REVOLUTIONARY GOVERNMENT OF ZANZIBAR.

COMPREHENSIVE MULT YEAR PLAN -

ZANZIBAR

2010 – 2014

EPI/MOHSW ZANZIBAR July 2009.

TABLE OF CONTENTS Acronyms And Abbreviations 3

Executive Summary 4

1.0 Background 4 1.1. Introduction ...... 4 1.2. Location And Surface Area...... 5 1.3 Administrative Structure ...... 5 1.4 Climate...... 5 1.5 Population Projection 2008...... 5 1.6 Economy...... 6 1.7 Socio-Economic Status ...... Error! Bookmark not defined. 1.8 Health Service Delivery...... 7 1.9 Linkage Of Epi To Moh ...... 8 1.10 Number Of Health Facilities By Districts...... 8 1.11 Number Of Health Facilities Offering Immunization Services ...... 8 1.12 Users’ Fees And Immunization...... 8

2.0 Epi In The Context Of Global And National Priorities 9 2.1 Global Priorities...... 9 2.2 Who African Regional Strategic Plan For Epi...... 9 2.3 Epi In The Context Of Global Priorities ...... 9 3.1 Routine Immunization ...... 11 3.2 Cold Chain And Other Epi Logistics ...... 12 3.3 Advocacy, Communication And Social Mobilization...... 13 3.4 Capacity Building ...... 13 3.5 Targeted Disease Initiative And Disease Surveillance...... 14 3.5.1 Polio Eradication...... 14

4.0 New Vaccine 20

ii ACRONYMS AND ABBREVIATIONS

1. AD------Auto –disable (syringe) 2. ADB ------African Development Bank 3. AEFI------Adverse Event Following Immunization 4. AFP------Acute Flaccid Paralysis 5. BCG ------Bacillus Calmette Guerin 6. CMS ------Central Medical Stores 7. CFC------Cloro –fluoro- carbon 8. DHMT ------District Health Management Team 9. DHO------District Health Officer 10. DMO ------District Medical Officer 11. DTP – HB ------Diphtheria, Pertussis, Tetanus and Hepatitis B 12. DQS------Data quality self-audit. 13. EPI ------Expanded Programme on Immunization 14. FSP ------Financial Sustainability Plan 15. GAVI------Global Alliance for vaccines and immunizations 16. GDP------Gross Domestic Product 17. Hib------Haemophilus influenzae type b 18. HMIS------Health Management Information System. 19. LP gas ------Liquid Propane gas 20. MCH------Maternal and Child Health 21. MDVP------Multi dose Vial Policy 22. MLM------Mid Level Management 23. MNT------Maternal and Neonatal Tetanus 24. MNTE------Maternal and Neonatal Tetanus Evaluation 25. MOHSW ------Ministry of Health and Social Welfare 26. NIDs ------National Immunization Days 27. NT ------Neonatal Tetanus 28. OPD ------Out Patient Department 29. OPV ------Oral Polio Vaccine 30. PIU ------Program Implementation Unit 31. PHCU ------Primary Health Care Unit 32. SIAs ------Supplemental Immunization Activities. 33. SNIDs ------Sub National Immunization Days 34. TBA------Traditional Birth Attendant 35. TT------Tetanus Toxoid 36. UNICEF------United Nations Children’s Fund 37. UNFPA------United Nations Population Fund 38. VVM------Vaccine Vial Monitor 39. WHA ------World Health Assembly 40. WHO------World Health Organization 41. ZFDB------Zanzibar Food and Drug Board 42. ZMO------Zonal Medical officer

3 EXECUTIVE SUMMARY

The immunization programme in Zanzibar has it’s the goal of reducing morbidity and mortality due to vaccine preventable diseases. The programme broad areas of activity include service delivery, disease surveillance and supplementary immunization activities. The comprehensive Multi-Year Plan 2010-2014 identified several reasons for poor immunization performance in different levels. The plan will focus on empowering and supporting districts and utilizing the opportunity of integrated health services including introduction of new vaccines such as Pneumococcal in 2010 and rotavirus in 2011. Although immunization services are among the highly accepted services by the community in Zanzibar, advocacy and social mobilization remains an essential to maintain it. Vaccination against EPI targeted diseases is provided in government and private Reproductive and Child Health (RCH) clinics and the coverage exceeded 80% in 80% of the districts. The immunization program for Zanzibar aims to achieve and sustain coverage rate of above 90% for all antigens in 80% of the districts by the end of 2014. However, vaccine preventable diseases, particularly measles outbreaks, are major challenge for the implementation of EPI program.

Social mobilization strategies were outlined and will be used to improve access and utilization of immunization services in the coming five years. The program will also strengthen its advocacy role in order to put immunization issues as an agenda for political decision-makers and promote strengthening of routine immunization coverage at all levels. The main issues that need to be addressed includes:- • Increasing immunization coverage in low performing districts • Introduction of new and under-utilized vaccines such as Pneumococcal in 2010 and Rotavirus in 2011 • Conducting supplemental immunization activities especially for measles in 2011 and 2014. • Strengthening integrated disease surveillance. • MNT Validation • Measles pre elimination • Polio eradication and implementation of Polio importation preparedness plan.

Injection Safety will continue to be among the priority areas in 2010– 2014. Non-Polio AFP rate in 2008 reached above 1/100,000. The 2010 – 2014 Comprehensive Multi-Year Plan, will address more issues in integrated disease surveillance activities by conducting training of clinicians, community sensitization and advocacy to key stakeholders. Emphasis will be placed on those silent districts as far as AFP, Measles and MNT reporting are concerned. Immunization infrastructures in Zanzibar are among the areas earmarked for improvements in the coming five years. New Freezer room will be procured and installed and cold chain replacement plan will be implemented in all vaccine stores. This will also include the expansion of the storage capacity at Zonal vaccine store. The Ministry of Health through EPI with the support of GAVI, WHO, UNICEF and other partners have prepared this cMYP with full section on costing, financing and Financial Sustainability of the programme covering the period of 2010-2014. The Multi year plan has incorporated the activities earmarked in the previous Financial Sustainability Plan (FSP). This includes programme costing, financing and future resource requirements activities as well as advocacy, mobilization of resources from central and local government.

1.0 BACKGROUND

1.1. Introduction Zanzibar is one of the political entities constituting the United Republic of Tanzania. It consists of two large Islands, Unguja and Pemba and few sparsely populated islands such as Tumbatu and Uzi in Unguja, Kojani, Fundo, Shamiani and Makoongwe in Pemba. Zanzibar has considerable autonomy in her domestic affairs administered through the Revolutionary Council and the House of Representatives. Although the Health care portfolio for Zanzibar is not a Union Government matter, there is considerable collaboration with the mainland on health matters. The Ministry of Health and Social Welfare remains the responsible agency for health services in Zanzibar.

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1.2. Location and surface size Zanzibar is located in the Indian ocean, about 30km off the east coast of Africa, between latitude 5 and 7 degrees south off the equator . Zanzibar consists of two islands , Unguja and Pemba , and several other smaller islands some of which are uninhabited .The island has an area of 2,654sqkm out of this, Unguja, which is the largest, has an area of 1,666 square kilometers while Pemba has an area of 988 square kilometers.

1.3 Administrative structure Zanzibar is divided into five administrative regions, three in Unguja and two in Pemba. Each region is subdivided into two districts, which make a total of ten districts for the islands. The lowest government administrative structure at the community level is the Shehia.

1.4 Climate The climate of Zanzibar is equatorial and humid. The maximum temperatures revolve around 30 oC during the hot season lasting from December to March and minimum temperatures are approximated at 20 oC during the cool season lasting from June to November. Zanzibar has two main rain seasons, the long rainy period (Masika) during March to June and short rainy period (Vuli) that starts in October and ends in December. The humidity is high ranging from 900 – 1000 mm during heavy rain season and 400 – 500 mm during short rainy period. The humidity is slightly higher in Pemba in comparison to Unguja. Because of the two rainfall peaks, Zanzibar is usually green all the year.

1.5 Population projection 2008 The population of Zanzibar shows an increase from 640,685 in 1988 (1988 census) to 981,754 in 2002 (2002 census). The population is estimated to be 1,193,383 in 2008, projected from 2002 National Population census. Of this population, under 1year is 47,205 and under 5year is 217,168. The details of the population are shown in Tables 1, 2 and 3 and Figure 1.

Table 1: Census Counts and Inter-censual Growth Rates by Region

Actual Population from Censuses Inter-censual Growth Rate (%) Region 1967 1978 1988 2002 1978 – 1988 –2002 1988 Total 354,360 476,111 640,685 981,754 3.0 3.1 Zanziba r North Unguja 56,219 77,017 96,989 136,639 2.3 2.5 South Unguja 39,004 51,749 70,313 94,244 3.1 2.1 Urban West 94,894 142,041 208,571 390,074 3.8 4.5 North Pemba 71,972 106,290 137,189 185,326 2.6 2.2 South Pemba 92,271 99,014 127,623 175,471 2.6 2.3

Source: NBS, Census 2002

Table 2: District Population, Zanzibar 2008.

DISTRICT TOTAL 0 – 11 UNDER 5 UNDER 15 POPULATION MONTHS YEARS YEARS URBAN 256,543 7,202 35,219 88,064 WEST 202,959 7,600 36,177 89,782 NORTH ‘A’ 99,186 4,277 19,253 45,457 NORTH ‘B’ 66,687 2,511 11,511 27,698 CENTRAL 71,035 2,190 10,402 27,918 SOUTH 36,776 1,055 4,883 13,273 UNGUJA TOTAL 733,186 26,138 118,449 292,192 MKOANI 116,129 5,806 25,946 59,555

5 CHAKECHAKE 109,926 5,341 23,920 56,082 WETE 127,923 5,673 25,944 60,364 MICHEWENI 106,219 5,550 23,913 52,645 PEMBA TOTAL 460,196 21,806 99,158 228,646 TOTAL ZANZIBAR 1,193,383 47,205 217,168 520,838

Table 3: Projected population, Zanzibar 2010 – 2014

YEAR TOTAL 0 – 11 UNDER 5 UNDER 15 POPULATION MONTHS YEARS YEARS 2010 1,159,941 50,012 230,650 497,871 2011 1,197,005 51,321 237,471 514,219 2012 1,234,972 52,638 214,254 531,318 2013 1,403,166 53,894 251,005 616,483 2014 1,448,773 55,235 257,739 639,092

1.6 Economy Macroeconomic policies implemented in the last five years (2003-2007) resulted into positive growth of the economy from 5.9 percent in 2003 to 6.5 percent in 2007, which is slightly below the target of 6.6, but 0.5 percent above the growth for the year 2006. GDP per capita increased from TShs. 284,000 in 2003 to TShs. 518,000 in 2007 while capital formation given up from 21 percent in 2003 to 38 percent in 2007.

The service component of GDP composition (comprising trade, hotel, restaurants, transport and communication, among others) constitute the larger part of economic development in Zanzibar. The sector registered remarkable growth and its contribution to GDP, revenues, employment generation as well as attracting investment is promising. Its share to GDP increased to 43.9 percent in 2007, exceeding 43.5 percent recorded in 2006. The projected economic growth in Zanzibar during 2008 is 6.8 percent, but may not be attained due to current global financial and economic crisis. However, the current global financial and economic crisis and Zanzibar power outrage may disrupt the economic growth in Zanzibar during 2009 and 2010.

In the fiscal year 2006/07 agricultural sector declined as a result of drought. Investment projects registered by Zanzibar Investments Promotion Authority (ZIPA) increased from 13 in 2003 to 65 in 2008 with a total value of US$ 1,296.8 million. The trend of the projects registered is expected to decrease as a result of the world financial crisis in 2009/2010. ( Zanzibar economic bulletin Vol.2 No.1 january –march,2009)

Income per capita 1990- 2005 Index 1990-1999 2000-2004 2005 GDP at market price (Tshs millions) 189,500 255,600 395,700 Population (Numbers) 725,000 966,400 1,072,000 Per capita income (Tshs) 142,000 263,800 369,000 Per capita income (USD) 157 276 327 Source: OCGS (2005) Socio-Economic Survey 1999 and 2004

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Figure 2: Map of Zanzibar

UNGUJA

PEMBA

1.7 Health Service Delivery Zanzibar’s public health service infrastructure relies on a fairly dense network of Primary Health Care Units (PHCU’s), that are meant to serve in principle a population of 3,000 to 5,000; they are divided into two types: PHCU-1 provide basic primary health care services, while PHCU-2 are supposed to provide the same services, plus professional assistance with normal deliveries, laboratory services and dental care;

The performance of the health sector in Zanzibar remains unsatisfactory even though geographical coverage of the health facilities is considered equitably distributed to all regions and districts, and easily accessible to 95% of the population. The access to health services is constrained mainly by poor quality of service due to lack of equipment and qualified staff. Furthermore, health services utilization is associated with socio-economic conditions. Maternal and child health services in Zanzibar are provided in all health care facilities in the country.

Traditional birth attendants (TBAs) provide a significant proportion of maternal health services. It is estimated that there are 2000 TBAs in Zanzibar and they conduct about 40% of all deliveries.

Almost all Primary Health Care Units (PHCU) provide integrated RCH services including antenatal care, delivery services, prevention and management of STI and family planning services. Over 95% of pregnant women in Zanzibar attend clinic for antenatal care, but only about 60 percent of the them attended by trained personnel and the rest are attended by traditional birth attendant . Immunization services are offered at all levels. In line with on going Health Sector Reform (HSR), health services are provided at the following levels:-

Primary (Level I) This is the lowest level of health care structure. It includes 1 st and 2 nd Line Primary Health Care Units (Dispensaries) and Primary Health Care Centers (Cottage Hospitals).

Secondary (Level II) These are the district hospitals that serve as referral points for the Primary Level health care facilities.

Tertiary (Level III) There is only one specialized hospital (Mnazi Mmoja Hospital) located in Unguja Island.

7 This hospital provides a full range of specialized services for referred and emergency conditions. It is also the teaching hospital in Zanzibar.

1.8 Linkage of EPI to MOH The EPI Programme is housed within the Directorate of preventive Services in the Ministry of Health and Social Welfare. The main task of the programme is to provide vaccination services to children and mothers in order to prevent vaccine preventable diseases. The implementation of immunization services in both Unguja and Pemba zones are coordinated and supervised by Health Management Teams. Unguja has six teams while Pemba has four. The National level provides supplies, logistics and technical assistance for the zones and districts.

1.9 Number of Health Facilities by Districts Zanzibar has about 158 Health facilities distributed by districts as follows:-

Table 6: Health facilities offering immunization service by district, Zanzibar 2008

No. District Total No. of Offering Not offering Health immunization immunization facilities services services 1 Urban 18 15 3 2 West 18 15 3 3 Central 22 22 0 4 North A 13 13 0 5 North B 12 12 0 6 South 10 10 0 7 Mkoani 16 16 0 8 Chake chake 16 16 0 9 Wete 19 19 0 10 Micheweni 14 13 0 TOTAL 158 152 6

1.10 Number of Health facilities offering Immunization services and outreach per District Out of 158 health facilities, 152 (96%) provide immunization services. In total, there are 68 outreach sessions conducted monthly in all districts of Zanzibar. These services are supported by either National or DHMTs. However health facilities conduct their own outreaches according to their needs by utilizing available resources such as bicycles etc. The minimum number of outreaches per district in a month is 3 while the maximum is 10. About 95% of the planned outreaches were conducted in 2008 through DANIDA support.

1.11 Users’ fees and immunization EPI services are provided free of charge to all eligible children and women of child bearing age in both Government and private health facilities.

8 2.0 EPI IN THE CONTEXT OF GLOBAL AND NATIONAL PRIORITIES

2.1 Global Priorities Expanded Programme on Immunization is considered as one of the global health priorities as depicted in the global coverage goals. The coverage in Zanzibar has reached the global set target of over 80% of districts to have DTP-HB3 coverage of 80% in 2008. In the coming five years, the EPI programme is envisaged to raise the national coverage of DTP-HB3 from 86 % to 95% and above so as to meet the global set goals including WHA 1989, GAVI 2002 and UNGASS 2002. EPI contributes substantially to the achievement of the Millennium Development Goal 4 which aims at reducing childhood mortality with a target of reducing the under five mortality rate by two-thirds, by the year 2015.

The Global Immunization Vision and Strategies provides a strategic framework to guide all partners in immunization, making the case for sharing linkages between immunization and other health interventions and addressing the need to overcome system wide barriers that go beyond immunization and affect the whole sector.

2.2 WHO African Regional Strategic Plan for EPI. In implementing EPI activities, Ministry of Health Zanzibar is also aware and committed to the African region strategic plan with the vision to improve the health of children through the eradication of polio and the control of other vaccine preventable disease in the context of health system strengthening. To attain this vision, it is expected that
At least 80% of countries attain DTP3 coverage of at least 80% in all districts.
All countries attain 100% immunization safety
All countries will have sustainable funding for EPI.
All countries attain Polio Eradication
Attainment of full regional certification.
Attain measles pre-elimination goals
Attain Neonatal tetanus elimination.

2.3 EPI in the context of Global priorities 2.3.1 National Development Plans The government of Zanzibar is committed to ensuring that high quality and equitable health care services are available to all Zanzibaris on a sustainable basis. In this context, the government of Zanzibar accords special attention to the prevention, control and where possible, the elimination of communicable diseases that are of public health importance as well as safe motherhood and child survival.

The Zanzibar Poverty Reduction Plan (ZPRP 2002–2005) includes health related issues aimed at improving the health of women and children. Specific activities geared towards improving the health of women and children include strategies aimed at increasing immunization coverage in children and women of child bearing age and creating equal opportunities for access to basic and essential quality health care.

2.3.2 Vision 2020 The Revolutionary Government of Zanzibar has embarked on a plan of the Zanzibar Development vision 2020 whose overall objective or goal is to eradicate absolute poverty in the society.

The Zanzibar development vision 2020 further emphasizes that the eradication of poverty will require, among others, sound macroeconomic managements policies aimed at creating a stable environment for growth (including investments and trade) that will subsequently promote sustainable livelihood through chosen productive employment and work and the provision of basic social services including health care services. It has remained a point of reference for subsequent development policies, strategies and programmes for Zanzibar.

2.3.3 ZSGRP (2007 – 2010).

In 2000, Zanzibar launched the Zanzibar Development Vision 2020 which gives social, political, cultural and economic philosophy up to the year 2020. The thrust of the vision is eradication of absolute poverty and attain sustainable development. In line with that, the first three-year Zanzibar

9 Poverty Reduction Plan (ZPRP) launched in 2002 from which some significant achievements were recorded after its implementation. However, there were also challenges highlighted by stakeholders during the ZPRP review process which were taken as strength towards development of this strategy; The Zanzibar Strategy for Growth and Reduction of Poverty (ZSGRP) The ZSGRP document forms part of strategies to implement the long term development plan, the Vision 2020. The four-year Zanzibar Strategy for Growth and Reduction of Poverty (ZSGRP) known as Mkakati wa Kukuza Uchumi na Kupunguza Umasikini Zanzibar (MKUZA) in its Kiswahili acronym is the second generation of national development framework to implement Vision 2020. ZSGRP is in line with Millennium Development Goals (MDGs) and other international agreed commitments and targets. The focus is on the reduction of both, income and non- income poverty; and ensure the attainment of sustainable growth. The ZSGRP offers recommendations or interventions on how the stakeholders – the Government, the Non State Actors including Development Partners, the Private Sector, Civil Society Organizations and the Community – can engage their actions and approaches to significantly enhance economic growth and thus poverty reduction. The ultimate objective is to achieve high standards of social well being to the citizens. The Zanzibar Strategy for Growth and Reduction of Poverty concentrates on strategic interventions aimed at i. Reducing income poverty ii. Improving human capabilities, survival and social wellbeing iii. Containing extreme vulnerability (including diseases)

2.3.4 MOH Priorities Health Sector Reforms

In 2002, Zanzibar initiated a Health Sector Reform under the guidance of the Zanzibar Health Sector Reform Strategic Plan I 2002/03 – 2006/07. The reform was seeking to decentralise planning, prioritising and integration of services to district level. In addition, it aims at ensuring the availability of equitable high quality health care services, which focus on priority diseases or burden of diseases and according to an essential health care package. The essential health care package focuses on the principles of primary health care (PHC) approach based on the strengthening health delivery at the community level and in Primary Health Care Units (PHCUs) and Centres (PHCCs).

A 2004 assessment of Zanzibar Health Sector Reform Strategic Plan I (ZHSRSP I) concluded that “in general, ZHSRSP I (2002/03 –2006/07) has not been implemented as programmed and failed to guide planning of Ministry of Health and Social Welfare (MOH&SW) and stakeholders activities.” The current document, a more comprehensive and feasible ZHSRSP II (2006 –2010), has been developed a year before the end of the first plan period in order to address this concern, and to enable the sector programme to run concurrently with the new Zanzibar Strategy for Growth and Poverty Reduction (MKUZA).

Eleven areas have been identified within the HSSP which includes: i. Improvement of organization and management of health services ii. Human resources development iii. Strengthening health services delivery iv. Health sector financing and mobilization of resources v. Research development vi. Health legislation vii. Pharmaceutical, medical supplies and equipments viii. Strengthen secondary and tertiary referral hospital ix. Public and private Partnership in Health services delivery x. Social services/welfare xi. Donor coordination, advocacy and management of the reform process.

10 3.0 IMMUNIZATIO PROGRAMME COMPONENTS

3.1 Routine immunization 3.1.1 Immunization coverage 2004 - 2008 EPI plays a major role in contributing to the achievement of the Millennium Development Goal 4 which aims at reducing childhood mortality with a target of reducing the under five mortality rate by two-thirds, by the year 2015. The immunization program for Zanzibar set a goal of achieving immunization coverage rate of 90% nationally for all antigens and over 80% in every districts by the end of 2014.

Several strategies have been outlined and will be used to improve access and utilization of immunization services in this year. Also the programme aims at reinforcing support to all districts in order to make sure the desired coverage is achieved and sustained.

Immunization coverage for Zanzibar 2004 – 2008 Vaccine 2004(%) 2005(%) 2006(%) 2007(%) 2008(%) BCG 128.2 125 115 101.4% 116.3% OPV 0 51.4 53.3 46 51.8% 57.1% DTP Hep B3 88.8 85.7 86.0 78.4% 85.3% Measles 89.6 93.4 88.8 87.7% 91% OPV3 88.0 85.0 85.0 78.0% 81% TT2+ 72.9 67 60.0 60.3% 63.6% SOURCE: MoHSW ZANZIBAR

The plan is to maintain and sustain high immunization coverage of more than 90%. This can be achieved by support the low performing districts ( North A and North B in Unguja and Mkoani, Chakechake and Micheweni in Pemba ), improve data quality and eliminate MNT in the high risk districts. The problem of high measles coverage compared to DTP- HB3 coverage will also be addressed.

Table 1.2: Immunization Schedule in Zanzibar

Antigen Age OPV0 At birth up to 14 days BCG At birth or first contact OPV1, DTP-HepB-Hib 1,PCV1 6 Weeks of age Zanzibar OPV2, DTP-HepB- Hib2, PCV2 10 Weeks of age Zanzibar OPV3, DTP-HepB-hib3, PCV3 14 Weeks of age Zanzibar Measles 9 Months of age Vitamin A – 1 st dose 9 Months of age Vitamin A – 2 nd dose 15 Months of age Vitamin A – 3 rd dose 21 Months of age TT 1 First contact TT 2 1 Month after the 1 st dose TT 3 6 Months after the 2 nd dose TT 4 1 Year after the 3 rd dose TT 5 1 Year after the 4 th dose

3.1.2 Dropout rates Dropout rate of DTP-Hb1-DTP-Hb3 between 2004 and 2008 is within the acceptable rate of below 10%. However, DTP-Hb1–Measles dropout rate remains questionable, since data collected from health facilities shows the large number of children vaccinated against Measles compared to those vaccinated with DTP-HB 1 vaccine which results in negative drop out. This indicates the possibility of problems in the data collection at health facility level where all immunization data are collected and sent to higher level. Hence DQS will be among the most priority activities in the coming 5 year (2010 – 2014) so as to verify and improve the quality of data

Table 8: Dropout rate (DTP-HB1-DTP-HB3), Zanzibar 2004-2008

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Year DTP Hb1 DTP Hb3 Dropout rate (%) 2004 38,310 37,222 3 2005 39,314 36,886 6.2 2006 39,479 38,171 3.3 2007 38,686 35,954 7.1 2008 42,594 40,246 5.5

Table 9: Drop Out Rate (DPT-HepB1-Measles) 2004-2008

Year DPT-HepB1 Measles Dropout rate (%) 2004 38,310 37,581 1.90 2005 39,314 40,237 -2.35 2006 39,479 39,441 0.10 2007 38,686 40,211 -3.94 2008 42,594 42,965 -0.87 SOURCE: MOHSW ZANZIBAR

3.2 Cold chain and other EPI logistics There are 152 RCH clinics that offer immunization services, among them 96 (66%) RCH clinics have refrigerators. Proportion of Health facilities with refrigerators has increased in 2007 after installation of solar Fridges in most of the small hard to reach islands. .

In some areas health facilities are too closer hence it will not cost effective to put refrigerator in each of the RCH clinic. In these areas one refrigerator serves more than one RCH clinic, where the health facility with no refrigerator collect their vaccines from nearby health facilities.

At health facility level, only 10% of the cold chain equipments remain non CFC free and 100% of district stores contain CFC free refrigerators. The programme has planned to equip the remaining health facilities with CFC free equipment such as refrigerators, cold boxes, vaccine carriers etc. Programme also intends to provide training on maintenance of such equipments at all levels.

Three out of four districts in Pemba have started to use LP Gas Fridges as the alternative source of energy since the electricity in Pemba is not constant and kerosene refrigerators are not working properly. The plan is to continue using LP Gas fridges in all districts of Pemba.

3.2.1 Vaccine Stores 3.2.1.1 Central Vaccine Store At the moment different programmes are storing their products and supplies in the Central Medical Stores including vaccines. Management of the Central Medical stores is greatly incapacitated in terms of providing the required logistics support to programmes.

The central vaccine store in Zanzibar is within the Central Medical Store (CMS) in the Ministry of Health. Operational and management of CMS is in collaboration between EPI and Drug Management Unit (DMU).

The Central vaccine store is equipped with compression refrigerators and freezers and walk-in cold room. The existing EPI vaccine store has small storage capacity which is 1200lts (refrigerators) and 600lts (freezers). This capacity is not adequate compared to the increase in the population and the amount of vaccines to be stored especially the introduction of new vaccines. Thus, there is a need to install new cold and freezer rooms that will at least occupy a volume of 2000lts .

3.2.1.2 Zonal Vaccine Store

The introduction of Pneumococcal vaccine and Rotavirus vaccine has implication for greater storage space. Therefore, there is a need to extend the storage services at Zonal

12 levels so as to decongest the Central Medical Store and ensure required logistic support is provided to the programmes.

The Zonal store in Pemba is equipped with compression refrigerators and freezers as well as ice pack freezers. The programme planning to replace all non CFC free equipments in the coming five years. Both National and Zonal stores have generators for power back up.

3.2.1.3 District Vaccine Store There are ten district vaccine stores that are equipped with compression refrigerators and sibir . These Sibirs are old and non CFC Free. The replacement of CFC containing refrigerators to CFC free refrigerators is among the activities in this plan The plan is to equip all district stores with CFC Free equipments by the year 2014. . 3.2.1.4 Health Facility There are 96 health facilities with refrigerators in Zanzibar. All refrigeratotor in Unguja zone run by electricity while more than 75% in Pemba zone run by LP gas. The remaining 25% of Pemba refrigerators are run by kerosene and unreliable electricity that necessitates the use of kerosene. The replacement plan has been in place since year 2006 and the aim is to replace the 100% of Pemba refregirators with LP gas by 2010 The models of refrigerators available at health facility are RCW 50EK, RCW 42EG, and RCW 42EK.Sibir V110EG, Sibir V170EK, Sibir V170EG

3.3 Advocacy, Communication and Social Mobilization One of the five components of the immunization system is advocacy and communication. Effective communication helps to mobilize resources for the immunization programme and encourages other sectors and organizations from various actors and the community to participate in immunization activities. EPI will continue to maintain dialogue not only with service providers but also with communities, including care givers, traditional healers, politicians, religious leaders and other influential people to enhance their understanding of the importance of immunization. Social mobilization activities in 2006- 2010 were very limited due to scarcity of resources. Community sensitization meetings were carried out in only villages where the outbreaks of vaccine preventable diseases occurred (i.e. Measles). Spot announcement, TV/Radio Programmes and production of IEC materials were only conducted during mass campaign

Advocacy for routine EPI will be conducted at National, district as well as Village (Shehia) levels during the mass (measles) campaign and introduction of new vaccines. Furthermore an EPI communication guideline has been developed and finalized in collaboration with Health education unit, ZHMT, IMCI and Save the Children. Special TOT conducted for all DHMTs to equip them with knowledge and skills in order to facilitate their work in their respective districts. In order to strengthen communication and advocacy at all levels, the programme will sensitize districts to incorporate advocacy and communication activities in their district comprehensive plans.

Much emphasis also will be on social mobilization and public education at the lower levels about immunization to ensure high community participation awareness on immunization . Among the social mobilization activities that will be designed and implemented include the following: • Routine sensitization meetings with community, political and religious leaders as well as other influential people. • Weekly health programme in Radio and TV • Production and distribution of IEC materials (Posters, leaflets etc).

3.4 Capacity building 3.4.1 Refresher training, MLM, Pre-service institution strengthening Over the course of time, district and health facility staff have been exposed to different trainings such as:- refresher training on data management, cold chain, data quality self assessment and disease surveillance. Also DHMTs had other opportunities such as micro planning training, social mobilization and communication training.

13 Although refresher trainings are conducted, the time allocated is not adequate to cover all the necessary aspects of EPI skills. Refresher trainings for all service providers are done once yearly, where most of time newly employed health workers miss the opportunity of being trained on time. Also health workers turnover causes unequal distribution of health staff among districts leading to some districts running shortage of staff. It is the plan of EPI programme in the coming five years to continue conducting refresher training to DHMTs and health facilities to overcome the problem of unskilled health workers and ensure the districts officers uses the opportunity of supervision by coaching and provide on the job training. Human resource development and capacity building at all levels is essential.

National level capacity has improved by its five staff being trained on EPI Mid-Level Management (MLM) course and almost all national staff has been exposed in to various trainings such as data management and epidemiology, Data Quality Self Assessment, retreats etc. The responsibility of Central EPI is to coordinate local trainings at district and health facility levels with technical assistance of partners (WHO, UNICEF, GAVI etc). One of the challenges in training districts and service providers the limited funds provided for training..

EPI also facilitate pre-service training on EPI subjects at the college of Health sciences on specific programmes prepared by the college. These involves clinical officers, Health officers, PHNB and Community Health Nurses In order to ensure sustainability and equip the college to deliver EPI education, one tutor from the college of Health sciences has received MLM training. There is a plan to adopt MLM modules and conduct training at the district which will include also some tutors from Collage of health sciences in this current strategic plan.

3.5 Targeted Disease initiative and Disease Surveillance 3.4.2. 3.5.1 Polio Eradication EPI national level capacity strengthening.

AFP Surveillance AFP surveillance is an integral part of the Polio Eradication effort. Any case of AFP in children younger than 15 years should be reported. Investigations should be initiated as soon as possible, including the collection of two stool specimens, preferably within 14 days of onset of paralysis. All Stool specimens are sent to EPI Central office Dar-es-salaam, using the reverse cold chain.

Follow-up examinations to all cases to define residual paralysis (leftover) were done at least 60 days after onset of paralysis. Delays in conducting 60 days follow-up made the final classification of cases to take longer time than the time recommended. AFP surveillance detection rate is improving (greater than 1/100,000 pop under 15 yrs) in most of the districts. Central and North B districts reported at least one case of AFP each in the past five years while Chake, district has never reported any AFP case for last five years. Availability of AFP surveillance funds and transport (vehicles and motorcycles) assisted to stimulate the proper active case search in most of areas in Zanzibar.

3.5.1.1 Polio Certification In the United republic of Tanzania the polio eradication activities are monitored under one system for both Tanzania mainland and Zanzibar. These includes the formation of polio eradication committees and polio surveillance data base. United Republic of Tanzania was among the 8 countries who presented the polio certification document in the African Regional Certification meeting conducted in July 2004 in Dar es Salaam, Tanzania. How ever the country was not certified as polio free. The next presentation was in 2006 in Uganda and tTanzania document was deffered and requested to conduct surveillance review country wide . The next presentation of the document is planned to take place in October 2009

3.5.1.2 Laboratory Containment The Ministries of Health (Mainland and Zanzibar) inaugurated and oriented the National

14 Polio Task Force members on 10 th of October 2003, marking the beginning of the implementation of Wild Polio virus containment activities in the country. The Task Force has identified the following activities as priority activities for Laboratory containment of Wild Poliovirus:
Laboratory Survey to identify laboratories storing Poliovirus and potentially poliovirus infectious materials.
National Inventory of all laboratories holding stocks of Poliovirus materials.
Storage of Poliovirus of Scientific value in secure laboratories.
Destruction of all unneeded Poliovirus and potentially Poliovirus infected materials.

The Task force has successfully managed to conduct a Laboratory survey in 60 Laboratories in the country and managed to identify the Laboratories storing Poliovirus or potentially polio virus infectious materials. List of all Laboratories holding the stocks were prepared. The recommendations were provided on how to work or destroy unneeded poliovirus or infected potential infectious materials. The Laboratory containment document formed part of the Tanzania Polio certification document presented in the ARCC meeting.

3.5.1.3 Wild Polio virus Importation and preparedness United Republic of Tanzania has prepared a wild poliovirus importation preparedness and response plan. The plan identified high risk areas including bordering districts, low OPV3 coverage and districts with port of entry. Urban, West, Micheweni, North B and Mkoani were identified. The rationale for the preparedness plan is to enable Tanzania maintains polio free status and appropriate response towards wild polio virus importation.

3.5.1.4 Task Force Meetings (Polio committees meetings) United Republic of Tanzania formed four committees which include: - National Polio expert, National Certification, National wild polio virus importation and preparedness and National Laboratories containment committees. These committees were formed by the Ministries of Health to provide technical support for polio eradication activities.

3.5.2 Measles pre elimination activities 3.5.2.1 Supplemental Immunization Activities. Measles mass campaign is a second strategy for measles control and also an opportunity to reach those children who were not reached in routine immunization services. Measles mass campaigns in Zanzibar were conducted from 1999 to 2008.

In the first two years (1999-2000), the campaign targeted children under five years of age and covered all districts in Zanzibar. While in 2001 and 2002, the campaigns were for children from 9 month to 15 years of age, in 2005 the measles campaign covered children aged 9 months to 5yrs. The coverage increased from 67% in 1999 to 92% in 2002 and 84% in 2005. The most recent measles SIAin 2008 vitamin A and mabendazole targeted the under 10years acheved 86% nationaly

Table 10: Measles mass campaign results, Zanzibar 1999-2008 YEAR TARGET. VACCINATED. COVERAGE %. 1999 100,598 67,440 67 2000 51,250 36,977 72.2 2001 232,271 175,950 75.7 2002 204,669 189,303 92 2005 143,328 120,408 84.0% 2008 346,081 299,445 86.7%.

3.5.3 There is need to sustain the results obtained especially for the low performing districts and the hard to reach populations. Strengthening the case search can facilitate higher performances. Zanzibar is planning to accelerate Measles pre elimination activities

3.5.3.1 Case based surveillance Zanzibar started measles case based surveillance after finishing a country wide measles campaign for under fifteen years in 2002. With this new strategy of measles control, a

15 single measles suspected case is considered as an outbreak. Therefore, a blood sample for each suspected case is collected up to a maximum of ten cases and the outbreak investigated.

3.5.3.2 Role of Laboratory The Virology Laboratory in Muhimbili National Hospital is responsible for testing blood specimens of suspected measles cases from Zanzibar. Serum samples are sent to EPI central office Dar Es salaam under reverse cold chain.

3.5.4 NNT Elimination The goal of neonatal tetanus (NT) elimination was adopted by the WHO in 1988 and by the World Summit for Children in 1990. In June 2000, fifty seven countries failed to meet the target of eliminating Neonatal Tetanus. Zanzibar is one among the 57 countries that have not yet eliminated NT. The goal of maternal and neonatal tetanus (MNT) elimination by 2005 was recently declared jointly by UNICEF, WHO, and UNFP.

3.5.4.1 High risk district activities In 2000, maternal neonatal tetanus (MNT) elimination status review was conducted in all 10 districts of Zanzibar which found Wete and Michewen i to be MNT high risk Districts. Following the results of the assessment three rounds of MNT campaigns were held in Micheweni and Wete Districts in December 2001, January and July 2002. Generally, the coverage was low, this is due to inadequate social mobilization and rumors. The last MNT high risk assessment was conducted in 2008 in all districts using MNT surrogate indicators. The review team found that three districts (Micheweni, Chakechake and Mkoani) remained a high risk districts based on the NNT incidence and other low surrogate indicators detected.. Recommendations were made to all districts in order to achieve elimination status. The three high risk districts recommended conducting MNT SIAs in 2008

Reported Neonatal Tetanus cases and deaths from 1999 - 2007

18 16 16 14 12 10 10 8 8 CASES 8 DEATHS 6 5 5 4 3 3 2 2 2 2 1 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007

3.5.4.2 Case investigation Neonatal tetanus case based surveillance started in 2004, which means all neonatal deaths investigated. However, investigation of neonatal deaths is still a big challenge in many areas of Zanzibar due to cultural and religious beliefs. Community awareness on neonatal tetanus and strengthening of NNT surveillance through training of health workers is one of the priority areas.

3.5.5 Hib Surveillance

A rapid assessment of the Hib disease burden was conducted in Tanzania Mainland in 2001. The findings revealed that the number of Hib disease cases ranged from 18,000 – 19,000 with deaths ranging from 3,300 – 3,500 per year using the meningitis and child mortality based methods. Following this, MOH/EPI established Hib surveillance at

16 Muhimbili National Hospital in 2001 and extended sentinel surveillance to Muheza District Hospital in Tanga. These findings are corroborated by those of many regional studies which suggest that Hib disease is a significant problem. In addition, the WHO Position Paper on Hib conjugate vaccines has recommended the inclusion of conjugate Hib vaccines in all routine infant immunization programmes in view of their demonstrated safety and efficacy 1.

3.5 Injection Safety and Adverse event following immunization Zanzibar started practicing safe immunization injections in measles mass campaigns in 1999 using Auto-disable syringes and needles. Currently, EPI Zanzibar is using AD syringes, needles and safety boxes in routine immunization services since 2002. EPI Zanzibar will ensure that all immunization injections are safe to the recipient, health worker, community and the environment by implementing the following strategies:-
Adequate supply of syringes and safe vaccines.
Surveillance and management of AEFI
Good injection practices
Proper waste management.
Communication and advocacy.

3.5.6 Injection safety and AEFI An injection safety assessment done in 2000 shows the need for an updated assessment. It has been observed that there is poor reporting of the AEFI, however some health facilities have started reporting the AEFIs following sensitization and trainings. The plan is to strengthen AEFI surveillance at health facility and district levels through on-the-job and refresher trainings as well as supportive supervision.

3.6 National Level Program Support At national level the proramme is led by the Programme Manager with the assistance of other technical personnel such as:
Zonal EPI Operational Officer
EPI logistics officer
EPI Surveillance Officer
National cold chain Officer
National training Officer
National vaccine store Manager The National EPI team mainly support the implementation of EPI national policies and guidelines. The national team also performs monitoring and evaluation activities through supportive supervision, compilation and analysis of monthly district reports and conducts quarterly and annual evaluation meetings. Based on findings from several reports and for the national team then designs a strategic guidance plan for the general implementation of the programme. EPI Organogram attached as annex.

3.7 Monitoring and evaluation 3.7.1 Data Quality Self Assessment. EPI Zanzibar in collaboration with EPI Tanzania mainland and partners conducted DQS training from 16 – 24 August, 2004 for national programme officers. Field visits showed the various weaknesses in different aspects at both districts and health facility levels. In 2006 another DQAs TOT training was conducted for the national EPI officers. The programme plans to conduct DQS training in all DHMTS.

3.7.2 Supervision National EPI program supervises districts on quarterly basis while districts supervise health facilities every month. The national and district supervisors use available supervisory checklist.

3.7.3 Immunization Coverage surveys The last national immunization coverage survey in Zanzibar was conducted in 1993. The EPI programme is mainly using administrative coverage data for its planning purposes. The measles post campaign survey was conducted in 2008 but the results are not yet displayed.

17 The programme is planning to conduct at least one routine coverage survey within the planning period 2010-2014

3.7.4 Operational research. Operations research will be used as a tool to for informing the policy and decision makers in the country. The program will identify researchers and research assistants to conduct identified areas/topics for research.

System will be established for assessing specific research topics to be addressed. This will include:-
Assess the affordable and appropriate low cost incinerators for rural health facilities.
Evaluate the cost-effectiveness and impact on routine services of different immunizations strategies, particularly in rural areas, including a comparative analysis of fixed sites, regular outreach, and campaigns.
Asses the feasibility and cost of alternative energy source for rural refrigerators, in order to convince partners to accept solar power and LP gases in the country rehabilitation plan.
Studies on social mobilization and communication strategies to increase community involvement.

3.7.5 Data Monitoring Form development/reprinting/ modification EPI in collaboration with HMIS Zanzibar uses standard monitoring forms which include tally sheet, health facility summary form, district summary form and national summary forms. The other forms used by the programme are performance monitoring charts for all levels, disease investigation forms and temperature chart monitoring forms. Health facility is the primary source of information where all immunization data are generated. These data are compiled monthly in a summary form. DHMTs collect monthly health facility summary forms, compile and analyze and electronically sends to the higher level.

At the national level, the monthly district summaries are compiled and analyzed to obtain national coverage and performance of the districts. The national level then shares these reports with partners and other stakeholders

3.7.6 EPI Assessment Several assessments were done in Zanzibar. Immunization service assessment was conducted in February 2000. The assessment focused on managerial issues related to vaccine supply, immunization services, disease surveillance, logistics, communication and EPI financing as well as external factors such as the various sectoral reforms. The country is due for another comprehensive immunization service assessment.

3.7.6.1 Vaccine management assessment. The Ministry of Health and Social Welfare of Zanzibar in partnership with the WHO carried out an EPI vaccine management assessment in Zanzibar from 2 nd to 4 th July 2002 and from 29 November – 12 December 2007 with a view to finding gaps and coming up with recommendations to address the gaps. A WHO eleven criteria standard tool was used to collect and analyze the data. All the three levels of vaccine management, the Central, the Sub-national and the Service delivery levels were covered. One Central Vaccine Store (CVS), five sub-national stores and eight service delivery facilities were assessed.

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A summary of the findings is indicated below:

Intermediate Service # Criterion National Level Level 1 Vaccine arrival process 100 2 Vaccine storage temperature 37 66 80 3 Cold store capacity 100 75 100 Building, cold chain equipment a nd 4 83 54 83 transport Maintenance of cold chain equipment 5 67 76 78 and transport 6 Stock management 55 65 30 7 Effective vaccine delivery 64 55 38 Correct diluent use for freeze dried 8 0 80 48 vaccines 9 Effective VVM use 9 85 68 10 Multi-Dose Vial Policy 100 100 98 11 Vaccine wastage control 67 77 58

As depicted above, Zanzibar has a lot of work to do to improve on all indicators of vaccine management below 80% of the standard. This is confirmed by the average score obtained for all indicators of the standard which stand at 68%.

Stock Management Tool (SMT) was introduced at national level in the mid 2007. This tool is not yet in use at sub-national level because the training has not been conducted. In 2008, the programme introduced the use of SMT as well as Inventory Tool so as to better manage the vaccines and related supplies.

The EPI programme in Zanzibar will ensure that the storage and transport of vaccines at appropriate temperatures is vital to vaccine safety and efficacy. Attention has traditionally focused on heat exposure of vaccines, but studies have indicated that exposure of vaccines to freezing temperatures may be more common. Freeze-sensitive vaccines like DTP-HB can loose their potency when exposed to freezing temperatures as a result of dissociation of the antigen protein from the alum adjuvant. Training on how to prevent freezing during storage and transportation will be prioritized with procurement of freeze tag indicators.

Despite the extensive operational benefits of VVMs, their use does not increase system costs. Indeed, there is a net saving to immunization programmes when VVMs are used. Therefore, the programme will continue to order the vaccines with VVMs and the cold chain equipments that meet WHO specifications. The assessment was done in all vaccine- handling levels of the country which included: Central vaccine store Zanzibar, zonal store in Pemba, district stores and health facilities.

The overall objective of this assessment was to review vaccine management performance (vaccine stock control, safe and effective vaccine storage and handling). Findings showed 40% of all cold chain equipment to be CFC free, and only 48% of Health workers had knowledge on MDVP and VVM.

19 4.0 NEW VACCINE

The United Republic of Tanzania is one of GAVI eligible countries for accessing GAVI support which include ISS, HSS, Injection safety support, Civil Society Organization support, and new and underused vaccines. Zanzibar is part of the united republic of Tanzania. The Government of Zanzibar has committed to reduce child mortality which is clearly articulated in the MKUZA document, MDGs, Party manifesto, HSSP II. Immunization Programme contributes towards achieving the goals of reducing child morbidity and mortality through vaccination. However not all available vaccines in the markets are accessed by the children United republic of Tanzania. GAVI window of supporting poor countries including Tanzania will facilitate further reduction of morbidity and mortality of the children. This goal of introducing Pneumoccocal and rotavirus vaccines will accelerate the achievement of MDG 4. To achieve these goals, the Programme has the following planned specific objectives:-

To prepare and submit Pneumococcal and Rotavirus vaccines application to GAVI in September 2009
To introduce Pneumococcal vaccines countrywide by the year 2010.
To introduce rotavirus vaccines countrywide by the year 2011
To conduct post introduction evaluation in 2012
To document the impact of introducing new vaccines.

Currently, the financing of the immunization programme is done by Government of Zanzibar in collaboration with partners. The government has started the procurement of all traditional vaccines and injection materials. The vaccine budget includes the co-financing funds and the procurement is done through UNICEF.

Since there is MSD, which stores and distributes all vaccines, drugs, equipment and medical supplies routinely in Mainland. The new vaccines for Zanzibar will arrive in MSD and allocation of Zanzibar collected from MSD by EPI logistician from Zanzibar.

Prior to the introduction of the vaccines, there will be appropriate preparations to facilitate smooth introduction and implementation of immunization services. This will include cold chain assessment, vaccines management assessments, advocacy, training, sensitization to the health workers and the community. However the vaccine management assessment was conducted and results indicates that the country will be able to accommodate new vaccine. The additional GAVI funds support for introduction of new and underused vaccines will facilitate the activities.

20 Table 11: Summary of situational analysis by accelerated disease control initiatives. Component Suggested indicator National status 2004 2005 2006 2007 2008 OPV 0 coverage 51% 53% 46% 52% 57% OPV3 coverage 96% 86% 85% 78% 81.5% Non polio AFP rate per 100,000 children Polio 0.6 2.1 1.8 0.6 1.7 under 15 years of age Percentage of silent districts for the 70% 40% 20% 70% 50% previous years Extent: SNID Number of rounds Coverage range MNT TT2+ coverage 84% 67% 60% 60.3% 63% Percentage of districts reporting >1case 10% 0 0 30% 0% per 1,000 live births Was there an SIA? (Y/N) N N N N Y Measles coverage 93% 94% 89% 87% 90% Number of suspected measles cases 1,191 77 156 1,199 423 Measles Number of lab. confirmed cases 20 10 3 0 20 Extent: NID/SNID N/A NID 9mths- N/A 9months – 10 yrs Age group N/A

Capacity Number of clinicians sensitized on building on integrated disease surveillance. 160 Nil 136 Nil 50 integrated diseases surveillance Number of new staff recruited (clinicians) 35 46 32 0 22

21 Table 12: Situational analysis of routine EPI by system components Component Suggested indicator National status 2004 2005 2006 2007 2008 DPT-Hep B +Hib3 coverage 96% 86% 86% 78.4% 85% Percentage of districts with > 80% DTP-Hep 90% 80% 80% 30% 70% B+Hib coverage Routine coverage National DTP-Hep B1–DTP-Hep+Hib B3 2.8% 6.2% 3.3% 7.1% 5.5% drop-out rate Percentage of districts with drop-out rate 20% 30% 20% 30% 30% DTP-Hep B1 – DTP-Hep B3+Hib >10 Percentage of surveillance reports received timely at national level from district 70% 70% 80% 80% 75% Routine compared to number of reports expected surveillance Percentage of complete surveillance reports received at national level from district 100% 100% 100% 100% 100% compared to number of reports expected Percentage of districts with adequate 90% 90% 95% 95% 95% numbers of functional cold chain equipment Percentage of health facilities with non CFC 50% 40% 30% 20% 20% free equipments. Availability of adequate vaccine storage Cold 75% 60% 75% 70% 60% capacity at Central vaccine store. chain/logistics Percentage of dry store space available for 75% 60% 60% 40% 40% syringes, safety boxes etc at central level. Percentage of health facilities with cold chain failure due to poor source of energy 35% 40% 30% 20% 10% (kerosene). Percentage of health facilities equipped with Injection safety injection safety materials (AD syringes, safety 100% 100% 100% 100% 100% and AEFI boxes) Percentage of districts reporting AEFI on a 0% 20% 40% 20% 20%

22 Component Suggested indicator National status 2004 2005 2006 2007 2008 monthly basis. Percentage of districts with functioning 20% 80% 80% 80% 70% incinerators. Was there a stock out at national level during No stock No stock out No YES YES the last year? out Vaccine supply If yes, specify duration in months - - - 3months 3weeks

Advocacy and Percentage of districts and health facilities Nil 40% of 60% 100% communication trained in communication and advocacy health 0% skills for EPI. facilities trained Percentage of districts and immunization 100% Nil 90% Nil 90% service providers updated with new EPI Capacity building policies and innovations. Percentage of districts trained in EPI-MLM 0% 0% 0% 0% 0% training What percentage of total routine vaccine Financial spending was financed using governmental 15% 15% 40% 0% 15% sustainability funds? (including loans and excluding external public financing) Linking to other Were immunization services systematically health linked with delivery of other Yes Yes Yes Yes Yes intervention interventions(malaria, nutrition, SMI, IMCI)

Are a series of district indicators collected Management regularly at national level? (Y/N) Yes Yes Yes Yes planning Yes

23 Component Suggested indicator National status 2004 2005 2006 2007 2008 ICC Number of meetings held per year 2 2 4 0 0 Waste disposal Availability of waste management plan Available Available Available Available Available Programme Vaccine wastage monitoring at national level Yes Yes Yes Yes Yes efficiency for all vaccines

24 Table 13: Strengths and weaknesses. AREA STRENGTHS WEAKNESSES 1. Service delivery Country wide availability of EPI Disparities in district coverage. Slight services decrease of immunization coverage Political commitment. since 2005 Technical Support from Development National immunization coverage of Partners DTP-Hep B 3 is below 90%

Low Drop out rate for DPT-HepB1-3 at Low TT2+ for pregnant women. National level Some small islands have no Availability of funds for outreach H/Facilities and are hard to reach services. population. Inadequate technical staff at service delivery level 2. Vaccine supply, Back up power supply facility at central Vaccine stock outs was experienced in quality and logistics. level. 2007 &. 2008.

100% of all district using AD syringes Limited vaccine storage capacity at and safety boxes National and intermediate level (cold and dry store) Availability of cold boxes, carriers and thermometers at all service delivery Inadequate supportive supervision points. from national and zonal level to district level. 90% of Health facilities offering immunization services have functional VVM is not used for planning and refrigerators. decision making at health facility level.

Only 30% of the districts has updated inventory None CFC free equipment are still available at H/ Facility level Unreliable electricity in Pemba island. 50% of Pemba Districts depend energy source of electricity/kerosene to store vaccines. 3. Advocacy and Support from partners in mobilizing 60% of the district implemented communication. resources for advocacy and social communication plans. mobilization. All districts have communication plans Lack of funds for media houses EPI communication guideline is to support advocacy and social available mobilization ( TV and Radio programme ) 4.Human Resource Refresher training for service providers In adequate time to cover all EPI capacity and DHMTs conducted annually. components in the refresher training. In consistency of funds allocation New recruited RCH service providers resulting in least priority in training were updated on EPI practices and policies. 5 National staff trained in MLM No MLM training done at district and including 1 tutor from the college of lower levels health sciences. EPI program facilitates training at the Un equal distribution of EPI service

25 AREA STRENGTHS WEAKNESSES college of Health sciences. providers. Shortage of staffs in some areas. Updated curriculum of Health officers In adequate funds to review and includes EPI new policies. curriculum for nurses and clinical officers. Presence of active surveillance system Some districts are silent for reporting Non polio AFP rate >1/100,000 AFP cases. population <15 years Availability of AFP surveillance funds Delays in conducting 60 days follow and transport. up.

Recruitment of new focal person in Retrieval of case note in major Hospitals. Hospital/H/Facilities for AFP cases is a Refresher training for focal person challenge. conducted annually.

Polio certification document presented and accepted by ARCC

5.Surveillance Tanzania was declared no wild Polio virus circulation in the country. Laboratory containment activities are Bio-safety level three training not yet ongoing. conducted to the labs that hold suspected infectious materials. Wild Polio Virus importation, Slow implementation of the plan as preparedness and response plan is in well as unsecured funds for the place. planned activities.

Measles case based surveillance is in Some focal persons are not submitting place. line list. Reduction in # of MNT high risk MNT case based surveillance system districts between 2004 and 2008. not well functioning.

Cultural and religious beliefs pose a challenge to neonatal deaths investigation. 6. Injection safety Use of AD syringes and safety boxes Regular maintenance of incinerators is since 2002. not done – need for repairs. Low cost incinerators constructed in all district Hospitals. AEFI monitoring tool is in place and Inconsistence reporting of AEFI from reporting is on going. health facilities. AEFI is not among the variables to be reported monthly for HMIS system. 7.Sustainable Financing FSP plan available and implementation In adequate implementation of is on going. Financial Sustainability Plans. Government allocated funds through Competing priorities in MOH&SW. MTEF and started procuring vaccines. Funds are not disbursed according to planned activities

26 AREA STRENGTHS WEAKNESSES 8. Programme Annual program retreats are held. EPI annual meeting not conducted management. Quarterly evaluation meeting regularly. conducted regularly. HMIS variables are linked with EPI at Irregular ICC meetings all levels 9. New Vaccine Availability of new vaccines in the Disease burden data may not be introduction. global market. available on certain diseases intended Co-financing support from GAVI. for new vaccines, e.g. Hib, Rota virus, Pneumo etc and not considered as a major public health problem.

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NATIONAL PRIORITIES, OBJECTIVES AND MILESTONES, 2010-2014 VISION. To improve the health of children and women of child bearing age through the provision of immunization services and the control of vaccine preventable diseases. GOAL: To contribute towards the reduction in under five and maternal morbidity and mortality through disease control initiatives.

Table 14: National priorities, NIP objectives and milestones, regional and global goals and order of priority.

Description of NIP objectives NIP milestone Regional and global Order of problems and other goals (until 2014) priority national priorities 1. SERVICE DELIVERY 1. National coverage 1. To increase DTP- 2010 : 40% of districts By 2014 or sooner all for DTP-HB – Hib 3 is HB – Hib 3 to achieve Penta countries will have below 90%. coverage to at least coverage of 90% and routine 90% nationally and above. immunization 2. Only 30% of over 80% in every 2011 : 60% of districts coverage at 90% districts have DTP- district by the end to achieve Penta nationally and over HB-Hib 3 coverage of of 2014. coverage of 90% and 80% coverage in all 90% and above above. districts 2012 : 70% of districts to achieve Penta coverage of 90% and above. 2013 : 90% of districts to achieve Penta coverage of 90% and above. 2014: All districts to achieve Penta coverage of 90% and above.

Only 30% of the 2. To increase 2010 : 50% of the By 2014, at least districts have TT2+ immunization districts to achieve 80% of countries will coverage for coverage of TT2+ TT2+ coverage of 75% attain a minimum of pregnant mothers ≥ to at least 85% for and above. 80% TT2+ coverage 80% all pregnant 2011 : 70% of districts among pregnant women in all to achieve TT2+ women. districts by the coverage of 80% and year 2014 above. 2012 : 80% of districts to achieve TT2+ coverage of 90% and above. 2013 : 85% of districts to achieve TT2+ coverage of 90% and

28 above. 2014 : All districts to achieve TT2+ coverage of 90% and above. 30% of districts have 2010 : 80% of district By 2014 or sooner all the DTP Hep B – Hib1 To maintain DTP to achieve the drop out countries will have - DTP Hep B – Hib3 Hep B – Hib1 - DTP rate of less than 10%. routine drop out rate of Hep B – Hib3 drop 2011 : 90% of district immunization above 10%. out rate to below to achieve the drop out coverage at 90% 10% in all districts rate of less than 10%. nationally with at by the year 2012 2012 : 100% of district least 80% coverage to achieve the drop out in all districts rate of less than 10%. 2013- 2014: To ma intain the drop out rate of less than 10% in all districts.

2. SURVEILLANCE. Low measles case To ensure that 2010-2014: To update detection especially 80% of the district clinicians on disease non febrile rush report at least one surveillance annually. illness suspected case of To conduct measles with blood sensitization meetings specimen and with community. attain annualized rate of non measles febrile rash illness of 1:100,000 population by December 2014 Weak reporting To improve 2010 : To improve system of neonatal neonatal death reporting of NN Death deaths occurring in investigation to at up to 40% the community. least 80% of all 2011 : To improve neonatal death in reporting of NN Death the community by up to 50% the year 2014 2012 : To improve reporting of NN Death up to 60% 2013 : To improve reporting of NN Death up to 70% 2014 : To improve reporting of NN Death up to 80% Non polio AFP case To improve and 2010-2014: To detection rate has sustain non polio achieve and maintain been low (<2 case per AFP case detection non polio AFP rate of 100,000 population rate to over 2 cases >2 cases per 100,000 under children of 15 per 100,000 population under 15

29 years of age) with the populations of years of age. exception of the year children under 15 2005. years of age by 2014. 50% of the districts To strengthen and 2010 : To attain 70% of remained silent for in maintain AFP districts reporting AFP 2008. surveillance cases. system in all silent 2011 : To attain 80% of districts by 2014. districts reporting AFP cases.

2012 : To attain 90% of districts reporting AFP cases. 2013-2014: To attain and maintain 100% of districts reporting AFP cases. 30% of district To improve 2010 : 80% of district reports are not timeliness of EPI reports to be submitted at National reporting system submitted at national level timely from 70% to 100% level timely. at all level by the 2011 : 90% of district year 2010 reports to be submit ed at national level timely. To encourage all 2012 : 100% of district districts to report reports to be electronically by submitted at national 2010 level timely. 2013-2014: To maintain the timelines of reports at all levels. To improve health workers skills in integrated disease and active case search by training 100% of the clinicians in every district by the year 2014 M&E tools for active To orient all 2010: 50% of focal surveillance visits surveillance focal persons will be do not routinely persons on M&E oriented. used. tools by the end of 2011: 50% of 2014 remained focal persons will be oriented.

AEFI is not among To incorporate 2010 Up date the variables of the AEFI variable in monitoring tools and HMIS surveillance HMIS system by sensitization of focal database year 2014 persons 2010 AEFI is

30 incorporated in HIMS database No existing To institute an 2010 formulation of structure for AEFI AEFI investigation AEFI investigation investigation team for every teams district and have an AEFI focal person at national level by year 2014

3. Vaccine supply, quality and logistics. 20% of cold chain 2010 : To replace by equipments at health 50% of district with facility level are non CFC free equipments CFC free. and by 90% at health facility level. Limited storage capacity at 2011 : To replace intermediate level 100% of CFC free (cold and dry stores). equipments at district and health facility VVM are not used for levels. planning and decision 2012 - 2014 : To making. maintain the available CFC free equipments. No updated inventory 2010: To increase 40% at district level. storage capacity at intermediate level and 2011: To increase by 100% storage capacity at intermediate level. Inadequate dry store To increase dry 2010 : To order and at central level and store storage install new container. zonal level capacity at intermediate level by the 2014

Poor quality of To equip 100% of 2010: To construct kerosene available in Pemba HFs with LP sheds for storing gas the market. gas refrigerators by and gas cylinders in Unreliable electricity the year 2014. chake chake district. in Pemba Island for 2011 : To start operating gas 30% of vaccine refrigerators at health refrigerators. facilities 2012-2014 : To maintain the use of gas refrigerators in all H/Facilities in Pemba.

31 Poor capacity of To 2010: Initiate dialogue ZFDB for vaccine strengthen/build with ZFDB. potency test and capacity of ZFDB to 2011: To build and regulation. regulate vaccine by equip ZFDB laboratory. 2010. 2012 - 2014: To start conducting quality assurance for vaccine. 4. Advocacy and communication 2010: To conduct To mobilize advocacy and resources for social communication mobilization and training in 80% of the support Media districts and health program by 2014 facilities. 2011 : To conduct advocacy and communication training in 100% of the districts.

2012 -2014 : To monitor and supervise communication activities at district and health facility levels. Shortage of resources 2010: To mobilize in routine advocacy resources for IEC, and and communication Media program activities 2011: To implement Lack of funds for IEC and Media media to support program. advocacy and social 2012 - 2014: To mobilization ( TV and Sustain IEC and Media Radio programme ) programs

Create community 2010: Preparation and awareness on EPI development of EIC services by and advocacy conducting 80% of messages. IEC planned 2011: Pre-testing and activities distribution of IEC and advocacy materials. To undertake a 2010: Develop strategic behavior behavioural change change strategic plan and communication protocol. survey. 2011: Implement behavioural change strategic plan 2012: Conduct communication survey.

32

5. Injection safety

20% of districts have To construct at 2010 : To construct no incinerator least one incinerators in 100% facilities. incinerator in of the remaining 100% of the districts. remained districts by 2014. 2011 -2014 : To use and maintain incinerators constructed. Inconsistent To incorporate 2010: To identify and reporting of AEFI AEFI variable in sensitize district focal from health facilities HMIS system by persons on AEFI. 2010 2010: AEFI is not among the To institute AEFI variable in HMIS To constitute an investigation team at report. AEFI investigation district and review team for every team at national level. district and have 2011-2014: To follow an AEFI focal up AEFI at district and person at national health facility levels level by 2014 2010: To incorporate AEFI variable in HMIS system and train the Health care workers. 2011: to receive AEFI report from all H/ Facilities. 6. Introduction of new vaccine To introduce 2010 : To introduce Pneumococcal Pneumococal Vaccine vaccines and Rota in all districts. virus vaccines by 2011 : To introduce 2012 . Rotavirus Vaccine in all Introduction of new districts. vaccine

2011 : To proceed with the administration of new vaccines.

7. Sustainable financing FSP implementation To mobilize 2010-2014: Advocate is slow resources from with private agencies Competing priorities local government, and government for in the MOHSW private sectors and resources to support Disbursement of partners. immunization funds though programme. Government support is very low 8. Human resource capacity.

33 To improve health 2010-2014 : To update workers’ skills on clinicians on disease EPI issues by surveillance annually. clinician sensitization training 100% of 2010-2014 : To training is not regular the districts by the provide EPI refresher and its covers few year 2011 training for number of clinicians immunization service New recruited staffs providers. are not aware of EPI To increase the 2010: To conduct MLM issues. managerial training in 40% of the Many health staff capacity of EPI districts. currently positioned managers at all 2011: To conduct MLM in EPI Management at levels from 40% to training in 100% of the district level were not 100% by 2014 for districts. trained on MLM effective EPI course planning and strengthening RED/GIVS strategies. To update and 2010 training EPI support the national officers on National level staff public administration with management 2011 train National EPI and public health officers on MPH skills by the year 2014

9. Programme management

To support the 2010-2014 : To operational cost of conduct EPI evaluation

the central EPI meetings annually. office. EPI quarterly and To conduct EPI 2010-2014 : To annual evaluation quarterly and conduct EPI evaluation meetings are not annual evaluation meetings annually. conducted regularly. meetings on annual basis. Operational research To conduct at least 2010-2014 : one operational To conduct EPI research per year evaluation meetings so as to see the annually. need of modifying 2010-2014 : programme To conduct operational policies and research annually. improving performance. 10. Accelerated disease control Polio To ensure no wild To conduct polio SNIDs

34 ichekiwe ibadilishwe polio virus in high risk areas when importation in need arises. Zanzibar by 2014. 2010: To achieve the Non Polio AFP rate of To achieve polio more than 2/100,000 eradication status among the population by 2014 under 15 years. 2011 - 2014: To To achieve Non Sustain the Non Polio Polio AFP rate of AFP rate of more than more than 2/100,000 among the 2/100,000 among population under 15 the population years under 15 years by 2014 Sporadic measles To implement 2010: To attain two out breaks. measles “pre primary measles elimination goal” surveillance indicators. Over reporting of by 2014. 2011: To conduct measles routine measles SIAs. coverage data. 2012: To introduce measles second dose (MCV2) opportunities in all district. MNT Case based To achieve MNT 2010: Community Surveillance system elimination status sensitization for MNT. is not well by 2014 2011: To have 50% of functioning. neonatal deaths from community reported Neonatal deaths and investigated. occurred in the 2012 2014: To have community are not 80% of NN deaths reported for from community investigation. reported and investigated. To conduct Lot 2010: MNT Elimination Quality Assessment To review MNT for MNT (LQA) by surrogate indicators the year 2010 and conduct LQA

35 OBJECTIVES, STRATEGIES, KEY ACTIVITIES AND TIMELINES, ZANZIBAR 2010-2014. Table 15a: Service delivery.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To increase DTP-HB – - RED strategy 1. Review and update the Zonal EPI Hib 3 coverage to at implemented in Team and DHMT on RED approach least 90% nationally every district. 2. Conduct EPI quarterly review and and over 80% in every - Ensure annual evaluation meeting district by the end of availability of 3. Provide support in quarterly bases 2014. vaccines, AD to 3 districts with high number of syringes and unvaccinated children To increase other logistics. 4. Conduct supportive supervision in immunization coverage - Update all district and health facilities of TT2+ to at least 85% knowledge and 5. Review, update and harmonize EPI for all pregnant women skills of Health supportive supervision tools. in all districts by the workers in EPI 6. Hire boats for outreach and year 2014. service delivery. supervision in small islands 7. Procure motorcycles (bajaj) for mobile teams 8. Conduct refresher training at district and Health Facility level 9. Conduct quarterly and annual evaluation meetings.

1. Prepare detailed micro planning for To maintain DPTHB1- Plan to reach hard to reach areas. DPTHB3 drop out rate hard to reach 2. conduct out reach services to all to below 10% in all areas at least hard to reach areas districts by the year once a month. 3. Procure bicycles and motorcycles 2014. for mobile teams.

36 Table 2(c) Surveillance.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 Objective 2: To ensure Measles 1. Clinicians sensitization on that 80% of the surveillance with measles surveillance district report at least other vaccine 2. Conduct measles case based one suspected case of preventable surveillance measles with blood disease 3. Conduct measles outbreak specimen and attain surveillance. investigation annualized rate of non measles febrile rash illness of 1:100,000 population by December 2014. To improve neonatal enhance 1. Conduct sensitization death investigation to community meeting with community and at least 80% of all involvement and traditional birth attendants. neonatal death in the participation 2. to recruit community community by the surveillance focal person year 2014 To improve and AFP surveillance 1. Conduct integrated active case sustain AFP case integrated with search detection rate to over other vaccine 2. AFP case investigation 2 per 100,000 preventable 3. Conduct 60 days follows up of population of children diseases all cases under 15 years of age surveillance. 4. Sensitization meeting to and 80% of stool traditional healers adequacy by 5. Re-orientation training to focal December 2014. persons on EPI Surveillance 1. Active case search to PHCU, Physiotherapy Unit and Community

37 1. To orient all conduct training for surveillance surveillance focal focal person on Management persons on M&E Tools for active surveillance tools by the end of 2014 Procure specimen kit for AFP and measles

To improve timeliness 1.train districts tosubmit of EPI reporting monthly reports system from 70% to electronically 100% at all level by the year 2010

To improve health 1. Train new health workers workers skills in (clinicians) on MNT, AFP, integrated disease and measles and Hib surveillance active case search by 2. Conduct refresher training 100% of the surveillance training for clinicians in every existing focal persons. district by the year 2014 To incorporate AEFI Strengthen EPI variable in HMIS disease 1.Update monitoring tools and in system by year 2014 surveillance cooperate AEFI reporting system and improving 2. Printing and distributing data quality monitoring tools

38 3. Sensitise district focal person Strengthen EPI 1..institute district investigation disease teams To institute an AEFI surveillance investigation team for reporting system 2. investigate any reported AEFI every district and and improving have an AEFI focal data quality person at national level by year 2014 3. reporting of AEFI to National focal point

39 Table 3 (d) Vaccine Supply, quality and logistics

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To equip at least 90% Ensure availability 1. Procure bundled vaccines that of all vaccine stores of cold chain (CFC meet international standards and health facilities free) equipment 2. Procure CFC free Refrigerators, with CFC free cold and cold chain RCW 42EKG, RCW 50EKG. chain equipments by equipment. 3. Prepare annual vaccines and the year 2014. cold chain forecasting. 4. Procure cold boxes RCW 25 5. Procure vaccine carriers. 6. Procure spares for refrigerator RCW 42 and RCW50. 7. distribution of vaccine and injection material Create resource 1. Conduct advocacy meeting for mobilization resource mobilization. forum for cold chain equipment.

ensure the 1. Install 2 new containers for To increase storage availability of storing dry supplies capacity at enough storage 2. Procure Freezer room intermediate level by capacity at 2014 3. Install Freezer room at CVS intermediate level

by 2014 To equip 100% of Replacement of 1. Construct LP gas structure Pemba Health energy source 2.Conduct training to LP Gas Facilities with LP gas from kerosene to refrigerator users at health facility refrigerators by the LP gas level

40 year 2014. 3. Procure and distribute LP gas cylinders.

To strengthen / build strengthen the 1. Institute dialogue with ZFDB capacity of ZFDB to ZFDB capacity in 2. Apply vaccine regulation in regulate vaccine by applying vaccine Zanzibar year 2014 regulations in Zanzibar

Table 4 (b) Advocacy and communication.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To mobilize support advocacy 1. Support districts to integrate resources for social meeting with social mobilization activities in mobilization and stakeholders the district plans. support media 2.Conduct advocacy meetings programs by year at village level 2014. 3.Conduct refresher training at district and H/Facility level. 4.Conduct communication skills training at district and H/Facility level.

41 5.Develop, print and distribute IEC material for routine immunization

6..Production and air EPI messages in Radio and TV Advocacy and sensitization Create community meetings to district, community awareness on EPI leaders and other stakeholders services by on RI Advocacy and conducting 80% of sensitization meetings to IEC planned district, community leaders and activities. other stakeholders on RI

Undertake a strategic support survey on 1.Develop survey protocol behavior change behavior change 2.Conduct behavior change communication communication communication survey survey.

4. Injection Safety:

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To construct at least one improve injection construct district incinerator in 100% of the safety incinerators remained districts by 2014

42 6. Introduction of New Vaccine:

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To introduce Pnemococcal and To introduce 1.Advocacy to policy Rota Virus Vaccines into Pneumococal makers routine EPI Programme by vaccine by 2010 year 2012 and rotavirus by 3.Development, printing 2011 of guidelines

3.Training of service providers 4.Introduce pneumococal vaccine country wide

8. Sustainable Financing.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To mobilize resources from local government, private sectors and Partners.

8. Human Resource Capacity.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To improve health workers’ Provide technical 1.Clinician sensitization skills on EPI issues by training support to EPI on disease surveillance 100% of the districts by year service providers 2.Conduct refresher 2014 training for service providers annually

43 To increase the managerial 1.conduct MLM training skills of EPI Managers at all for National and district levels from 40% to 100% by supervisors year 2014 for effective EPI planning and strengthening RED/GIVS strategies To update and support the strengthen EPI 1.Train National EPI National level staff with managerial officers on Public management and public health capacity administration, and skills by the year 2014 MPH. 2. conduct EPI evaluation meetings annually

9. Programme management.

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 1. Procurement of Ensure availability of vehicles, computers, To support the operational reliable transport, and other office cost of the central EPI office. stationary, and other consumables office supplies. 2. Payment of internet services. To conduct at least one strengthen 1. prepare research operational research per programme protocol year so as to see the need of performance 2.Conduct one operational modifying programme research annually policies and improving performance.

44 10. Accelerated disease control

Objective (1) Strategy (2) Key activities (3) Year 1 Year 2 Year 3 Year 4 Year 5 To ensure the support for To conduct SIAS 1. Procure vaccine and accelerated diseases control for polio Measles injection materials initiatives so as to to reach the and NNT when 2. Micro planning and global goals of polio eradicate need arises. training. measles control and NNT 3. Advocacy and social eliminate by the year 2014 mobilization. 3. Conduct SIA.

45

5. COSTING AND FINANCING OF MULTI-YEAR PALN 20010 - 2014 5.1 Costing and Financing Methodology The costing of this Comprehensive Multi Year plan for Zanzibar is based on the priorities set out in the programmatic section of the plan. A situational analysis was conducted identifying the strengths and weaknesses of the programme, leading to the setting of national objective and priorities for the period 2010 -2014. The national objectives have been linked with those of the overall heath sector strategic plan. It is also linked to the Zanzibar Strategy for Growth and Reduction of Poverty (ZSGRP). The costing was done using the standard cMYP costing tool version 2.2a

The baseline data on expenditure on cold chain, transport and personnel, coverage and wastage targets for 2010-2014 came from previous reports such as Annual Progress report and WHO-UNICEF Joint Reporting Forms (JRF). The team also took advantage of the knowledge of the EPI structure by the EPI Manager, logistician and Data Manager in filling information gaps on coverage, vaccine management, cold chain, logistics and distribution, SIAs and in some cases prices and costs. However, since EPI is one of several health services provided at the health facilities, no significant emphasis was placed in costing buildings. The main costing for building is based on the renovation of few staff houses and expansion of zonal vaccine stores

Standard programme inputs such as vaccines, injection materials and cold chain equipment were costed using the UNICEF prices. This is because; virtually all the EPI supplies in Zanzibar are purchased through UNICEF. Operational costs for routine and supplementary immunization activities were based on past expenditure. SIAs costs for measles in 2011 and 2014 are based on information provided on previous SIAs in 2008. The staff cost was based on government pay scale and the government allowances circular.

The financing information was obtained from past expenditures of the Revolutionary Government of Zanzibar and partners such as HSPS (DANIDA), UNICEF, WHO and ADB.

The future costing and financing for the EPI programme (2010-2014) is in line with the National Health Strategic Plan and the ZSGRP cycles of Zanzibar.

The future cMYP costing is based on the following assumptions: • Increase and maintain coverage for traditional vaccines • Expansion of cold chain capacity at National, zonal, district and health facilities. • Reduction of dropout rate • Reduction vaccine wastage • Introduction of new vaccines (Pneumococcal vaccine by 2010 and Rotavirus vaccine by 2011).

5.1.2 Cost profile The Revolutionary Government of Zanzibar through the Ministry of Health and Social Welfare (MOHSW) has long recognised the effectiveness of EPI expenditure as a preventative intervention. As such, the programme has benefited from uninterrupted support from the government. The programme also benefited from donor support. The baseline cost for the EPI programme in 2008 shows that the total expenditure on immunization amounts to $2.3 million. The three main areas of routine immunization programme were traditional vaccine and co-financing (50%), personnel (26%) and other routine recurrent cost (11%). The immunization specific expenditure in 2008 (the base year) was around US$ 2.3 million. Out of this, only US$462,104 was spent on campaigns while the rest was on routine. The cost profile is presented in Figure 5.1 and the details in Table 5.1.

46

Figure 5.1:

Baseline Cost Profile (Routine Only)*

0% 5% 0% 5% 11%

0%

26% 50%

3%

0%

Traditional Vaccines Underused Vaccines New Vaccines Injection supplies Personnel Transportation Other routine recurrent costs Vehicles Cold chain equipment Other capital equipment

5.3 Baseline Financing

The baseline financing of the EPI programme in Zanzibar indicates that The Revolutionary Government of Zanzibar bears 42%, GAVI 30% and UNICEF 20% of the programme cost. The rest of the financing was undertaken by partners such as DANIDA and WHO.

The details are shown in Figure 5.2.

47

Figure 5.2

Baseline Financing Profile (Routine Only)*

0%0%0%0%0%0%0%0%0%0%0%

30%

42%

6%

2%

20%

Government UNICEF WHO HSPS(DANIDA)

GAVI ADB

5.4 Cost by immunization strategy The bulk of the costs for the planning period (2010 – 2014) are in routine immunization. The rest of the cost is Measles campaign which is planned for 2011 and 2014 as shown in Figure 5.3.

48

Figure 5.3:

Costs by Strategy** $6.0

$5.0 Millions $4.0

$3.0

$2.0

$1.0

$0.0 2010 2011 2012 2013 2014

Campaigns

Routine Fix Site Delivery

Outreach Strategy

Mobile Strategy

5.5 Programme cost requirement for 2010-2014 The Revolutionary Government of Zanzibar will strive to achieve the Global Immunization Vision and Strategy (GIVS) targets. Therefore, the future resource requirement of the immunization programme is based on current objectives of the programme, elaborated in programmatic section of the comprehensive Multi-Year Plan (cMYP) 2010-2014. The resources requirements for the new cMYP have risen above the baseline level. The introduction of Pneumococcal and rotavirus vaccines in Zanzibar is planned to commence in 2010 and 2011 respectively.. The year 2009 will be utilized to prepare the ground in terms of purchase and distribution of new vaccines, training of staff, social mobilization, improving cold chain and logistics for the eventual introduction of the new antigen.

49 Based on the assumptions, approximately $24 million will be required to cover the needs of the programme for the planning period. This translates into approximately $5.0 million per annum.The cost is almost the same for all year with slight increase in 2011 and 2012 due to introduction of new vaccines and Measles campaign.

. The details are shown in Table 5.1 and Figure 5.4.

50 Table 5.1: Programme costs and Future Resources Requirements

Expenditures Future Resource Requirements Total 2010 Cost Category 2010 2011 2012 2013 2014 2014 Routine Recurrent Cost US$ US$ US$ US$ US$ US$ Vaccines (routine vaccines only) $718,900 $3,335,919 $2,932,820 $3,043,867 $3,165,972 $3,288,583 $15,767,161

Traditional vaccines $68,056 $71,599 $94,901 $95,146 $100,352 $104,023 $466,021

New and underused vaccines $650,844 $373,700 $414,161 $426,545 $443,297 $460,342 $2,118,045

Injection supplies $33,428 $73,198 $75,562 $78,091 $81,648 $84,413 $392,911 Personnel Salaries of full-time NIP health workers (immunization specific) $15,806 $16,123 $20,790 $21,205 $28,332 $30,912 $117,362 Per-diems for outreach vaccinators/mobile teams $144,195 $147,102 $150,068 $153,094 $156,181 $159,330 $765,776

Maintenance and overhead $122,946 $130,680 $145,041 $145,327 $150,613 $157,228 $728,888 Training $15,000 $15,300 $15,606 $15,918 $16,236 $16,561 $79,622

IEC/social mobilization $960 $1,077 $1,209 $1,356 $1,521 $1,707 $6,870

Disease surveillance $4,000 $4,488 $5,036 $5,650 $6,339 $7,113 $28,625

Programme management $6,400 $6,936 $7,491 $8,065 $8,659 $13,249 $44,400

Other routine recurrent costs $1,600 $23,600 $44,864 $25,894 $28,298 $31,553 $154,208

Subtotal Recurrent Costs $1,782,135 $4,199,722 $3,907,549 $4,020,158 $4,187,448 $4,355,014 $20,669,889 Routine Capital Cost

Vehicles $435,600 $595,320 $1,102,068 $556,358 $2,689,346

Cold chain equipment $58,918 $40,969 $12,264 $17,563 $15,966 $276 $87,038

Other capital equipment $45,390 $4,786 $18,571 $19,700 $4,416 $92,864

Subtotal Capital Costs $58,918 $521,959 $612,370 $1,138,202 $592,024 $4,692 $2,869,248 Campaigns Polio $0 $0 $0 $0 $0 $0 $0 Measles SIAs

Vaccines and Injection Supplies $129,987 $87,429 $0 $0 $99,117 $186,546

Operational costs $158,000 $203,000 $0 $0 $242,000 $445,000

MNT campaigns

Vaccines and Injection Supplies $18,117 $0 $0 $0 $0 $0 $0

Operational costs $156,000 $0 $0 $0 $0 $0 $0

Subtotal Campaign Costs $462,104 $0 $290,429 $0 $0 $341,117 $631,546 Other Costs

GRAND TOTAL $2,303,157 $4,721,681 $4,810,348 $5,158,360 $4,779,472 $4,700,823 $24,170,683

51 5.5.1 Projected Financing from all sources from 2010-2014. From the total future resource requirements of $24 million in five years, the bulk of the cost goes towards new and underused vaccines, followed by transportation, personnel, and traditional vaccines. The total resource requirement increased from 2011 and then slightly decreased in 2013 with peak in 2012. The financing trends for the years covered in the cMYP are further elaborated in Figures 5.4 & 5.5 and Table 5.2.

Figure 5.4: Projection of Future Resource Requirements** $6.0

$5.0 Millions $4.0

$3.0

$2.0

$1.0

$- 2010 2011 2012 2013 2014

Traditional Vaccines Underused Vaccines New Vaccines Injection supplies Personnel Transportation Other routine recurrent costs Vehicles Cold chain equipment Other capital equipment Campaigns

5.5.2 Future Financing Out of the total resource requirement, $11.0 million is secured over the live of the plan. The funding gap with secured funding amounts to $22.8 million. However, there is a probable funding of $1.2 million, which if taken into account will reduced the funding gap to $10.6 thousand.

Table 5.2: Resource Requirements, Financing and Gaps*

Avg. 2010 - Resource Requirements, Financing and Gaps* 2010 2011 2012 2013 2014 2014

Total Resource Requirements $4,451,952 $4,515,673 $4,863,349 $4,525,765 $4,452,051 $22,808,790

Total Resource Requirements (Routine only) $4,451,952 $4,225,244 $4,863,349 $4,525,765 $4,110,934 $22,177,244 per capita $3.6 $3.3 $3.7 $3.3 $3.0 $3.4

52 per DTP targeted child $106.5 $92.8 $103.7 $93.4 $82.8 $95.5

Total Secured Financing $2,276,666 $1,970,009 $2,343,703 $3,237,652 $1,178,787 $11,006,817 Government $276,666 $353,616 $579,331 $763,471 $399,348 $2,372,432 UNICEF $2,000,000 $116,357 $62,222 $26,842 $128,326 $2,333,747 WHO $0 $105,036 $12,150 $6,339 $249,113 $372,638 HSPS(DANIDA) $0 $0 $90,000 $1,500,000 $0 $1,590,000 GAVI $0 $1,395,000 $1,600,000 $941,000 $402,000 $4,338,000 ADB $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Funding Gap (with secured funds only) $2,175,286 $2,545,664 $2,519,646 $1,288,113 $3,273,264 $11,801,973 % of Total Needs 49% 56% 52% 28% 74% 52%

Total Probable Financing $435,200 $218,000 $0 $354,000 $195,330 $1,202,530 Government $0 $0 $0 $200,000 $0 $200,000 UNICEF $0 $0 $0 $0 $0 $0 WHO $0 $0 $0 $0 $0 $0 HSPS(DANIDA) $85,200 $218,000 $0 $154,000 $179,330 $636,530 GAVI $350,000 $0 $0 $0 $0 $350,000 ADB $0 $0 $0 $0 $16,000 $16,000 Funding Gap (with secured & probable funds) $1,740,086 $2,327,664 $2,519,646 $934,113 $3,077,934 $10,599,443 % of Total Needs 39% 52% 52% 21% 69% 46%

Financing is classified either as secured, or probable. Secured funding refers to those funds already mobilized to support the implementation of the cMYP. Probable funds are those potentially available but may require additional efforts such as proposal development, negotiations to secure them. From the total cost of $24 million from 2010-2014, $11.0 was secured mainly from the RGoZ and other partners, thus leading to a funding gap of $11.0 million (See Figure 5.5 and Table 5.2). The major providers of secured funding were the RGoZ and GAVI. The total secured financing represents a 45.8% of the total programme cost. The financing of Pneumococcal and Rotavirus vaccines was considered probable because its availability depends on the approval of the application by GAVI.

Figure 5.5:

53 Future Secure Financing and Gaps**

$6.0

$5.0 Millions $4.0

$3.0

$2.0

$1.0

$0.0 2010 2011 2012 2013 2014

Government UNICEF WHO HSPS(DANIDA) GAVI ADB

FUNDING GAP

When both secured and probable funding was taken into account, the funding gap reduced to approximately $10.6 million for the five years of the life of the cMYP (2010-2014). The bulk of the probable funding is expected from GAVI, RGoZ and DANIDA. The RGoZ expenditure is mainly in relation to co-payment for the three new vaccines. Therefore, all funding towards new vaccines from GAVI will be secured as soon as approval is granted for Pneumococcal and rotavirus vaccine application for reasons explained in the financial sustainability section. The Government component of Pneumococcal and rotavirus vaccine was classified as secured because the government has committed itself to co-finance these vaccines. The partner funding is not expected to rapidly increase over the planned period. However, turning such probable funds to secure ones will require engaging partners well in advance of the implementation timeline of the activities concerned. This is ideal at the time of their respective programme development period.

5.5 FINANCIAL SUSTAINABILITY STRATEGIES, ACTIONS AND INDICATORS In the previous sections, the financial challenges of the EPI programme in Zanzibar have been highlighted. The programme intends to ensure it can appropriately respond to these challenges in order to be able to implement its stated objectives. The Zanzibar cMYP includes all the important components of an effective immunization programme. The plan is to address the weakness in the programme and at the same time build on the strengths. The Revolutionary Government of Zanzibar through the MOHSW intends to take a number of steps that will have positive effects on the overall costs and financing of the plan. To achieve that, the opportunities and threats in raising and effectively managing donor funds are analyzed.

5.5.1 Opportunities Opportunities for funding exist at international and national levels. There has been relatively strong partners support for routine and supplementary immunization activities in Zanzibar. Partners have in the

54 past offered substantial resources for both routine and supplementary immunization activities (SIAs). EPI programme receives significant commitment from the Revolutionary Government of Zanzibar. This commitment has been demonstrated through the baseline contribution of 42%. This is a very high proportion considering the competing priorities of Government. The governmet of Zanzibar has set a budget for procurement of traditional vaccine through MTEF budget. The cold chain for EPI is in good state to withstand the introduction of Pneumoccocal and rotavirus vaccines although the storage volume needs to be increased.

5.5.2 Threats Despite availability of the opportunities in Zanzibar for improved EPI financing and efficient service delivery, there are some threats the Revolutionary Government of Zanzibar need to overcome for better mobilisation of resources for immunization financing. The successful implementation of the cMYP depends on how the government and the EPI get around these threats. The recent proliferation of Global Health Initiatives that target specific interventions outside of immunization limits government’s ability to secure budgetary support from many traditional partners that will otherwise prefer to channel their funds through these initiatives.

5.6. Alternative policy scenarios for financial sustainability The Revolutionary Government of Zanzibar (RGoZ) will explore all possible options to provide the best possible EPI programme to the population. The government will consider the programmatic implications, the impact on disease burden and poverty reduction and the impact towards the achievement of Millennium Development Goal (MDG) 4 of the various options of financial sustainability.

5.7 Strategies and actions for financial sustainability Within the framework of these opportunities and threats, the three main strategies the Revolutionary Government of Zanzibar intends to pursue in order to improve the financial sustainability of the programme include: (i) Mobilizing additional resources (ii) Improving resource reliability (iii) Improving programme efficiency

Mobilizing additional resources

In order to fill the financing gaps, the MOHSW shall seek additional resources from Government by ensuring its costing and financing information is included in the next and subsequent budgets and MTEF. Vaccine preventable diseases are estimated to contribute up to 8% of the total disease burden in the country (World Health Report, 2004). In line with that, the programme shall target 8% or more of the health sector funds to be utilised for immunization activities.

The EPI shall seek additional resources from its partners. There shall be targeted resource mobilization from specific partners based on the respective cost category for which funds are required. The funding gap shall be discussed with the multilateral partners through whom most of the funds are usually channeled. The programme shall have discussions with partners that could support specific EPI interventions. The cMYP shall be presented to various partners, including those currently not active in health, and/or EPI. The publicity and advocacy of the programme shall be increased among potential partners with the programme achievements and financial situation elaborated. This shall ensure that a wider group of partners is aware of the cMYP objectives, strategies, costs and financing gaps for an informed decision on support.

Government shall ensure it continues support for the traditional vaccines as well as co-payment/co finance for Hib Pneumococcal and rotavirus vaccines . The government will on annual basis increase its contribution towards Hib Pneumococcal and rotavirus vaccines cost with a view to eventually takeover at

55 the end of GAVI support. The Revolutionary Government of Zanzibar has recently introduced various methods of securing financing for mainly for curative health. It is hoped that by securing alternative source of funding for other competing health interventions, the government resources will be freed to finance EPI and other preventive health programmes.

Improving reliability of resources The EPI programme gets planned funds from the Revolutionary Government of Zanzibar on an annual basis. Therefore, the programme is comfortable with the reliability of its allocated resources from the revolutionary government. However, the main challenge it faces is funds from partners, which cannot be committed longer than the lives of their respective plans. The programme shall seek additional resources, but also seek to have its resources available in a more reliable manner. At present, the programme is only aware of its financing for less than one year’s equivalent of activities. This reliance on ad hoc operational activities in line with the availability of funds makes long term planning difficult. The first step towards achieving reliability of funding is to ensure the budgetary requirements for EPI are included in national health strategic plan, budget and MTEF. The programme shall seek to have improved accounting and reporting mechanisms to ensure that partners and the Revolutionary Government of Zanzibar are always aware of how the resources directed to EPI are utilized. This will lead to transparency and improved donor confidence. The cMYP will be discussed at the ICC as well as with individual partners to improve the awareness of the programme and its financing situation in the medium term, thereby giving partners better time to plan their resource commitments in the future.

Improving programme efficiency There are a number of areas where the programme shall work to ensure efficiency. High vaccine wastage for reconstituted vaccines and poor maintenance of equipment also lead to poor utilization of limited resources. Therefore, putting in place strategies to work towards limiting these inefficiencies shall free such resources and be a strong advocacy tool to attract additional resources. The present wastage rates shall be reduced through better vaccine management, cold chain improvement and proper monitoring and supervision.

5.8 Implementation and follow-up of financial sustainability strategies This section presents the plan of action for the implementation of the financial sustainability activities outlined in the previous sections. The activities, persons responsible, and monitoring indicators for the different strategies of achieving financial sustainability are outlined in the Table 5.2. The responsibility for monitoring the implementation rests with ICC. A technical sub-working group shall follow up on a regular basis, on behalf of the ICC, the implementation of the plan. This shall include representation from the EPI (EPI Manager, Surveillance Officer and Logistician), WHO, UNICEF and Ministry of Finance. Depending on the need and discretion of ICC, additional members could be co-opted. The working group will select a focal point to oversee the implementation of the plan and coordinate the membership. A detail Plan of Action (POA) guiding the work of the group shall be drawn. A report should be submitted to ICC, which shall review and monitor progress every quarter and plan for the following quarter. On an annual basis, the ICC and other stakeholders shall meet to review progress on financial sustainability indicators and plan the financial sustainability strategies and actions for the following year.

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Table 5.5: Activities and indicators for follow up of financial sustainability strategies Target Activity for which Person for Indicators for follow up resources needed follow up Indicator Freq of Value follow up Basel Target ine Mobilise Increase from the current MOH % of government Annually >8% additional level the RGoZ support to planning expenditure on health resources EPI Dept/EPI EPI expenditure as Annually >8% for EPI proportion of total health expenditure Target additional support EPI EPI recurrent Annually >8% for EPI from health sector expenditure as a plan proportion of GOSW recurrent expenditure Conduct target resource UNICEF/WH Number of non- Quarterly - 4 mobilization from partners O traditional EPI partners times for specific EPI needs that are presented the cMYP Present the contents of the ICC Number of fora utilised to Bi- 0 3 cMYP to traditional and present the cMYP Annually non-traditional partners and in the process use it as an advocacy tool for resource mobilization Improve Negotiations with specific EPI Number of traditional Quarterly 4 8 Reliability partners for funding Programme partners that gave of pledges beyond one year Manager funding commitment resources beyond one year Include the EPI in MTEF EPI EPI needs included in 3 yrs By Programme MTEF 2012 Manager Programme Improve monitoring and EPI Number of regions with Quarterly 100% efficiency evaluation of the monitoring and ensured programme evaluation in place Update cMYP EPI Annual update of cMYP Continuo Annua Manager annual plan usly lly

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