VOL. 6, ISSUE 2, AUGUST 2014 Immunization

Financing News

Quarterly news from the Sustainable Immunization Financing (SIF) Program

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From left to right: Dr. Paba Palihawadana, Hon. Maithripala Sirisena, Dr. SRI LANKA ADVANCES ITS NATIONAL Palitha Mahipala. IMMUNIZATION POLICY

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. Minister Sirisena will next pass the policy document to the Sarath Amunugama, Deputy Director General of Public Council of Ministers. From there it will go to Parliament Health Services, Dr. Ananda, Consultant Epidemiologist and where a corresponding Act of Parliament will be generated, EPI team. They were joined by officials from the Ministries translating the policy into law. 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 MONGOLIAN AUTHORITIES REPORT Senior Program Officer Devendra Gnawali, who also HEALTH INVESTMENTS TO CITIZENS attended. Minister Sirisena recognized the members of the National Immunization Policy Development Subcommittee On 6 May, Mongolia unveiled a new advocacy strategy to and thanked them for their contributions to the effort. consolidate immunization financing. The setting was a sunny plaza in western Hovd District (aimag) where approximately A necessary step in the legislative process, the draft policy, two-hundred citizens gathered to commemorate Tax Day. was formulated over a one-year period with input from the The ceremony was opened by parliamentarian Hon. Battsogt public and a range of non-government stakeholders. The Dogsom, who represents this district in Mongolia’s Grand policy states that the Federal Government will provide Hural, accompanied by Mike McQuestion, Director sufficient funding for timely procurement and supply of Sustainable Immunization Financing Program, and Director quality vaccines and their delivery. It provides for a separate of the District Tax Department Ms. Khandtsetseg Galindev. budget line item for the national immunization program. Ms. Galindev called out the names of artisans and Secondly, the policy states that provincial governments shall entrepreneurs, who received their plaques on stage, and co-finance immunization delivery. Thirdly, mechanisms will commemorated them for the taxes they had paid. The be put into place to monitor the financial sustainability of the ceremony continued with singing and dancing by children immunization program. dressed in traditional attire.

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The program then shifted to sustainable immunization the importance of this sub-regional briefing, seeing that it financing. Leaflets were distributed to the crowd with a photo marked the first time discussions were held regarding the of a child being immunized and a list of bullet points about importance of effective spending for immunization at the immunization. The leaflets included general information on provincial and district levels. Prof. Duong commented on immunization, in addition to financial data on local increasing contributions from provincial governments on government expenditures for immunization and other health immunization financing. He noted that in collaboration with services in Hovd District the previous year. the Sabin Vaccine Institute, NIHE has already demonstrated progress towards sustainable financing. In 2014, all health- In a briefing of health workers later that day, discussions related budgets, including immunization, were reduced by 40 focused on resource tracking at the local level and advocacy percent as a result of a downturn in the economy. However, activities for sustainable immunization financing. During the NIHE was able to increase its budget for immunization by briefing, district health workers were given a more detailed closely working with the National Assembly. analysis of local health expenditures. Hon. Dogsom emphasized the fact that it would be very useful to have Following, Dr. An, Deputy Director of Finance in Vietnam’s detailed budget and finance data on health to leverage funding Ministry of Health, highlighted the success of the EPI for following year budgets. Dr. Enkhamgalan Agvaandash, program and its long history of high performance in District Health Officer, agreed, adding that she will make it a sustainable financing practices. Dr. An challenged the Hai priority to include this type of financial reporting and analysis Duong province to step up its financial commitment to the in future meetings. program. He stated that the national government is committed to achieving sustainable financing; however, it still needs Another important topic that was covered at the briefing was provincial support to reach the overall goals of the program. that of fuel and transportation costs needed for health officials to travel to households for vaccinations. Local vaccinators Dr. Bui Huy Njanh, Director of the Hai Duong Provincial and health officers worked together to come up with ideas to Center of Medicine, discussed provincial financing practices make the programs more efficient. which was later followed by briefings led by district and commune officials. Last year, Dr. Khongorzul Dari, Sabin Senior Program Officer, along with counterparts at the General Tax This briefing emphasized the importance of sustainable Department and Ministry of Health, developed a model to immunization financing and resource tracking to local leaders demonstrate how the government uses tax revenue for public at the subnational level. In light of the goals set forth by Dr. health services. This work produced a national report, which Khongorzul Dari, Senior Program Officer at the Sabin was well received by government officials and the public. The Vaccine Institute, a series of subnational briefings are planned next step is to work with the country’s remaining 22 districts, in Vietnam. with the goal of delivering financial data on immunization.

CENTRAL AFRICAN PEERS REVIEW VIETNAM BRIEFINGS FOCUS ON THEIR IMMUNIZATION FINANCIAL SUSTAINABLE FINANCING AT REPORTS SUBNATIONAL LEVEL On 7-9 April 2014, in Kinshasa, DRC, health officials sought On May 20, officials from the Ministry of Health, Ministry of to strengthen their immunization programs by scrutinizing Finance, National Institute of Hygiene and Epidemiology each others’ financial reports. The WHO/UNICEF- organized (NIHE), and provincial-level officials from the People's peer review meeting drew around sixty participants Committees Health Centers and Finance Departments, representing ten Central African countries. Such peer review gathered in Vietnam’s Hai Duong province to discuss meetings, which date back to 2007 in this subregion, usually sustainable immunization financing at the provincial level. focus on preparing new grant proposals. This time, participants assessed how well they and their peers are Hai Duong province has a population of 1.7 million, tracking and reporting what their governments are spending encompassing 12 districts and 265 communes. At each level, on immunization. there is a health committee responsible for immunization and other health programs. The budget for immunization is Countries report this information annually through the currently 680M VND, higher than other provinces. WHO/UNICEF Joint Reporting Form for immunization (JRF). Getting the numbers right is increasingly important Prof. Duong Nhu Tran, Deputy Director of NIHE, opened the because government expenditures comprise the key indicator briefing by welcoming all of the participants. He highlighted of country ownership in the Decade of Vaccines Global www.sabin.org/fr (en français) page 2 www.sabin.org/sif

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Vaccine Action Plan Monitoring and Evaluation/ Evaluation and Accountability Report, which was prepared Accountability Framework. for the session by the WHO Secretariat. Among other issues, the ministers recognized the need for countries to increase The peer review process was straightforward. First the their immunization investments in order to achieve country delegations presented their figures, describing how they ownership. The GVAP provides for similar monitoring and obtained and aggregated the data. Next they scrutinized each feedback sessions in each World Health Assembly through others’ reports, identifying logical inconsistent and missing 2020. Read more on the 67th WHA GVAP session here. 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 CONGOLESE PARLIAMENTARIANS their reports before they become official. EXPAND THEIR IMMUNIZATION

Among the workshop facilitators were Remy Mwamba NETWORK (UNICEF Regional Office for West and Central Africa, Dakar), Alexi Satoulou (WHO/AFRO Inter-country Support In the Democratic Republic of Congo, the innovative Team for West and Central Africa, Ouagadougou) and Helene Parliamentary Support Network for Immunization (Réseau Mambu-Ma-Disu (Sabin Senior Program Officer, Kinshasa). des Parlementaires congolais pour l’Appui à la Vaccination) All three had attended the Central African EPI managers has expanded further with the recruitment of parliamentarians meeting in Bujumbura, Burundi last February where they in two more provinces. The action took place on 4-11 May presented detailed feedback reports to the countries 2014 when four MPs from the National Assembly visited the highlighting the quality and completeness of their past JRF provincial capitals Mbuji-Mayi, Kasai-Oriental and Kananga, expenditure reports [see related article in IFN 6(1)]. Kasai-Occidental, to confer with local authorities about immunization financing and to challenge their provincial MP Tracking resources at program level is no easy task. In a counterparts to get involved. The Réseau emissaries included WHO-led survey earlier this year, 55 percent of respondents President Honorable Gregoire LUSENGE, Rapporteur stated they had difficulties accessing any immunization Honorable Célestin BONDOMISO and Members Honorable program expenditure data. Most of what governments spend Louis KASWENDE and Honorable MUBIKAYI, who on immunization is in the form of shared health system represents Kananga City. Accompanying the MPs were expenditures for items such as salaries, transportation and national immunization program counterparts Docteur maintenance. Different approaches are being developed to Guillaume NGOIE MWAMBA, Docteur Jacky MATONDO capture and include them along with the more easily observed and Monsieur Benjamin MATATA. Sabin Senior Program direct program expenditures. Officer Helene MAMBU-MA-DISU joined the mission and sent this report. “The added attention to expenditure reporting is already paying off,” comments Sabin Senior Program Officer Alice The visit to the Kasais followed a similar Réseau mission to Abou Nader, who regularly works with the JRF data. Nader Bas-Congo Province last December [see related story, IFN, and Mwamba developed the logical rules the Kinshasa volume 5 issue 4]. Team leader and Réseau President Hon. participants used to clean their data. “The 2013 results show Gregoire LUSENGE has vowed to carry the crusade to the the Central African countries increased their immunization country’s remaining eight provinces over the next two years. spending by 30 percent. We did not see an increase that big in The federal Ministry of Health has added a line item to its any of the other subregions,” added Nader. immunization budget to co-finance the Réseau’s advocacy work.

HEALTH MINISTERS DISCUSS GLOBAL The MPs make two simple but compelling arguments. If a VACCINE ACTION PLAN AT THE WORLD country does not fully finance its own immunization program, HEALTH ASSEMBLY it may not claim sovereignty over its children. Secondly, immunization will save each province money by reducing On 21 May, ministers of health took up the Global Vaccine hospital care costs. The MPs are urging each provincial Action Plan (GVAP) at the 67th World Health Assembly in government to create a separate budget line item for Geneva. Ministers from 54 WHO Member Countries spoke immunization delivery and to increase that budget every year about their countries’ immunization programs and what they as needed. are doing to achieve the six GVAP Strategic Objectives. The mission kicked off on 5 May, in Mbuji-Mayi, where the Among them were ministers from six SIF countries: Congo MPs were briefed by the Provincial Health Department and Republic, Ethiopia, Indonesia, Kenya, Mongolia and explained the purpose of their visit. “Better late than never,” Vietnam. Discussion focused on the 2013 GVAP Monitoring, www.sabin.org/fr (en français) page 3 www.sabin.org/sif

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remarked the Provincial Health Minister. The MPs then WHO/UNICEF JOINT REPORTING FORM proceeded to the Kasai-Oriental Provincial Assembly where FINANCIAL INDICATORS REPORTED they were warmly received by the Assembly President and the President of the Health Commission, Honorable FOR 2013 NTEMBO NYERERE. That afternoon, the MPs joined a working session with the provincial immunization program Over the past eight years WHO and UNICEF have gathered team. The next day, the Réseau emissaries met with students performance indicators that evaluate national immunization at l’Institut Supérieur des Techniques Médicales, the programs through the Joint Reporting Form (JRF). Government expenditures on routine immunization, JRF provincial governor and a civil society association active in th immunization. On 7 May, they met with the full Provincial Indicator 6500, received particular attention at this year’s 67 Assembly, accompanied by the provincial health minister. World Health Assembly session, where health ministers The result: All Provincial Assembly members pledged to join reviewed the data [see related story, this issue]. Country the Réseau. Their final visit that day was to the mayor of ownership is one of the six GVAP guiding principles and can Mbuji-Mayi and his council of advisors (Bourgmestres des be measured by a country’s immunization expenditures. Communes). Dividing JRF Indicator 6500 by the total amount spent (from all sources) on the program (Indicator 6510) yields the The team then proceeded to neighboring Kasai Occidental percent of contributions made by the government. Province for a second round of intense advocacy work. Again the authorities agreed to create an immunization delivery The quality, consistency, and validity of the financing JRF budget line item and a new batch of parliamentary MPs joined data are also important. Recently Sabin developed a series of the Réseau. logical statements that check for data inconsistencies. Only 6 percent (12/193) of Member Countries have completely and

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consistently reported their government expenditures during inconsistent government expenditures and/or inconsistent 2006-13. Overall, reporting completeness has been decreasing reporting. Reporting completeness has also varied. Sri Lanka, for all but one financial indicator. On a positive note, the for example, has missing data for four out of the six years, African Region countries became more complete reporters making it hard to follow the country’s financial trend. Yet for from 2012-13 for all six JRF financial indicators. years it did report, Sri Lanka consistently ranks high. Underreporting obscures Sri Lanka’s progress towards As a group, the 18 SIF countries improved their reporting as sustainable immunization financing. well. From 2012-13 the number of countries reporting Indicator 6500 increased by 36 percent. The magnitude of The graph below shows average government routine their government routine immunization expenditures also immunization contributions for those SIF and other GAVI increased by 8 percent. The chart ranks the SIF countries eligible countries that reported data. From 2008-2012, both according to their reported government expenditures per groups follow similar trends. In 2013, the average surviving infant. From 2011-13 Mongolia is the only country government contribution of SIF countries decreased by 20 that was within the top echelon for JRF Indicator 6500. percent. This could be due to a number of factors. It could be Notably, the ranks change from year to year, reflecting a true decrease and/or a reporting artifact.

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OBITUARY: DR. CIRO DE QUADROS

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)

NEW SIF SENIOR PROGRAM OFFICER

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.

NEW SIF PROGRAM ASSISTANT

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.

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OTHER SIF HIGHLIGHTS

April  In May, the Liberian senate endorsed a proposed national  April 17, the Council of Ministers of Nepal approved the immunization bill. immunization draft law. The Minister of Health subsequently sent the bill to the Ministry of Law and  Also in May, a team from the Cambodian National Justice for final review. Ministry of Health finalized a draft immunization law. The

bill will next be shared with various stakeholders.  21 April, SPO Jonas Mbwangue and Government of Cameroon counterparts reviewed that country’s proposed June Health Support Fund, which will cover immunization financing. The strategy is for the Minister of Health to  On 9 June, SPO Diana Kizza Mugenzi and SIF Director prepare an act establishing it as a “Special Allocation Mike McQuestion met national counterparts in Nairobi, Fund” to be managed by the Ministry of Finance and Kenya to discuss the country’s pending vaccine legislation. incorporated into the financial law every year.  On 11-13 June, SIF Program Director Mike McQuestion  24-25 April, Dr. Mambu-Ma-Disu participated in a facilitated a three-day WHO/GAVI meeting in WHO/UNICEF/GAVI/SIF mission to Republic of Congo Hammamet, Tunisia. Among the seven participating (Brazzaville) to conduct a financial review and make countries were three SIF countries: Kenya, Madagascar recommendations on the country’s chronic immunization and Sierra Leone. The countries developed work plans to financing challenges. increase their immunization budgets.

May  In June, SIF SPO Alice Abou Nader analyzed recently  On 10-17 May, SPO Dr. Mambu-Ma-Disu participated in a released WHO/UNICEF joint Reporting Form financial joint WHO/UNICEF/GAVI/SIF mission to Madagascar. A data from 73 GAVI-eligible countries. Results showed that financial review was conducted and recommendations governments increased their investments from US$6 per were made to address the country’s chronic immunization surviving infant in 2012 to $7 in 2013. financing challenges.

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Achieved Cumulative Milestone/Activity Details: this quarter (1.IX.09– 30.VI.14)

Congo (2), Sri Lanka (2), Liberia, Mali, Visits to field Countries 9 166 Indonesia, Kenya, Madagascar Nepal (2), Mongolia (2), Kenya, Cameroon, National Briefings 7 108 Sierra Leone Sub-regional briefings 3 18 Vietnam, Indonesia, Mongolia

GAVI/WHO/IST-West Africa Annual Peer Review, Ouagadougou, Burkina Faso; International Partners WHO/IST-West Africa Action Plan 3 83 Meetings Development Workshop in Dakar, Senegal; WHO/UNICEF/GAVI JRF Peer Review Workshop, Kinshasa, DRC Workshops/Capacity 7 21 Nepal (6), Cameroon Building Meetings Peer Exchanges Involving SIF Target 1 62 DR Congo Countries Number of ICC Cameroon, Congo, DR Congo (2) Meetings (measured 6 27 Madagascar, Uganda since Jan 2013)

Sustainable Immunization Financing is an initiative of the Sabin Vaccine Institute.

SIF is funded by generous grants from the Bill & Melinda Gates Foundation and GAVI.

2000 Pennsylvania Avenue NW, Suite 7100 Washington, DC, USA 20006 www.sabin.org/sif www.sabin.org/fr (en français) [email protected]

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