Immunization Financing News
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VOL. 5, ISS 2, JULY 2013 J VOL. 5, ISS 3, SEPTEMBER 2013 Since the first colloquium, held in Addis Ababa, Ethiopia in 2011, countries involved in Sabin’s Sustainable Immunization Financing Program have been working to increase their commitments to immunisation through two pathways: legislation and innovative financing. The second colloquium, in Dakar, revealed that A milestone was reached when peers from 17 all but one country have drafted new, or are countries met in Dakar, Senegal on August 5-6, amending existing, laws relating to 2013 for the Second Sustainable Immunization immunisation. Countries discussed their Financing Colloquium. More than 100 legislative work and brainstormed ways to participants, including delegates from ministries accelerate their respective legislative of health, ministries of finance and processes. The emerging role of parliaments in parliamentarians, exchanged advocacy crafting and championing the bills was noted. In strategies and best practices and charted several countries, MPs have formed progress toward ownership of their national immunization forums, or caucuses, to facilitate immunisation programs. the legislative process. Innovations in immunization financing and budgeting were also shared. Among the key innovations in the countries are efforts to create new “ring-fenced” national immunization funds. In one case, government is matching private sector donations to the fund. Countries are also identifying new revenue sources, such as excise taxes on cellular phone calls, as a way to increase their immunization investments. In recent years, the countries as a whole have steadily increased their immunization spending. However, development partners (such as GAVI Alliance, UNICEF, and others in civil society) continue to finance more than 50 percent of routine immunization budgets in many of the www.sabin.org/fr (en français) page 1 www.sabin.org/sif VOL. 5, ISS 2, JULY 2013 countries. Achieving country ownership and and other immunization stakeholders on the meeting the six strategic objectives of the challenges facing Kenya’s Expanded Global Vaccine Action Plan will require nothing Programme on Immunization (KEPI) and to less than a paradigm shift, remarked Sabin brainstorm ways to ensure sustainable Executive Vice President Ciro de Quadros. immunization financing. The expected Countries must increase their financial outcomes were to develop a set of follow‐up contributions to the immunization programs that activities for upstream (high level advocacy) protect their citizens and ensure the health of and downstream (district and point of service the next generation. They must reduce their delivery) advocacy. dependence on external funding. KEPI Manager, Dr Tatu Kamau, presented the major issues and challenges facing the Program. Reviewing the financial situation, Dr. Kamau pointed out that the Government of Kenya (GoK) has for years funded all of its immunization delivery system, 90% of its cold chain and all of its traditional vaccines. Kenya has kept up with its GAVI co-payments for pentavalent, yellow fever and PCV-10 vaccines. To avoid onerous importation duties, the program purchases its syringes domestically. The program, however, still depends on external partners for most of the new vaccines and about 50% of its supervisory and 90% of its The full report from the Second Sabin training costs. Program funding is limited by Colloquium on Sustainable Immunization the Government’s Medium Term Expenditure Financing can be downloaded here. Framework (MTEF) and the Ministry’s Sector wide Approach (SWAP), through which a capped budget is distributed annually among the various health programs. Though there is a budget line item for vaccines, the immunization budget is not ring-fenced. Recent elections and a new constitution have According to its 2011-2015 comprehensive opened the doors for renewed immunization Multi-Year Plan (cMYP) for immunization, advocacy work in Kenya. A briefing held on 12 Kenya’s direct, recurrent routine immunization July brought together representatives from program costs came to about US$23m in 2010, Kenya’s National Assembly, Kenyan Pediatric of which the GoK paid $6.6m. Adding in shared Association, Ministry of Health, Ministry of health system costs brought total expenditures Finance and the Ministry of Devolution and to about $134.8m. Of this total, the GoK Planning. They were joined by UNICEF, WHO, financed about $67m. Like other countries, USAID and Sabin counterparts. A Sabin- Kenya likely underreports its immunization sponsored peer exchanger from Uganda also expenditures. Dr. Kamau presented the 2013 attended. budget shown on the next page: The purpose of the briefing was to inform parliamentarians, key government counterparts www.sabin.org/fr (en français) page 2 www.sabin.org/sif VOL. 5, ISS 2, JULY 2013 concern that this would greatly increase risks of vaccine stockouts and would be relatively more expensive. Experience elsewhere has shown that these commodities are best procured centrally. Dr. Kamau felt that a legal framework is urgently needed, particularly to spell out the immunization program financing, vaccine Not included in the table are the shared health procurement and other rules the federal and system costs for 2013. To summarize, the county governments will follow. She recalled GoK’s direct, central-level immunization budget that this was one of the action points that she, has increased, however, Kenya’s immunization Hon. David Eseli and the other Kenyan program remains dependent on external delegates identified in the 2011 SIF Colloquium financing. in Addis. In fact, two draft immunization laws were prepared by members of the National Another challenge lies in the decentralization of Assembly Health Committee in 2011-12. In the vaccine procurement. With the new Constitution last Sabin Kenyan briefing (February 2012), and devolution plan, Kenya’s 47 counties are participants decided not to push the bill until expected to assume responsibility for routine after the 2013 elections. immunization delivery within the coming three years. Some counties will have their own Ugandan MP, Hon. Mathias Kasamba, revenues. Others will receive direct external described the SIF advocacy work underway in partner funding “off budget”. Most of the his country, highlighting the formation of the counties will depend on annual federal transfers Uganda Parliamentary Forum on Immunisation to pay immunization and other health service (UPFI) and its achievements in the areas of delivery costs. Annual transfers will be on the legislation and budgetary oversight. order of KSh 210b. The central MoH will provide normative, technical and quality Representing the newly created Ministry of assurance support to the counties. Devolution and Planning, Mr. James Mwanzia gave his views of the health devolution process. Dr. Kamau displayed county by county 2013 Above all, public health should not be routine immunization budgets which she and compromised at any point in the process, he her team prepared in anticipation of the stated. Mr. Mwanzia listed several of the key devolution process. In total, the counties will policy documents his group is using to define need about KSh 800m (~US$10m) in federal the constitutional changes and devolution transfers and about KSh 2.6b (~US$30m) more modalities (e.g., Urban Areas and Cities Act, in additional funding per year to maintain Public Financial Management Act 2012, current vaccine coverage levels. Government Relations Act). One useful conduit through which his ministry works is the *(The latter figure includes vaccines and Governors’ Summit. The counties will need to syringes. It remains unclear which government meet some strict technical and managerial tests level will pick up cold chain equipment costs.) before the government actually sends the She expressed concern that the Treasury may health sector transfers, he commented. No have already made the transfers and that transfers have yet been sent for health, he counties intend to use the funds to assured the group. In the third session, independently procure their own vaccines and participants summarized their observations and vaccination supplies. Participants shared her www.sabin.org/fr (en français) page 3 www.sabin.org/sif VOL. 5, ISS 2, JULY 2013 began charting a way forward. What is urgently challenges faced by the National Immunization needed, suggested Mr. Mwanzia, is a policy Program, such as the introduction of the new paper spelling out these specific benchmarks Railway Development Levy which is causing a and technical criteria for immunization in delay on clearance of vaccines and injection Kenya. Specific recommendations need to be equipment from the entry ports. Clearance formulated on vaccine procurement, resource requires numerous exemption letters from tracking, reporting by the counties locally and to various government ministries and institutions, and from the respective federal ministries and among them Treasury, Kenya Revenue other issues identified. Authority, Kenya Bureau of Standards, and Kenya Medical Supplies Agency (KEMSA). Mr. Mwanzia also agreed that up-to-date Mutie also brought up the issue of co-financing immunization legislation is needed, not only to of the country’s GAVI new vaccine grants. Co- accommodate the structural changes in how financing payments are supposed to be made services are delivered but also specifying how directly by Treasury but they are often delayed they are to be publicly financed. He endorsed because no money is designated