1 TABLE of CONTENTS List of Abbreviations & Acronyms

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1 TABLE of CONTENTS List of Abbreviations & Acronyms TABLE OF CONTENTS List of Abbreviations & Acronyms Acknowledgement Executive Summary Introduction Section I: Impact of Country and Health System Context 1.1 Geography and Climate 1.2 Demographic Situation 1.3 Socio-economic background 1.4 Federal administrative structure 1.5 Ethiopian National Health Policy 1.6 The Health System 1.7 Organization of the Health System 1.8 Health Care financing 1.9 Total Health Expenditures 1.10 Functional distribution of expenditures 1.11 Government planning budgeting and reporting process Section II Program Characteristics, Objectives and Strategies 2.1 Immunization Schedule 2.2 Supplemental Immunization Activities 2.3 Vaccine wastage 2.4 Future plan for EPI 2.5 The role of UN agencies and NGOS in the national immunization program Section III Pre-vaccine fund and vaccine fund year program costs and financing 3.1 Pre vaccine fund year (2001) expenditure and financing 3.2 Vaccine fund year (2003) expenditure and financing Section IV Future Resource Requirements and Program Financing / Gap Analysis 4.1 Projections of future program costs 4.2 Future financing for the immunization program, and funding gap analysis 4.3 Financial impact of selected alternative policy options to decrease program costs Section V Sustainable Financing Strategy, Actions and Indicators 5.1 Opportunities for financial sustainability: 5.2 Challenges of financial sustainability 5.3 Strategy for financial sustainability 5.3.1 Mobilizing additional resources 5.3.2 Increasing reliability of resources 5.3.3 Improving Program Efficiency 5.4 Action Plan, monitoring process and indicators for FSP 1 Tables and Illustrations Tables: Table 1.1: Total and per capita health expenditure by major source classifications, 2000 Table 2.1 The national EPI schedule. Table 3.1 Past EPI expenditure by cost categories, 2001 – 2003, in US $ Table 4.1 Future program costs by cost categories, 2004 - 2013 Table 4.2 Secure, and probable resources from different partners Table 5.1 Indicators for follow up of progress of implementation of the financial sustainability plan Figures Figure 1.1 Health care expenditure by source in Ethiopia Figure 1.2 Government health expenditure in Ethiopia Figure 1.3 Breakdown of PHC expenditures in Ethiopia Figure 2.1 Trends in immunization coverage in Ethiopia, 1996 - 2004 Figure 2.2 Routine immunization coverage by regions Figure 3.1 Program costs (US$ millions) by category for 2001 – 2003 in Ethiopia Figure 3.2 Financing sources for immunization in 2001 Figure 3.3 Financing sources for immunization in 2003 Figure 4.1 Projection of immunization costs by strategy, US$ millions, 2004 - 2013 Figure 4.2 Secure and probable financing for immunization, US$ millions, 2004 - 13 Figure 4.3 Impact on total program costs, and funding gap of different new vaccine policy options 2 Acknowledgements The Federal Ministry of Health would like to take this opportunity to thank all partners particularly, UNICEF, WHO and World Bank for their technical and financial support to develop the Financial Sustainability Planning for Ethiopia (FSP). We extend our gratitude to all ICC members and technical group of the national immunization program for their active participation in the development of this important document. 3 Abbreviations and Acronyms AD syringe Auto-Distract Syringe AEFI Adverse Effect Following Immunization AFP Acute Flaccid Paralysis BCG Bacillus Callmunt Guirine CDC Center for Diseases Control CIDA Canadian International Development Agency CHW Community Health Workers CMH Commission on Macroeconomics and Health CSA Central Statistic Authority DFID Department for International Development DPT Diphtheria Pertussis and Tetanus EFY Ethiopian Physical Year EPI Expanded Program on Immunization FSP Financial Sustainable Plan FMOH Federal Ministry of Health GAVI Global Alliance for Vaccines GDP Gross Domestic Product HDI Human Development Index Hep B Hepatitis B HEP Health Extension Program HEW Health Extension Worker Hib Hemophilus Influenza type B HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome HSDP Health Sector Development Program ICC Inter Agency Coordinating Committee IEC Information Education Communication JICA Japan International Cooperation Agency MDGs Millennium Development Goals MNT Maternal Neonatal Tetanus MOFED Ministry of Finance and Economic Development MOH Ministry of Health NGOs Non Governmental Organizations NHA National Health Account NIDs National Immunization Days NIP National Immunization Program NORAD Norwegian Agency for Development Cooperation OPV Oral Polio Vaccine PHCU Primary Health Care Unit RED Reaching Every District RHB Regional Health Bureaus SDPRP Sustainable Development Poverty Reduction paper SIAs Supplemental Immunization Activities SNIDs Sub- national Immunization Days SNNPR Southern Nations and Nationalities People SOS Sustainable Outreach Services TFR Total Fertility Rate TT Tetanus Toxoid UN United Nations UNDP United Nations Development Program UNICEF United Nations International Children’s Fund USAID United States Agency for International Development WHO World Health Organization ZHB Zonal Health Bureau 4 Executive Summary Introduction In order to control vaccine preventable diseases, the World Health Organization and member countries including Ethiopia have established the Expanded Program on Immunization (EPI). The Ethiopian EPI program was launched in 1980, with the objective to reach 100% coverage to all children under two by 1990. Progress in coverage has been slow and up know the Ethiopian EPI program has not achieved the target coverage. However, with the introduction of the two new approaches known as Reaching Every Districts (RED) and Sustainable Outreach Services (SOS) significant improvement has been documented in the last few years. Currently the national DPT3 coverage stands at 65%. The Health System The Ethiopian health system currently reaches about 61% of the population. There are too few facilities, particularly at the levels closest to the community, and there are long-term shortages of skilled human resources. The FMOH is responding to this recognized need through two major initiatives in the context of the Health Sector Development program: • A plan for expansion of primary health facilities and staff, which will raise health coverage to 85% by 2009. • The health extension program (HEP) institutionalizes the community health system. The Health Extension Workers (HEWs) are intended to be the main change agents for health in the community. Their primary task will be to mobilize and empower households and communities to take responsibility for their own health by involving them in the planning and execution of community health activities and services. HEWs, working with other community-based workers and supported by their local health center will be trained and equipped to provide a wide range of promotive and preventive services including provision of routine vaccines Health Care financing The health services in Ethiopia are financed from four main sources: • Government (both federal and regional) • Bilateral and multilateral donors (both grants and loans) • Non-governmental organizations, and • Private contributions, both from out-of-pocket payments and through private sector investment in health services The routine immunization program is funded primarily by the Government and partners like, UNICEF and Irish Aid. Whilst vaccines are financed by UNICEF and salaries by the government, funding for a number of other components such as cold chain equipment, transport, social mobilization and some operational costs have been made available by WHO and other donor agencies under the Polio eradication initiative. 5 Program characteristics, objectives and strategies The overall aim of the immunization program is to improve the quality and coverage of national immunization services. The Ethiopian EPI program focuses mainly on four objectives: • Strengthening the immunization system: strengthen and optimize the delivery of sustainable, quality immunization services by increasing DPT3/ measles coverage to 95% by 2009. • Introduction of new vaccines: it is planned to introduce Hepatitis B vaccine as monovalent in 2005-2006 and Hib vaccine as pentavalent in 2007. The target is to achieve 95% coverage by 2009. • Minimizing vaccine wastage: the wastage rate should be properly calculated and minimized by focusing on accurate forecasting and proper stock management, effective cold chain system and improvement in the ratio of children to vials opened. • Accelerated disease control: accelerate effort to achieve polio eradication, measles control/ elimination, and neonatal tetanus elimination. Ethiopia has a five year EPI plan which was developed in 2001. The prime focus of the plan was to increase the coverage by 5% annually, and likewise decrease the vaccine wastage rate. Trends in immunization coverage in Ethiopia, 1996 - 2004 75 70 65 60 55 BCG 50 % DPT3 45 Measles 40 35 30 25 1996 1997 1998 1999 2000 2001 2002 2003 * 2004 Year Supplemental Immunization Activities To reach the remote zones of the country and to synergize the routine immunization activity, supplemental immunization was introduced in 1996. Supplemental immunization was designed mainly for Polio and Measles and since 1999 SIA for MNT was also started. Note : * 2004 annualized report 6 Vaccine wastage Vaccine wastage is a problem in Ethiopia. At present the wastage rate is more than 65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT. It is due to poor planning of static and out reach
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