Immunization Financing News | Volume 7.1, April 2015
In this Issue
A new legislative strategy to assure sustainable immunization financing is coming into focus in Cameroon. Originally conceived in February, 2012 as an immunization-only, ring-fenced fund, the proposal was later altered at the request of the Council of Ministers to encompass financing for all communicable diseases. [See related stories, Immunization Financing News 4.1, pg. 4 and 4.2, pg. 3].
The general health support fund proposal soon proved unwieldy. “…the idea of a more targeted fund caught on with other Ministry of Public Health (MOPH) program managers. Now we are contemplating a fund to finance only immunization and antiretroviral (ARV) drugs as the Ministry’s priority health programs”, Sabin SIF Senior Program Officer Mr. Jonas Mbwangue observed in July 2013. On the advice of the Minister of Finance, Minister of Health H.E. Andre Mama Fouda charged an Inter-ministerial committee he had created earlier with establishing the Health Support Fund. The Fund will be created as a “Special Allocation Account” (SAA) and legislation is being drafted to back it. [See related story, Immunization Financing News 5.3, p. 11]. The Inter-ministerial Committee began the task in November 2014. On 27 February, the Committee met to plan and frame the Terms of Reference for its work. Mr. Mbwangue and Sabin SIF Program Coordinator Mr. Andrew Carlson attended the meeting and sent this report.
Among the participants were MOPH Deputy Director of Cooperation Dr. Engelbert Manga and twenty other Committee members, including EPI Manager Dr. Marie Kobela, MP Hon. Gaston Komba, Ministry of Finance representative Mr. Effila, and MOPH HIV/AIDs Program Manager Dr. Elat. Other observers included two representatives from the Clinton Health Access Initiative, Mr. Divine and Ms. Alice Raymond, along with WHO & UNICEF counterparts.
EPI Manager Dr. Marie Kobela opened the discussion by pointing out the need for the Health Support Fund to be a Special Allocation Account. With its rapidly growing economy, Cameroon will soon become ineligible for most foreign aid programs. There is no choice but to find sustainable domestic financing. Committee members felt it would be beneficial to organize a study tour to one or more countries where similar funds and supporting legislation are in place. One proposal was Costa Rica, whose robust immunization law the Committee members had studied. A second proposed study tour country was neighboring Gabon, where a telecom tax finances a similar national HIV fund. Hon. Komba added that only highperforming countries should be studied if the MPs on those visits are to commit fully to the cause.
In other business, the Committee resolved to extend the deadline for submitting the draft HIV/immunization law to the National Assembly for a vote from 30 April to 30 November 2015. The added time will be needed to arrange the study tours and revise the proposed fund accordingly.
Eleven months into the Ebola outbreak, Liberia’s health system is in tumult. Advocacy work on immunization financing has been shifted to the back burner, and all SIF country peers and international partners are hard at work organizing campaigns to forestall predicted vaccinepreventable disease outbreaks. The situation in Liberia resembles that of neighboring Sierra Leone. [See Immunization Financing News 6.3, pp. 5-6]. As Ebola cases recede, reports Sabin Senior Program Officer Cliff Kamara, attention can again be refocused on immunization financing.
On the eve of the Ebola outbreak, Liberian government and parliamentary counterparts were working on two promising sustainable immunization financing advocacy strategies: organizing a Parliamentary Forum on Immunization and writing a national immunization bill.
The Parliamentary Forum on Immunization was motivated by a SIF-sponsored subnational briefing held in Bassa County on the 15 June 2012. Legislators attending that meeting pledged to oversee the budget, planning and expenditure monitoring for the national immunization program. Representative and SIF peer exchanger Hon. William Dakel was elected to lead the new Forum, which would cross parliamentary chambers and party lines. Its purpose: to accomplish the Bassa goals and to track its disbursement and health impacts. Another influential legislator, Hon. Dr. Peter Sonpon Coleman and his senatorial colleagues had already convinced the government to increase its 2012 immunization budget request. In June 2013, Hon. Coleman, Hon. Dakel and Hon. Johnson Toe Chea recruited ten more legislators to form the Parliamentary Forum on Immunization. The Forum met regularly until the Ebola outbreak.
Work on new immunization legislation in Liberia began in mid-2012. EPI Manager Ms. Mary Momolu agreed to lead the process. She identified a legal expert to conduct a legislative review and determine the appropriate language for the draft law. Members of the Parliamentary Forum began drafting the bill in March 2013 and finished in June 2013. Both houses of congress discussed it that following July and October. The Senate approved the law in May 2014 and sent it to the House for its approval.
The legislative work came to a screeching halt as Ebola cases mounted.
During his visit to Monrovia, on 12-17 February, Kamara noted that the Ebola epidemic is nearly under control. The Ministry of Health & Social Welfare, in coordination with WHO and other partners, is drawing up post-Ebola recovery plans. Catching up with Hon. Dakel, Hon. Chea, and Hon. Coleman, and Deputy EPI Manager Adolphus Clarke, Kamara learned that his counterparts are ready to continue their work. Kamara was asked to help them organize an inter-institutional briefing on immunization and immunization financing proposed for mid-April 2015. “There is so much to do”, comments Kamara. The line items for vaccine purchase and Gavi co-payments disappeared from the 2015 health budget. Vaccinations were stopped for most of the past year and large-scale measles outbreaks are thought to be imminent. Kamara has proposed a peer exchange with neighbors Nigeria and Sierra Leone to share recovery and legislative strategies.
Many citizens associate the Ebola outbreak with the health system. Their fear of health services extends to immunization. The Liberian EPI team views this vaccine hesitancy as their most pressing obstacle. The Ministry has requested SIF’s assistance in orchestrating a largescale vaccine safety social mobilization drive at the subnational level later this year.
Following the Sabin-organized Asia Peer Review Workshop on Sustainable Immunization Financing, which took place on 21-23 July, 2014 in Phnom Penh, Cambodia, the Cambodian authorities began reorienting their immunization legislative strategy. Instead of leading with a new, freestanding law, their new strategy is to draft a faster moving ministerial sub-decree. A comprehensive law would follow later. On 21-23 January, Sabin Senior Program Officer Dr. Devendra Gnawali, accompanied by Mr. Babu Kaji Baniya, Chief of Legal Section of the Ministry of Health and Population of Nepal, traveled to Phnom Penh to review the new sub-decree strategy with Cambodian counterparts.
Such legal cooperation between the two countries dates back to the SIF-organized Fourth Asian Sub-Regional Symposium, held in Phnom Penh on 4-5 July, 2012. Five of the six participating countries had existing immunization laws or new laws under development; only Cambodia did not. [See related story, Immunization Financing News 4.3, pp. 1-2]. By October 2013, the Deputy Director General of the Cambodian Ministry of Health Prof. Sann Chan Soeung had encouraged MOH Legal Department Officer Mr. Hok Khiev to draft an immunization bill. Following Nepal’s example, Prof. Soeung suggested that representatives from the National Immunization Program and the Ministry of Economy & Finance staff the legislative team.
In the July 2014 workshop, Mr. Hok Khiev and MOH Legal Department Deputy Director Dr. Koam Sinoun presented the provisions of the draft Cambodian law: mandatory & universal vaccine uptake, public financing, tax exemptions for domestic donors, and penalties for non-vaccination. They received feedback from their Nepali, Sri Lankan, Mongolian, Vietnamese and Indonesian peers. [See peer review report here, pp. 10- 11]. Though considered comprehensive and well written, actually getting the law through the approval process will be time-consuming. A ministerial sub-decree, in contrast, can be approved straightaway.
Mr. Kaji Baniya expressed admiration for the inclusiveness of the Cambodian legislative work and the way it streamlined input from a wide range of stakeholders into the draft sub-decree. Dr. Gnawali noted that the sub-decree would insulate the government’s vaccine budget from political, economic, or other shocks, ensuring continuous vaccine financing.
Drawing from Nepal’s experience, Mr. Baniya encouraged the Cambodians to consider inserting an even stronger provision establishing a National Immunization Fund, to be seeded by revenue earmarks and domestic & foreign contributions.
The revised immunization sub-decree is currently under consideration by the Cambodian government and parliament.
On 12-14 March, twenty-five members of Uganda’s National Assembly Health Committee met to study and revise the pending National Immunization Bill so that it will be ready for its second reading before all members of parliament later this year. Assisting the committee members were five parliamentary health committee clerks, including the legal and economic clerks/experts, counterparts from the Ministry of Health, civil society representatives, National Immunization Technical Advisory Group (NITAG) officers, and expert advisors from a number of non-governmental organizations. The review took place in Kampala, supported and facilitated by Sabin SPO Mrs. Diana Kizza Mugenzi, who sent this report.
Work on the bill began in April 2012 when a group of interested MPs, who would later form the Ugandan Parliamentary Forum on Immunization (UPFI), began systematically consulting government and nongovernment stakeholders about immunization financing. A first draft of the bill was crafted and presented to Parliament by MP Hon. James Kyewalabye Kabajo on 22 November 2012. Such a member-sponsored bill is unusual in Uganda. The benefit, governmental and parliamentary counterparts agreed, would be speediness. Consultations on the bill continued for the next eighteen months. The MPs added provisions acknowledging that the government is already covering vaccine, co-financing, and operational costs, and the law now calls for an immunization fund, to further support the increasing schedule of vaccines in a tenable manner. In May 2014, the SIF program agreed to sponsor a study tour for a team of Ugandan MPs to observe a similar law operating in another country- Mongolia. The tour took place on 6-7 October 2014.
In their 12-14 March session, members of the Parliamentary Health Committee heard from a range of high-level government officials including the Ministers of Health and of State for Economic Monitoring. Also testifying were Ugandan Local Government Association representatives, the Ministry of Health Budget and Planning Commissioner, civil society, WHO consultants and NITAG officers. The testimony was followed by discussions and a closed door, clause-by-clause review of the draft bill. The committee members concluded that the bill still failed to address financing, and that the state should be legally obligated to meet its financing commitments for immunization in proportion to the country’s GDP and population growth. They therefore amended the bill to specify the government’s role in financing immunization, and drafted a new clause for an immunization fund.
The MPs incorporated the revisions and passed the revised bill to the Health Committee clerk legal counsel. The next version of the bill will again be reviewed by the Ugandan NITAG before being submitted to parliament for the second reading.
This year, the DRC National Assembly allocated US$14 million to the national immunization program-the fifth annual increase since 2010. Much of this progress can be attributed to the Parliamentary Network for Immunization Support (REPACAV), a large advocacy coalition spanning legislative and executive branches, which was founded in 2009 and became active in 2012. From their National Assembly vantage point, REPACAV MPs scrutinize annual budget requests and follow the actual disbursement and use of immunization program funds.
Elsewhere, REPACAV has dedicated much of its work to establishing parliamentary antennae in the country’s eleven provinces. Their national-level advocacy work has drawn in supporters from various institutions, including: private medical practitioners; officials from Ministries of Finance, Budget, and Health; civil society representatives, such as Rural Health (SANRU); and international partners.
On 29 January, Sabin Senior Program Officer Dr. Helene Mambu-Ma-Disu organized a meeting of fifteen REPACAV members, with EPI Manager Dr. Audry Mulumba, and Health Minister Hon. Dr. Félix Kabange.
In the meeting, REPACAV President Hon. Grégoire Lusenge described the group’s advocacy efforts and challenged Hon. Minister Kabange to ask his Treasury counterparts to improve the immunization budget disbursement rate. For his part, Hon. Minister Kabange urged the parliamentarians to spur disbursement using their legislative oversight privileges. The Minister also asked the parliamentarians to advocate for immunization directly with their respective constituencies. He commended REPACAV members for crossing political party lines to achieve a common goal for the welfare of the people. The group agreed to hold quarterly informational sessions to follow progress and discuss future problems.
The Minister soon took action. In a 13 February meeting of DRC’s Interagency Coordination Committee (ICC), he announced he would write a letter to the Prime Minister reminding him to reclassify the vaccine budget from discretionary to obligatory, and to disburse the funds in a timely fashion.
Further progress came when Dr. Mambu-Ma-Disu then organized a briefing on 31 March with REPACAV President Hon. Lusenge and fourteen other members. They were joined by representatives from SANRU (a rural health organization), GAVI, PATH and the Bill & Melinda Gates Foundation.
Dr. Mambu-Ma-Disu opened the briefing and summarized Sabin’s collaboration with REPACAV since the coalition’s inception. Hon. Gregoire Lusenge, honorary member Hon. Hubert Masala, and members Hons. Kiro and Kaswende highlighted the coalition’s major functions.
Among the BMGF delegates was Program Officer Mr. Brad Tytel and former Bolivian Health Minister Dr. Enrique Paz, who shared his experiences in public immunization financing in his country. Five percent of the social security purse in Bolivia is dedicated to the immunization budget. He commended REPACAV for their successes in mobilizing resources for operational costs at the provincial level. Dr. Paz expressed his interest in Bolivia receiving REPACAV delegates in a future peer exchange.
In a later discussion, PATH representative Mr. Anselme Manyong asked whether REPACAV is following up on their provincial advocacy missions. REPACAV member Dr. Yukulu replied affirmatively and described his follow up visit to Bas Congo in December 2014, exactly one year after REPACAV’s inaugural visit there.
This quarter, WHO/HQ launched an updated Vaccine Product, Price, and Procurement (V3P) program website. The site allows countries to submit details on the vaccines they order- the products, the prices they paid, and how they were procured them. The information is compiled into an online database for countries to consult. By sharing this information, the V3P Program facilitates the further development of the global vaccine market. Twenty-three EUR countries, one SEAR country, and one WPR country submitted vaccine price information last year. Of these twenty-five countries, seven are lower-middle and lower income. Starting this year, countries are encouraged to share vaccine price information through both the V3P website and the WHO/UNICEF Joint Reporting Form (JRF) system. The number of countries sharing vaccine price information in each region is now an indicator followed annually by the World Health Assembly through the GVAP monitoring process.
Readers can visit the V3P Platform here.
The SIF team enjoyed a fruitful annual planning meeting in Istanbul on 2 & 5-6 March. The meeting bracketed the Inaugural Conference of the International Association of Immunization Managers, which took place on 3-4 March. In the meeting, SIF team members compared and contrasted their advocacy experiences. The group went on to identify opportunities for synergizing and scaling up efforts in the coming year. “You will not find a more knowledgeable group on immunization financing anywhere,” enthused SIF Director Dr. Mike McQuestion.
- 23 January, Copenhagen, Denmark. Sabin SPO Eka Paatashvili attends WHO/EURO/Gavi country planning meeting.
- 30 January, Washington, DC. SIF Program Steering Committee meeting (virtual)
- 3-5 February, Geneva, Switzerland. SIF Director Mike McQuestion attends Gavi IF&STT meeting.
- 12-13 February, Geneva, Switzerland. Sabin Executive Vice President Jon Andrus and SIF Director Mike McQuestion attend WHO Task Force on Middle Income Countries meeting.
- 16-20 February, Geneva, Switzerland. Sabin Senior Program Officers Alice Abou Nader and Eka Paatashvili attend WHO Training workshop on comprehensive multi-year planning (cMYP) for immunization.
- 23-26 February, Douala, Cameroon. Sabin SPO Helene Mambu-Ma-Disu, SPO Jonas Mbwangue, and SIF Program Coordinator Andrew Carlson attend WHO/AFRO/IST/CA EPI managers meeting.
- 24-27 February, Colombo, Sri Lanka. Sabin SPO Devendra Gnawali joins Gavi graduation assessment mission.
- 3-4 March, Istanbul, Turkey. Sabin SIF Team attends Inaugural International Association of Immunization Managers meeting.
- 9-13 March, Victoria Falls, Zimbabwe. Sabin SPO Diana Kizza Mugenzi and SIF Director Mike McQuestion attend the WHO/AFRO/IST/ESA EPI managers meeting.
- 16-19 March, Lome, Togo. Sabin SPOs Jonas Mbwangue and Cliff Kamara attend WHO/AFRO/IST/WA EPI managers meeting.
- 23-25 March, Lome, Togo. Sabin SPO Clifford Kamara attends Gavi/WHO/AFRO/IST/WA JRF peer review workshop.
- 23-27 March, Kinshasa, DRC. Sabin SPO Helene Mambu-Ma-Disu attends Gavi/WHO/AFRO/IST/CA JRF peer review workshop.
- 30 March-3 April, Pretoria, South Africa. Sabin SPO Alice Nader attends GAVI/WHO/AFRO/IST/ESA JRF peer review workshop.