Immunization Financing News | Volume 8.1, April 2016
In this Issue
Kathmandu, Nepal | January 26 2016:
On Jan. 26, 2016, President Bidya Devi Bhandari of Nepal signed into law, “Immunization Bill 2072”, culminating a five-year long legislative project by government and parliamentary counterparts [see related articles, Immunization Financing News, 6(4), 7(1), 7(3)]. The law goes into effect in late April.
“This legislation is an important milestone for Nepal in protecting children’s rights to getting quality immunization service; increasing country ownership; and sustaining the national immunization program by securing adequate funding,” said the Hon. Ranju Kumari Jha, chairperson of the Nepali Parliamentary Committee on Women, Children, Senior Citizen and Social Welfare. “I hope Nepalese children will be able to receive the full benefits of our immunization program. However, to achieve this goal, we need to work together to ensure the effective implementation of the law.”
Among its provisions, the law provides for a dedicated national immunization fund to allocate money for the immunization program. This innovative fund will include both government and private contributions. Proceeds will be used to purchase vaccines and support immunization delivery. The Nepali government has already allocated 60 million Nepalese rupees, or approximately US$550,000, to the fund, which will be managed by the private sector. The new national immunization fund will be supplemented by another fund set up earlier by Rotary District 3292. Both funds move Nepal closer to full domestic financing of its immunization program, reducing dependency on external financing. In recent days, Hon. Jha and her committee members have called a series of meetings with Ministry of Health and Ministry of Finance officials to identify public revenue and private sector funding sources.
The necessity of comprehensive, uninterrupted national immunization programs is recognized by GVAP, a framework for extending the full benefits of immunization to every man, woman and child by 2020. However, rising costs due to the addition of new life-saving vaccines and unguaranteed external funding pose serious challenges for national immunization programs. Among the 73 poorest Gavi-eligible countries, 56 governments reported spending about US$7 per surviving infant on average for routine immunization in 2014.
“Collective efforts have paid off. Evidence-based advocacy works in Nepal,” said Devendra Gnawali, M.Sc., Ph.D., of the SIF program at Sabin. “Now Nepal has an immunization law. Its effective implementation will help secure adequate funding for immunization from the government, it is protected by the law. Domestic private partners' contribution through National Immunization Fund is an innovation in the law. The law will make the Expanded Programme on Immunisation (EPI) team and partners more responsible and accountable for fully immunizing children in Nepal. I hope Nepal will achieve its goal of country ownership in fully self-financing its national immunization program in the years to come.”
Nepal joins five other SIF countries with immunization laws on their books. Three of these laws (Nepal, Nigeria, Uganda) were developed during the SIF Program. New immunization laws are under development in another thirteen SIF countries.
Immunization laws from Nepal and twenty-six other countries are housed on the Sabin SIF website.
“The race is on to see how many more countries pass laws before we all meet again for the third Sabin SIF Colloquium”, commented SIF Program Director Mike McQuestion. The event will be co-hosted by the Nepal Ministry of Health, on 19-21 July, in Kathmandu.
On 25-28 February, African ministers of health and finance gathered in Addis Ababa, Ethiopia to discuss immunization on the continent. The Ministerial Conference on Immunization in Africa was hosted by the World Health Organization’s Regional Offices for Africa and for the Eastern Mediterranean, in conjunction with the African Union. A year in the making, the event brought together all fifty-four countries on the African continent to discuss how they will achieve the ambitious Global Vaccine Action Plan and related African Strategic Plan for Immunization strategic objectives. Over 800 persons attended. Sabin sent a four-person delegation, including Executive Vice President Jon Andrus, SIF Program Director Mike McQuestion and the four African Sabin Senior Program Officers Clifford Kamara, Diana Kizza Mugenzi, Helene Mambu-Ma-Disu and Jonas Mbwangue.
The official conference report, Fulfilling a promise: Ensuring immunization for all in Africa, can be downloaded here.
There was much to celebrate. Vaccines have vanquished polio and all but eliminated meningitis A from the continent. African immunization programs save well over a million lives annually. Yet Africa lags the other regions in vaccine coverage and government expenditures on immunization. African immunization programs currently reach four in every five children. In 2014, only 17% of countries in Africa (9/54) met the GVAP target of at least 80% DTP3 coverage in all districts. That year, the 47 WHO African Region governments spent just US$12 per infant on routine immunization. In comparison, the EMR countries spent $26 per infant in 2014.
Assuming countries adopt the newer, costlier vaccines (pneumococcal, rotavirus, papillomavirus), it will likely cost at least $60 to fully immunize a child by 2020. (That cost is currently estimated to be $46.50 in African countries.) EMR countries are currently on track to reach that 2020 $60 per infant target. Though their immunization spending is gradually increasing, African governments will need to triple their current rates of spending in order to reach the target.
In the course of the Conference, participants were updated on other key issues, including vaccine coverage trends, prospects for disease elimination, the power of new and underutilized vaccines and the benefits of integrating immunization into health systems.
A highlight of the Conference was a declaration of support presented by ten parliamentarians in attendance. Invited by the WHO African Regional Office, the MPS represented eight of the twelve African SIF countries (Cameroon, Republic of Congo, DRC, Kenya, Madagascar, Senegal, Sierra Leone and Uganda). Among the provisions of the parliamentary statement is a commitment to: “Establishing the African Parliamentary Caucus for Immunization to serve as a platform for sharing knowledge and best practices in advocacy, oversight and legislation on immunization for sustainable and performing immunization programs.”
In effect, the proposed Caucus will be a vehicle for generalizing parliamentary action for immunization from the twelve African SIF countries to all forty-seven African Region countries. This added political support will help African governments achieve the ambitious GVAP/ASPI strategic objectives.
In plenary addresses, Hons. Gregoire LUSENGE (DRC) and Huda Oleru (Uganda) elaborated on the parliamentarian declaration and challenged the ministers to take the necessary steps to own their respective immunization programs. The entire parliamentary declaration, in English and French, can be found here.
On March 7- 12, Sabin Senior Program Officer Khongorzul (Hongor) Dari joined colleagues from Gavi, the Vaccine Alliance, WHO, UNICEF and the World Bank on a Gavi transition assessment mission in Hanoi, Vietnam. The purpose of the mission was to work with Vietnamese colleagues from the National Immunization Program to develop the transition plan from GAVI support. Vietnam entered transitional status in January 2015. Gavi support to the country will cease in December 2019. On the team, Hongor was responsible for the themes of legislation and political will. She sent this report.
In the area of legislation, immunization in Vietnam is governed by “The Law on Prevention and Control of Infectious Diseases (LPCID),” which was passed in 2007. This law covers the prevention and control of infectious diseases, including immunization. The immunization provisions are comprehensive. The state encourages use of vaccines and assures free vaccinations to all citizens at risk of particular vaccine-preventable diseases. Article 30 of the law provides that the State shall ensure funds for the use of vaccines as recommended by medical authorities and to prevent epidemics. Social participation in immunization is assured. For example, Clause 3 of Article 30 states: “Peoples Committees of provinces and centrally run cities … shall direct the organization of the immunization and use of vaccines and medical bio-products”.
Vietnam’s 2007 Law on Prevention and Control of Infectious Diseases stands as one of the strongest among the SIF countries. But changing conditions, including transition from Gavi support, have led the government to update the legislative basis for the immunization program, addressing in particular its organizational structure and how it is financed. The Ministry of Health is leading the inter-ministerial project which is producing a new ancillary immunization decree. According to Ms. Nguyen Minh Hang, Deputy Director of General Department of Preventive Medicine, Ministry of Health, “The decree will combine all provisions in different government regulations, circulars, and decisions related to immunization activities into one legal documentation. In addition, the newly drafted immunization decree will be a strong legal documentation for immunization, which will be complied by all Ministries and signed and approved by the Prime Minister.” Previously, the Ministry of Health was solely responsible and implementation was through separate circulars and decisions. The draft decree has been submitted to the Prime Minister and is expected to be approved in May- July, 2016.
From the political will perspective, the Government of Vietnam is committed to immunization and provides strong political support for its National Immunization Program, wrote Dari, who has organized SIF Program support with her Vietnamese counterparts in this area since 2013 [See related articles in Immunization Financing News 5(4), 6(2), 6(3) and 6(4).] The advocacy work has focused on a series of subnational workshops organized by the National Immunization Program team in collaboration with The National Assembly Department of Social Affairs. The workshops included the joint reporting and analysis of immunization expenditures from both state and provincial levels. An immediate result has been improved provincial expenditure reporting, which the National Immunization Program team has been using to strengthen its annual investment cases. They have been effective. The National Assembly approved immunization budget increases of 98% and 8% in 2014 and 2015, respectively.
As part of their routine work, members of the National Assembly occasionally visit provincial, district, and commune health centers to review immunization and other health program performance. The Sabin-assisted workshops have dovetailed with these statutory visits. During the assessment, members of parliament assured the team they would continue to strongly support the National Immunization Program and would continue to encourage local government officials to support the immunization program in their jurisdictions. In the words of Deputy EPI Manager Dr. Nguyen Van Cuong, “The provincial governments have a huge potential to support the National Immunization Program at the provincial level as Vietnam operates under decentralized budget system”.
Provincial government immunization spending varies widely. Most of the 63 provinces rely on state transfers to fund immunization activities. Some provinces, however, contribute additional funds from local revenues for immunization campaigns, minor repairs to facilities, allowances for health workers and so on. The trend is in the right direction and bodes well for a successful transition. In summarizing the mission’s findings, Gavi team leader Dr. Santiago Cornejo pointed out that “The contribution from provincial governments for immunization activities increased over the period 2012-2014, totaling US$1.8 million. Nine of the 63 provinces reported their contributions for all three years, 15 provinces reported contributions for two consecutive years and 13 began reporting contributions in 2014.
The Uganda Immunization Act 2015 was signed into law on 10 March 2016 by President Museveni, further strengthening the country’s national immunization program. [See related story, Immunization Financing News 7(4).] The culmination of a four-year long effort, the bill is comprehensive in scope.
Among its provisions are compulsory vaccinations for children and women (both tetanus toxoid and human papillomavirus vaccine). The State is to provide vaccinations free to the public with the Ministry of Health charged with the Act’s implementation.
The Act creates a new National Immunization Fund within the Ministry of Health, to be used for procuring vaccines and vaccination supplies. Three sources of funds are identified: Annual Parliamentary appropriations, donations and voluntary contributions. The Fund will be administered by an inter-ministerial, inter-sectoral Board of Directors, which will meet quarterly and whose work will be supported by a secretary. There will be annual program reports and audits performed by the Auditor General.
Additional provisions protect vaccination providers from liability for vaccine-related injuries and fine individuals promulgating false anti-vaccine information.
“With the enactment of this Act, Uganda joins nine other SIF countries that have taken steps to reduce dependency on external funding and create more predictability and sustainability in immunization program financing,” said Mike McQuestion, SIF program director. “It was a textbook example of good governance.”
Among the parliamentarians who steered the Act to fruition were Hons. Mike Sebalu, James Kabajo, Rose Akol, Henry Banyenzaki, Jeremiah Twa Twa, Mathias Kasamba, Huda Oleru, John Amos Okot, Anne Auru and other members of Uganda’s Parliamentary Forum for Immunization. On the government side, supporters included former immunization program managers Dr. Possy Mugyenyi, Jacinta Saabiti, Rachel Seruyange and, elsewhere in the Ministry of Health, Dr. Rogers Enyaku. From the Ministry of Finance, crucial support came from Mr. Ishmael Magona. Dr. Nelson Sewankambo and other members of Uganda’s NITAG played an important domestic advocacy role.
The Uganda Immunization Act 2015, along with legislative documents from a host of other countries, can be found here.
Attention in the Ministry of Health is now focused on writing the regulations needed to implement the Act, reports Sabin Senior Program Officer Diana Kizza Mugenzi who facilitated every step of the legislative project.
Sabin Senior Program Officer Clifford Kamara to Move On
After seven productive years, Dr. Clifford Kamara has transitioned from the SIF team back to a position in his native Sierra Leone. He has been asked by President Koroma to help reorganize the Ministry of Health and Sanitation in the wake of the Ebola epidemic. His first day on that new job was 1 May.
As his many colleagues and counterparts will attest, Cliff made important contributions in the area of immunization financing in Liberia, Nigeria and Sierra Leone. He represented the SIF Program in many international activities and venues.
Thanks, Cliff, and all the best in your new capacity as special presidential advisor in health.
- 18-20 January, Manila, Philippines. SIF Director Mike McQuestion attends Gavi Regional Working Group Meeting, WHO/WPRO.
- 25-26 January, Capetown, South Africa. Sabin SPO Helene Mambu-Ma-Disu attends East and Southern Africa Gavi/WHO Regional Working Group meeting
- 9 February, Washington, DC. SVI Executive VP Jon Andrus and SIF Director Mike McQuestion present papers from Health Affairs, February 2016 issue, at National Press Club press conference.
- 9-11 February, Washington, DC. Annual SIF team planning meeting.
- 7-12 March, Hanoi, Vietnam. Sabin SPO Khongorzul Dari joins joint Gavi assessment of Vietnam’s immunization program.
- March, Henti aimag, Mongolia. Sabin SPO Khongorzul Dari, national and subnational counterparts conduct a routine immunization costing exercise.