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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

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countries. Achieving country ownership and and other immunization stakeholders on the meeting the six strategic objectives of the challenges facing ’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

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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

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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 in the budget the suggestion made by Hon. Kasamba that specifically for this purpose. Dr Mutie hoped parliament and government jointly write the that the parliamentary committee will support legislation but, he added, government must the Ministry of Health in ensuring timely lead and not just wait to be summoned by disbursement of these previously approved Parliament to act. funds.

On 4 September, a second SIF parliamentary *Addressing the issue of establishing Kenya’s briefing took place in . Attending were National Immunization Technical Advisory 24 MPs, representatives from the Ministries of Group (NITAG), Mutie emphasized that Health and Finance and partner organization parliament should make necessary legal counterparts. provisions. Progress has been hampered in their absence.

Honorable Dr. David Eseli from Kenya’s National Assembly took the floor next and applauded the presentations which, in his view, enabled the MPs to fully appreciate the importance and challenges involved in vaccinating Kenya’s children. These issues, commented Eseli, can be addressed by the MPs at various levels through legislation, oversight, budget appropriation and advocacy. Kenyan MPs discussing sustainable immunization financing in The MPs in attendance represented various September 2013. committees. Eseli urged them to consolidate their efforts to ensure their advocacy work has The introductory remarks were led by the KEPI far reaching, long lasting effects. Also Deputy Director Dr Dominic Mutie, who represented was the Kenya Women’s highlighted the challenges implicit in the Parliamentary Association (KEWOPA). This sustainable financing objective and called for group includes MPs from all 48 counties in more collective action by the executive, Kenya. Engaging KEWOPA in the action would legislators and stakeholders in order to address assure that immunization advocacy efforts have these concerns. He mentioned several

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nationwide reach. Hon. Eseli emphasized the team that attended the SIF Dakar colloquium need to correctly frame the immunization and reiterated that her Committee is ready to financing challenge. In the past KEPI was take action- by reaching out to other funded mainly by development partners, parliamentary committees and forming a making the Program dependent on their parliamentary forum for immunization and goodwill. The success of immunization is its formulating arguments to support the KEPI largest downfall, he remarked. Once budget. government feels that the partners will provide the funds needed and disease outbreaks are no Participants went on to discuss and formulate longer occurring, public funding begins to fall. action points each institution would subsequently lead. These included the Legislation is one tool for addressing elaboration of immunisation legislation, sustainable financing. The Kenyan Public formation of Parliamentary Lobby Group Health Act, pointed out Eseli, is outdated in that (forum) on Immunization and a series of it only mentions smallpox. The law does not advocacy activities to be carried out in support mention that the onus is on the government and of sustainable immunization financing. parents to ensure full immunization of each child. New legislation on immunization is needed to address these issues. If we do this, and organize a forum within parliament, added Eseli, “We will be able to safeguard vaccines, safeguard vaccination coverage and vaccination financing”. It has been an eventful quarter for immunization in DRC. Throughout July, Kinshasa-based The Chairperson of the Health Committee, Senior Program Officer Helene Mambu-Ma- Hon. Dr Rachael Nyamai, noted that MPs self- Disu worked with her counterparts to prepare select the committees to which they belong.”We for the Dakar SIF Colloquium, which took place therefore have a group of interested and on 5-6 August. Their efforts paid off. In a peer- influential members willing to move forward on reviewed poster session, DRC was scored in addressing challenges of vaccine and the top third of SIF projects in terms of immunization financing”. She acknowledged innovativeness of the work. [See related article that donor dependency alarms have already in this issue]. been raised at cabinet meetings, so this immunization financing advocacy is a timely On the legislative front, Mambu-Ma-Disu intervention. However, she stressed to reported attending four meetings with Members government counterparts, when it comes to of Parliament, legal advisors from the Ministry matters of legislation, the committee must be of Health and the National Assembly, the kept well informed to avoid complications, national EPI Manager and counterparts from particularly in the later legislative stages. Such the Ministry of Budget, UNICEF and WHO. All complications were experienced in developing are helping to refine a draft immunization law a recent health bill. The Ministry of Health and prior to depositing it for formal consideration by WHO are in positions to share accurate, the National Assembly. updated information with the Health Committee. Its members can then make appropriate, On 22-23 July, Mambu-Ma-Disu joined a informed decisions. The Chair then thanked the visiting GAVI mission in Kinshasa. The purpose was to develop a country-tailored approach for GAVI support to the national immunization program.

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On 29-31 July, Mambu-Ma-Disu facilitated a workshop in Kinshasa organized by the Agence de Medecine Preventive (AMP). The workshop trained immunization managers from all 11 provinces to use a costing tool for better management of resources at the delivery level. Other topics addressed included budgeting, resource mobilization, data analysis and reporting. The workshop built on resource tracking work started last year by the Ministry of Health. During the workshop, EPI Financial Officer Mr. Benjamin Matata presented a table the Program uses to track immunization resource flows. The table summarizes commitments and disbursements from all sources for the years 2010-2013. “It was a true peer-to-peer learning experience. The EPI team will follow up with the participants to make sure they prepare their budgets for 2014 and present them to their provincial governments so that they are included in their 2014 provincial budgets”, reported Mambu-Ma-Disu. The EPI team subsequently updated its resource tracking table (see below) and presented it on 4 September in a meeting of the Technical Inter-Agency Coordinating Committee for immunization. The team used the Sabin budget flow analysis sheet to prepare their report. The table shows that the government’s contributions have increased in absolute terms and as a percentage of total financing. The table also shows that the disbursement of budgets is not always complete for any given source or year, however, the government’s disbursement rate has been steadily improving.

“We expect the Government to disburse the GAVI co-financing payments any day. That will bring the disbursement rate for EPI close to 100% by the end of the year”, commented Mambu-Ma-Disu, who attended the meeting. [Editor’s note: The Government of DRC subsequently made the disbursements for co-financing and for vaccine procurement.]

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On 25 September, EPI team members and members of the Parliamentary Forum on Immunization (Réseau des Parlementaires Congolais pour l'Appui à la Vaccination) met to discuss the details of the proposed 2014 immunization budget. Such meetings have become routine in DRC.

“They exemplify the kind of institutional innovations countries are developing to reach the sustainable immunization financing objective”, observed SIF Program Director Mike McQuestion.

A SIF Program analysis of recently published data shows government expenditures on routine immunization expenditures declined in 2012. Table 1 below shows gross national income (GNI) per capita, government health expenditures and total government routine immunization expenditures for subsets of reporting GAVI-eligible countries during 2006-2012. Over the period, mean GNI rose 63% and government health expenditures rose 78%. Reported government expenditures on routine immunization increased from 2007 to 2011 but decreased in 2012.

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It is not clear whether government immunization investments truly dropped in 2012 or whether the drop reflects poor reporting. Governments report their routine immunization expenditures annually through WHO/UNICEF Joint Reporting Form (JRF) Indicator 6500. They report their vaccine expenditures through JRF Indicator 6470. As shown in the table below, only 66% of countries reported any expenditures at all in 2012. This compares to an average reporting rate of 75% for 2006-2011. By definition, vaccine expenditures any given year should be less than total immunization program expenditures. Of 45 countries reporting any expenditure information in 2012, 8 (18%) reported greater vaccine than total expenditures. For prior country-years, 23% misreported expenditures in similar fashion.

According to the Global Vaccine Action Plan Monitoring & Evaluation/Accountability Framework, governments are to begin reporting their annual immunization expenditures in the May 2014 World Health Assembly, using JRF Indicator 6500.

Reported JRF immunization expenditures are reported for each SIF country here.

Table 2 shows the 2010-12 JRF government expenditures for reporting SIF countries. Also shown are unofficial annual routine immunization budget estimates for the same countries. The unofficial data were generated by the Sabin Senior Program Officers and their national counterparts using a standard Sabin budget flow analysis tool. The results show that 2012 government routine immunization expenditures declined in this sample of SIF countries as well. Although higher, the government expenditures tracked using the Sabin flow sheet also declined, from US$12 in 2011 to $7 in 2012.

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On 14-18 July 2013, a joint GAVI-WHO-Sabin mission took place in Jakarta, Indonesia. Representing GAVI was Director of Immunization Financing, Santiago Cornejo. National Immunization Officer Asmaniar Saleh represented WHO/Jakarta. Senior Program Officer Khongorzul Dari and SIF Program Director Mike McQuestion represented Sabin. Dr. Theresia Sandra Diah Ratih, Chief of the Ministry of Health’s Immunization Sub-Directorate, prepared the agenda and accompanied the team throughout the visit. The first objective of the mission was to assess prospects for Indonesia graduating from GAVI grant eligibility. The second was to invite Indonesia to join the SIF Program.

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With an annual birth cohort of 4.8m, Indonesia counterparts, but absorptive capacity: not all is the world’s fourth most populous country. jurisdictions prepare and request their Over the period 2006-2011, Indonesia’s per immunization budgets on time. Experience capita gross national income grew from elsewhere has shown that bringing together US$1,370 to $2,940, qualifying it a GAVI sub national health authorities and local elected graduating country. In the political sphere, the officials can sometimes induce action to quickly country has moved steadily from an improve program performance. authoritarian to democratic form of government. The first direct local elections took place in “This works wherever we manage to involve 2004. Since 2009, all 560 members of the sub national counterparts in larger collective People’s Representative Council (parliament) action processes”, commented McQuestion. “It have been popularly elected. A decade ago, often leads to healthy competition among Indonesia implemented a “big bang” devolution peers. Counterparts learn from each other and program. The result is that 34 provinces and no one wants their place to be last”. 497 districts prepare and manage their own The second proposed advocacy area is the immunization delivery operations. introduction of new vaccines. Hib and Hepatitis Indonesia launched its national immunization B vaccines (pentavalent) came into nationwide program in 1977. The program has progressed use just this year through GAVI’s first vaccine steadily. Polio transmission was interrupted in grant to the country. Indonesia produces its 2006. Maternal and neonatal tetanus has been own vaccines through Bio Farma, a parastatal eliminated from 87% of the country. Measles is company. To introduce the more advanced targeted for elimination by 2018, rubella control conjugate pneumococcal and rotavirus by 2020. According to WHO/UNICEF vaccines while maintaining a policy of vaccine estimates, 64% of Indonesian children were self reliance will require the government to getting DTP3 in 2012. Due to the country’s size, considerably increase its immunization the remaining 36% constitute the world’s third investments. Manufacturing technological highest number of unimmunized and partially transfer agreements will need to be worked out. immunized children. In the meantime, if the new vaccines are introduced, Indonesia stands to achieve Indonesia is well on the way to GAVI Millennium Development Goal #4 (reduce child graduation. The country is financing all of its mortality by two-thirds by 2015) and will have traditional vaccines. Laws enacted in 2002 and partially achieved Strategic objective #5 of the 2009 guarantee the right to childhood Global Vaccine Action Plan (Immunization vaccination. There is a well functioning national programs have sustainable access to regulatory agency, a committee monitoring predictable funding, quality supply and acute events following immunization (down to innovative technologies). district level) and an independent expert advisory committee. Indonesia’s People’s Consultative Assembly (parliament), counterparts agreed, must be The mission revealed two areas where added sensitized to these issues and asked to play an advocacy strategies could help strengthen active role in the immunization program. During Indonesia’s immunization program. a parliamentary visit, the Vice President of Commission IX (Demographic affairs, health, The first is improving program performance in manpower and transmigration), Hon. Dr.Nova the provinces, districts and where pockets of Riyanti Yusuf, agreed and pledged to work low vaccine coverage persist. The problem is with the national EPI team. not financing, explained Ministry of Finance www.sabin.org/fr (en français) page 10 www.sabin.org/sif

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The mission resulted in a consensus for Senior Program Officer Jonas Mbwangue Indonesia to join the SIF Program. Dari, who attended both events and has been part of the manages SIF activities in Vietnam and her institutional innovation process. native Mongolia, will assume responsibilities for the Indonesia SIF project. “This was the first time all the ministries were briefed on immunization financing options”, The Indonesians wasted no time in developing remarked Mbwangue. “The original idea was to a first round of sustainable immunization create a single, ring-fenced immunization fund. financing advocacy activities. The proposals But the idea of such a fund caught on with other were presented by a five-person delegation of program managers. Now we are discussing a government counterparts and parliamentarians fund to finance all of the Ministry of Health’s who attended the second Sabin SIF Colloquium priority health programs”. in Dakar, Senegal on 5-6 August. In the coming months, government counterparts will In the workshop, the EPI Program team shared concentrate on resource tracking and improved the working draft of a proposed immunization data management, targeting low-performing law and presented a recently completed budget districts and provinces. MPs will study the flow chart for the Program. Impressed, proposed immunization budget and will join Committee members agreed to take up the government and provincial MPs in selected field draft immunization law and to ensure that the activities. Government and parliamentary final bill contains a provision establishing the counterparts will review existing laws and Health Support Fund. The Fund will have a regulations and proposed needed updates. special immunization financing window. Sabin will assist by organizing periodic briefings Committee members agreed to convene again for parliament and local health and elected in late October to review their work. \ officials.

SIF SPO, Clifford Kamara attended the official launch of “A Promise Renewed: Committing to Child Survival in Liberia” opened by President Mrs. Ellen Johnson Sirleaf, in Tubmanburg, On 22-25 July, a novel inter-ministerial Bomi County. Remarks were made by Dr. workshop took place in Yaoundé, to Bernice Dahn, Deputy Minister/ Chief Medical consider pending legislation on immunization Officer, WHO Representative Dr. Nestor financing. Chaired by the Minister of Health, Ndayimirije, UNICEF Representative Mr. Hon. Dr. Andre Mama Fouda, the first meeting Sheldon Yett, Deputy Asst. Administrator, of the Inter-ministerial Committee on Bureau for Global Health/ USAID, Hon. Minister Sustainable Immunization Financing drew 49 of Health and Social Welfare Dr. Walter T. governmental, parliamentary and external Gwenigale, Hon. Deputy Chair of Senate partner agency counterparts. Established in Committee on Health and Social Welfare, 2012 at the request of Minister Mama Fouda, Geraldine Sheriff. This was a successfully the Committee implements a recommendation implemented, well-attended activity during put forth in a May 2012 parliamentary briefing which Kamara met with representatives from on sustainable immunization financing. Its the Ministry of Health and Social Welfare and charter is to review and approve public other Ministries, Departments and Agencies. In financing proposals for the country’s addition in July the Terms of Reference for the immunization program. Yaoundé-based Sabin Liberian Parliamentary Forum has been

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finalized and progress was made on the draft  22-25 July, Yaounde, Cameroon: Inter- amendments on Immunization that have been ministerial workshop29-31 July, submitted to the Senate. Kinshasa, DRC: National immunization financing workshop (HM with AMP)

 5-6 August, Dakar, Senegal: Sabin SIF Colloquium II

 26 August, Kampala, Uganda: UPFI and Partner planning meeting

 16-21 August, Bamako, : National EPI conference

 26-30 August, Bamako, Mali: National EPI review

 18 August, Washington, D.C: IAIM launch

SPO Clifford Kamara in discussions with the  4 September, Nairobi, Kenya: SIF WHO Representative, Dr. Nestor Ndiamirije ; parliamentary briefing Deputy Chairman of the House Standing Committee on Health and Social Welfare, Representative Hon. Johnson Chea ; and Deputy EPI Manager, Adolphus Clarke, during the launch of ‘A Promise Renewed’ in Tubmanburg, Bomi County.

 11 July, Washington, D.C. USA: Launch of SIF mini-course online

 12 July, Nairobi, Kenya: SIF Parliamentary Briefing  16-17 July, Dakar, Senegal: SIF Parliamentary Briefing

 13-18 July, Jakarta, Idonesia: Joint GAVI-Sabin-WHO mission22-23 July, Kinshasa, DRC: Tailored approach meeting

 22-24 July, NYC, USA: IF&STT meeting, UNICEF www.sabin.org/fr (en français) page 12 www.sabin.org/sif

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Milestone/Activity Achieved this Cumulative (1.IX.09– Details: (1.IV.13 - 30.VI.13) quarter 30.VI.13)

Congo (July), Kenya (July, Sept), Liberia (July), Visits to field 9 141 Mali (July), Senegal countries (July, 2), Sri Lanka (Sept), Indonesia (Sept), Vietnam (Sept) Cameroon (July), Kenya National briefing 4 95 (July, Sept), Senegal (July) None reported this Sub-regional briefing 0 14 period International 22-24 July: IF&STT 1 73 Partners Meetings meeting, UNICEF Workshops/capacity None reported this 4 building meetings period Peer exchanges Ugandan peer involving SIF target 1 58 exchangers attended countries Kenyan briefing (July) Cameroon (July, Sept), Number of ICC Mali (July, Aug), Sierra meetings (measured 7 13 Leone (July), Uganda since Jan 2013) (August), Nepal (Sept)

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

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

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