Immunization Financing News | Volume 7.4, Jan 2016
In This Issue
Nairobi, Kenya | 26-28 October 2015:
Twenty-four parliamentarians and ministerial officials from Kenya, Liberia, Nigeria, Sierra Leone and Uganda came together on 26-28 October 2015 to assess progress toward country ownership of their immunization programs. The occasion was the Sabin SIF-organized Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing, in Nairobi, Kenya. Over two-and-a-half days, participants engaged in four rounds of plenary presentations and three rounds of small group work, culminating in a peer review poster session.
The event was the third of three-peer review workshops in preparation for the Third Colloquium on Sustainable Immunization Financing, slated for July 2016. The first peer review workshop took place in Phnom Penh, Cambodia, on 21- 23 July, 2014, drawing delegations from the six Asian SIF countries. The second workshop, held in Kribi, Cameroon on 4-6 December 2014, brought together peers from the six Francophone African countries. (see Immunization Financing News, 6 (3) and Immunization Financing News, 6 (4)).
Facilitating the Nairobi workshop were SIF team members Clifford Kamara, Mike McQuestion and Dana Silver. They were joined by partner agency counterparts Mr. Mike Brison, Senior Associate, Clinton Health Access Initiative, Kampala, Uganda; Mr. Jack Ndegwa, Head, Policy & Advocacy, Kenya AIDS NGOs Consortium, Nairobi, Kenya; Mr. Samburu Wa-Shiko, Senior Advisor, Bill & Melinda Gates
Foundation, Nairobi, Kenya, and; Dr. Subroto Mukhrjee, East Africa Regional Mission, USAID, Kenya.
To set the stage, results from an internal Sabin analysis of recent government immunization expenditures were presented. The data came from the WHO/UNICEF Joint Reporting Form. Over the period 2011-2014, African governments only slightly increased their routine immunization spending [see related article, Immunization Financing News, Volume 7, Issue 2.] Spending in all regions tended to flatten out among countries in the US$500-1100 range. Given that costs are rising even faster, the trends point to increasing dependency on external financing. The alternative vision is country ownership- a central goal of both the Global and African regional vaccine action plans. While each of the five SIF Anglophone African countries increased its government spending over the period, bigger increases will be needed to reach the 2020 ownership goal.
The workshop was an opportunity for peers to present and critique the new practices they have developed, or are still developing, to get there. The agenda focused on four ownership themes: Domestic financing arrangements, budgeting and resource tracking, legislation and local advocacy activities. In the final session, delegations presented specific action points they would employ to move their countries closer to the ownership goal. Recurring discussion topics included new advocacy practices, ways to increase stakeholdership in the programs, dealing with devolution, methods of resource tracking and innovative financing arrangements, including immunization trust funds and public-private financing partnerships. The full workshop report is available here.
On 17 December, the Parliament of Uganda passed the National Immunization Act 2015. Yumbe District MP Hon. Huda Oleru presented the Act, which had been introduced as a private member’s bill in 2012. In her remarks, Hon. Huda described the Act as a holiday gift to the children of Uganda. Among its provisions, the Act declares that immunization of children, women of reproductive age, and other target groups will henceforth be compulsory. ,. A parent or guardian who refuses to immunize a child will face a fine or a jail sentence. Another provision calls for the government to create an “Immunization Financing and Administration Fund”. The Health Committee added the financing provision to the draft bill in November, following an October 2014 study tour of three Committee members to Mongolia where such a fund was created by law in 2000. [see Immunization Financing News 6.4] Speaking to Parliament, Hon. Huda articulated the Committee’s rationale for the establishment of the Fund, stating:
“The Committee was…informed that the Government of Uganda funded 55% of the routine immunization services in 2009-10 and 2012/13, while external donors…contributed a substantial portion of the operational costs. This external funding, however, is neither guaranteed nor predictable. When immunization funds are interrupted, widespread and devastating epidemics ensue. Uganda must therefore find ways to increase and sustain her national immunization budget.”
The Committee report further recommends that an independent body be created to manage the Fund.
The Act must now be approved by H.E. President Yoweri Museveni before it is enacted into law. The Ugandan Immunization Act 2015 will soon be accessible online.
Borojomi, Georgia | 7-8 November 2015:
Borojomi, Georgia was the setting for Georgia’s first Sabin-sponsored Policy Dialog on Immunization. Sabin Senior Program Officer Dr. Eka Paatashvili coordinated the event, which took place on 7-8 November 2015. Attending were about 40 participants, representing a range of Georgian institutions, including: Parliament of Georgia, Ministry of Labor, Health and Social Affairs; Ministry of Finance; National Center for Disease Control; Georgia’s NITAG; the Ministry of Health of Adjara Autonomous Republic; the Local Government of Tbilisi, Curatio International Foundation; Family Doctors’ Association; Family Medicine Study Center; Tbilisi State University. Also attending were counterparts from WHO and UNICEF country offices.
The purpose, reported Paatashvili, was to inform all key stakeholders on immunization financing and legislation needs so that full country ownership of the immunization program can be assured. The dialog was particularly useful for decision-makers who were in the process of 2016 state budget hearings.
A considerable cut to the 2016 immunization program budget had recently been proposed. Yet the financial implications of recent new vaccine introductions mandate a budget increase, observed Paatashvili. Beginning in 2009, Georgia introduced pentavalent, rotavirus and pneumococcal vaccines, all with Gavi support. Co-financing obligations on those grants through 2017 total around US$720,000. After that, the country will need to fully finance its entire vaccine bill. In her presentation, Paatashvili highlighted Georgia’s recent progress in immunization financing as reflected in recent WHO/UNICEF Joint Reporting Form reports. Representing the National Center for Disease Control, Mr. Vladimer Getia presented a detailed analysis of recent immunization program expenditures. The government immunization budget must be increased, he stated, to cover certain recurrent expenses that were being externally financed. Winning future budget increases will require firm political support, commented Paatashvili afterwards.
There are solid policy bases for Georgia to increase its immunization spending. In back-to-back presentations, Dr. Georgi Kurtsikashvili, Medical Officer based in WHO Tbilisi office, and Dr. Lia Jabidze, national immunization manager, summarized the Global and European vaccine action plans and illustrated how Georgia’s own health and immunization program policies are carrying them out.
But more than policy will be needed, agreed the participants. The case for added immunization funding must be forcefully made, on an annual basis. Ms. Ekaterine Guntsadze, head of the Budgetary Department of Ministry of Finance, presented the state budget cycle and described the basic budget principles the government follows. The MOF uses a performance-based program financing approach, which links outputs to annual budget amounts. The approach provides appropriate direct mechanism for justifying immunization program budget increases.
A second promising area is legislation. Dr. Marina Darakhvelidze, head of the Health Care Department, Ministry of Health, presented a review of existing immunization-related legal documents. Following this, Paatashvili compared Georgia’s legislative documents to those from other lower and middle income countries, identifying a set of common legislative provisions.
Following a question and answer session, representatives from each institution formed a panel and discussed how they can intensify their collaboration to ensure sufficient financing, delivery and oversight of the national immunization program. The need to review and update immunization-related regulations was noted. The day ended with a briefing on the program’s technical performance.
Day Two began with a panel of various immunization experts who shared their impressions of the program. Following the expert panel, participants were assigned to two working groups to elaborate possible action steps Georgia might take to secure a fully owned, sustainably financed and regulated immunization program. The working groups were moderated by Dr. Ketevan Goguadze and Dr. Ivdit Chikovani from the Tbilisi-based Curatio Foundation. In a final plenary session, the group rapporteurs presented their proposed next steps in the areas of immunization financing, regulation and program performance monitoring.
In June 2015, the Sabin SIF Program organized a resource tracking workshop in Dakar, Senegal. Nine immunization officials from Senegal, Mali and Cameroon attended. The peers identified and evaluated common immunization expenditure tracking practices and empirical budget advocacy approaches (see Immunization Financing News 7.2). Over the next six months, all three delegations reorganized their financial data and helped win budget increases for their national immunization programs.
Following their plan, Senegalese EPI Manager Dr. Ousseynou Badiane, Ministry of Health & Population Monitoring & Evaluation Officer Dr. Boly Diop, and Budget Tracking Office Director Mr. Cheikh Bamba took their investment case to the Finance Minister and presented an analysis of the 2014 program budget execution. The Honorable Minister reacted positively, and increased the 2016 program budget by 86 percent. Providing timely oversight were Senegalese Parliamentary Coalition for Immunization Chairman Hon. Elene Tine and Vice Chairman Hon. Alfa Balde.
Following another strategy, the Malian peers elected to provide key financial data directly to the newly formed Parliamentary Network for Immunization Sustainability. Prepared by interim EPI Manager Dr. Alimata Naco Diallo, Database Management Officer Mr. Seydou Kouyate, and Database Management Accountability Officer Mrs. Sitan Bagayoko Coulibaly, the information included an analysis of immunization program expenditures for 2009-2014. The analysis revealed that the government was contributing less than 20 percent of the routine immunization budget. When the health budget reached parliament, Network President Hon. Abdoulaye Dembele and 65 other Network members convinced the government to increase the 2016 routine immunization budget by 17 percent.
In Cameroon, the advocacy strategy was internal to the Ministry of Health. Returning from the Dakar workshop, Permanent Joint Secretary of the EPI Dr. Désiré Nolna, EPI Internal Controller Mr. Tobie Mvogo, and Database Management Unit Leader Mr. Yves Alain Omgba learned that the national immunization program was facing a 2016 budget cut due to Ministry-wide rollbacks. Working with EPI Manager Dr. Marie Kobela and MOH Cooperation Director Mr. Maina Djoulde, the peers used the SIF budget flow analysis tool to organize their budget figures and packaged the information into an advocacy memo sent to the Health Minister. The Minister not only agreed to maintain the 2016 budget at the 2015 level, but increased the budget by 29 percent.
“This experience demonstrates the power of resource tracking in the advocacy sphere,” commented Sabin Senior Program Officer Jonas Mbwangue, who works with all three countries. In the coming months, Mbwangue plans to bring the three peer networks together again, this time to analyze program expenditures at both national and subnational levels.
Kenya’s ongoing devolution program stems from the country’s revised 2010 National Constitution. The program was officially launched in March 2013 following local elections in the country’s 47 counties. The program involves the direct transfer of the central government’s power, resources, representation, and responsibility to subnational county governments, including the devolution of basic health services. As the county governments set up these new functions, the issue of vaccine procurement has come to the forefront.
Counties have found that vaccine prices are higher if they purchase them individually, without the benefit of pooled procurement. Further, they must contend with import taxes and slow delivery times. Some counties have determined that the feat is too large and have approached the MoH and the Ministry’s Unit of Vaccines and Immunization Services (UVIS) for help. The MoH began the uphill task of trying to get all the counties to return funds to the MoH so that traditional vaccine orders can be pooled and the vaccines delivered in timely fashion. This has proved unwieldy and the UVIS has had to borrow money from another ministry budget line item.
“In the midst of the growing pains of the devolution process, there were now growing suspicions over monies between the two entities, and limited vaccines,” stated Kenyan EPI Manager Dr. Ephantus Maree.
With no precedent to go by, roles at the national and county level are unclear, creating procurement and budgetary headaches. Many counties have accorded immunization low priority, preferring to spend instead on more visible investments such as infrastructure. As immunization program performance issues arose, national and county governments blamed each other.
With this backdrop and after numerous discussions between MoH and county leaders, the UVIS coordinated two meetings, bringing together county decision makers who oversee health and immunization financing. The meetings, in Nakuru on 10th October 2015 and Nairobi on 15th October 2015, allowed counterparts to discuss the challenges together and chart a way forward. Sabin Senior Program Officer Diana Kizza Mugenzi attended the Nairobi meeting and shared her observations.
One source of mistrust between the UVIS and the counties was the perception that each was hoarding funds. The counterparts clarified that the Kenyan government does not buy any cold chain equipment or vaccination supplies, and that external partners have provided these in the past.
The need to find sustainable immunization financing solutions is exacerbated by Kenya’s recent re-classification as a middle-income country. This classification reduces eligibility for external partner support. Kenya has no choice but to increasingly self-finance its immunization program. One approach the MOH and UVIS are considering is to develop a public-private national immunization fund. Contributions to the fund would be collected and managed using private sector expertise. Proceeds from the fund would be used in the short run for program operations and, in the long run, for vaccine procurement.
The two county meetings produced three areas of agreement for charting a way forward. UVIS will organize a meeting with governors and County Executive Committee members to finalize and formalize a joint decision on vaccine procurement. Second, counties will request technical assistance on budgeting, planning and expenditure tracking. Third, counties will make their own immunization delivery budgets. While counties are struggling with procuring immunization supplies, a legal framework allowing for pooled vaccine procurement remains to be fashioned.
Meeting participants left with a clear appreciation that the devolution process requires constant communication, transparency and consensus on immunization program implementation decisions.
The SIF Program team recently revised the SIF Legislative Process Graph. Created in September 2012, the graph charts country-by-country progress toward new immunization legislation. The status of each legislative project is shown across six phases (Figure 1): (1) background/legislative research, (2) legislative strategy selection, (3) drafting of bills/amendments, (4) stakeholder consultation, (5) bill submitted to parliament, (6) passage of bill.
The graph was used in the recent round of sub-regional peer review workshops to help participants represent and compare their legislative work [see related story, this issue]. Some peers found the simple bar graph insufficient, noting that legislative projects often stop at a certain phase, say following elections, and are replaced by new ones. Further, legislative processes tend to be iterative rather than linear. Following stakeholder consultation, for example, a bill may need to be redrafted. Such iterations have been observed in at least seven SIF countries (Nepal, Cambodia, Cameroon, DRC, Madagascar, Uganda, Kenya).
To capture these dynamics, the legislative process has been reconceptualized. Ten SIF countries are represented above using the new scheme. Click to view a larger version.
Six legislative phases are now identified. To illustrate, Phase VI (“Parliament Registers Bill for Vote”) was inserted to capture the period between the submission of the bill to parliament and the bill’s passage. Successive projects in a given country are represented by two or more bars. Gray-colored bars indicate truncated projects; green bars represent active ones. A completed law is represented by a green bar all the way across the seven phases. In the coming months, more countries and their respective legislative projects will be added.
Look out for a new manuscript in the February 2016 issue of Health Affairs, authored by the SIF Team. It is titled,
“Routes Countries Can Take To Achieve Full Ownership Of Immunization Programs.” The article is available, free of charge, here: https://www.sabin.org/updates/blog/setting-immunization-programs-success-new-articles-published-health-affairs
The SIF Program’s newly updated website pages are now available in French and Russian. View them online at: https://www.sabin.org/programs/vaccine-advocacy-education/sustainable-immunization-financing-sif-program?language=fr (French) https://www.sabin.org/programs/vaccine-advocacy-and-education/sustainable-immunization-financing-sif-program?language=ru
The following are the names of individuals who participated in SIF-organized peer exchanges during 2015. 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.
- Mr. Hok Khiev
- Dr. Koam Sinoun
- Dr. Nolna Désiré
- Mr. Mvogo Tobie Yannick Fridolin
- Mr. Omgba Yves Alain
- Hon. Alain Pascal Leyinda
- Dr. Ephantus Maree
- Ms. Sharon Wanyeki
- Mr. Christopher Malala
- Dr. Dominic Mutie
- Hon. Saah Joseph
- Hon. Daniel Naatehn
- Mrs. Alice O. Peters
- Dr. Coleman
- Hon. Mathew Jaye
- Hon. Nyonblee Kangar Lawrence
- Hon. Johnson Chea
- Hon. William Dakel
- Christian S. Chea
- Ms. Mary Momolu
- Mr. Adolphus Clarke
- Rev. John Sumo
- Ms. Angie Tarr
- Mr. Roland Tuopileyi
- Mrs. Coulibaly Sitan Bagayoko
- Dr. Diallo Alimata Naco
- Mr. Seydou Kouyate
- Mr. Babu Kaji Baniya
- Hon. Dr. Chukwuemeka Ujam
- Dr. Ben Anyene
- Dr. Damaris Onwuka
- Dr. Lekan Olubajo
- Mr. Oluremi Onabajo
- Dr. Michael Ajuluchuku
- Dr. Obikwelu Emelife
- Dr. Ousseynou Badiane
- Dr. Boly Diop
- Mr. Cheikh Ahmadou Bamba Ndiouck
- Hon. A.B.D. Sesay
- Ms. Isha Kamara
- Mr. Mustapha Alpha
- Dr. Dennis Marke
- Hon. Moses Baimba Jorkie
- Mr. Peter Sam-Kpakra
- Mr. Jonathan Abass Kamara
- Hon. Leonard Fofanah
- Mr. Sam Aruna
- Dr. Henry Luzze
- Mr. Ishmael Magona
- 1 October, Abuja, Nigeria. SIF SPO Cliff Kamara attends GVAP/Vaccine Financing meeting.
- 6-7 October, Brazzaville, Congo. SIF Director Mike McQuestion and SPO Helene Mambu-Ma-Disu attend planning meeting for African Continental Ministerial Conference on Immunization.
- 13 October, Tbilisi, Georgia. SIF Director Mike McQuestion and SPO Eka Paatashvili attend Parliamentary briefing on immunization financing.
- 15 October, Yerevan, Armenia. SIF Director Mike McQuestion and SPO Eka Paatashvili attend Parliamentary briefing on immunization financing.
- 20-23 October, Geneva, Switzerland. Sabin Executive Vice President Jon Andrus and SPO Helene Mambu-Ma-Disu attend SAGE meeting.
- 5 November, Kinshasa, DRC. SIF SPO Helene Mambu-Ma-Disu organizes Parliamentary briefing on immunization financing.
- 10-11 November, Maseru, Lesotho. SIF SPO Helene Mambu-Ma-Disu attends GAVI ESA regional working group meeting.
- 6-20 November, Istanbul, Turkey. SIF SPO Eka Paatashvili attends WHO/EURO EPI Partners Meeting, resource mobilization workshop.
Visits to non-resident field Countries
Kenya, Liberia, Sri Lanka, Armenia, Congo, Senegal, Mali, Vietnam, Nigeria, Cambodia
International Partner Meetings
Regional Workshop on Monitoring and Development, Togo | Gavi Regional Working Group Meeting, Turkey | GAVI Sub-regional Working Group Meeting, Lesotho | Planning Meeting, African Continental Ministerial Conference on Immunization, Brazzaville | SAGE Meeting, Geneva | GAVI ESA Regional Working Group Meeting, Lesotho | WHO/EURO EPI Partners Meeting, Istanbul | UNICEF Workshop on Commercial Financing for Immunization, Nutrition and Health Supplies, Dakar
Peer Exchanges Involving SIF Target Countries
Number of ICC Meetings (measured since April 2013)
Nepal (2), Uganda (1)