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Asia Peer Review Workshop on Sustainable Immunization Financing Practices

Phnom Penh, Cambodia

July 21-23, 2014

Report Prepared by the Sabin Vaccine Institute

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Contents

Introduction ...... 3 Workshop Goals ...... 3 Methods ...... 3 Proceedings ...... 3 Day One ...... 3 Opening remarks ...... 3 Theme I: Budgeting and Resource Tracking ...... 5 Theme II: Immunization Legislation ...... 8 Day Two ...... 9 Theme II: Immunization Legislation, continued ...... 9 Peer Review Exercise ...... 13 Day Three ...... 15 Theme III: Advocacy in Practice ...... 15 Workshop Evaluation ...... 15 Closing Remarks ...... 16 Annex A ...... 17 Annex B ...... 19 Annex C ...... 23 Annex D ...... 25 Annex E ...... 29 Annex F...... 31 Annex G ...... 34 Annex H ...... 35

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Introduction Since 2008, the Sabin Vaccine Institute has been working with fifteen lower and lower middle income (LLMICs) in Africa and Asia through its Sustainable Immunization Financing (SIF) Program. The focus of the Program has been on nurturing innovations- new ways of working- by national counterparts within the key public institutions concerned with health financing. In August 2013, peers from the SIF countries reviewed their innovations in a Sabin-organized SIF Colloquium in Dakar, Senegal. Since then, the six Asian SIF countries have made further progress toward the sustainable immunization financing objective. To assess this progress, Sabin and the Government and Parliament of Cambodia organized the “Asia Peer Review Workshop on Sustainable Immunization Financing”, which took place on 21-23 July, 2014 in Phnom Penh, Cambodia. Representing the Parliament of Cambodia were Senators, Representatives and staff members from the Senate and National Assembly. Representing the Cambodian Government were officials from the Ministry of Health (MoH), Ministry of Economy and Finance (MoEF) and the National Development and Planning Agency (NDPA). Joining them were parliamentary counterparts from Mongolia, Nepal and Sri Lanka and ministerial counterparts from Indonesia, Mongolia, Nepal, Sri Lanka and Vietnam. The workshop was facilitated by counterparts from WHO (Cambodia and Indonesia), UNICEF (Cambodia, Nepal and Indonesia) and two Sabin Senior Program Officers. The list of participants is shown in Annex A. Workshop Goals The goals of the workshop were to: a) Identify and share best financing, budgeting, resource tracking and advocacy practices; b) Assess proposed immunization-related legislation c) Document institutional innovations to achieve sustainable immunization financing in the six countries Methods The workshop employed a peer-to-peer learning approach (Annex B). Delegates worked in small groups and interacted collectively in plenary discussions. External partner agency counterparts facilitated the small groups and documented the proceedings. A formal peer review exercise was carried out in which each delegate was asked to assess work in three other countries. A standard checklist was used. Upon completion of the workshop, delegates presented their results to parliamentarians in the Cambodian National Assembly.

Proceedings Day One

Opening remarks

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Mr. Hok Khiev, Director of the Department of Legislation, Ministry of Health of Cambodia, welcomed the participants and presented the workshop objectives. He then described recent developments regarding Cambodia’s draft immunization law. Dr. Devendra Gnawali, Senior Program Officer, Sabin Vaccine Institute, summarized the evolution of SIF Program advocacy work with the Asian countries, highlighting the periodic peer exchanges through which peers from the countries learned from one another. The parliamentarians engaged in these exchanges generated a series of influential parliamentary declarations which testify to the countries’ commitment to achieving the sustainable immunization financing objective. In the Dakar Colloquium, recalled Gnawali, the innovative work undertaken by the Asian peers was plain for all to see. The SIF Program has since grown to twenty-two countries with the Asian countries setting the pace so far.

In his remarks, Dr. Shafiqul Hossain, representing WHO/Cambodia, emphasized the importance of sustainable immunization financing to health systems. This is an area where WHO is committed to supporting ministries of health, he added. WHO works as well with UNICEF, Sabin and many other development partners, at national, regional and global levels to accomplish this goal.

Dr. Chheng Morn, Deputy Manager of Cambodia’s National Immunization Program (NIP), provided an overview of national immunization financing. The Program budget has steadily increased in recent years, he stated, indicating the government’s growing financial commitment to the Program. Complementing Dr. Morn’s presentation, Mr. Kim Phalla, Deputy Director General, Department of Public Finance Policy in the MoEF, explained the policy basis for the government’s increasing support to immunization. The country’s national health and development plans squarely recognize the important contributions immunization that makes to the nation’s health and prosperity.

H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of the Cambodian Association of Parliamentarians on Population and Development (CAPPD), noted the important complementary role external partners and civil society organizations have played in the development of the NIP. Their efforts have helped the Royal Government of Cambodia to build the program. He then described how the Cambodian Parliament has also emerged as a key NIP supporter in recent years, reflecting the leadership of Prime Minister Hun Sen who has revitalized the country’s health sector through the Government’s Rectangular Strategy for Growth, Employment, Equity, and Efficiency.

Following these opening remarks, the workshop took up three technical themes, the results of which are summarized towards the end of this report. P a g e | 5

Theme I: Budgeting and Resource Tracking Plenary session (Chair: H.E. Mr. Ouk Damry) Dr. Shafiqul Hossain, WHO/Cambodia, summarized the Global Vaccine Action Plan (GVAP). He said that WHO/WPR has developed a Regional Framework for Implementing the Global Vaccine Action Plan which translates the strategies and activities recommended by the GVAP into the Western Pacific Regional context. Dr. Hossain stated that GVAP charts a path for necessary changes in the immunization field. Particularly significant, he added, is the GVAP Monitoring and Evaluation/Accountability Framework, through which WHO Member Countries are annually reporting their progress toward the six GVAP strategic objectives. To fix ideas for this first technical theme, Dr. Devendra Gnawali shared a presentation entitled “Budgeting and Resource Tracking for Immunization: Concepts and Applications”. In the presentation, Dr. Gnawali summarized how LLMIC immunization programs are currently being financed. The poorer countries are still largely dependent on external funding. Estimating progress toward sustainable immunization financing is difficult due to the poor quality of the available immunization expenditure data. Governments report their routine immunization expenditures annually through the WHO/UNICEF Joint Reporting Form (JRF). Sabin analyses have revealed that the JRF expenditure data are widely under-reported and misreported. These reporting problems need to be fixed. JRF Indicator 6500 (government expenditures on routine immunization) is a key indicator in the GVAP Monitoring & Evaluation/Accountability Framework; it is the best direct measure of country ownership and financial sustainability, Dr. Gnawali stressed. It is up to immunization program managers to find ways to improve, and to themselves utilize, those expenditure data. Proper expenditure reporting will help managers make their immunization programs more efficient. They can use the data to compare actual vs. expected expenditures. Secondly, they can use current expenditures to formulate the coming year’s budget. Each delegation then presented its innovative work in this area.

Cambodia Ms. Bola Kan, Deputy Chief Officer of the Budget Department, MoEF, addressed the theme “Budgeting and Resource Tracking Practices in Cambodia”. Her focus was on public financial management structures and current budget practices, including Cambodia’s budget cycle, budgeting, and resource tracking processes. One innovation her Department is discussing is performance-based budgeting. In this approach, managers cross-analyze program and financial information to make programs more efficient and budgets more realistic. Human resources and procurement are two areas where the MoEF and MoH could cross-analyze expenditure data with program data to the benefit of Cambodia’s immunization program. The main problem is that current information systems are not quite up to the task. The MoEF is working to institute timely, comprehensive expenditure tracking procedures whereby line ministries will submit P a g e | 6

more punctual and detailed performance reports to MoEF, which would then do the needed analyses and produce the feedback to each ministry. The immunization program is a good place to start this kind of innovation, concluded Ms. Kan. Dr. Chheng Morn, EPI Manager of the Cambodian Ministry of Health spoke next, sharing his views on these budgeting and resource tracking concepts. The need to innovate is growing, he said, as government immunization spending continues to increase. The MoH has committed to strengthening routine immunization, including financial management of the program. The Ministry continues to meet its (Gavi) grant co-payments for pentavalent and pneumococcal vaccines, and is prepared to absorb the additional co-financing costs associated with the introduction of the Japanese Encephalitis vaccine. Mongolia Dr. Ganchimeg Ulziibayar from the National Center of Public Health, Ministry of Health, described current immunization financing and resource tracking practices in Mongolia. The Mongolian EPI program was 100% dependent upon external development partner support until 2000. Since then, the government share for immunization financing increased from 7% in 2003 to 89% in 2011. A National Immunization Foundation was established in 2001 under Government Order N67. Its associated trust fund serves as the main resource tracking mechanism for the national immunization program.

Dr. Ulziibayar offered three recommendations to countries considering the establishment of such a fund. 1. Stakeholders should first map out resource tracking gaps, compile all relevant legal and regulatory documents, and then harmonize them to devise a bridled strategy. 2. The immunization program team should conduct an immunization cost analysis at subnational levels. 3. The immunization program team should develop the best corresponding expenditure tracking system and link it to the disease surveillance system.

Sri Lanka Mr. Sameera Wickramasinghe, Director of the Budget Department, Sri Lankan Ministry of Finance and Planning, presented Sri Lanka’s budgeting and resource tracking practices. The government accounts for 90% of the immunization budget, reported Mr. Wickramasinghe. The remainder is funded by international partners. Because the immunization budget is comingled with that of other health programs, immunization expenditures are not readily identifiable. With Sabin support, the Department of Epidemiology of the Ministry of Health recently carried out a routine immunization costing study in one district. Results were extrapolated to estimate national routine immunization costs. The study revealed that the estimated per capita cost to P a g e | 7

immunize a child under five years is ~USD13.00 (excluding vaccine costs). The Epidemiology Unit plans to repeat the study in four other districts. Indonesia Mr. Entos Zainal, Head of Health Promotion and Nutrition Community Sub-Directorate of the National Development Planning Agency, outlined Indonesia’s health expenditure data and tracking mechanisms for routine immunization and other programs. The expectation is that a new government-wide e-Monev resource tracking mechanism, established in 2013, will capture immunization expenditures as well. The e-Monev system operates at national and subnational levels. However, the Federal Ministry of Finance alone has the authority to trace expenditures and this information is not yet available to the immunization program, precluding expenditure tracking. Taking another approach, the Ministry of Finance recently partnered with UNICEF to conduct a four-district resource tracking study in East Java. In order to institutionalize quality resource tracking, however, Indonesian stakeholders must advocate for new or amended legislation, whether a law or a Presidential decree. Nepal Mr. Shambhu Prasad Jnawali, incoming national immunization manager, Ministry of Health and Population (MoHP), described how his program does resource tracking and financial reporting. Expenditures are tracked for cold chain maintenance and equipment, human resources and monitoring & supervision functions. Mr. Jnawali explained that Nepal’s JRF under-reporting is due to the omission of shared system expenditures for immunization. This problem aside, the government expenditure reporting and monitoring system is robust. Mr. Jnawali described how it works: 1. Regional and district level health officers submit their monthly expenditure and programmatic reports to the District Treasury Controller’s Offices (DTCOs) before the 7th of every month. They send analogous quarterly reports to the Finance Section in the MoH Department of Health Services. 2. Each DTCO submits its combined financial report to the Office of the Auditor General Control. The latter audits and verifies the reports before entering them into the National Compilation Form, which is relayed to the Auditor General. 3. The Auditor General enters the information from the National Compilation Form into the annual financial report and conveys it to the President of Nepal.

As far as formal financial control is concerned, the system is effective, stated Mr. Jnawali. Thinking of the immunization program’s needs, he suggested one innovation: that regional and district level authorities submit their information to the DTCOs online. The digitized, pre- audited information could then be more easily made available to immunization and other managers. P a g e | 8

Mr. Jnawali next outlined the immunization program budget cycle: 1. The MoHP immunization program submits its budget request to the Department of Health Services (DoHS) 2. Upon approval, the DoHS Finance Section distributes the funds to each DTCO 3. The DTCOs allocate the funds to their respective Regional and District Health Authorities

In summary, stressed Mr. Jnawali, the current government disbursement and transfer systems are adequate but are not granular enough to track program resources and expenditures. The Program Division of MoHP is currently developing guidelines for resource tracking which will be piloted in three districts. Vietnam Dr. Nguyen Van Cuong, Deputy National Immunization Program Manager, National Institute of Hygiene and Epidemiology, next presented his Program’s recent advances in budget allocation and resource tracking. Over the period 2006-2014, the government Program budget rose to US$14.2m-a 250% increase. Engaging provincial immunization managers in resource tracking has been an effective innovation. Expenditure reporting has risen from around half to nearly all of the 63 provinces. The improved reporting helped the program avert a planned budget cut last year. Theme I: Small Groups After the plenary session, delegates were assigned to work in small groups. External partner counterparts facilitated the group work using the nominal group technique. The theme for the group work was resource tracking experiences for immunization. The small group findings were reported out in plenary by a six-person panel consisting of one spokesperson for each country delegation. The presentations were followed by a question and answer session. Small group results are shown in Annex C.

Theme II: Immunization Legislation Plenary session (Chair: H.E.Mr. Ouk Damry) As an introduction to this theme, Dr. Khongorzul Dari, Senior Program Officer, Sabin Vaccine Institute, presented the provisions of a model immunization law and outlined the steps through which such a law is created. The model law, outlined below, is based on research in Latin America.

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Declarative Criteria Free Vaccination Free and universal provision of vaccines by the government for all citizens; vaccination as a free public good, guaranteed by the state. Compulsory Vaccination Mandatory vaccination of all citizens

Financial Criteria Budget Line Required line item in national budget for vaccine purchase and immunization program

Tax Exemptions Guaranteed tax exemptions for the importation of vaccines, vaccine-related supplies, and cold chain materials Supply Mechanism Identification of specific procurements mechanism (e.g. Revolving Fund) to guarantee a safe, efficient and reliable supply of vaccines and vaccine-related supplies

Operational Criteria Regulatory Oversight Established regulations on vaccination program to ensure safe, efficacious vaccines are administered Immunization Schedule Required definition of a national immunization schedule

Enforceability Established sanctions for failing to comply with provisions of law (fines, restrictions on school entry, etc.) Existence of NITAG Legally chartered National Immunization Technical Advisory Group

(Source: Trumbo et al 2012) Among its provisions, a model vaccine law ensures free, universal access to immunization. Public financing sources are defined as are vaccine procurement procedures. Any law is designed to give general direction and orientation. Actual implementation of the law is through more detailed regulations, executive decrees and other executive instruments. The presentation was followed by an open discussion. With this, Day One came to a close.

Day Two

Theme II: Immunization Legislation, continued Dr. Dari opened Day Two with a summary of the proceedings of Day One. Delegations then presented their legislative projects. The status of the six projects is summarized in the figure below. As can be seen, the three newest SIF countries, Indonesia, Mongolia and Vietnam, already had vaccine laws in place before joining the Program. Of the remaining three countries, Nepal moved two stages forward since the August 2013 Dakar Colloquium.

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Legislative projects, SIF Asian Countries (May 2014) Phase I Phase II Phase III Phase IV Phase V Phase VI Bill Background Legislative Drafting of SIF-pilot Countries Stakeholder Submitted Passage of Legislative Strategy Bill/ Consultation to Bill Research Selected Amendments Parliament Cambodia Phase III Indonesia† Mongolia† Nepal* Phase V Sri Lanka Phase II Vietnam† † Laws passed prior to joining the Sabin-SIF Program. * Moved one or more phases since August 2013.

Following this introduction, each delegation presented its immunization law or legislative work in progress. Cambodia: Dr. Koam Sinoun, Deputy Director of Department of Legislation, Ministry of Health, outlined the key provisions of Cambodia’s draft immunization law. Mandatory, Universal Vaccine Uptake: The draft law stipulates that all citizens must uptake all vaccines introduced by the National Immunization Program. Country Ownership: The draft law ensures that the Royal Government of Cambodia shall provide sufficient funds for implementing the national immunization program. The government will cover the cost of vaccines, vaccine and cold-chain equipment, and distribution and logistics at the national level. Immunization Fund: The draft law envisions the establishment of a Vaccination Fund and National Immunization Council to oversee the Fund. The Health Minister will chair the Council with participation from relevant ministries and institutions. The composition, organizational structure and operation of the council will be determined by a sub-decree. Tax Exemptions: The law will exempt vaccines and vaccination equipment from import taxes. Penalties: The provision of penalties for parents of unvaccinated children was widely discussed. Participants, especially those from Cambodia, suggested this provision be revised.

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Nepal: Mr. Komal Acharya, Under Secretary (Legal) of the Ministry of Health and Population, presented the declarative, financial and operational provisions included in Nepal’s draft immunization law. Free, Universal Vaccine Uptake: The law provides that everyone has the right to be vaccinated and that the government will provide free vaccines via the National Immunization Programme. It is strictly prohibited for an institution, individual, or group of people to impede vaccine delivery. Country Ownership: The draft law clearly stipulates that the government alone will adequately finance the national immunization program. The government will further maintain a quality cold chain system, the storage and distribution of vaccines following given standards, and the efficient and reliable supply of vaccine-related supplies. Immunization Fund: The draft law will establish a public-private immunization fund to do so. Mr. Acharya reported that the National Immunization Fund Regulation was published in the Nepal Gazette in January 14, 2014 and the Ministry of Health and Population established the National Immunization Fund on July 8, 2014. The sources of funding will be the Nepalese private sector (financial institutions, corporate houses, philanthropists, and other institutions), foreign governments, external development partners and others. Proceeds from fund investments will be allocated to the immunization program. The provisions of the draft immunization law correspond closely to the national immunization fund regulations. Tax Exemptions: Mr. Acharya also emphasized that tax exemptions afforded to importers of vaccines, vaccine-related supplies, and cold chain materials are already guaranteed by other laws. Sri Lanka: Dr. Paba Palihawadana, Chief of Epidemiology Unit, Ministry of Health, described Sri Lanka’s draft immunization law. Free, Universal Vaccine Uptake: The Government of Sri Lanka will continue to provide quality, free, and universal immunization services to the population in a sustainable and equitable manner. The draft law further includes a regulatory oversight mechanism to ensure the vaccination program continues to promptly administer only safe and effective vaccines. Country Ownership: The Ministry of Health has already developed a National Immunization Policy that emphasizes financial sustainability. The national budget will dedicate a stand-alone budget line for the National Immunization Program. The draft law currently stipulates that each provincial authority will ensure the timely availability of adequate funds and other resources. P a g e | 12

The next step, Dr. Palihawadana concluded, will be the introduction of necessary legal provisions to achieve key policy objectives. Tax Exemptions: There is a tax exemption mechanism in place for the importation of vaccines, vaccine-related supplies, and cold chain materials. NITAG: The National Advisory Committee on Communicable Diseases (NACCD) of the Ministry of Health acts as the National Immunization Technical Advisory Group (NITAG). The NACCD is chaired by a variety of immunization experts from different backgrounds. Mongolia: Next, Mrs. Otgontuya Majaa, Senior Officer of Standing on Social Policy, Education, Culture and Science of the State Great Hural (Parliament), presented Mongolia’s immunization law. Parliament passed the law on 20 July, 2000. It has since been amended three times (first in 2003, second in 2006, and in 2010). Free Vaccine Uptake: According to the law, vaccination is mandatory and vaccines are provided free of charge. Country Ownership: The government is entrusted to finance the immunization program and mobilize the necessary resources for its operation.

Immunization Fund: A Government Resolution in 1993 established the National Immunization Program, and the immunization law established the Immunization Fund. The Immunization Fund is chaired by the Vice Minister of Health, with support from the Ministry of Finance and the National Center for the Study of Infectious Diseases. The National Immunization Fund is financed by state and local governments, external development partners, and the Mongolian private sector. Indonesia: Indonesian delegates stated that eighteen pieces of health-related legislation exist which are relevant to immunization. The Decree for Immunization was passed in 2013 by the Minister of Health and is still a part of the national health law. Still, the NIP/MOH sees the need to update this and plans to pass a free-standing immunization law. Free, Universal, Mandatory Vaccine Uptake: The decree guarantees free and universal vaccinations provided by the state. Vaccination is mandatory for under-5 and elementary school children, and women of reproductive age. Country Ownership: The decree further includes a stand-alone budget line for vaccine procurement. P a g e | 13

NITAG: The National Immunization Technical Advisory Group was established by a piece of legislation in 2006. A plenary discussion followed the country presentations. Delegates then broke into small groups to further analyze their projects. Theme II: Small Groups In their small groups, participants compared legislation and legislative advances, drawing on the introductory themes. Results reported by the small groups are captured in Annex D. Countries were also invited to document their legislative projects in a follow-on round of small groups. Two countries, Indonesia and Nepal, produced legislative narratives (Annex E).This exercise completed Day Two.

Peer Review Exercise The final activity of the workshop entailed a peer assessment of each other’s institutional innovations using a standard peer review guide (Annex F). The guide included several open- ended and multiple choice questions and a list of ten items scored on a Likert scale (1=doubtful, 2=unlikely, 3=uncertain, 4=likely, and 5=almost certain). Each peer reviewer was asked to evaluate three countries. The peer review activity was divided into two consecutive 30-minute sessions. In the first session, reviewers interviewed their peers from Cambodia, Nepal, and Sri Lanka. In the second round, peers from those countries interviewed their peers from Mongolia, Indonesia, and Vietnam. Completed forms were collected at the end of each session. Scores were tabulated by Sabin staff. At the end of the workshop, delegates were asked to complete a standard workshop evaluation form.

Results

The exercise generated thirteen assessments (response rate= 23%). All were in the areas of resource tracking and legislation with one country (Nepal) contributing innovations in both categories. Eight peers (44%) from three countries (Indonesia, Nepal, Sri Lanka) served as raters. At least one assessment was received for each innovation. Multiple assessments were received for two (Indonesia, resource tracking; Nepal, legislation). Median responses are reported for these cases.

Results are shown in Annex G.

Summarizing the Likert items, raters determined that one of the innovations (Cambodia, legislation) had begun within the past year, four had begun 1-2 years earlier and one (Mongolia, legislation) was launched more than three years earlier.

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In all but two cases, reviewers unanimously agreed, the innovations had been launched in “top down fashion”, i.e., they were developed at the national level and progressed downward. The exceptions were Indonesia and Nepal, which each received one “bottom up” assessment.

Reviewers enumerated as many as seven institutions involved in the innovative practices. All cases involved one or more government ministries with non-governmental organizations participating in 5/6 countries (83%).

Considering how advanced the innovations were, reviewers rated one resource tracking innovation (Nepal) and two legislative innovations (Indonesia, Nepal) as fully institutionalized. Three were judged to be in earlier stages of implementation and two were still being theorized.

Some resistance to the innovation was noted in 4/6 countries.

Four of the 13 raters (30%) thought countries should have taken another approach to the problem. At least one rater per country thought the innovation would incur added costs. Only three raters did not foresee added costs (countries: Indonesia, Nepal).

Considering whether the innovation would ultimately be institutionalized nationwide, one or more raters responded affirmatively for 5/6 countries. Only 3/12 (25%) raters responded negatively to this item. For all but one country, one or more raters felt the innovations would succeed or have already succeeded in accomplishing their objectives.

Raters formulated a number of recommendations for their peers. Nepali peers were encouraged to keep pushing their legislative project until the bill becomes an Act of Parliament. One rater urged Sri Lankan peers to publish their proposed legislation online. Another congratulated Cambodian peers for their comprehensive legislative work but predicted that it would put new budgetary demands on the government. Mongolia was urged to start work on resource tracking. Two raters advised Indonesian peers to expand their pilot resource tracking innovation nationwide. Another added that Vietnam should study vaccine legislation in other countries.

Discussion

A formal peer review of institutional work for sustained immunization financing in six Asian countries was carried out by peers engaged in the Sabin SIF Program. Thirteen peers rated seven institutional innovations in the areas of resource tracking and legislation.

Results show the peers generally understand the concept of institutional innovations. Most of the innovations they examined had been launched more than a year before. The innovations tended to materialize in top-down fashion and to involve multiple institutions. They often encountered resistance and were judged likely to add costs to national immunization programs. P a g e | 15

The innovators were not always seen as taking the best approach to increasing national financing. Yet the raters felt the innovations would ultimately succeed.

These results are encouraging but must be interpreted with caution due to the low response rate. Only 44% of the peers participated in the exercise. Of these, only three scored two or more innovations. Inter-rater reliability (consistency) could therefore not be calculated.

The peer review exercise took place at the end of a busy two days. Delegates may have been too fatigued to participate. Alternatively, they may have misunderstood the exercise, disliked evaluating or being evaluated, or were simply unmotivated to participate. Language barriers were also a likely cause of the low participation. Interpreters were not available and the workshop was conducted only in English.

Day Three

Theme III: Advocacy in Practice Following a review of the proceedings from Day Two, Mr. Hok Khiev, Director of the Department of the Department of Legislation, Ministry of Health, Cambodia, presented the country’s draft immunization law and fielded participants’ suggestions for improvement. Suggestions addressed budgeting and resource tracking, penalties, and public education provisions.

Next, Dr. Chheng Morn, EPI Manager, Ministry of Health, Cambodia, moderated a one-hour discussion on how to best advocate and persuade governments to take on the sustainable immunization financing challenge. Delegates from all six countries participated, often using homegrown examples to make their points.

The delegates then identified their main conclusions from the workshop. Conclusions are found in Annex H.

Workshop Evaluation Delegates were invited to evaluate the workshop using a standard evaluation form. Evaluations were received from 21 participants, of whom 16 were delegates from the target national institutions. Two-thirds of respondents were previously familiar with the work of the Sabin Vaccine Institute. Nine respondents (43%) stated they had attended previous Sabin-organized SIF events; 18/21 (86%) would recommend their peers participate in a future Sabin peer review workshop. P a g e | 16

Respondents uniformly felt that the three thematic rounds in the workshop (resource tracking, legislation, advocacy practices) were informative and that their small groups had been productive. Seven respondents (33%) felt two days were sufficient for the workshop. Seventy-seven percent (15/21) felt they had sufficient time to complete the peer review. Seventeen respondents (81%) indicated they had learned of an innovation which might work in their countries. All respondents plan to continue working with the Sabin SIF Program. Looking ahead, respondents were evenly divided on whether they thought their countries would achieve sustainable immunization financing by 2020. Seven (33%) thought their countries have already achieved it while 8 (38%) thought they have not.

Closing Remarks H.E. Mr. Ouk Damry adjourned the workshop with closing remarks. Legislative work often faces difficult challenges, he noted, and it is a long process involving a plenitude of stakeholders and obstacles. However, he was hopeful that, as a result of the learning and sharing exhibited over the three-day period, all participating countries may develop strategies and policies conducive to securing greater government support for and promoting financial sustainability in immunization programs. H.E. Damry extended the Parliament’s invitation to all delegates to attend a Solidarity Dinner at 18:30 that evening.

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Annex A List of Participants

Name Title/Institution Country Dr. Otgontuya Dari Public Health Institute Mongolia Standing Committee on Social Policy, Education, Culture, and Mrs. Otgontuya Majaa Mongolia Science; Parliament of Mongolia Dr. Ganchimeg Ulziibayar Ministry of Health Mongolia Under-Secretary, Legal Department, Mr. Komal Prasad Acharya Nepal Ministry of Health and Population Mr. Shambhu Prasad Jnawali EPI Manager, Ministry of Health and Population Nepal Secretary; Women, Children, Senior Citizen and Social Welfare Mr. Birendra Bahadur Karki Nepal Committee; Parliament of Nepal

Dr. Nguyen Van Cuong Deputy Manager, National Institute of Hygiene and Epidemiology Vietnam

Mr. Do Cong Thanh Ministry of Finance Vietnam

Dr. Paba Palihadawana Chief Epidemiologist, Ministry of Health Sri Lanka

Ms. Nandini Ranawaka Appuhamillage Health Committee, Parliament of Sri Lanka Sri Lanka

Mr. W Arachchilage Don Dushantha Director, Budget Department, Ministry of Finance and Planning Sri Lanka Sameera Wickramasinghe Head of Planning and State Budget Subsection, Mr. Maliki Arif Budianto Indonesia Bureau of Planning & Budgeting, Ministry of Health Dr. Diany Litasari Immunization Sub-Directorate, Ministry of Health Indonesia Head of Health Promotion and Nutrition Community Sub- Mr. Entos Zainal Indonesia Directorate, National Development and Planning Agency Senior Advisor to the National Assembly, H.E. Ouk Damry Cambodia General Secretary of CAPPD Director, International Relations Department, H.E. Uy Visal Cambodia National Assembly of Cambodia Prof. Sann Chan Soeung Advisor, National Immunization Program, Ministry of Health Cambodia

Dr. Chheng Morn Deputy NIP Manager, Ministry of Health Cambodia

Mr. Hok Khiev Director, Department of Legislation, Ministry of Health Cambodia Deputy Director General, Department of Finance and Public Policy, Mr. Kim Phalla Cambodia Ministry of Economy and Finance Department of Public Finance and Policy, Ministry of Mr. Sok Khorn Cambodia Economy and Finance Health Economist, Budget Department, Ministry of Economy and Ms. Bola Kan Cambodia Finance P a g e | 18

Hon. Mr. Uk Bun Chhoeun Chairman of Commission 8, Senator Cambodia

Hon. Mr. Yan Sen Chairman of Commission 1, Senator Cambodia

Hon. Mr. Chhit Kim Yeat Vice-Chairman of Commission 8, National Assembly Cambodia

Hon. Mrs. Pov Savoeun Secretary of Commission 8, National Assembly Cambodia

Hon. Mrs. Krouch Sam An Secretary, National Assembly Cambodia H.E. Kob Maryas National Assembly Cambodia

H.E. Khim Hi Advisor to the National Assembly Cambodia

H.E. Mr. Kin Ratha Advisor to the National Assembly Cambodia

Mr. Kal Ketnin Advisor to the National Assembly Cambodia

Mr. Sur Sovanpheach Advisor to the National Assembly Cambodia

Mr. Son Kakson Advisor to the National Assembly Cambodia Dr. Koam Sinoun Deputy Director, Department of Legislation, MOH Cambodia

Dr. Enheng Morn Ministry of Health Cambodia

Mr. Thiep Chanthan Senior Program Officer, Ministry of Health Cambodia

Chhat C. Valthanak Cambodia

Mr. Phar Cambodia Development Partners Dr. Md. Shafiqul Hossain Technical Officer, WHO Country Office Cambodia

Dr. Chham Samnang Technical Officer, WHO Country Office Cambodia

Mr. Hong Rathmony Health Specialist, UNICEF Country Office Cambodia

Mr. Chum Aun Health Officer, UNICEF Country Office Cambodia

Dr. Ashish KC Child Health Specialist, UNICEF Country Office Nepal

Dr. Kenny Peetosutan UNICEF Country Office Indonesia

Dr. Asmaniar Saleh WHO Country Office Indonesia

Dr. Devendra Prasad Gnawali Senior Program Officer, Sabin Vaccine Institute Nepal

Dr. Khongorzul Dari Senior Program Officer, Sabin Vaccine Institute Mongolia

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Annex B

Workshop Agenda

Day One: Cambodiana Hotel

Time Presentation Presenters Places/Notes

Registration 8:00-8:30

Welcoming remarks, objectives of the Mr. Hok Khiev, Director of the Department of 8:30-8:40 meeting Legislation, Ministry of Health, Cambodia Dr. Devendra Prasad Gnawali, Senior Program Remarks by Sabin Vaccine Institute Officer, Sabin Vaccine Institute Dr. Md. Shafiqul Hossain, Medical Officer, Remarks by WHO Cambodia WHO Cambodia Remarks by UNICEF Cambodia TBC Plenary Dr. Chheng Morn, Deputy Manager of the Keynote address by Ministry of Health National Immunization Program (NIP), 8:40-9:30 Ministry of Health Mr. Kim Phalla, Deputy Director of the Keynote address by Ministry of Economy General Department of Public Finance Policy, and Finance Ministry of Economy and Finance H.E. Mr. Ouk Damry, Senior Advisor to the Opening address National Assembly and General Secretary of CAPPD

9:30-10:00 Coffee Break

Theme I: Budgeting and resource tracking Chair: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD An overview of the Global Vaccine Action 10:00-10:20 Dr. Shafiqul Hossain, WHO Cambodia Plan 2011-2020 Budgeting and resource tracking for 10:20-10:40 Dr. Devendra Gnawali, Sabin immunization: Concepts and applications 10:40-10:50 Discussion Cambodia: Budgeting and resource tracking Ms. Bola Kan, Department of Budget, Ministry 10:50-11:00 practices in Health of Economy and Finance Plenary Cambodia: Budgeting and resource tracking Dr. Chheng Morn, Deputy NIP Manager, 11:00-11:10 practices in Immunization Ministry of Health Mongolia: Budgeting and resource tracking Dr. Ganchimeg Ulziibayar, National Center of 11:10-11:20 practices Public Health, Ministry of Health Sri Lanka: Budgeting and resource tracking Mr. Sameera Wickramasinghe, Ministry of 11:20-11:30 practices Finance and Planning Indonesia: Budgeting and resource tracking 11:30-11:40 Indonesian delegation practices P a g e | 20

Nepal: Budgeting and resource tracking Mr. Shambhu Jnawali, EPI Manager, Ministry 11:40-11:50 practices of Health and Population Vietnam: Budgeting and resource tracking Dr. Nguyen Van Cuong, National Institute of 11:50-12:00 practices Hygiene and Epidemiology, Ministry of Health 12:00 – 12:20 Discussion Summary and instructions for Group Work 12:20 – 12:30 Dr. Devendra Gnawali, Sabin (Round One) 12:30-13:30 Lunch Break Group Work (Round One): Processes and experiences completing and using SIF Budget Flow analyses for management and 13:30-14:30 advocacy; documenting best resource Group Work Breakout Rooms tracking practices (1) Nepal and Cambodia; (2) Sri Lanka and Vietnam; (3) Mongolia and Indonesia Panel presentation: Best budgeting and 14:30-15:30 resource tracking practices Country Delegates Plenary (20 min allocated to each group) 15:30-15:45 Coffee Break

15:45 – 16:30 Discussion and Summary of Theme I Sabin Plenary Theme II: Immunization legislation Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD Overview of model immunization laws and 16:30-16:45 Dr. Khongorzul Dari, Sabin legislative processes

16:45 – 17:00 Discussion Country Delegates/Sabin Plenary

17:00 End of Day One

Day Two: Cambodiana Hotel

Time Presentation Presenters Places/Notes Theme II: Immunization legislation, continued Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD Plenary 8:30-8:40 Summary of Day One Sabin

Cambodia: Update on immunization Dr. Koam Sinoun, Deputy Director of 8:40-8:50 legislation Legislation Department, Ministry of Health Mr. Komal Acharya, Under Secretary (Legal), 8:50-9:00 Nepal: Update on immunization legislation Ministry of Health and Population Sri Lanka: Update on immunization Dr. Paba Palihawadana, Chief Epidemiologist, 9:00-9:10 legislation Ministry of Health Plenary Otgontuya Majaa, Senior Officer, Standing Mongolia: History and role of immunization Committee on Social Policy, Education, 9:10-9:20 legislation Culture and Science of Great Hural State (Parliament) Indonesia: History and role of immunization 9:20-9:30 Indonesian delegation legislation P a g e | 21

Vietnam: History and role of immunization Dr. Nguyen Van Cuong, National Institute of 9:30-9:40 legislation Hygiene and Epidemiology, Ministry of Health 9:40-10:10 Discussion Sabin 10:10-10:15 Instructions for Group Work (Round Two)

10:15-10:30 Coffee Break Group Work (Round Two): Comparative review of vaccine-related legislation and 10:30-11:30 regulatory documents Group Work Breakout rooms (1) Nepal and Cambodia; (2) Sri Lanka and Vietnam; (3) Mongolia and Indonesia Panel presentation: Legislative review findings and recommendations 11:30-12:30 (10 mins per group, 30 mins open discussion) Plenary

12:30-12:45 Discussion

12:45-13:45 Lunch Break

Group Work (Round Three): Documenting 13:45-14:30 country legislative case studies (delegates Group Work Breakout Rooms work by country) Group Work -Mr. Hok Khiev, Director of the Department of Legislation, Ministry of Health (Cambodia) 5 mins Panel presentation: Country case studies (5 14:30-15:30 -Nepal 5 mins Plenary mins per country, 30 mins open discussion) -Vietnam 5 mins -Mongolia 5 mins -Sri Lanka 5 mins -Indonesia 5 mins

15:30-15:45 Coffee Break

15:45-16:15 Discussion & Summary of Theme II Country Delegates/Sabin Plenary

Theme III: Advocacy in practice Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD

Advocacy for sustainable immunization 16:15-16:30 Sabin Plenary financing: Concepts and applications

Group Work -Dr. Chheng Morn (NIP Cambodia), 5 mins Group Work (Round Four): Documenting -Nepal 5 mins advocacy case studies (delegates work by 16:30-17:30 -Vietnam 5 mins Breakout rooms country; each country 5 mins, 30 mins open -Mongolia 5 mins discussion) -Sri Lanka 5 mins -Indonesia 5 mins 17:30 End of Day Two P a g e | 22

Day Three: Cambodiana Hotel

Time Presentation Presenters Places/Notes

***Peer Review Exercise: Innovations in sustainable immunization financing*** Moderator: H.E. Ouk Damry, Sr. Advisor to the National Assembly and General Secretary of CAPPD Presentation on Cambodia’s draft law and 9:00-10:00 Mr. Hok Khiev, Ministry of Health (Cambodia) discussion Delegates prepare “Conclusions” of the 10:00-11:00 Delegates workshop Peer review, Part One: Delegates from 11:00-11:30 Mongolia, Indonesia, Vietnam interview Country Delegates delegations from Cambodia, Nepal, Sri Lanka Plenary

Peer review, Part Two: Delegates from Cambodia, Nepal, Sri Lanka interview 11:30-12:00 Country Delegates delegations from Mongolia, Indonesia, Vietnam 12:00-12:30 Recap of workshop proceedings and Sabin evaluation

12:30-13:00 Closing remarks H.E. Mr. Ouk Damry

13:00-14:00 Lunch Break

18:30 Solidarity Dinner Hosted by H.E. Ouk Damry P a g e | 23

Annex C Theme I: Budgeting and Resource Tracking Purpose:  Exchange processes and experiences in using the SIF budget flow analysis tool for management and advocacy purposes  Document best budgeting and resource tracking practices

Group One

Facilitator: Kenny Peetosutan (UNICEF/Indonesia) Spokesperson: Shambhu Jnawali (Ministry of Health and Population, Nepal) Members: Nepal: Birendra Bahadur Karki (Parliament), Komal Acharya (MOHP) Cambodia: Dr. Enheng Morn, Dr. Chheng Morn, Thiep Chanthan (MoH); H.E. Kob Maryas (Parliament); Bola Kan, Sok Khorn (MEF); Loeng Vuthy, Mr. Phar, Chheang Thary

Problems Facilitating Factors

• Funding for resource tracking is • Government prioritizes and insufficient or non-existent because adequately funds NIP policy-makers have yet to be • Adequate support and coordination persuaded to prioritize immunization among stakeholders across • Health Management Information institutions, including MOH and MOF System (HMIS) doesn’t provide for reporting NIP expenditures • HR isn’t equipped for resource tracking

Problems Proposed Solutions

• 1. Funding for resource tracking is • 1. Advocacy to policy-makers and insufficient or non-existent because high-level officials policy-makers have yet to be • 2. HMIS needs to incorporate persuaded to prioritize immunization immunization-related expenditures • 2. HMIS doesn’t provide for reporting • 3. Improve competency of health NIP expenditures workers (HWs) in resource tracking • 3. HR isn’t equipped for resource procedures tracking • Formulate comprehensive immunization law • Establish a trust fund • Improve coordination between MOH and MOF P a g e | 24

Group Two

Facilitator: Dr. Ashish KC (UNICEF/Nepal) Spokesperson: Members: Sri Lanka: W.A.D.D.S Wickramasinghe (Ministry of Finance and Planning), Nandini Ranawaka Appuhamillage (Parliament) Indonesia: Dr. Asmaniar Saleh (WHO) Vietnam: Dr. Nguyen Van Cuong (Ministry of Health), Do Cong Thanh (Ministry of Finance) Cambodia: Dr. Koam Sinoun (Ministry of Health)

Problems Proposed Solutions

• Data collection at national and • Establish data collection system at subnational levels national and subnational levels • Misreporting of data (delayed • Centrally-controlled funding reporting & under-reporting) mechanism • Inconsistencies in reporting • Train and raise the awareness of health workers and managers in resource tracking

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Annex D Theme II: Immunization Legislation

Purpose:

Review vaccine-related legislation and regulatory documents

Group One

Facilitator: Kenny Peetosutan (UNICEF/Indonesia) Spokesperson: Komal Acharya (Ministry of Health and Planning, Nepal) Members: Nepal: Birendra Bahadur Karki (Parliament); Komal Acharya, Shambhu Jnawali (MOHP), Cambodia: Dr. Shafiqul Hossain (WHO), Dr. Chheng Morn, Dr. Chhat C. Valthanak, Dr. Koam Sinoun (MOH)

Problems Facilitating Factors

• Coordination and cross-consultation • Nepalese govt. has prioritized among stakeholders is lacking or immunization act inadequate • Both countries (Nepal & Cambodia) • Poor institutional memory have signed Phnom Penh, • Long process Kathmandu, Kampong, etc. declarations • Previous peer review meeting is ongoing • Draft of immunization law is in hand

Problems Proposed Solutions

• Coordination and cross-consultation • Establish an in-country coordination among stakeholders is lacking or mechanism, i.e working group inadequate • Such a task force should be organized • Poor institutional memory and should facilitate a series of • Long process consultative meetings

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Group Two

Facilitator: Spokesperson: Dr. Ashish KC (UNICEF/Nepal) Members: Sri Lanka: W.A.D.D.S Wickramasinghe (MOFP), Nandini Ranawaka (Parliament) Indonesia: Dr. Asmaniar Saleh (WHO) Vietnam: Dr. Nguyen Van Cuong (MOH), Do Cong Thanh (MOF) Cambodia: Dr. Koam Sinoun (MOH)

Overview of Vietnam’s Immunization Legislation Landscape • The Law on the Prevention of Communicable Disease covers immunization financing • If the legislative process permits, an immunization fund provision will be inserted as well • If the legislative process proceeds, NEPI and the MOH Planning Department will provide input to the law from the immunization program • The immunization program is approved by the MOH • For the introduction of new vaccines, recommendations from ICC, NITAG, MoH, and MoF will be required for funding and approval from the government

Overview of Sri Lanka’s Immunization Legislation Landscape • There is an existing law on prevention & control of communicable diseases • Free vaccination is compulsory • There is a separate EPI budget for vaccine procurement • Tax revenues are guaranteed to subsidize vaccines and cold chain • There is a procurement mechanism for vaccines under special consideration (fast track vaccines) • The National Immunization Policy enhances access to and sustainability of the vaccination program • The National Advisory Committee for Immunization assesses the disease burden and decides on new vaccine introduction. • Vaccine financing is somewhat sustainable

Group Three

Facilitator: Dr. Khongorzul Dari (Sabin) Spokesperson: Ms. Otgontuya Majaa (Parliament, Mongolia), Members: Mongolia: Dr. Ganchimeg Ulziibayar, Dr. Otgontuya Dari (MOH, Mongolia) Indonesia: Dr. Maliki Arif Budianto, Dr. Diany Litasari (MOH); Entos Zainal, (NDPA)

P a g e | 27

Problems Facilitating Factors

1. The law is too general; a more specific 1. Government is capable of supporting immunization decree is needed the law’s implementation and raising 2. Regulations are satisfactory for solid public awareness. national programs but not 2. National mid-term planning session subnational ones sets a budget and an achievable 3. Weak community participation target 3. Health law contains articles pertaining to immunization

Group Four Facilitator: Spokesperson: Members: Cambodia: H.E. Chhun Sirun, H.E. Nuon Sarin, Nuom Sophorn, Khim Chhun I (Parliament); Chum Aun (UNICEF), Mao Phirun (MOJ), So Chhorvy Roth (MOEY), Kim Phalla (MoEF), Seng Phal Davin (MOWA), Theab Chanthorn (MOH); Am San Ath, Khat Sok, Sar Sokha, Leong Vuthy

Suggestions on draft immunization law by Cambodian MPs and officials: • Each article should be organized by title • Chapter 10: “Penalties” should be changed to “administrative fines” to avoid criminalizing language; the fine should be reduced • Violators under Article 36, 39 should receive proper warning or education before incurring such a fine • The government should provide additional education to those unfamiliar with the necessity of immunization injections; an article should provide that violators receive proper education upon being fined • The law should establish an evaluation committee in case unanticipated issues are encountered, such as an adverse event following immunization (AEFI), at both national and sub-national levels. • Should an AEFI occur, a procedure should be established to protect personnel • H.E. Chhun Sirun, Member of 8th and 9th Committee of the National Assembly, announced his full endorsement of the immunization law. He raised two issues in reference to Article 31: • It stipulates that products may be destroyed in line with the existing procedure. H.E. Sirun asked whether such a procedure indeed exists, and if not, which ministry should develop one. P a g e | 28

• Regarding the fact that it is the vaccine owner’s responsibility to incur the cost of destroying a vaccine in such a case, H.E. Sirun inquired as to what the government should do if the vaccine owner doesn’t comply. • A concern was raised pertaining to the utilization of the Khmer words for “son” and “daughter” in Article 10. • Article 35: The Ministry of Economy and Ministry of Health alone should administer the provision of incentives to officers, instead of the “Royal Government” more generally. • Chapter 6: The MPs requested the addition of one more article stipulating that the MOH should cooperate with related ministries, especially with local authorities, so that immunization percolates to the community level. • Chapter 4: Article 14 should include a provision for the inclusion of vaccinations administered by the private sector to be captured in an annual report to the National Immunization Program (NIP) • Article 13: Provincial and municipal health departments are responsible for safe storage and distribution of vaccines at the provincial level. • The district and khan (city) immunization program managers are responsible at the district level, and the health center managers are responsible at the health center level. • Chapter 1, Article 1: General Regulation • First Revision: Requested to replace “this law has the purpose of managing immunization in the Kingdom of Cambodia” with “The National Immunization Program is a national priority”. • Second Revision: Requested replace “this law has the purpose of managing immunization in the Kingdom of Cambodia” with “Law on Providing Immunization” • Chapter 9, Article 26: The non-compliance fine should be moved to Chapter 10 • Chapter 2 should be administered by relevant management institutions, including the National Immunization Council (NIC), National Immunization Program (NIP), and the immunization working group. • The NIC should be responsible for the annual budget and fund; the NIP, for processing and vaccine issues (such as vaccine type)

P a g e | 29

Annex E Documenting Country Legislative Case Studies

Country: Nepal Spokesperson: Komal Acharya, MOHP Delegates: Birendra Bahadur Karki (Parliament), Shambhu Jnawali (MOHP), Dr. Ashish KC (UNICEF)

NOTE: Different actors are involved at each legislative phase

Government Stakeholders Development Partners

• Ministry of Health and Population Agencies • Ministry of Finance • UNICEF • Ministry of Education • WHO • Ministry of Law & Justice INGOs • Council of Ministers • Sabin • Parliament Philanthropic • Ministry of Women, Children and • Rotary International Social Welfare • Lions Club • Ministry of Federal Affairs and Local Business Community Development • FNCCI • Chamber of Commerce

Advocacy techniques used to generate draft legislation 1. Drafting of concept note 2. Sharing and discussion of concept note 3. Consultative meetings with line agencies and stakeholders 4. Consensus of the Ministry of Law and Justice in formulating a separate immunization law 5. Briefing to relevant Cabinet committee to secure high-level approval 6. Referencing a case study from another country 7. Peer review with other SIF program countries

Challenges encountered at each legislative phase and solutions proposed

Challenges Solutions

• Stakeholder under-appreciation of • Series of consultation meetings the necessity of an immunization law • Frequent briefings to Ministers and • Delay in law-drafting process due to policy-makers changes in the government

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Lessons learnt: • Developing a health-specific law requires a combination of technical knowledge, administrative skill and legal expertise • Developing the capacity of different institutions is instrumental in promulgating the law at large. • The proposed milestone is the formulation of a law vis-à-vis an orientation targeting non-health sector stakeholders on the importance of health and immunization especially.

Country: Indonesia Spokesperson: Delegates: Entos Zainal (NDPA); Dr. Maliki Arif Budianto, Dr. Diany Litasari (MOH)

Approach Challenges

• Review eighteen existing pieces of • Not strong enough for compliance immunization-related legislation from sub-national level because of • Initiated by MoH, with support from decentralization the Ministry of Internal Affairs • A presidential decree would be more (MOIA), NDPA, universities, successful Indonesian Technical Group for Immunization (ITAGI), NAEFI, the Pediatrician Association, and other stakeholders • MoH (inter program), MoIA, Bappenas, University, ITAGI, NAEFI, Pediatrician Association, Stakeholders

P a g e | 31

Annex F

SABIN SUSTAINABLE IMMUNIZATION FINANCING INNOVATION PEER REVIEW GUIDE ****************************************************************************** Reviewer’s country: ______Reviewer’s home institution (check one): ___Min health ___Min finance ___parliament ___other (specify: ______) ___Partner agency counterpart Country studied: ______****************************************************************************** *** Classify the innovation by functional area (check one or more): ___ financing ___ budget, resource tracking ___ legislation ___advocacy activity ___other (specify: ______) In the presenters’ words, what problem or opportunity does the innovation address? In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): When- how long ago- did the innovation begin (check one)? ___three or more years ago ___past 1-2 years ___this year How did the innovation begin (check one)? ___ Top -> down ___ Bottom -> up ___ Outside third party introduced it On which level of governance did the innovation originate (check one)? _____ regional or sub-regional multiple countries) ___ national ___sub-national ___ both levels together Which institutions are or were involved in developing the innovation (check one or more)? Government ___ ministry of health ___ ministry of finance ___ elected body P a g e | 32

___ other government ministry or agency (identify: ______) Non-government ___ community service organization (identify: ______) ___ domestic business sector (identify: ______) ___ other (identify: ______) At this point, how advanced is the innovation (check one)? ___ people are just talking about it ___ the new practice(s) is (are) now being tried ___the new practice(s) is (are) becoming institutionalized ___the new practice(s) is (are) fully institutionalized ___ the innovation is being blocked What feedback and recommendations do you wish to convey to these delegates about this particular innovation? (continue writing on back of page if needed) On a scale of one to five, with 1 being no chance and 5 being almost certain, please answer the following questions. Circle one response per item. Item 1 2 3 4 5 No chance Not likely Unsure Likely Almost certain The innovation is well conceptualized. The proposed solution matches the problem or opportunity it addresses. 1 2 3 4 5 Another approach would have been more suitable for solving the problem/improving the sustainability of the immunization program. 1 2 3 4 5 The right mix of institutions is or was involved in developing the innovation. 1 2 3 4 5 There is or was a lot of resistance to this innovation. 1 2 3 4 5 P a g e | 33

This innovation is or was carried out without incurring significant new costs. 1 2 3 4 5 The innovation will help the country reach sustainable immunization financing sooner. 1 2 3 4 5 The innovation will ultimately be institutionalized nationwide. 1 2 3 4 5 If successful, the innovation will increase country ownership of the immunization program. 1 2 3 4 5 Considering all the factors, how likely is the innovation to succeed, to become institutionalized? 1 2 3 4 5 This innovation would likely succeed in your own country. 1 2 3 4 5 List below and briefly describe any other innovations you observed in this country. THANK YOU FOR YOUR CONTRIBUTIONS! THE SABIN SIF TEAM WILL ANALYZE AND DISTRIBUTE THESE RESULTS TO ALL PARTICIPANTS. P a g e | 34

Annex G Peer Review Results

Innovations in Resource Tracking Country Indonesia Nepal Cambodia (No. raters) (n=4) (n=1) (n=1) Status of innovation Implemented Institutionalized Implemented

MOH, MOF, Natl Dev & MOH, MOF, ADB, MOH, MOF, Sabin, Institutions involved Planning Agency, WB, IMF, UNICEF, UNICEF, WHO Parliament WHO Right institutions are involved almost certain almost certain Likely Solution to problem almost certain almost certain Likely Better solution exists likely uncertain Likely High resistance to innovation unlikely doubtful Likely Low new costs from innovation uncertain uncertain Likely Innovation catalyzes SIF progress likely/almost certain likely almost certain Likelihood of institutionalization likely uncertain Likely

Innovations in Legislation Country (No. raters) Indonesia (n=1) Nepal (n=2) Sri Lanka (n=1) Vietnam (n=1) Mongolia (n=1) Implemented/ Status of innovation Institutionalized Implemented Theorized Theorized Institutionalized MOH, MOF, Natl MOH, MOF, MOLJ, MOH, MOF, MOE, Dev & Planning MOH, MOF, Institutions involved UNICEF, WHO, MOJ, WHO, MOH Agency, Cabinet Elected Body Sabin UNICEF, SABIN Secretary Right institutions are likely/almost likely almost certain likely Unlikely involved certain likely/almost Solution to problem likely almost certain likely Unlikely certain Better solution exists likely unlikely/unsure Likely likely almost certain High resistance to uncertain Unlikely Doubtful uncertain almost certain innovation Low new costs from unlikely uncertain/likely Likely likely almost certain innovation Innovation catalyzes almost certain almost certain almost certain almost certain Doubtful SIF progress Likelihood of likely/almost likely almost certain almost certain Uncertain institutionalization certain

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Annex H Asian Peer Review Workshop on Sustainable Immunization Financing Phnom Penh, Cambodia 21-23 July, 2014

Conclusions

The Decade of Vaccines (2011-2020) envisions a world where all individuals and communities are free from vaccine-preventable diseases. To achieve this ambitious goal, the 65th World Health Assembly endorsed the “Global Vaccine Action Plan (GVAP)”. One of the GVAP objectives is for national immunization programs to be adequately and sustainably funded to ensure that every child is immunized for vaccine-preventable diseases. This is achieved through improved financial management and efficient allocation of resources directed at this preventative health intervention. Expenditures must be linked to outputs and impacts, and demonstrate a clear investment case for immunization. Maximum political and administrative support at both national and subnational levels is essential for the formal endorsement of sustainable, country-owned legislation and national policies.

Following the “Phnom Penh Declaration 2010” made by the Parliamentarians and inspired by the GVAP’s guiding principles, we, the delegates from Indonesia, Nepal, Sri Lanka, Cambodia, Mongolia and Vietnam, support and recommend the following:

1. Track resources (based on WHO/UNICEF JRF) for the efficient use of available resources and collect financial data that demonstrates a sound investment case for routine immunization. This information will equip government officials to advocate for increased national financial commitments and immunization-related legislation. 2. Promote the use of cost-benefit analysis to secure funds, support policy, and motivate decision making-all in pursuance of sustainable immunization financing. 3. Ensure that legislation or a legal framework for long-term sustainable funding and vaccine provisions promotes the National Immunization Program and are not preventing any child from being fully immunized. 4. Continue advocacy to increase and sustain a high-performing immunization program, and further, to synergize sustainable immunization methods with health system strengthening.

July 23, 2014 Phnom Penh, Cambodia