wrote the first implementation guide on using music as a peace-promoting tool in post-conflict communities. Andrew is a fluent French speaker and recently translated a forthcoming book on French philosophy from French to English.
- April 17, the Council of Ministers of Nepal approved the immunization draft law. The Minister of Health subsequently sent the bill to the Ministry of Law and Justice for final review.
- 21 April, SPO Jonas Mbwangue and Government of Cameroon counterparts reviewed that country’s proposed Health Support Fund, which will cover immunization financing. The strategy is for the Minister of Health to prepare an act establishing it as a “Special Allocation Fund” to be managed by the Ministry of Finance and incorporated into the financial law every year.
- 24-25 April, Dr. Mambu-Ma-Disu participated in a WHO/UNICEF/GAVI/SIF mission to Republic of Congo (Brazzaville) to conduct a financial review and make recommendations on the country’s chronic immunization financing challenges.
- On 10-17 May, SPO Dr. Mambu-Ma-Disu participated in a joint WHO/UNICEF/GAVI/SIF mission to Madagascar. A financial review was conducted and recommendations were made to address the country’s chronic immunization financing challenges.
- In May, the Liberian senate endorsed a proposed national immunization bill.
- Also in May, a team from the Cambodian National Ministry of Health finalized a draft immunization law. The bill will next be shared with various stakeholders.
- On 9 June, SPO Diana Kizza Mugenzi and SIF Director Mike McQuestion met national counterparts in Nairobi, Kenya to discuss the country’s pending vaccine legislation.
- On 11-13 June, SIF Program Director Mike McQuestion facilitated a three-day WHO/GAVI meeting in Hammamet, Tunisia. Among the seven participating countries were three SIF countries: Kenya, Madagascar and Sierra Leone. The countries developed work plans to increase their immunization budgets.
- In June, SIF SPO Alice Abou Nader analyzed recently released WHO/UNICEF joint Reporting Form financial data from 73 GAVI-eligible countries. Results showed that governments increased their investments from US$6 per surviving infant in 2012 to $7 in 2013.
Volume 6.1, April 2014
Amidst the political turmoil of the past two years, the Government of Nepal has managed to draft a national immunization law with accompanying regulations. The centerpiece of the law is an innovative public-private national immunization fund. Officials from the Ministry of Health and Population and Ministry of Finance produced the first draft of the law in early 2012. The fund aims to increase and stabilize financing for the country’s routine immunization program. A high performer, Nepal’s immunization program consistently reaches around 90 percent of the country’s roughly 670,000 newborns. High vaccine coverage is one reason Nepal is on track to achieve MDG4. The challenge now is country ownership. According to WHO estimates, the Nepali Government financed about 45% of the program’s 2012 budget. In coming years, immunization program costs will rise to around US$30m annually when all ten WHO-recommended vaccines come into routine use. With gross national income at around $700 per capita, those costs will not likely be met by government revenues alone.
The ownership strategy is to partner with the country’s burgeoning private sector. Early backers included members of the country’s hundreds of Rotary and Lions clubs, who began raising seed funds in 2012. [See related story, SIF Summary Digest, Vol 5, No 1.] A number of private firms have since expressed interest in contributing to the fund. “The new law will give them tax breaks for their contributions. Government will match the private funds with public funds”, explained Kathmandubased Sabin Senior Program Officer Dr. Devendra Gnawali.
Before the law could be passed, Nepal’s Parliament was dissolved in mid-2012 for failing to write a new constitution. A caretaker government held power until national elections took place last November. It wasn’t until 10 February 2014 that Parliament elected a new Prime Minister. In the interim, reports Gnawali, government counterparts have been busy writing detailed regulations to match the provisions of the draft law.
On the government side, the key player has been the Ministry of Health and Population. Dr. Shyam Raj Upreti, Director of the Child Health Division, and Mr. Komal Acharya, Chief of the Legal Section, have led most of the technical work. Former health minister Hon. Vidyadhar Mallik pushed the immunization fund regulation through to the Council of Ministers last October. In January, legal approval for the bill was granted by the Council of Ministers and it was published in the official Nepal Gazette. On 7 February, the immunization fund regulation was announced in a press conference. Now fully vetted, the bill will be on the Parliament’s agenda, thanks in part to the efforts of Mr. Birendra Bahadur Karki, Secretary of Women, Children and Social Welfare Committee. An interministerial committee, with representatives from WHO, UNICEF and Sabin, is finishing terms of reference for the National Immunization Fund Management Committee.
An analysis of government immunization program expenditures in lower and lower middle income countries 2006–12. Abou Nader, Alice, Ciro de Quadros, Claudio Politi and Michael McQuestion. Health Policy and Planning 2014; 1-8. doi:10.1093/heapol/czu002.
In 2012, ninety-four WHO Member Countries endorsed the Decade of Vaccines Global Vaccine Action Plan. In it, the countries resolve to achieve six strategic objectives by 2020. A guiding principle in the plan is country ownership. One implication of country ownership is that countries will be fully financing their routine immunization programs by the end of the decade. Recent research estimates the cost is now at least US$60 per surviving infant. Though only a fraction of the roughly 120 million infants born annually in the developing world are currently receiving them, by 2020, the GVAP states, at least 90% of children will be receiving both the traditional and newer, costlier pneumococcal, rotavirus and human papillomavirus vaccines. Given their rapid economic growth rates, developing countries should be able to meet these future costs. In this paper, the authors analyze officially reported government immunization expenditures during 2006-12 and project how much more the countries will need to invest in order to reach that $60 per infant objective. The expenditure data come from the WHO/UNICEF Joint Reporting Form, which annually collects a range of immunization indicators. A longitudinal time series model is used in which government expenditures from 68 lower and lower middle (GAVI-eligible) countries are regressed on gross national income per capita, child mortality levels, immunization program performance, corruption control efforts, geographical region and an indicator for underreporting. Results show the expenditures increased with GNI. Expressed as an elasticity, the countries spent approximately $6.32 on immunization for every $100 in GNI increase from 2006 to 2012. Projecting forward and assuming continued annual GNI growth rates of 10.65%, the authors find the countries could be spending $60 per infant by 2020, provided they find ways to increase their national immunization investment functions fourfold. Put differently, governments will need to capture and “ring fence” four times more of their future revenues for their immunization programs.
As the Decade of Vaccines proceeds, immunization expenditures are rising everywhere. The latest studies estimate the cost of fully immunizing a child with all ten WHO-recommended vaccines is now in the US$55-75 range. Countries report their government immunization program expenditures annually though the WHO/UNICEF Joint Reporting Form (JRF). That information is increasingly valuable, both to managers who must account for ever bigger budgets and to health ministers who must report those expenditures annually through the Global Vaccine Action Plan (GVAP) Monitoring and Evaluation/Accountability Framework. For the Sabin SIF Program, the JRF expenditure indicators are the best measure of whether or not country immunization budgets are increasing due to the advocacy and legislative work it facilitates.
Over the past year, Sabin, WHO and UNICEF have been collaborating in an in-depth analysis of the JRF financial reports. A paper was published using the JRF data [see related article this issue]. Most recently, the data were used to prepare country-specific “report cards” detailing the completeness and quality of each country’s JRF financial reporting from 2006-2012. These feedback reports were presented to African managers in this year’s round of EPI managers meetings. Sabin, WHO and UNICEF counterparts attended the meetings and provided these observations.
Immunization team leaders from ten Central African countries and external immunization partner counterparts held their annual meeting this year on 24-26 February in Bujumbura, Burundi, under the auspices of the WHO/AFRO Inter-Country Support Team for Central Africa. The second day included a one-hour plenary session on immunization financing. Mr. Remy Mwamba, Health Officer and Data Manager of the UNICEF West and Central African Regional Office in Dakar, began the session with a presentation on recent immunization financing trends. According to their annual JRF reports, the 46 AFRO Member Countries spent more per infant on routine immunization in 2011 (US$19) than they did in 2012 ($15), a 21% drop (see table below). For the subset of reporting Central African countries, government contributions decreased by 5%, from $20 to $19. Focusing on the quality of the JRF reports, Mwamba showed how the proportion of countries reporting their expenditures dropped from 90% in 2011 to 80% in 2012. The financial data were also tested for consistency. Here there was some deterioration. In 2011, just one government of 9 (11%) reported spending more on vaccines than it did in total for routine immunization (a logical inconsistency). That proportion rose to 25% in 2012.
A lively panel discussion followed in which the ten EPI managers described how they actually finance and manage their program budgets. Treasuries often fail to disburse the full EPI budgets, remarked some managers. Countries have devised a range of solutions to this problem. In Chad, a special immunization fund was created and is directly controlled by the President. In DRC, Cameroon and Republic of Congo (Brazzaville), legislation now in preparation will “ring-fence” immunization budgets. Despite these and other problems, the managers felt, their governments are actually spending more than they are reporting to the JRF. All acknowledged the need to solve their financial reporting problems. Suggestions included harmonizing the various tools and reporting formats currently in use. More importantly, the managers agreed to search for new ways to increase their budgets. One manager suggested using the previous year’s expenditures as the basis for the coming year’s budget (empirical budgeting). Another favored an advocacy approach, saying she would report routine immunization expenditures to her minister each year before the WHO Regional Working Group Meeting so that progress toward the 2020 GVAP country ownership goal can be reported.
The second of the three sub-regional EPI managers meetings took place in Ouagadougou, Burkina Faso on 3-5 March. In attendance were over 100 managers and external partners active in the subregion’s 17 countries. In a plenary session on Day Three, WHO/AFRO/IST/WCA Health Economist Mr. Alexis Satoulou set the financing theme, presenting results from recent immunization costing studies in three West African countries. Sabin Senior Program Officer Mr. Jonas Mbwangue followed with a presentation of recent JRF financing data for the sub-region. As in the Central African meeting, each manager was given a “report card” summarizing that country’s JRF financial reports over 2006-12.
In his presentation, Mbwangue pointed out the observed 60% increase in government routine immunization expenditures in the sub-region from 2011-12. Expenditures per infant rose from $5 in 2011 to $8 in 2012. The observed increase, however, could be due to reporting errors. Among the three AFRO sub-regions, reporting frequency was lowest in West Africa. Fewer than half the countries (8/17) reported any government expenditures at all in 2011 and 2012. The problem appears to be worsening. In previous years, government expenditure reporting had averaged 58%. Consistency of reporting also increased. Governments reported spending more on vaccines than they did in total for routine immunization 37% of the time in 2011 and just 12% in 2012. Participants then worked in small groups, one of which focused on vaccine and immunization financing.
Both the costing studies and the JRF analyses point to increasing dependency of the West African countries on external financing for their routine immunization programs. Costs are far higher than reported expenditures. The managers discussed ways to solve this problem. The first step, they agreed, is to improve their day-to-day immunization budget management. Mali’s EPI manager described how efforts to harmonize the country’s comprehensive Multi-Year Plan (cMYP) with the GVAP strategic objectives are leading to the development of a real-time routine immunization budget management system. A second step, agreed the managers, is to develop innovative financing mechanisms. Burkina Faso, for example, makes strong, evidence-based investment cases for its routine immunization program each year. These have helped convince the Head of State to designate a ring-fenced, perennial immunization fund. The managers thanked Satoulou and Mbwangue for their presentations and called for immediate efforts to develop new resource tracking practices and apply them in their JRF reporting.
East and Southern Africa
This year’s meeting for East and Southern African countries took place on March 10-12th in Harare, Zimbabwe. In attendance were over 150 high officials from ministries of health and multiple partner agencies from all 19 sub-regional countries. In a parallel session on Day One, Dr. Amos Petu, Health Economist with the Harare-based WHO Inter-Country Support Team Office, presented a review of immunization financing trends in the subregion using the JRF financial indicators. Eleven immunization managers attended the session. Petu opened the presentation with an overview of the GVAP, emphasizing the important GVAP guiding principles of country ownership and sustainability. He then presented an analysis of reported (JRF) government routine immunization expenditures. Governments in the sub-region reported a 36% decrease in their routine immunization expendituresfrom $28 per infant in 2011 to $18 in 2012. Petu went on to show that reporting consistency (vaccine expenditures less than total expenditures) also fell among these countries, from 85% to 75%. As in the other sub-regions, JRF financial “report cards” were given to each manager.
In a Q&A session, the managers acknowledged their countries need to change course if they are to achieve country ownership, sustainability and the ambitious GVAP 2020 objectives. They discussed how they can improve their financial reporting. Being able to track the expenditures in real time and ensure funds destined for immunization are correctly allocated to the programs were the two competencies they felt to be most important. Managers should be regularly collecting and analyzing financial data, they felt, just as they now treat their vaccine coverage and disease surveillance data. The managers urged the external partners to work with them to build their resource tracking, expenditure analysis and financial reporting capacities.
Thanks to the generous support of the GAVI Alliance and the recruitment efforts of the IAIM ad hoc Governing Council, more than 100 immunization professionals – including immunization managers and health workers – have joined the association to date. All members have access to the IAIM network and benefits. These include the bi-lingual (English and French) IAIM website, the IAIM Membership Directory, invitations to future meetings, information on vaccines and diseases and daily news feeds on events and information regarding the world of immunization and vaccines.
Two premiere IAIM benefits for members who are current immunization managers include the Peer-to-Peer Exchange Program and the Training Scholarship Program. The Peer-to-Peer Exchange Program provides the opportunity for managers who would like to advance their management skills to visit a manager in another country to learn from that program's successes and challenges. The Training Scholarship Program provides current immunization managers with the opportunity to take a training or course in a management-related topic to improve their management and leadership skills.
Applications for these programs are due in mid-May.
Don’t miss your opportunity. Join the IAIM movement here: www.iaimanagers.org.
The IAIM was launched in 2013 with generous funding from the BMGF.
- January 7th , Phnom Penh, Cambodia: Ministry of Health writes 1st draft of national immunization law
- January 20-25th, Colombo, Sri Lanka: Sabin SPO Devendra Gnawali confers with national counterparts
- January, Kathmandu, Nepal: Immunization Fund Regulations published in Nepal Gazette
- January, Washington, DC: Sabin receives a second GAVI grant to extend the SIF Program to Armenia, Georgia, Moldova, Uzbekistan
- February 6th, Kampala, Uganda: Sabin Program Officer Diane Coraggio attends ProVac briefing on rotavirus vaccine cost-effectiveness
- February 3-5th, Copenhagen, Denmark: SIF Director Mike McQuestion represents Sabin at GAVI IF&STT meeting
- February 7th Kathmandu, Nepal: Ministry of Health and Population organizes a program for dissemination of "National Immunization Fund Regulation 2014”
- February 10-13th, Monrovia, Liberia: Sabin SPO Clifford Kamara confers with counterparts on pending vaccine legislation and EPI budget
- February 12th, Kampala, Uganda: Ministry of Finance issues certificate of financial approval for National Immunization Law 2013
- February 17-21st, Phnom Penh, Cambodia: Sabin SPO Devendra Gnawali and national and external counterparts discuss vaccine legislation and plan a June parliamentary briefing
- February 24-27th, Bujumbura, Burundi: Sabin SPOs Jonas Mbwangue and Helene Mambu-Ma-Disu, accompanied by DRC peer exchangers Honorable Louis KASWENDE BATWANINI (National Assembly) and Mr. Benjamin MATATA (Ministry of Health), represent SIF at the WHO/IST/CA EPI managers meeting
- February 28th - March 1st, Ouagadougou, Burkina Faso: Sabin SPOs Clifford Kamara and Jonas Mbwangue represent SIF in WHO/IST/WCA routine immunization costing workshop
- March 3-5th Ouagadougou, Burkina Faso: Sabin SPOs Clifford Kamara and Jonas Mbwangue represent SIF in WHO/IST/WA EPI managers meeting
- March 10-12th, Harare, Zimbabwe: Sabin SIF SPO Helene Mambu-Ma-Disu represents SIF at WHO/IST/ESA EPI managers meeting
- March 20th, Washington, DC: First International Association of Immunization Managers (IAIM) webinar
- March 25-26th, Sharm-el-Sheikh, Egypt: SIF-prepared country JRF financial reporting feedback reports are distributed in EMRO Regional Working Group meeting