Assessment of the Financial Flows in

June, 2016

VillageReach is a global health innovator that develops, tests, implements and scales new solutions to critical health system challenges in low-resource environments, with an emphasis on strengthening the “last mile” of healthcare delivery.

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Table of Contents

Executive Summary ...... 3 Background ...... 3 Methods ...... 4 Results ...... 5 3.1 Planning process ...... 5 3.2 Financial flow ...... 8 3.3 Gavi funding ...... 11 3.4 Challenges that have affected the EPI ...... 13 Discussion and Recommendations ...... 14 Annex ...... 17 List of people interviewed ...... 17 Quantitative questionnaires ...... 18 Qualitative questionnaires ...... 18

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Executive Summary VillageReach conducted a study to identify financial flow bottlenecks negatively impacting Mozambique’s vaccine program (Programa Alargado de Imunização or PAV) at each level of the health system. The study aimed to identify the causes of delays and strategies to improve the financial flow for a more efficient financial management and improved supply chain functioning for routine immunization. Working together with UNICEF, the study used a rapid assessment tool that was developed and first piloted by UNICEF in Uganda, by adapting it to the Mozambique context. The purpose of this tool is to quickly assess areas of financial flow at each administrative level of the government and identify potential solutions to financial flow issues.

Main challenges identified through the study include the following: EPI programs are not always fully implemented as planned, mainly due to limited funding and delayed availability of funds, however it has never completely stopped operations due to lack of funding. Districts and health facilities also indicated not knowing what resources are available to the program.

Recommendations for improving the financial flow include:

 Improve the planning process  Improve monitoring of core immunization service activities and expenses  Build capacity for financial management

Background An immunization supply chain ensures that vaccines and related supplies are available at their intended point of use. The supply chain is an integrated system that must operate from end to end in a reliable, consistent fashion. If the people tasked with operating the supply chain are missing any of the key inputs, the entire supply chain system becomes unreliable or ad hoc, resulting in stockouts, increased supply related costs, and decreased coverage rates.

A critical input into the supply chain is financing. Appropriate financial mechanisms need to be in place to keep vaccines and associated supplies moving through the chain. In decentralized systems, where different actors are responsible for the storage and distribution of vaccines at different stages of the supply chain, this financing can become complicated to quantify, manage, and distribute. Many low- and middle-income countries (LMICs) do not have adequate systems for tracking how the vaccination resource allocations flow through the system down to the point of delivery. Further, there is little documented insight into the financial bottlenecks or accounting methods to track actual compared to planned expenditures along sub- national levels.1 The result is that persistent weaknesses have been noted in securing funds at the lower levels of the chain to deliver vaccines to the child that needs it. 2

1 Kabaniha G, Zikusooka CM, Guthrie T. Financing for immunization at sub-national levels: a systematic literature review. UNICEF. May 2014. 2 Guthrie T, Zikusooka CM, O’Connell T, Kwesiga B, Abewe C, Lagony S, Kanoowe S, Mayanja R. Assessing sub-national bottlenecks for immunization services: piloting a rapid assessment approach. UNICEF. 2014. Page 4

Each country has its own unique challenges facing the immunization supply chain and financial flow, and which need to be evaluated individually in order to determine what is working and what needs improvement or re-evaluation. In Mozambique, the EPI program experiences frequent delays in funding which leads to gaps in on-time deliveries; however, it is not clear why these delays happen or how they can be prevented in the future. Without clarity about where and why the problems occur, appropriate improvements cannot be made. This study aims to identify financial flow bottlenecks in the country’s EPI program, and identify strategies to improve the financial flow to result in more efficient financial management and improved supply chain functioning for routine immunization. Importantly, this is not an academic exercise or extensive diagnostic that will capture all aspects of the financial flows for integrated health interventions. Instead the findings of this financial flow study have the potential to increase clarity regarding the immunization financial flow.

Methods This study used the rapid assessment tool that was developed and first piloted by UNICEF in Uganda. The purpose of this tool is to assess areas of financial flow at each administrative level of the government and seeks potential solutions to financial flow issues.3,4 VillageReach and UNICEF Mozambique adapted the tool to the Mozambique context. The tool was designed to capture information about funding levels and budget requests, funding delays related to requisition and reporting requirements, and funding predictability based on staff’s opinions and perceptions.

The VillageReach portion of this study targeted the heath sector and collected qualitative data through key informant interviews at national level, provincial (Gaza and Cabo Delgado), district (Meudumbe and Meluco

3 UNICEF. Addressing sub-national financial bottlenecks for immunization services: Piloting a rapid assessment approach. September 2014. 4 UNICEF. Financing for immunization at sub-national levels: A systematic literature review. May 2014. Page 5 in Cabo Delgado, and Manjacaze and Chibuto in Gaza), and health facility level (Chaimite in , Gaza, and Muaguide in , Cabo Delgado). The following people were interviewed:

 National Director of Public Health, within the National Directorate of Public Health  National head of EPI, within the National Directorate of Public Health, Ministry of Health  National level Head of Administration and Finance  Provincial heads of Administration and Finance  District heads of Administration and Finance  Directors, Provincial Directorate of Health (DPS)  EPI Managers, DPS  EPI Managers, SDSMAS  Directors, District Directorate of Health (SDSMAS)  Heads of health facilities  EPI representatives at health facilities

UNICEF conducted the same study in two districts in Zambezia where the Reaching Every Community (REC) project is being implemented. The two organizations collaborated with finalizing the survey tool and interviews at the national level MoH, as well as with the MoH partner Deloitte that provides technical assistance to the MoH in terms of financial systems and monitoring.

Quantitative data from provincial and district level was also requested (see Annex 2) to track budget amount requested, received, and the duration of the process, using financial documents from 2014 as a benchmark.

Results This study identified the financial process, from the planning stages to the dispersal of funds, in two provinces in Mozambique. In identifying the steps in the financial flow, several bottlenecks were found to impede the intended financial process. The following section will discuss how activities and budgets are planned and how those finances are intended to flow. Shortcomings and sources of delays will be identified and discussed. Non-governmental financial flows are also discussed, both in terms of their intended flow and how the processes are actually implemented.

3.1 Planning process The financing of Mozambique’s health sector is closely linked to the overall health sector strategic planning process. Mozambique creates their Strategic Plan in five-year planning cycles, where government activities and funds are outlined and approved in five-year increments. A report outlining all planned activities for the next five years is created during strategic planning and followed until the next strategic planning occurs. Within the five-year strategic planning cycles, the government also must prepare an annual Plano Economico e Social (PES), which operationalizes the strategic plan. In principle, the country’s health sector implements, and therefore budgets around, the activities that were outlined in the PES during the previous year.

The planning for both the Strategic Plan and the PES is done individually in every district, every province, and at the national level. However, all budgets must be in line with the goals and priorities the national Page 6 government has set for the specific planning period. The district plans are aggregated at the provincial level and the provincial level plans are then aggregated at national level. The ministerial and other sectors’ plans are aggregated by the Ministry of Economic Planning and Finance, which submits the plan (PES) and the budget to the Parliament for approval.

To ensure that the planning process from the district through to the national level is done on time, the government has set deadlines for each planning level to follow to submit its plan to the next level (see Table 1 and 2).

Table 1: Central (National) level planning calendar

National Provincial District Annual PES review January 20th to MPD* Until January 10 Until January 20 Until January 15

Semiannual PES review July 21 to MPD Until July 15 Until July 10 Until July 20 Integrated planning - June May through June Final PES Turn in to the MPD by July Until July 15 Until June 30 31 Deadline until July 30 PES adjustment with - June June planning *MPD: Ministry of Planning and Development

Table 2: National level planning calendar translated to English

In order to help in the planning process and meet deadlines, the health sector at the provincial level has created planning support teams, which assist the districts in ensuring that their plans are of acceptable quality and submitted on time. During the district planning period, the support team makes visits to each district in the province. Page 7

Findings showed that, generally, the plans are prepared and submitted on time from the district to the provincial level and from the provincial level to the national level. It is notable that the calendar for the national level is not quite clear with multiple dates for different activities (see submission note in Table 2). Respondents also indicated that despite having the support teams, the plans do not meet the required quality due to lack of qualified staff for planning, in addition to the fact that new planning guidelines are often introduced and planning staff are not informed or trained on how to use the new guidelines which results in misinterpretation and poor quality submissions.

Respondents indicated that despite having support teams, the plans do not meet the required quality due to lack of qualified staff for planning, in addition to the fact that new planning guidelines are often introduced and planning staff are not adequately informed or trained on how to use the new guidelines which results in misinterpretation and poor quality submissions.

Figure 1: Provincial plan submission note to the Provincial Directorate of Planning and Finance

The plans that do not meet acceptable standards are sent back to the districts or provinces for improvement. This back-and-forth process delays the final submission of the plan. However, there were no reports about the PES not being approved by Parliament due to these delays.

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When PES and the national budget are approved, the Ministry of Economy and Finance informs the different levels. While the Ministerial plan compiles the provincial and district plans and can be approved with few or no amendments, the budget is always drastically reduced. As a result, consolidation, adjustment and re-planning are required to fit all planned activities into the total budget allocated. This re-planning takes place in January.

Figure 2: Incomplete results of the survey form requesting information for budget information for 2015. The second column (B) list the amount of funds requested while the third column (C) lists the amount of funding received. Note that column C is left entirely blank.

The extent of the consolidation, adjustment, and re-budgeting When PES and the national budget needed remains unclear as neither province was able to are approved, the Ministry of complete the quantitative data requested as part of this study. Economic Planning and Finance One province reported information on budget requested but informs the different levels. While could not provide information on funds that were actually the Ministerial plan compiles the received related to that budget (Figure 2). Additionally, none of provincial and district plans and can the individual respondents in either province could confirm be approved with few or no dates of funds requests and received to track the true time and amendments, the budget is always process. Each respondent noted the insufficient funds available drastically reduced. for EPI, but were unable to provide specific justifications or quantifications of the actual gaps.

3.2 Financial flow The financial flow in the health sector has two main paths: (1) the Government Finance Administration System (SISTAFE) path, funding through the Ministry of Health (MISAU), which plans health related activities at the national level, the Direção Provincial de Saude (DPS), which sits at the Provincial level and manages all health related activities, and the District Service of Health and Social Affairs (SDSMAS); and (2) donor support direct to sub-national levels.

3.2.1 SISTAFE Path Each year, the PES budget includes various financial flows, representing a variety of programs and donors. Once Parliament approves the budget, the Ministry of Economic Planning and Finance can disperse the funds to the appropriate levels and users. All government funds are first deposited into one central bank Page 9 account managed through SISTAFE, which is an electronic accounting system created to limit the corruption and misuse of funds and to ensure the appropriate end parties receive the budgeted funds.

Once the funds are in SISTAFE, the Ministry of Economic Planning and Finance must register all planned activities into the system. Upon completion of the registration, the money can be released directly to the Ministry of Health (MISAU), the Provincial Directorate of Health (DPS) and to the District Services of Health, Women and Social Action (SDSMAS). As such, the provinces and districts do not depend directly on the administrative levels above them (e.g., MISAU and the DPS respectively) for their finances. There are some exceptions to this direct deposit pathway, namely the funds used for National Health Week. In this case, MISAU sends the funds to the DPS, which then sends the funds to SDSMAS. The health units do not manage their own funds rather all goods and services used by the health units are paid for directly by SDSMAS or the DPS.

The PES is approved or denied by the Parliament in November or December, but each level does not find out how much money has been allocated to their activities until January. Budgets that are managed through SISTAFE are sent to MISAU, DPS and SDSMAS during the first or second week of January. For example, users were informed of their 2014 budgets on January 9, 2014 and their 2016 budgets on January 8, 2016. The 2015 cycle differed from this usual trend as the budget was not approved by Parliament until April 2015 (instead of November/December 2014) due to the general election process.

While users learn about their budgets in early January, funds are not immediately available. It may take up to a week for the funds to be available for requesting. Once they are available, MISAU, DPS and SDSMAS must call/register for funds by submitting a funding request. Once funding is requested and approved by the Ministry of Economic Planning and Finance, it is scheduled to take approximately two weeks for it to arrive into the bank accounts. In reality, however, funds are distributed for use in February, or about six to eight weeks after MISAU, DPS and SDSMAS registration of funds are submitted, and are far below the amount budgeted and requested. Page 10

By January, before the new funding is available and deposited, By January, before the new funding is MISAU, DPS and SDSMAS typically have very little money available and deposited, MISAU, DPS available as any remaining funds in December must be and SDSMAS have very little money returned to the national level at the end of the year to be available as any remaining funds in reallocated into the budget. This compromises the completion December must be returned to the of EPI activities, particularly the mobile brigades (groups of national level at the end of the year to health workers that travel to remote areas and perform be reallocated into the budget. This vaccination campaigns). An additional constraint to this compromises the completion of EPI system is the preparation of bids and contracts for goods and activities, particularly the mobile service providers. The contracting process can take up to two brigades (groups of health workers months and cannot be initiated until the annual budget is that travel to remote areas and approved and available. This can delay the delivery of those perform vaccination campaigns). goods and services significantly.

The EPI does not have a specific budget line of its own - the funds that cover EPI activities are mixed with all other DPS programs. According to the EPI staff at the provincial level, EPI activities occur evenly throughout the year. However, some programs like Malaria or Nutrition that share the same budget line categories and funds with EPI have months of intensive or high-level-of-effort activities and concentrated periods of high spending. This is an issue for fuel or other transport and distribution costs that are used in large quantity during campaigns or outreach events for these programs, but which are also needed for routine vaccine distribution every month. For example, the nutrition program implements a National Health Week in April and November and the malaria program implements bed net distribution campaigns prior to the rainy season in September/October. Respondents felt that these periodic intensive activities drain the budget available for EPI activities.

Currently, the authorities at each level cannot qualify how much has been spent on EPI, partly due to EPI not having its own budget line. Additionally, the EPI program EPI does not have a specific budget line cannot directly access the funds as they do not manage the of its own so shares resources with budget. MISAU, DPS and individual district official have other programs; this has an impact access to the funds. EPI officials have no role in budget when other programs spend more and management. Finally, when money is requested by any more quickly, thus reducing funds program, there is no system that tags or labels what that available for EPI. money is being used towards. Any money that EPI requests and receives is not tracked as money specifically for the program.

The DPS and MISAU can request funds from SISTAFE as they are the approved end recipients. SDSMAS, on the other hand, are not yet official SISTAFE terminals and they must access and manage their funds through the district secretary. This adds about two weeks to the disbursement of funds.

Once the funds are available in SISTAFE, the funds must be formally requested. According to participants in the study, there are always issues with communications between different structures/departments, which results in additional delays to the funding calendar. Without clear and direct communication, departments do not know what others are doing, which results in duplication of efforts or things being forgotten. Page 11

Within the Ministry of Finance, the Division of Accounting and Accountability is a new department with the responsibility for managing and tracking MISAU, and DPS expenses as this division becomes better established, they will have the capability to track all EPI-related funding and thus better plan accurate budgets.

3.2.2 Donor support direct to sub-national levels

This pathway is used for partners/donors who provide funding directly to the national, provincial and/or district levels. According to respondents, the amount of funding that partners can give is discussed during the PES planning period – May/June of the year before the funding is needed. The district or province directors inform the next administrative level up how much partners have agreed to give. They also indicate a specific activity or program that will benefit from partners’ funding. Respondents have the perception that the national level reduces government budgets to the province and districts when partner funding is available, although there is no documentation to support this perception.

For example, if a partner agrees to give 100,000 Meticais, the director of the district or province must specify to the higher administrative level where and how that money will be used. The conditions for receiving the funds, their purpose and management plan must be outlined in a Memorandum of Understanding (MoU) between the partner/donor and the MoH and/or DPS. According to the DPS, partner funding should also go through SISTAFE as the Mozambican government is trying to ensure that all funding that is spent in the country, whether it be governmental or donor funding, is passed through the system before dispersal to the end-users. However, this typically doesn’t happen as some donors prefer to support directly at sub-national level and are wary to pass donations through the national system. Thus, this system may not capture all funds available in a province if partners choose to pay directly for activities or services, thus additionally skewing the understanding of true costs of EPI.

MISAU, DPS and SDSMAS all maintain more than one bank, each for funds from a different partner/donor. This allows each donor to audit the use of the funds and facilitate specific activities. Such partners/donors include Elizabeth Glaser (HIV/AIDS pediatric), Agha Khan (for nutrition), Save the Children, World Vision, and UNICEF.

3.3 Gavi funding Gavi, the Vaccine Alliance, which supports immunization related activities, has supported the EPI in Mozambique for the past 15 years. Most recently, Gavi supported the introduction of the Rotavirus vaccine and the Inactivated Polio Vaccine (IPV). They also recently approved financial support for a Health System Strengthening (HSS) grant for 2014-2018. Despite Gavi having released these funds in July 2015, funds became available for use by the Provinces only during the second quarter of 2016.

A series of delays and bottlenecks has delayed the use of these funds significantly. Typically, donor funds would be released to a designated transitory forex account at Banco de Moçambique where all other financial support for MISAU are deposited. Upon receipt of the funds, Banco de Moçambique transfers the money to the unique treasury account Conta Unica de Tesouro (CUT), housed in the Ministry of Finance (MOF). Once this is complete each level of the Ministry of Health (MISAU, DPS, SDSMAS) is told the money has arrived. Once each level is informed, they must formally ask for the money to be made available for their use. When the requests for the money are approved, the money can then be transferred to local Page 12 ministry accounts. The entire process – from the time the funds are deposited into the forex account to the time it arrives in the local ministry accounts – take approximately 12 weeks.5

Arrival of Funds arrive in Transfer of money into transitory funds to CUT at sub- forex account the MOF national from Gavi accounts

Figure 3: Gavi Financial Flow in Mozambique

In the case of the HSS grant, Gavi released the funds in July 2015 to the Banco de Moçambique; yet they were not made available for use until December 2015, which is longer than the general 12 weeks. Respondents say that these delays occur when funds for a new project are deposited and personnel have to organize the new process. After the first installments are pushed through the flow, subsequent installments allegedly should be distributed to their end users more quickly and delays should be less common.

Provinces were informed on March 16, 2016 by MISAU that the HSS funds were available. Once they were informed of availability, Provinces had to register for use of the funds and still follow the lengthy request and disbursement process that must be repeated again by the district level. This was considerably more time than Gavi and partners anticipated it would take for the funds to arrive to the provinces. Once the funds arrive at the provinces, they are controlled by the Medical Chief and/or the Provincial Director. It should be noted that the HSS funds have a separate budget line specifically for EPI activities. The EPI director can use those funds directly without having to compete with other programs or activities.

The districts revised their planned activities and budgets for the HSS grant and submitted the revised plans to the provinces when the Gavi funds arrived in the country in mid-2015. However, as of April 2016, the districts do not yet know if they will receive the amount they requested. Without this, they still do not know which of their planned programs they will be able to implement. The Ministry of Health processes and sends the HSS disbursements to the Provinces. The Provinces, once they have the funds, can determine how much money each district gets and disperse the money. It took MISAU nearly five months to distribute the funds to the Provinces, and an additional 4 months for the provinces to actually access the funds from the system which caused great delay in knowing how much funds were actually available versus requested and which activities to prioritize accordingly.

5 Gavi Full Country Evaluations Team. Gavi Full Country Evaluations: 2015 Dissemination Report, Mozambique. Seattle, WA: IHME, 2015 Page 13

3.4 Challenges that have affected the EPI According to respondents, the EPI has never completely stopped operations due to lack of funding. However, they recognize that the EPI programs are not always fully implemented as planned, mainly due to limited funding and delayed availability of funds. The delayed availability of funds highly affects the EPI activities, especially in January (as described above).

Additionally, the budget line for EPI activities is shared between several other programs and, as previously noted, is made without understanding true costs of activities. Because multiple program’s budgets are pooled, there appears to be more than sufficient money in the account. As such, the head of Department of Finance at each level sees that there are funds in the shared budget line, s/he often approves the implementation of the programs with intensive activities, which results in a relatively high expenditure of the budget. This process negatively affects the implementation of other, even-spending programs like EPI.

Many EPI activities are negatively affected by limited funding and delayed availability of funds. EPI programs require reaching isolated and hard to reach communities typically done through mobile brigades and educational activities. Additionally, planned activities include building capacity of staff, maintaining the cold chain, and providing monitoring and supervision across all vaccination activities, all of which require access to funds for operational expenses such as paying for fuel and per diem.

It is interesting to note that efficiency was not a consideration in responses to this study. Budgets are cut due to lack of funds availability, yet the planning required isn’t linked to where spending could be more efficient.

When funds are available in the system (SISTAFE) for use, the provinces and districts must submit a request for use of the funds. Once use is requested, respondents indicated that it may take up to two weeks for the funds to be approved and disbursed once the request has been submitted, further delaying and jeopardizing EPI activities. Examples of challenges that arise from delayed funding are:

 Falling behind on routine maintenance of fridges which forces staff to use a seven day cooler box, which is unreliable and results in vaccines spoiling.  Inability to finance mobile brigades meaning that those who live in remote areas will not get vaccinated.  Delays in distribution which can lead to stockouts.

One solution in place to mitigate the effects of limited funding, delayed disbursements, and programs with shared budgets is that the EPI managers get fuel from trusted suppliers on credit and repay them later when funding is available, or will buy fuel in bulk before the funds are used by other programs. Page 14

Discussion and Recommendations This study identified key bottlenecks in the health system’s financial flow across all levels and asked respondents to identify potential solutions, both immediate and long-term, to address the bottlenecks. It should be noted that the information and recommendations presented are based on qualitative interviews in only two provinces; as such the opinions presented are doubtlessly biased and may not be generalizable to other provinces in Mozambique or other funding stream and categories. Despite this limitation, this study serves as a good preliminary step to bring attention to the limited knowledge surrounding the financial flow as well as the intricacies of the current system. We recognize the design of this study using a rapid assessment tool presents only a high level view of the issues; much more can be done to better understand the minutiae of the issues and which potential solutions can be introduced.

The following recommendations for the Mozambique MoH build on information gathered through these qualitative interviews and experiences from other countries in addressing financial flow issues.

EPI Specific Recommendations:

A. Monitoring core immunization service activities and expenses

There is no reliable tracking of immunization budget and activities. Study participants were unaware of how much money was spent annually on EPI activities and did not have any mechanism of tracking or reporting the amount of money spent. Additionally, there is no way to ensure that the data that is being collected is accurate. To date, the country’s focus has been on improving estimates of vaccine coverage but there have been little to no efforts to implement budget tracking for core immunization activities.

Overall, no one could give a reliable estimate on the number of supervisory visits each health center receives annually, the number of planned and completed vaccine outreach sessions each district conducted, and other similar routine vaccination measurements. Without this information, it is impossible to develop reliable estimates of unit costs of each activity in order to put together a cohesive and accurate budget each year. Additionally, there was no information on the actual vs. planned outputs, making it impossible to determine how much money and time are actually being spent on completed immunization service activities.

A. Understand the true costs of EPI activities. Without a true understanding of costs, the PES planning process is breaking down and an accurate budget cannot be completed. As of now, the EPI program is competing with other programs for a share of the overall health budget. Without reliable estimates of how much EPI activities cost, there is no way for them to ask for the appropriate budget.

This extends to planning a budget that matches the activities and particularly the distribution system. In Gaza and Cabo Delgado, the DPS is responsible for paying for distribution from the province level directly to health facilities. However, the district budget does not reflect this in the sample collected for this study, showing requested funds for distribution costs (Figure 2).

B. Create a budget line for EPI in SISTAFE. Large gaps in activity tracking and budgeting were found throughout this assessment. One of the most concerning is the EPI’s lack of its own budget line, which means EPI officials have to compete with other programs for funding. An EPI-dedicated Page 15

budget-line in SISTAFE would give the EPI program teams a clear budget each year and allow them to begin establishing an expense tracking system, also providing insight into true costs.

C. Adapt planned activities to fit within the known budgeting delays. While it is impossible to change the time when budgets are submitted and funds are distributed, it is possible to factor delays and funding shortages into the budget. Planned activities that require significant investment, such as mobile brigades, would be best suited to be planned between March and November when there is still sufficient funding available. Additionally, district and provinces know that there is often insufficient funding for fuel by January. As such, they can plan ahead and deliver double the vaccine amount delivered in December. This makes distributions in January unnecessary but also prevents stock-outs. Other usual delays should be factored into the budget and planned activities throughout the year.

D. Prioritize, budget for and track vaccine distribution costs. Moving forward, EPI officials need to prioritize and adequately budget for vaccine distribution as well as track the costs. The HSS funding presents a unique opportunity for this to be done. With better understanding of the true costs, EPI managers will be better equipped to appeal to the government and donors for funding. By having a concrete budget that is fully supported with the unit cost of each activity, donors will clearly see what their money will support. Additionally, the government will be able to track activities and milestones achieved through the funding for distribution costs. A common phrase in Mozambique sums this up well: a criança que não chora, não mama (the child that doesn’t cry, doesn’t eat).

B. Performance-Based Financing

Many governments and organizations have used performance-based financing with positive results. The many different models are all tied to providing incentives for good performance and meeting predetermined metrics. In terms of the vaccine supply chain, performance-based financing has the potential to find efficiencies and decrease stockout rates. This promotes finding efficiencies while ensuring that all metrics are being met.

Past studies of performance based financing in low and middle income countries have shown that PBF can successfully shift the focus of the financial flow from input to output funding. PBF directly impacts the structure of the financial flow – duration of fund holding, accountability and transparency.6 These improvements are made in large part because of the increased focus on budget tracking and payments. In order for PBF to be effective, the incentive payments must be dispersed and tracked on time. This puts pressure on the overall system to improve the financial flow and general tracking of spending and outcomes.

C. Build Capacity for Financial Management

This financial flow study has demonstrated a general gap in knowledge of how to manage tracking of finances for EPI related activities. This gap stems from two closely related sources– a lack of know-how regarding budget and financial tracking and absence of detailed costs and expenses. In order to correct this gap in the future, it is recommended that EPI managers begin to build financial management capacity within their program Improved tracking of spending is needed in order to get money to where it is most needed.

6 http://www.who.int/contracting/PBF.pdf Page 16

Project like Deloitte’s FORSASS have worked with provinces and some districts to install SISTAFE; some organizations like Elizabeth Glaser have also provided additional training and support to government administration and finance staff. These activities need to continue with a focus on better understanding of true costs.

Related to financial management capacity, special attention needs to be paid to the Gavi HSS grant and management of those funds at each administrative level. Results from this study indicate that procedures and responsibilities for managing those funds are still unclear at the provincial level and down. Once there is more clarity on the procedures and responsibilities and a clearly identified capacity for financial management, focus can turn to finding efficiencies in the system.

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Annex

List of people interviewed National Level Dr Mbofana (National Director of Public Health) Dr Graça (Head of EPI at the Ministry of Health)

Gaza Province

1. DPS  Provincial Doctor in charge (Dr Alface)  Head of Finance and Administration (Dr Artur Gonçalo)  EPI representative (Mr Majamo Machatine)  Head of Planning (Dr Luis Machai) 2. SDSMAS -  District Director (Dr Andre Paulo)  Doctor in Charge (Dr Cremildo Antonio)  Head of EPI (Ms Pricilia Antonio)  Head of Finance and Planning (Ms Lucia Nhone Machava)  Head of Community Health Sector (Mr Donaldo Artur) 3. SDSMAS – Chibuto District  Head of EPI (Mr Arlindo Mudumbe)  Head of Finance and Administration (Jéssia Claudina António)  Preventive Medicine Technician (João Nhacoonga) 4. Chaimite Health Centre – Chibuto District  Anastância Saveca (Head of the Unit)  Penicela Miambo (EPI and SMI technician)

1. DPS  Provincial Director (Dra Sãozinha)  Head of EPI (Momino Mussa)  Head of Finance and Administration (Orlando Muianga) 2. SDSMAS – Meudumbe District  District Director (Dr Abel Maio Jaime)  Head of EPI (Pedro Munongoro) 3. SDSMAS – Meluco District District Director – Substitute - (Daniel Bandeira) Head of EPI (Mr Pelicharde Abdala) 4. Muaguide Health Centre - Meluco District Rosalina Arune (EPI and SMI) Page 18

Quantitative questionnaires

Quant-Questionario Quant-Questionario Quant-Questionario Quant-Questionario Nacional Final.docx Distrito Final.docx Centro de Saude Final.docxProvincia Final.docx Qualitative questionnaires

Questionario Questionario Questionario Centro Questionario Nacional Final with UNICEFDistrito Comments.docx Final with UNICEFde Saude Comments.docx Final with UNICEFProvincia Comments.docx Final with UNICEF Comments.docx