Kazakhstan and Kyrgyz Republic National Immunization Program
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ASIAN VACCINATION INITIATIVE Kazakhstan and Kyrgyz Republic National Immunization Program FINANCING ASSESSMENT © 2002 Asian Development Bank All rights reserved The findings, interpretations, and conclusions expressed in this publication do not necessarily represent the views of the Asian Development Bank or those of its member governments. The Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility for any consequences of their use. Asian Development Bank P.O. Box 789 0980 Manila, Philippines Tel: (63-2) 632-4444 Fax: (63-2) 636-2444 Website: http://www.adb.org ISBN 971-561-420-5 Publication Stock No. 010602 Contents Illustrations and Tables iv Acknowledgments v Abbreviations vi Introduction vii Kazakhstan 1 Summary 3 Background 5 Socioeconomic Indicators 5 Demographic and Health Indicators 6 Health System 9 National Immunization Program 11 Immunization Schedule 11 Organizational Structure 11 Legislative Framework 11 Vaccination Coverage 13 Future Financing 15 Key Issues 15 Financing Needs, Sources, and Gaps 22 Policy Options 23 Recommendations 25 Kyrgyz Republic 27 Summary 29 Background 31 Socioeconomic Indicators 31 Demographic and Health Indicators 32 Health System 34 National Immunization Program 37 National Immunization Plan 37 Organizational Structure 38 Vaccination Coverage 39 Future Financing 41 Key Issues 41 Financing Needs, Sources, and Gaps 51 Policy Options 55 Recommendations 57 Appendix: Persons Interviewed 59 References 60 Illustrations and Tables Figures 1 Organization of Healthcare System 10 2 Vaccination Coverage by 12 Months of Age, 1991–1999 13 3 Overview of Vaccine Distribution 19 4 Organization of Healthcare System 35 5 Vaccination Coverage by 12 Months of Age, 1990–1999 39 6 Overview of Vaccine Distribution 42 Tables 1 Macroeconomic Indicators, 1990–1998 6 2 Trends in Healthcare Expenditure, 1991–1998 6 3 Demographic Indicators, 1989–1999 7 4 Health Indicators, 1990–1998 7 5 Routine Immunization Schedule, 2000 11 6 VII Cost Sharing, 1995–2000 16 7 Comparison of Vaccine Procurement and Estimated Requirements 18 8 Costs Associated with Adolescent and Adult Vaccines 18 9 Estimated Cost of Upgrading National Cold-Chain Equipment 20 10 Cost of Measles Campaign 22 11 Macroeconomic Indicators, 1990–1997 31 12 Trends in Government Healthcare Expenditure, 1990–1998 32 13 Demographic Indicators, 1989–1997 33 14 Health Indicators, 1990–1997 33 15 Schedule of Immunization in the Kyrgyz Republic 38 16 Summary of VII Vaccine Cost-Sharing Agreement, 2000–2005 41 17 Cost Estimates for Vaccines, 2001–2005 43 18 Cost Estimates for the Establishment of a National Regulatory Agency and National Surveillance Laboratory, 2001–2005 44 19 Equipment for Cold-Chain Upgrade, 2001–2005 45 20 Cost Estimates for Disposable Injection Equipment, 2001–2005 46 21 Estimated Cost of Improving Immunization Safety, 2001–2005 46 22 Cost Estimates for Training and Development Activities, 2001–2005 47 23 Cost Estimates for Social Mobilization Activities, 2001–2005 48 24 Cost Estimates for Research Activities, 2001–2005 49 25 Cost Estimates for Enhanced Surveillance Logistic Support, 2001–2005 50 26 Cost Estimates for National Measles and Rubella Mass Campaign 51 27 Projected Costs, EPI, 2001–2005 52 28 EPI Financing Gap, 2001–2005 52 29 Funding Gaps for Strengthened EPI, 2001–2005 53 Acknowledgments This report was prepared in December 2000 by Greg Sam, consultant, for the Agriculture and Social Sectors Department (West) of the Asian Development Bank. The study was supervised by Indu Bhushan, Senior Project Economist, under the overall guidance of Edward M. Haugh, Manager, Education, Health, and Population Division (West), ADB. Camille Contreras and Elena Roces of ADB provided production support. The author wishes to thank the following: In Kazakhstan: WHO Liaison Office in Almaty; Ministry of Economy in Astana; Sanitary Epidemiological Stations in Astana, Almaty, Karaghanda, and Kozylorda; Republican Agency for Healthcare in Astana; and the UNICEF Office in Almaty. In the Kyrgyz Republic: WHO Liaison Office, Ministry of Finance, Ministry of Health, State Sanitary Epidemiological Dept., Republican Center for Immunoprophylaxis, State Com- mittee on Foreign Investments and Economic Development, and UNICEF Office—all in Bishkek. The persons in those offices who were interviewed for this report are listed in Appendix 1. Special thanks also go to the staff of the ADB resident missions in the two countries. Abbreviations ADB Asian Development Bank AEFI adverse effects following immunization BCG bacillus Calmette-Guérin (anti-TB vaccine) CCME ? CDC Centers for Disease Control, Atlanta, US D diphtheria toxoid vaccine DAT diphtheria anti-toxin DPT or DTP diphtheria and tetanus toxoids and pertussis vaccine DT diphtheria and tetanus vaccine EPI Expanded Program on Immunization FAP feldsher-midwifery post GDP gross domestic product Hib Haemophilus influenzae type B IDU intravenous drug user NRA National Regulatory Agency OPV oral polio vaccine SES Sanitary Epidemiological Station TB tuberculosis tD ? TEIg tick-borne encephalitis immuno-globulin UNICEF United Nations Children’s Fund VII Vaccine Independence Initiative WHO World Health Organization Introduction Purpose This report, which was prepared under the Asian Vaccination Initiative, assesses the current and future financing needs of the national immunization programs of Kazakhstan and the Kyrgyz Republic. The assessment was made to assist the Governments of those countries in planning future program investments by providing an analysis of the following: • Economic, political, and demographic background of each country and the health context within which its immunization program is operating • Structure and performance of the immunization program, including: – coverage – immunization laws and regulations coherent analysis of – management capacity – vaccine procurement and supply Afinancial requirements, – service delivery – surveillance systems available resources, and – quality assurance • Costs and future financing requirements of the immunization program financing gaps is an A coherent analysis of financial requirements, available resources, and financing gaps is important aspect of medium- an important aspect of medium-term planning and, therefore, program sustainability. term planning and, therefore, Methodology program sustainability The information and data for this report were collected between October and December 2000. An international consultant spent two weeks each in Kazakhstan and the Kyrgyz Republic and collaborated with a national consultant in each country for the assessments. In Kazakhstan, the consultants interviewed representatives of the Agency for Healthcare, Ministry of Finance, Ministry of Economy, republican and subnational Sanitary Epidemio- logical Stations (SESs), United Nations Children’s Fund (UNICEF), and World Health Organization (WHO) in the cities of Astana and Almaty and the oblasts of Karaganda and Kozylorda. In the Kyrgyz Republic, they interviewed representatives of the Ministry of Health, Ministry of Finance, republican and subnational SESs, UNICEF, and WHO. A list of the people interviewed is in Appendix 1. Overview Before they gained independence from the Soviet Union, Kazakhstan and the Kyrgyz Republic had health systems that were based on a highly centralized and command- driven model. This system provided very high coverage but was financially unsustainable because it depended (as did the entire economy) on large subsidies from Russia. The viii transition to a market-based economy, and the withdrawal of this budget support, there- fore led to a dramatic decline in health spending in absolute terms. However, in relative terms health spending was largely maintained at about 10 percent of total Government spending in Kazakhstan and 11 percent in the Kyrgyz Republic. Predictably, health services suffered when there were less financial resources. Immuniza- tion programs were not exempt: a drop in vaccination coverage rates opened the door to vaccine-preventable disease. In the early 1990s a diphtheria epidemic swept the newly independent states. Kazakhstan and the Kyrgyz Republic undertook to reform the health sector in the process of political and economic change. Health systems were largely decentralized, and author- azakhstan and the ity and responsibility for program implementation passed to the provincial (oblast) governments. However, responsibility for policy development, supervision, and monitor- Kyrgyz Republic ing of vertical national programs such as immunization remained with national Govern- K ment agencies or institutions. undertook to reform the By 1998 both countries were recovering from economic crisis. Gross domestic product health sector in the process (GDP) in Kazakhstan was growing at a rate of 1.7 percent and per capita GDP was $1,468, up from $741 in 1994. The Kyrgyz Republic, on the other hand, had a GDP growth rate of political and economic of 6 percent and per capita GDP of $2,140, from $1,712 four years earlier. Their immu- nization programs improved, with significant support from the Japanese Government and change. Health systems were UNICEF, and coverage rates returned to over 90 percent. largely decentralized, and However, the parallel experiences of the two countries in the matter of independence, economic transition and recovery, and structural health reform did not extend to their authority and responsibility approach to the financing of their national immunization programs.