ZANZIBAR REVOLUTINARY GOVERNMENT
MINISTRY OF HEALTH AND SOCIAL WELFARE
NATIONAL IMMUNAZATION PROGRAM FINANCIAL
SUSTAINABILITY PLAN
REVISED
NOVEMBER 2003, ZANZIBAR
TABLE OF CONTENTS
Content Page No.
Table of contents ii
Executive Summary ………….. ………. …………. iv
Acknowledgement ………….. ………. …………. viii
Abbreviations ……… ………. …………. ix
1.0 COUNTRY AND HEALTH SECTOR CONTEXT 1.1 Country Profile 1
1.2 National Health Policy and Other Reforms 2
1.2.1 Overall Government reforms 2
1.2.2 National Health Policy 2
1.2.3 National Policy Reforms 3
2.0 BUDGET PROCESS AND FINANCIAL MANAGEMENT 2.1 Phase I: Pre-budget Guidelines 4
2.2 Phase II: Budget Preparation and Scrutiny 5 2.3 Phase III: Budget Approval 5
2.4 Phase IV: Budget Execution 5
2.4.1 Disbursement of Funds 5
2.4.2 Procurement of goods and Services 5 2.4.3 Accounting 5
2.4.4 Reporting 5
2.4.5 Auditing 6
3.0 PROGRAM CHARACTERISTICS, OBJECTIVES & STRATEGIES 3.1 Program Characteristics 7
3.1.1 Immunization Coverage 7
3.1.2 Vaccine Wastage Rate 8
3.1.3 Immunization Technology and Antigen 8
4.0 BASELINE AND CURRENT PROGRAMME COSTS
AND FINANCING
4.1 Baseline Program Costs and Financing Patterns 9
5.0 FUTURE RESOURCE REQUIREMENTS AND
PROGRAM FINANCING
5.1 Estimate of future resource requirements 12
5.2 Projection of future financial levels and patterns 13
5.3 Estimates of financing gap 14
5.4 Risk assessment 15
6.0 SUSTAINABILITY STRATEGY PLANS AND INDICATORS
6.1 Immunization Program Constraints 16
6.2 Financial strategies and indicators 16
6.3 Conclusions and Final Recommendations 26
7.0 COMMENTS FROM STAKEHOLDERS 27
ANNEXES
Annex A: Programme characteristics, objectives and strategies
Annex B: baseline and current year programme costs
Annex C: Log frame of strategies and actions
EXECUTIVE SUMMARY
The immunization programme in Zanzibar has as its goal of reduction in morbidity and mortality due to vaccine preventable diseases. The programme’s broad areas of activity are routine immunization service delivery, disease surveillance and supplementary immunization activities. In the recent past, Zanzibar has revitalized EPI, with improvements in the planning process, immunization coverage and in safety of immunization, as well as in strengthening community ownership and involvement, and the effective mobilization of funds for EPI. Year 2001/02 saw a switch from the use of sterilizable needles and syringes to use of auto disable syringes and needles, as well as in the introduction of DPT-Hep B combination vaccine into the immunization schedule. A new vaccine (Hib Vaccine) introduction is planned for the year 2005/06. This vaccine protects against the bacterium Haemophilus influenza, a major contributor to ill health and death in children under 5 years.
The programme is operating in a general macroeconomic environment of low GDP per capita, with limited resources available to the government for health service delivery. The health sector receives on average 8% of the total Government resources, with the EPI programme at present receiving less than 1% of this.
The EPI programme resources have in the recent past been limited. The total programme cost for the Financial Year 1999/2000 (excluding shared costs of USD$ 121,341) was USD$143,133, with a per capita cost of 0.16 USD. Of this cost, 34% (i.e. USD$ 48,665) was for operational cost 14% for capital cost (i.e.$ 20039) and 53% (i.e. USD$ 74,429) for supplemental immunization activities. Government contributed 17% (i.e.$ 24,333) to this cost, whilst developmental partners provided 83%.
In 2001/02, the programme introduced the HepB vaccine in its schedule. The programme costs for this year (excluding the shares costs of USD$ 174,457) increased to USD$347,076 with a per capita cost of 0.36 USD. Operational cost accounted for 61% (i.e. USD$ 211,716) of the cost whilst 39% of the cost (i.e.$ 135,360) went to supplemental immunization activities. In this year, 2001/02 the government contribution reduced to 7% (i.e.$ 25,052) of the total programme costs with increase in the donor support to the programme, partly as a result of input of resources from the Global Alliance for Vaccines and Immunization.
Over the medium term (up to 2008/09), the total programme costs is expected to increase, with the increase partially attributable to population increase, and partially due to increase in immunization coverage, and the costs of the introduction of the new vaccines. The costs of the programme, by activity up to the year 2008/09 are illustrated in the graph below
EPI programme resource requirements projections to the year 2008/09 -100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1,000,000 1999 2001 2002 2003 2004 2005 2006 2007 2008 Year SIA 's Ro utine capital co sts Other recurrent co sts Vaccines
On average the government contribution during the Vaccine Fund period (i.e. 2003/04-2005/06) is US$ 32,636 with peak of 8.1%( i.e. US $ 32,960) in 2004/05. Though the percentage government contribution declined compared to the pre-vaccine period, there is absolute increase in government contribution during the Vaccine Fund period. GAVI contribution during the Vaccine Fund period (2003/04) is 76% of the total EPI cost (i.e. US$ 1,242,957 ) The Government contribution during the post Vaccine Fund (2006/07-2008/09 ) is estimated to increase to 56% (US$108,080) of the secured funds. Additional support for both the Vaccine Fund and post Vaccine Fund is expected from multilateral and bilateral organizations. The program will therefore be faced with a funding gap that increases from (US$110,305 in the year 2004/05 to US$778,051 by the year 2008/09. The total funding gap for the period from 2003/04 to 2008/09 is US$ 2,294,463 (50%) out of the required resources of US$ 4,544,409. This is depicted in the summary tables attached and the graph below.
Funding gap for the immunization programme up to 2008/09 0 1 00,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1 ,000,000 2001 / 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09 Ye a r Unsecured funds Secured funds
The programme has identified strategies to undertake to fill this funding gap. These are:
1. Mobilizing additional resources,
2. Improving the reliability of resources, and
3. Improving the efficiency of the programme.
The programme will seek additional resources from the health sector, local Governments, private sector and bilateral and multilateral donors. The ability to raise the additional resources from Government is the key strategy. These additional resources will be mobilized, within scope of financial realities of the Health. From a present (2003/04) funding of under1% (US$$32,247) of the health sector resources, the programme shall seek an increase to 4% (US$233,459) of the health sector resources by 2008/09. In addition, improvements in programme efficiency shall be sought, with a planned reduction of vaccine wastage of DPT-Hep B from 20% during 2002 to 10% in 2005. These strategies shall each raise resources to fill the funding gap as illustrated in the graph below.
Contribution to the funding gap from the different strategies
-200,000 400,000 600,000 800,000 1,000,000 1,200,000 2003 2004 2005 2006 2007 2008 Year Remaining gap M obilize privat e resources Additional donor support Increase multilateral cont ributions New GAVI application f or Hib support Improved programme eff iciency M obilize LG resources M obilize additional Govt resources Total secured
The Inter Agency Coordinating Committee (ICC) will outlined the action plans for Financial sustainability for implementation. The ICC shall, on a quarterly basis, review progress on the action plan as presented by the financing sub working group, and plan for activities from the action plan to be completed in the coming quarter.
A technical sub-working group from ICC (the Immunization financing working group) will follow up the day-to-day implementation of financial sustainability activities. This sub-working group made up of a maximum of eight people, will include representatives from the EPI, representatives from the technical organizations (WHO and UNICEF), the Ministry of Finance and three additional members chosen by the ICC. The financing sub working group shall meet on a monthly basis to review progress on expected activities, and plan for upcoming tasks
On an annual basis, the ICC shall have a retreat to review progress on financial sustainability based on the agreed district and national based indicators, and will chart out the expected activities for the next year. Findings from this retreat shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability.
ACKNOWLEDGEMENTS
The Ministry of Health wishes to acknowledge with sincere gratitude the Financial Sustainability Task Force and others who in one way or another contributed to the development and finalization of the EPI Financial Sustainability Plan. The Task Force comprised of Dr Mohamed Dahoma, Ms Mwaka Said, Mr Habibu Chwaya, Mr Juma Rajabu, Mr.Idrisa, Abeid Ahamte, Mr.Yusuf Makame, Dr Cornelia Atsyor. The Ministry also acknowledges with gratitude the technical support on the FSP from Ms. B. Sakagawa, Mr. C.V. Maziwisa Mr.P.A.Ilomo and Dr H. Karamagi of AFRO-WHO. The support from WHO, UNICEF, and the GAVI Secretariat for their financial support of the FSP development process is much appreciated. Special thanks also should be given to the ICC members who provided comments on this document.
Last but not least, thanks should go to Ms Amina Badri,the Secretary, for assisting with assembling this document.
PERMANENT SECRETARY
Abbreviations
AFP - Acute Flaccid Paralysis
BCG - Bacillus Calmette Guerin
BD - Becton Dickinson East Africa Operations
CUAM - Italian Development Agency
CHF - Community Health Fund
DANIDA - Danish International Development Agency
DFID - Department International Development
DMO - District Medical Officer
EPI - Expanded Programme on Immunization
DPT- HB - Diphtheria, Pertussis, Tetanus and Hepatitis B
DPT - Diphtheria Pertussis Tetanus
EPI - Expanded Programme on Immunization
GAVI - Global Alliance for Vaccine and Immunization
GDP - Gross Domestic Product
GFS - Government Financial Statistics
GOZ - Government of Zanzibar
HIPC - Highly Indebted Poor Countries
IFMS - Integrated Financial Management System
JICA - Japanese International Cooperation
MCH - Maternal and Child Health
MCHA - Maternal and Child Health Aid
MDAs - Ministries, Departments and Agencies
MOF - Ministry of Finance
MOH - Ministry of Health
MTEF - Medium -Term Expenditure Framework
NIDs - National Immunization Days
OPV - Oral Polio Vaccine
PER - Public Expenditure Review
PM - Programme Manager
POW - Programme of Work
PRS - Poverty Reduction Strategies
RCCO Regional Cold Chain Officer
RCHS - Reproduction and Child Health Services
RHMTs - Regional Health Management Teams
RMO - Regional Medical Officer
SIA - Supplementary Immunization Activities
SNIDs - Sub-National Immunization Days
TFR - Total Fertility Rate
TT - Tetanus Toxoid
UNICEF - United Nations Children’s Fund
USAID - United States Agency for International Development
US$ - United States Dollars
1.0 COUNTRY AND HEALTH SECTOR CONTEXT 1.1 Country Profile
Zanzibar, together with the Tanzania mainland, forms the United Republic of Tanzania and is situated south of the equator, along the Indian Ocean. It covers an area of approximately 2,642 sq. km’s. It is made up of the two islands of Unguja and Pemba, each of an area of 1,658 and 984 sq km’s respectively. It has an estimated population of 984,625 (2002) with a growth rate of 3.1 percent. The proportion of the population below the age of 15 years is estimated at about 47%. The population in the 15-64 year age group is estimated at 49% with the remaining 4% covering those above the age of 65 years.
Administratively, Zanzibar has 5 regions and 10 districts, with each district sub divided into divisions and wards. Decision making is still largely controlled by the Ministry of Health, though it is in the process of deconcentrating power to the districts.
Significant progress has also been made in the macro economic stabilization, which has facilitated positive economic growth in recent years. Overall the GDP growth has steadily risen from 3.0% in 1997 to 5.3% in 2001. The GOZ predicts that, by year 2005, the economy will grow at a rate of 6.7%. The exchange rate was 890 Tanzania shillings to the dollar (rate in 2002).
The health status of Zanzibar and Mainland Tanzania’s population is considered to be among the lowest in African countries with similar economic characteristics. In recent years, infant mortality in Zanzibar increased by 10%, from 88 (1996 TDHS) to 99 per 1,000 births (1999 CRHS). The Government of Zanzibar (GOZ) has recognized the need to address the health status of women and children and has begun to implement several health sector reforms and initiatives aimed at improving the health of its population. Reforms include the development of a health sector strategic plan, emphasis on decentralization, and the preparation of a poverty reduction strategy paper.
Zanzibar has pledged to achieve Millennium Development Goals in health, articulated as:
Reducing the under-five mortality rate by two-thirds between 1990-2015 Reducing by three quarters the maternal mortality ratio between 1990-2015 Halting and reversing the spread of HIV/.AIDS by 2015
Halting and beginning to reverse the incidence of malaria and other major diseases by 2015
1.2National Health Policy and Other Reforms 1.2.1 Overall Government reforms
From the late 1980’s, the GoZ undertook reforms in line with the market based Government reforms that were ongoing internationally. These have been civil service reforms, political reforms and economic/financial reforms. These shape the structures and processes used for Health Service Delivery in Zanzibar.
1.2.2 National Policy Reforms
Prior to the 1964 revolution, health service delivery was mainly oriented to curative services and centralized in urban areas. Efforts to decentralize basic health services, started immediately after the revolution. Management structures for the MOH have been deconcentrated through the creation of zonal and district health management teams. However, financial decision-making and budgeting decisions continue to be made at the national level in the Ministries of Finance and Health. Decentralization policies were also included in both the Vision 2020 and Zanzibar’s poverty reduction strategy framework.
The GOZ has developed a Poverty Reduction Plan (ZPRP) since 2002. This plan has included health related issues such as those aimed at improving the health of women and children by reducing mortality rates to ensure longer survival. The plan also has immunization related indicators. With this plan, it is expected that resources to the health sector will be increased (pg 48 of ZPRP)
Despite these reforms, Zanzibar’s health system faces a number of challenges to improving and strengthening its immunization program. These challenges include limited government contribution to the immunization program and heavy donor dependency to implement the program and inadequate human resources both in terms of capacity and staffing.
Specific actions under the objective of improving the health of women and children
• Improving MCH and reproductive health services.
• Increasing vaccination to cover all children less than five years of age.
• Creating equal opportunities of access to basic and essential quality health care.
• Increasing the focus on strengthening management financing of the overall health care system.
• Reducing the morbidity and mortality resulting from human exposure to environmental hazards.
Box 1: Eleven reform areas identified within the HSSP
• Improvement of organization and management of health services
• Human resource development;
• Strengthening health service delivery;
• Health sector financing and mobilization of resources;
• Research development;
• Legislation;
• Pharmaceuticals, medical supplies and equipment;
• Secondary and tertiary referral hospitals;
• Public and private partnerships;
• Social services/welfare; and
• Donor coordination.
1.2.3 National Health Policy
Zanzibar National Health Policy emphasizes the need to promote the health status of women and children. As part of this policy, the Government of Zanzibar has developed a health sector strategic plan (HSSP, year 2001 to 2006) that aims to make institutional and structural changes to improve existing organizational structures, management systems and capacities so that the health system can better address the health needs of the population
The goal of the Zanzibar Health Sector Policy is to: improve and sustain the health status of all Zanzibar people by ensuring that vulnerable groups i.e. those at risk particularly the poor women of child bearing age, children, the disabled and elderly have access to high quality health care services. (See also The Eleven reform areas identified in the HSSP in Box 1.)
The Immunization Program is geared at achieving the above-mentioned vision and aims to protect the majority of children and women against vaccine preventable diseases.
The EPI program is housed within the Directorate of Preventive Services (DPS) in the Ministry of Health. The EPI program is tasked with providing vaccinations to children and mothers in order to prevent communicable diseases. Two zonal and ten district management teams implement the immunization program. EPI services are provided free of charge and is the responsibility of the zonal and district management teams. The national level provides logistics support and technical input for the zones and the districts. No changes to the current management and governance system are planned.
2.0 BUDGET PROCESS AND FINANCIAL MANAGEMENT
The financial year in Zanzibar is from the month of July to June the next year. The Government of Zanzibar commences the Public Expenditure Review process and the Medium Term Expenditure Framework process of budgetary planning in the Financial Year 2003/04.
The table below highlights key macro economic figures for GoZ.
Table 1: Key macro economic indicators for Zanzibar, 2001/02 (millions of Tanzanian shilling) Planned Received EPI programme 60,000 2,000 MOHSW 5,463,027 3,410,087 Total Government 67,402,560 Budget and expenditure
EPI to MOH 1.1% 0.1%
Proportion of resources
received MOH to Govt 8.1%
The health sector receives approximately 8% of the total government budget. Of this, the EPI programme received below 1% of the health budget, and expenditure.
Funds from the recurrent budget are used for the operational costs of running the EPI programme, such as building maintenance, salaries, etc.
The government budget process and financial management has four phases namely, pre- budget guideline phase, budget preparation and scrutiny phase, budget approval phase, and budget execution phase.
2.1 Phase 1: Pre-Budget Guideline
This phase is involves the review of the past macroeconomic performance in areas of policy targets, economic growth, inflation, government finance, monetary and credits development, exchange rate and external sector. It is at this stage that global resource allocation to sectors, Ministries and departments are made. Both the macroeconomic review and projections provide important inputs to the budget guidelines. For the immunization program, this stage may serve as an entry point for soliciting resources by making sure that the program requirements are reflected in the health budget. The Ministry of Finance and Economic Affairs (MOFEA) is responsible for financial planning, monitoring and evaluation of the government structure in Zanzibar. Funds from the MOFEA are channelled to the Ministry of Health through the recurrent and development budgets. .
Funds from the recurrent budget are used to pay for general operating costs of the EPI program such as salaries, building and fuel costs. The government development budget supports projects that receive significant partner (donor) support. The EPI program is one of five prioritized programs of the Ministry of Health and Social Welfare (MOH-SW) that are funded through the development budget. Funds from the development budget are used to pay for specific operating costs of the EPI program excluding salaries.
2.2 Phase II: Budget Preparation and Scrutiny
The issuing of budget guidelines triggers this phase. The government planning and budget cycle starts in January/February of each year. The MOFEA, in collaboration with the Zanzibar Revenue Board, identifies and forecasts the overall governmental expenditures for the coming fiscal year based on collected revenues. The MOFEA and the Revenue Board then set budgetary guidelines and ceilings for each ministry. The MOH-SW uses these annual guidelines and the budget ceiling provided by the MOFEA to prepare its annual budget proposals. These plans are reviewed by the MOFEA’s directors and if necessary, returned to MOH-SW for revisions.
2.3 Phase III: The Budget Approval
The revised proposals are then submitted to the principal secretaries in the MOFEA for approval. The principal secretaries examine and adjust the plans and allocations prior to forwarding them to the Revolutionary Council for preliminary endorsement. The total budget proposal is then sent to the Committees of Finance and Economic Affairs of the House of Representatives for review and authorization before being presented at the House of Representatives budget session.
2.4 Phase IV: The Budget Execution
This stage involves disbursement of funds, procurement of goods and services, accounting, reporting and auditing. The phase may also serve as an avenue for the monitoring and tracking of the program resource inflows and expenditure.
2.4.1 Disbursement of Funds
In reality, implementation of the EPI program is significantly affected by low and slow disbursement of funds. The reasons why the EPI program does not receive all of its approved funds have been attributed to inaccurate revenue forecasting as well as administrative and logistical problems related to collecting projected revenues. 2.4.2 Procurement of Goods and Services
Government funds are mainly utilized to procure supplies for the program and the procurement has to follow the laid down procedures.. All vaccines and injection supplies are currently procured through UNICEF.
2.4.3 Accounting
The financial transactions of the government are done through the exchequer systems and IFMS. All revenue collection, payments, issuing of cheques, expenditures and procurement commitments are managed though the IFMS. Immunization Program financial transactions for all monies budgeted on the Government budget are also accounted through the exchequer and IFMS.
2.4.4 Reporting
The planning unit of the MOH-SW prepares physical and financial reports on quarterly and annual basis and forwards them to the MOFEA. These reports describe the activities of the program that were funded under the development budget during that period.
2.4.5 Auditing
Internal auditors in the MOH-SW and MOFEA external auditors conduct accounting and auditing of the EPI program. During the 2003-2004 fiscal year, the government will introduce the PER/MTEF system of planning and accounting in order to create better accountability of government and donor funds. The financial challenges that the immunization program faces are highlighted in Box 3 below.
Box 3: Financial challenges facing the Immunization Program
For long periods of time, very little surplus revenue has been available to finance development expenditures.
Dependence on general tax revenues is evidence that health sector financing is heavily influenced by the overall performance of the public economy and on total government revenues.
Actual EPI program needs are much higher than what is planned and provided for in the EPI program budget. This situation hinders the effectiveness of the program to meet its planned objectives.
Irregular disbursal of funds from the treasury to the MOHSW has undermined the capacity of the ministry to effectively manage its resources.
A centralized financial management structure weakens the capacity of other levels of the ministry, especially at the district and community levels for effective and efficient planning and management of resources.
The EPI program is highly donor dependent on most program inputs such as capital equipment and vaccines and injection supplies.
Box 4: Plans for Implementing Program Improvements
• Improving district micro planning,
• Increasing community ownership and involvement,
• Supporting outreach immunization and supervision,
• Effective mobilization of funds for EPI.
• Introduction of a new injection safety policy, which replaces sterilizable syringes with AD syringes and needles and requires injection equipment to be disposed of safely.
3.0 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES
3.1 Program Characteristics
The Zanzibar EPI Program’s goal is to decrease morbidity and mortality caused by vaccine preventable diseases. The program’s broad areas of activity are routine service delivery, disease surveillance and supplemental immunization to eradicate polio, control measles and eliminate neonatal and maternal tetanus.
Specific descriptions of program performance and targets have been addressed at length in the GAVI application, inception report and multi-year strategic plan. Updated national and district immunization coverage information for 1999-2001 is located in Annex A. It is expected that the EPI program will be able to meet its coverage targets if all resources requested by the EPI program are provided. However, if funding is not available, experience has shown that it will be difficult for the program to reach these targets. The five-year Strategic Plan has highlighted plans for implementing program improvements and these are highlighted in Box 4 below.
3.1.1 Immunization Coverage
The DPT3 immunization coverage rate as of 2001 was 83%. This has changed from a rate of 84% in 1999 and 81% in 2000. Since the development of the strategic plan, the EPI program has identified a need for funds for transportation to reach populations in difficult to access regions. In Pemba, for example, there are about 22 small islands which will either require funding for the purchase of two small fiberglass boats with outboard motors for reaching these islands or funding for hiring small boats when needed.
The immunization program has faced financial constraints in the past, notably since 1996 when bilateral support for the immunization program ended. If the EPI program does not receive the funding that it needs, EPI staff will focus on activities where funding is available. During funding shortages, routine immunizations continue, but supplementary immunizations are temporarily suspended.
3.1.2 Vaccine Wastage Rate
The EPI program calculates the vaccine wastage rate by including all types of wastages, i.e. discarding open vials, freezing, broken and missing vials. The program’s goal is to reduce wastage for all types of wastage. As part of its wastage policy, EPI program staff will focus on reducing vaccine wastage at the national and district levels. Once wastage has been reduced at these levels, they will work to reduce wastage at the lower levels i.e health centre and community levels.
The wastage rate for all antigens ranged from 25-60% in 2000 but shown signs of decreasing in 2002 (15-49%). See Table 2 below. The decrease in vaccine wastage has occurred primarily as a result of implementation of the multi-dose vial policy in 2002. It is expected that wastage rate will continue to fall to reach the target rate of 15%.
Table 2: WASTAGE RATE (%) BY ANTIGEN 2001-2002
3.1.3 New Immunization Technology and Antigens
The program introduced DPT-HB in 2001 and plans to introduce DPT-HB-Hib by 2005/06 FY. DPT-Hib vaccine will be introduced to achieve an expected coverage rate of 90% for all antigens for all districts by 2005. The Hib disease burden rapid assessment conducted in October, 2001 suggested that there is a great need of Hib vaccine to be introduced in the routine immunization schedule. The assessment revealed that, Meningitis based estimates (lower end) of 15,000 cases with 2,500 deaths per year, Meningitis based estimates (high end) of 18,000 cases with 3,000 deaths per year. Child Mortality based method of 19,000 cases with 3,300 deaths per year. To address injection safety, EPI has introduced the auto disable syringes in place of sterilizable needle and syringes. Other measures undertaken to improve injection safety include sensitization, education of health workers, and the construction of incinerators in all district hospitals. All of these measures have cost implications. Antigen 2000 2001 2002 BCG 60 65 49 OPV 30 24 18 DPT (Hep B) 25 25 18 Measles 32 25 23 TT 25 20 18.5
4.0 BASELINE AND CURRENT PROGRAMME COSTS AND FINANCING
Before 1996, Zanzibar’s major EPI financial partners were bilateral organizations such as DANIDA, CUAM (Italy), and multilateral organizations such as WHO and UNICEF. Since 1984, CUAM and DANIDA fully supported all program developmental costs including logistics for vaccine purchases and distribution of cold chain equipment, human resource development, and transport for program management such as supervision and office operations. DANIDA’s average annual contribution over 1991-1995 was approximately US$250,000. During the years prior to 1996, GOZ supported program infrastructure and staff remuneration. UNICEF and WHO provided technical support such as specification of EPI vaccines and equipment and technical materials.
After 1996, bilateral donors, CUAM and DANIDA, ended their support of the EPI program in Zanzibar. To make up for the shortfall, increased support from the government and multilateral organizations (WHO and UNICEF) was provided to the program. As of 2002, WHO and UNICEF provide funds for disease control initiatives to address measles and polio, support routine immunization through the provision of vaccines and cold chain equipment, and provide technical support for capacity building. However, this support is inadequate to cover all program needs and often leads to shortages of vaccines and fuel for cold chain and supervision.
Some additional funds and in-kind donations from the private sector are mobilized through the ICC. Funding sources include ECOTEC, a British petroleum company that supplies fuel and kerosene during NIDs, local Rotary Clubs and private business institutions.
4.1 Baseline Program Costs and Financing Patterns
The pre vaccine fund year for which accurate data is available for the immunization program is 1999/00 and for the purpose of this exercise, this will be the baseline year. The programme costs are illustrated in Annex B table 1.1. The total expenditure during the period for the immunization program was $143,133. These costs represent both the operating, and capital costs of the programme. Inclusion of shared costs such as personnel for EPI raises the total programme costs to US$ 264,474.
The categorization of these costs (without the shared costs) is shown in the diagram below;
Vaccines 16%
Ot her r ecurr ent cost s 18%
Rout ine capit al cost s 14% SIA's
52%
The bulk of the programme costs were due to the supplemental immunization activities for polio and measles that were carried out then. The other cost components; the routine capital, vaccine costs and other routine recurrent costs were approximately of the same amount to the programme.
Of these programme costs, the Government contributions represented 17% of the total costs. Inclusion of the shared costs rises the Government contribution to 48% of the total costs.
4.1.1 Expenditures for 2001/02 (Current Year)
The programme expenditures are detailed out in Annex B, table 1.2 for the year 2001/02. The total expenditure for the immunization program was US$347,076. If shared personnel costs are included, the total cost of the program would be $521,532. The categorization of these costs (minus shared costs) is shown below.
Vaccines 16%
Ot her recur rent cost s 45% Rout ine capit al cost s
0% SIA' s
39%
There is a marked increase in the proportion of routine operational costs as compared to the previous year. This is largely attributed to the operational costs incurred during the introduction of the new vaccines.
Comparison of the different donors over the two years is presented in the diagram below.
Relations of funders for the EPI programme, 2000/01 and 2001/02
0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 1999 2001 Year Cost (USD) GAVI Mulitlaterals Bilaterals Government
We see the overall increase in the programme costs in the year 2001 as compared to the year 1999. While the government contribution is largely the same, it reduces in proportion to the total costs to 7%, down from 17%. An increased number of bilateral governments were offering support to the programme, shown by the marked increase in bilateral support. Support from the multilaterals (represented by the UN agencies) was on the whole similar. We see the introduction of GAVI funds reflected.
5.0 FUTURE RESOURCE REQUIREMENTS AND PROGRAM FINANCING: 5.1 Estimates of future resource requirements
Estimates of future resource requirements have been derived using projections of the program objectives which were described in Section 3. The projections are calculated using the multi-year financing plan that was developed as part of the program’s Multi-Year Strategic Plan. Projections of resource requirements, future funding levels and patterns, and estimates of financing gaps have been developed based on the two funding periods, the GAVI/Vaccine Fund period 2001/02- 2005/06 and the Post–Vaccine Fund period 2006/07-2008/09. For each of the period, projections of resource requirement have used one scenario which is to introduce DPT-Hib in 2005/06. Also the projections for future funding have used one option which assumes GAVI Vaccine Fund is used over a period of 5 years (2001/02-2008/09). This is summarized in the diagram below.
EPI programme resource requirement projections to 2008/09
-100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1,000,000 1999 2001 2002 2003 2004 2005 2006 2007 2008 Year SIA 's Ro utine capital co sts Other recurrent co sts Vaccines
From the above, there is an increase in the programme costs over the years, with two peaks at the periods when the HepB is introduced 2002, and again when the Hib vaccine is expected to be introduced 2005/06 FY. The causes for the cost increases include the increase in the birth cohort, and strategies for increased coverage and new vaccine introduction. The new vaccine introduction leads to the highest increase in programme costs, with the result that the vaccine cost increasingly becomes the cost driver for the programme.
The table below is a breakdown of the expected program requirements for specific line items for 2002/03-2008/09.
2002 2003 2004 2005 2006 2007 2008 Operational Cost
Vaccines 204,530 206,231 212,411 747,642 661,646 680,834 700,578
Vaccines (traditional 6 antigens) 41,370 38,790 39,952 42,385 43,657 44,923 46,226
Vaccines (new and underused vaccines) 162,560 167,441 172,459 705,257 617,989 635,911 654,352
Injection supplies 25,007 24,984 25,733 27,299 28,119 28,119 28,119
Personnel (salaries) 5,899 5,899 5,899 9,000 9,000 9,000 9,000
Transportation 10,000 9,500 9,500 9,500 9,500 9,500 9,500
Cold chain maintenance and Overhead 47,387 21,150 15,150 5,899 5,899 5,899 5,900
Kerosene/gas 6,400 6,400 6,400 6,400 6,400 6,400 6,400
Short-term training 55,500 4,000 6,800 72,204
IEC/Social mobilization 8,000 8,000 8,000 8,000 8,000 8,000 8,000
Monitoring and surveillance 46,626 11,274 10,206 10,206 10,206 10,206 10,206
Other operational costs 43,801 46,198 50,148 67,804 73,104 75224.016
Sub total operational costs 453,150 343,636 350,247 896,150 806,574 831,062 852,927 Capital costs
Vehicles 28,000 28,000
Cold chain equipment 58,628 16,698 17,109 24,665 22,221 22,221 22,221
Other capital investments 3,720
Subtotal capital costs 86,628 44,698 17,109 24,665 22,221 22,221 22,221
Supplementary Immunizaiton Activities (polio and measles)
Subtotal SIA's 163,336 142,255 168,423
TOTAL COSTS 703,114 530,589 535,779 920,815 828,795 853,283 875,148
Optional information
Shared personnel costs 102,101 102,101 102,101 102,101 102,101 102,101 102,101 Suubtota; optional information 102,101 102,101 102,101 102,101 102,101 102,101 102,101
GRAND TOTAL (with optional information) 805,215 632,690 637,880 1,022,916 930,896 955,384 977,249 Note: Breakdown of the Supplemental Immunization Activity costs was not feasible due to data gaps
The total programme requirements for the period 2002/03 to 2008/09 including the shared personnel costs are USD$ 5,962,230, of which USD$ 2,075,785 are required for the period 2002/03 to 2004/05, while USD$ 3,886,445 are required for the period 2005/06 to 2008/09
5.2 Projections of Future Financing Levels and Patterns:
Projections of future financing during the GAVI/Vaccine Fund period (2001/02-2005/06) and after the GAVI/Vaccine fund period (2006/07-2008/09) were calculated based on the programme strategies and available information on the funding levels from both the government and development partners.
Government funding is based on the present level of support, adjusted for population growth.
Future funding can only be estimated for the multilateral partners, and is based on present and past programme support. The estimates of the secured funding are shown below.
Funding Source 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Government 32,000 32,960 33,949 34,967 36,016 37,097
GAVI/Vaccine Fund 243284 296383 703290 335000 0 0
UNICEF 95,000 50,000 30,000 30,000 30,000 30000
WHO 50,000 30,000 30,000 30,000 30,000 30000
*The support from GAVI/Vaccine Fund for the 2006/07 was unspent balance from the year 2001/02. Based on the distribution of funds from GAVI/Vaccine Fund, Zanzibar will get US$ 2,075,213 for the period of 5 years (2001/02- 2005/06). This is 6.9 percent of the total available from GAVI/Vaccine Fund for both Tanzania Mainland and Zanzibar.
5.3 Estimates of Financing Gap
The following of diagram shows estimates of the financing gap for the period of 2001/02-2008/09 based on the scenario and option discussed above.
Funding gap for the EPI programme, up to 2008/09
0 1 00,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1 ,000,000 2001 / 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09 Ye a r Unsecured funds Secured funds
The funding gap in US$.
2003 2004 2005 2006 2007 2008 Projected req. 530,589 535,779 920,815 828,795 853,283 875,148 Secured Funds 420,284 409,343 797,239 429,967 96,016 97,097 Funding gap 110,305 126,436 123,576 398,828 757,267 778,051 *The projected resource requirement does not include the optional information on shared costs of
The program is faced with a total funding a gap of US$ 2,294,463 (50%) out of the 4,544,409 US$ it requires over the period of 2003/04- 2008/09. This gap does not include the personnel shared cost of USD$ 612,606 over the same period We see the presence of a funding gap even before the introduction of the Hib vaccines, which significantly increases over the years following its introduction. 5.4 Risk Assessment
It should be noted that, this gap is large because of the difficulty in knowing resources available far into the future, from whichever source. As a result, a number of persons/organizations that will be investing in the programme then are not included in the secured funds. The aim is to illustrate the level of uncertainty in funding the programme objectives, as opposed to illustrating programme under funding.
The major source of secured funds is the GAVI resources, as illustrated in the diagram below.
Secured programme funds by source, 2001/02 to 2008/09
0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09 Others (DANIDA, Irish Aid, USAID) WHO UNICEF GAVI/Vaccine Fund Government
GAVI/Vaccine Fund support is the most secured source of funding for the VF period. The government financing is dependent on the actual allocation in respective years. These commitments depend on the outcome of negotiations and prioritization through the PER and MTEF processes. Since the government budget is calculated in Tanzania shillings any exchange rate fluctuation will affect contribution levels.
The present programme strategy as outlined in section 3 and in the EPI Multi Year Plan presents the most cost effective use of the government’s resources, and leads to the highest reduction in both mortality and morbidity for the particular conditions for which vaccines are being provided.
6.0 SUSTAINABILITY STRATEGIES PLAN AND INDICATORS 6.1 Immunization Program Constraints
In the implementation of immunization activities, there are various constraints, which affect the performance and sustainability of the program. These constraints include:
(i) Inadequate funds for funding all planned activities.
(ii) Delays in disbursement of funds from both government and Development Partners
(iii) Sometimes the program is faced with a problem of receiving fewer funds as compared to pledges from different sources. .
(iv) Delays in the procurement process affect the implementation of program activities. Delays in honouring pledges lead to funds being frozen and therefore affecting the program performance. (v) Lack of adequate and qualified health staff especially at the
facility district level, leads to poor forecasting and inefficient handling of vaccine supplies. This is one of the reasons for high wastage rate, which at 2002 stands at 20 percent for DPT-HB. (vi) Failure to realise additional resources as projected in the financing
strategies described below under section 6.2.
(vii) Failure to increase efficiency especially in reduction of wastage rate to 10% from the current rate of 20% of DPT-Heb prior to the introduction of new vaccine.
6.2 Financing Strategies, Indicators and action plan
To address the financing gap illustrated in section 5.3 above, the FSP Task Force has developed a series of financing strategies and indicators to help address current and future financing needs. The strategies are designed to mobilize existing and additional resources, ensure reliability of resources and increase the efficiency of resources. Some specific strategies include:
(1) Assuring mobilization of adequate resources; (2) Assuring reliability of resources, and
Mobilizing additional resources
The strategies and actions to be used by the programme to mobilize additional resources are varied. These additional resources shall be sought from government (both central and local), private sector and donors. The programme shall institute a number of activities to ensure these resources are achieved each year, and are reflected in the MTEF. These are outlined in the log frame that is Annex C. They are presented within the text that follows
Additional central Government resources
The resources sought have to fit within the financial realities of the sector, and so amounts sought shall be based on proportions of the sector budget, as opposed to basing them on the overall needs of the programme. Central Government funding for the EPI programme is presently at US$ 13,500. This amount is very small, compared to the impact socially, economically and politically of the programme for the Government and communities.
As such, the programme shall, within the financial realities within which the sector operates, and keeping in mind the needs of other health sector programmes, shall strive to have an increased resources through a gradual increase in its proportion of the health sector resources. This increase shall be sought in the medium to long term to ensure it has limited, or no impact on other Ministry of Health programme or activity budgets. The programme shall seek to receive 4% of the health sector expenditure by the year 2008/09 incrementally as is illustrated in the table below.
Incremental resources from Government, 2003/04 to 2008/09 (US$)
2003 2004 2005 2006 2007 2008
Govt health budget/expenditure 5,863,000 6,033,027 6,207,985 6,388,016 6,573,269 6,763,894 Proportion of health to EPI Govt budget 0.6% 1.0% 1.5% 2.0% 3.0% 4.0%
Amount 32,247 60,330 93,120 127,760 197,198 270,556
Incremental amount on secured funds 246 27,370 59,171 92,793 161,182 233,459
The ability to achieve these resources from Government will greatly impact on the ability of the other strategies to realise the expected resources.
Additional local Government resources
The local Government’s are resource constrained, and rely largely on resources from the central Government for their activities. However, some programme activities can be funded locally, particularly those relating to the usually funded activities for local Governments. The activities relate to social mobilization of communities for routine EPI activities. In the long term, the programme shall seek to shift 50% of the resources being spent on social mobilization to the local Governments. This shift shall be phased to ensure lessons learned are taken up in the most cost effective manner, and the local Governments are only able to take up these costs based on their capacities. The strategy shall be to have 25% of these costs transferred to the local Governments in the Financial Year 2004/05, 40% in the FY 2005/06 up to 50% beyond 2006/07.
The expected resources mobilized are illustrated in the table below
Incremental resources from Local Governments, 2003/04 to 2008/09
2003 2004 2005 2006 2007 2008
Social mobilization/Kerosene resources 14,400 14,400 14,400 14,400 14,400 14,400
Proportion to LG's 0% 25% 40% 50% 50% 50%
Incremental amount from LG's - 3,600.00 5,760.00 7,200.00 7,200.00 7,200.00
To mobilize additional Government (central and local Government) resources requires a plan focused at the key stakeholders responsible for resource allocation for the programme. These stakeholders include both technical and political actors, for which key advocacy messages shall be synthesized and presented in a brief (Annex D). The message from the programme to the political actors shall focus on the possible political dividends of the strategy (the strategy involves the first introduction of new vaccines in 20 years), its relation to the ruling part manifesto and the social implications of not being able to implement the strategy. These actors shall be:
- The Office of the President, State House from whom the programme would
benefit from a clear message of support for the strategy (particularly relating to introduction of Hib in 2005)
- The office of the Prime Minister for advocacy within Government, - The Parliament for wider political support for the strategy
An information memorandum shall be prepared and presented to the Government of Zanzibar highlighting the EPI strategy, with its financial feasibility to achieve government endorsement for the strategy. This shall make resource mobilization less difficult.
The technical actors include persons from the Ministries of Health and Finance. These include:
- Minister of Health and Social Welfare for top level political support in the
sector, and to the wider Government
- Ministry of Health and Social Welfare Permanent Secretary for support from
the top most key technical officer in the ministry
- Ministry of Health and Social Welfare Director, preventive services who is
the head of the directorate
- Ministry of Health and Social Welfare Director, policy and planning - Ministry of Finance and Economic Affairs health technical officer
- Ministry of Finance and Economic Affairs Directors of planning and
budgeting
For these technical actors, the focus of the advocacy shall be on highlighting the financial feasibility of the strategy, and the lack of impact on other programmes, sectors and the overall macroeconomic framework of the country. Also highlighted
shall be the availability of funding in the short, medium and long term, the impact of the strategy on disease burden, and the implications of not implementing the strategy.
Included in the advocacy shall be actors at the regional and district level, where the advocacy focus shall be on the feasibility of the strategy, and their required activities in support of sub national resource generation efforts.
Resources from private sector
The private sector includes the private for profit actors, and the Non Governmental Organizations. A number of these have the potential to support specific programme activities, but require to be provided with the appropriate message and strategies for collaboration. The NGO actors include humanitarian organizations, while the profit sector includes the large actors in the commercial sector like the communication and beverage companies.
Actions relating to these include initial identification of the appropriate actors to target. The programme shall identify 2 to approach in the 1st year, starting with a
humanitarian organization to understand the approach before contacting a commercial company. For each, background information is first required relating to estimates of the organizations advertising/support budget and activities it has supported in the past. The particular activities it could support are then identified within the programme activities. Before contacting each, it is important to have a brief that highlights:
- Proposed areas of collaboration with the organization, - Resources sought
- Benefits of the collaboration to the organization
- Benefits of the collaboration to the EPI programme and the Ministry of
Health and Social Welfare
- Social benefits (to the community) of the collaboration
The resources sought from these shall be conservative, as it is a new sphere of operation for the programme. As such, amount sought shall be limited at an equivalent of 50% of the social mobilization costs, starting from 30% in 2004/05 to 40% in 2005/06 and finally 50% in 2006/07. The expected resources are illustrated below.
Incremental resources from private sources, 2004/05 to 2008/09 (US)
MOBILIZE PRIVATE RESOURCES 2004 2005 2006 2007 2008
Social mobilization resources 14,400 14,400 14,400 14,400 14,400
Proportion to private sector 30% 40% 50% 50% 50%
Incremental amount from private sector 4,320 5,760 7,200 7,200 7,200
Additional resources from present EPI donors
The programme has a number of donors presently supporting its activities. These are the multilaterals WHO and UNICEF, and one bilateral donor, GAVI. It is only
the multilateral who can provide some indication of support to the programme in the medium to long term. As such, the bilateral contributions in the medium to long term cannot be estimated. Support from GAVI is secured up to 2005/06.
From the multilateral donors, increased resource input into the programme shall be sought, particularly for the areas of support being offered at present. Increases in support shall be sought, up to 30% increase in the present support. This increment shall be sought over time, from 10% of the present secured funds, up to the 30% increment by 2008/09. The resource implications of this are illustrated below.
Incremental resources from multilateral donors, 2004/05 to 2008/09 (US$)
2004 2005 2006 2007 2008
Secured resources 80,000 60,000 60,000 60,000 60,000
Proportional increments 10% 15% 20% 25% 30%
Amounts sought 8,000 9,000 12,000 15,000 18,000
As the Hib vaccine is introduced at the end of the present GAVI support, the introduction of this vaccine marginally benefits from the present GAVI support. As such, a separate application shall be made to the GAVI board relating to the Hib vaccine. The Hib vaccine represents 70% of the pentavalent vaccine costs. This application shall be for 75% of the pentavalent proportion due to the Hib vaccine in 2007/08, reduced to 50% the next year (2008/09) as other sources of funds take over the vaccine fund. The resource implications are illustrated below.
Incremental resources from a new GAVI application (US$)
2006 2007 2008
Cost of pentavalent vaccine 500,683 514,702 529,114
Proportion due to Hib 70% 70% 70%
Proportion of Hib costs sought 0% 75% 50%
Additional amount sought - 270,218 185,190
Additional resources from other donors (past or new donors)
Some donors have supported the programme in the past (locally or in other countries), and are not supporting the routine programme presently. These either provide targeted support (for example during NIDS) or ceased to support EPI activities. The programme shall seek funds from these for the routine programme, as they have expressed support for immunization activities.
In addition are donors that have not supported the programme before but are supporting activities similar to those of the programme in other sectors or programmes. These too shall be sought. They include multi-laterals such as the World Bank.
The programme shall seek to incrementally raise resources from these donors to the equivalent of the bilateral support prior to GAVI introduction. Resources sought each year are illustrated below.
Incremental resources from new donors to programme (US$)
2004 2005 2006 2007 2008
Secured donor funds (minus multilaterals) - - - - - Donor support for 2001 188,898 188,898 188,898 188,898 188,898
Proportion of funds sought 5% 10% 15% 20% 25%
Amounts sought 9,445 18,890 28,335 37,780 47,225
The programme shall engage these donors to increase its resource base. For those that have expressed support for the programme before, or in other countries, the initial activity shall be to determine reasons for non support of the present programme. Based on these, two donors shall be engaged annually. For each, the programme shall prepare a strategy that is based on:
- Activities for which support is required, with amounts of funds sought, - Impact of the additional funds on the programme activities
- Benefits to the community, and the donor for the support
Improved functionality and expansion of the ICC
The ICC shall be made functional and expanded to include any new financial donors that are mobilized as a result of this strategy. It shall be ensured that the ICC meetings shall be held regularly, with dates for the ICC predetermined annually. Developmental partners attendance shall be ensured for both those offering technical and financial support to the programme.
Increasing reliability of resources
Resource reliability becomes more difficult with planning into the future. However, it enables the programme develop and align its strategies in the future in line with the financial realities in the sector. As such, the programme shall seek to increase the reliability of its resources, both from Government and donors. This strategy shall lead to financial sustainability indirectly, and not leading to direct resources to the sector.
Increasing reliability of public resources
The programme shall ensure that its needs are included in the MTEF estimates. This shall be a result of active review of activities and costs of the programme annually before the MTEF ceilings are determined, and ensuring this information gets to the Ministry of Finance formally or informally. In addition, the programme shall ensure its resources remain protected within the Government, and sector budgets to ensure allocated resources are received by the programme.
Increasing reliability of donor resources
Advocacy illustrating the programme strategies, and performance shall be intensively applied to the present and potential EPI donors, in order to build and maintain confidence in the programme. This shall be aimed at ensuring targeted resource requirements from the donors are met.
Increasing programme efficiency
Reduce vaccine wastage
Vaccine wastage causes significant increases in programme costs. This is particularly so for the new vaccines, which are very expensive. The programme shall institute a monitoring mechanism for vaccine wastage by district. The present wastage rate of 18% for DTP-HepB shall be reduced to during the period of Hib administration. The impact of this reduction is illustrated in the table below.
Incremental resources saved through reduction in vaccine wastage, 2004/05 to 2008/09 (US$)
2004 2005 2006 2007 2008
Present vaccine costs (20% wastage) 212,411 747,642 661,646 680,834 700,578 Changes in vaccine wastage sought 15% 15% 10% 10% 10% Effect on programme costs 172,772 627,373 495,072 508,934 523,184
Amounts saved by programme 39,639 120,269 166,574 171,900 177,394
It is anticipated that there will be a higher than Norman wastage rate during the year of Hib introduction.
Further reductions in the vaccine wastage rates shall be sought based on focused activities in districts with high wastage rates. Inter district meetings will be organized to review activities being carried out that practically lead to reductions in vaccine wastage.
Maximize efficiency of static units for vaccination
Health facilities offer the most cost effective method of offering immunization services. These are limited in coverage and so for higher coverage, outreach services are a necessity. At present, only 75% of the health facilities are offering immunization services. This is because of two reasons.
1) Some facilities are with overlapping areas of responsibility, such that it is not economical to have both offering immunization services. This is particularly so for facilities in urban areas
2) Some facilities lack basic resources (human or infrastructure/equipment) to be able to offer immunization services
The programme shall seek to determine numbers of facilities not offering immunization because of lack of resources. In the short term, the programme shall focus on ensuring resources directly relating to the programme are made available in more facilities. In the medium term, the programme shall advocate for improved availability of resources required at the facility but are out of control of the programme, such as human resources. Advocacy shall focus on costs to the system of absence of these resources. Long term advocacy shall focus on improving numbers of
static facilities per population bases, again having advocacy based on financial implications of lack of these in the respective areas.
Maximize efficiency of outreach sessions
Many of the outreach sessions are inefficiently carried out, with very few, if any clients seen. There are two plausible reasons for this:
i) Poor social mobilization, and ii) Poor selection of outreach sites
These are costly to the programme. The programme shall determine costs incurred for outreaches carried out that see different numbers of clients. These shall be used to determine a recommended number of clients seen at each outreach, with social mobilization strategies geared at achieving this target. In addition, rationalization of establishment of outreach posts will be carried out by the programme.
Use of private providers
These are varied, and the sector rather complex. However, they are a source of health care and should be sought as possible providers of immunization services, particularly in hard to reach areas. Criteria will be determined by the programme for collaboration with these actors, based on distance from a provider of immunization, and the resources (human and infrastructure) available to the provider.
The diagram below shows the impacts of the above strategies on the funding gap. Closing the financing gap: Contribution from respective strategies
-200,000 400,000 600,000 800,000 1,000,000 1,200,000 2003 2004 2005 2006 2007 2008 Year Remaining gap M obilize privat e resources Additional donor support Increase multilateral cont ributions New GAVI application f or Hib support Improved programme eff iciency M obilize LG resources M obilize additional Govt resources Total secured
Significant reductions are brought about by the increased Government contribution to the programme, improved efficiency of the programme and the new application to GAVI for support following Hib introduction. However, ability to raise the additional resources from Government is the cornerstone strategy, as it
acts as a key advocacy message when mobilizing the resources from the other actors.
There are a number of strategies, whose cost implications are not included such as increasing resource reliability, maximised use of static units for immunization and increased collaboration with the private sector. These indirectly aid the attainment of the above strategies through acting as advocacy messages.
Process to achieve financial sustainability
The action plan is summarized in the logframe that is Annex C. A summary of the indicators to monitor from the action plan up to 2006 is summarized in the table below. Indicator value Strategies Indicator Bas e-line 2003 2004 2005 2006 2007 2008
EPI budget as a proportion of Govt. health budget
0.6% 0.6% 1% 1.5% 2% 3% 4% Mobilize additional Govt
resources
Govt contribution as proportion of recurrent programme costs
7% 7% 12% 19% 26% 41% 56% Mobilize additional local
Govt resources
Proportion of EPI social mobilization costs funded from district-own resources
0% 0% 25% 40% 50% 50% 50% Number of private firms supporting EPI
program
0 0 2 4 6 8 10 Mobilize additional private
resources
Proportion of EPI budget funded from private resources
0% 0% 0.9% 1.2& 1.5% 1.5% 1.5% Mobilize additional
resources from present EPI donors
Proportional increase in funds from present donors
0% 0% 10% 15% 20% 25% 30%
Mobilize resources from new donors
Proportional contribution from bilateral donors
0% 0% 1.9% 3.9% 5.8% 7.8% 9.7% Expansion of ICC Number of new ICC members 0
Proportion of program costs funded by Govt
7% 7% 12% 19% 26% 41% 56% Increase reliability of public
resources
Proportion of resources secured in the Medium Term
95% 95% 95% 95%
Improve reliability of donor resources
Proportion of 3-year secured program costs funded by donors
95% 95% 95% 95%
Reduce vaccine wastage Vaccine wastage rate 20% 20% 15% 15% 10% 10% 10% Increase vaccination
offered through static units
Proportion of health facilities offering immunization
75% Use of private providers in
providing vaccination
Proportion of areas with no health facilities using private providers for vaccination Increase in numbers of
infants per outreach session
Average number of children per vaccination outreach
The ICC shall implement the action plan, with a technical sub working group from it following up on a daily basis the implementation of the actions required to attain financial sustainability. This sub-working group (the Immunization financing working group) shall include a maximum of 8 people, who will include representatives from the EPI programme (EPI manager and one staff), technical organizations on the ICC (WHO and UNICEF), Ministry of Finance and 3 additional members chosen by the ICC.
The ICC shall, on a quarterly basis, review progress on the action plan as presented by the financing sub working group, and plan for activities from the action plan to be completed in the coming quarter. For its part, the financing sub working group shall meet on a monthly basis to review progress on expected activities, and plan for upcoming tasks.
On an annual basis, the ICC shall have a retreat to review progress on financial sustainability based on the indicators used, and chart out the expected activities for the next year. Findings from this retreat shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability (required with the Annual Performance Report)
The different indicators for the above strategies shall be used by the ICC to monitor performance towards financial sustainability. They are both district and nationally based indicators, and are based on normally available information, eliminating a need for data collection to monitor progress towards financial sustainability.
6.3 Conclusions and Final Recommendations
Zanzibar’s Financial Sustainability Plan has developed one possible scenarios and one financing immunization program. The FSP recommends that the pentavalent vaccine, DPT-HB-Hib, be introduced throughout the country in 2005/06. In order to ensure that adequate funding is available the FSP recommends that the GOZ apply for additional support from GAVI/Vaccine Fund. The application will propose that the Vaccine Fund pay for the pentavalent vaccine and operational costs for the post GAVI/Vaccine Fund period i.e 2006/07-2008/09.
Even if the price of pentavalent vaccine decreases, Zanzibar still faces significant funding gaps between projected program requirements and expected financial resources after the GAVI/VF period. The FSP Strategic Plan is designed to help reduce this funding gap by setting targets and indicators to help ensure mobilization of resources, increased reliability of resources and increased program efficiency. Zanzibar’s strategic plan is quite ambitious and will require the active and sustained participation of multiple stakeholders. Furthermore, it is expected that GAVI at the global level will provide assistance with advocacy for additional funding from its partner organizations. It is also hoped that GAVI will bring all of its resources and influence to bear on its pharmaceutical partners to reduce the price of pentavalent vaccine.
ANNEX A – Program Characteristics, Objectives and
Strategies
A-1 ROUTINE IMMUNIZATION
In routine immunization service delivery the program seek to provide safe and effective vaccines to at least 80% of all children with BCG, DPT_Hep B, OPV and measles vaccine before the age of one year.
Objectives
i. Increase immunization coverage to at least 80% of all antigens to children under one year in each district by the year 2007
ii. To increase the immunization coverage of TT2 + to 90% pregnant women in each districts by the year 2007
iii. Increase community knowledge on EPI related services and diseases Indicators:
i. Percentage of Measles and DPT3 coverage for children under one year. ii. Percentage of DPT-HB1/DPT-HB3 Drop out rate.
ii. Percentage of TT2+ coverage for pregnant women at district level.
iii. Percentage of beneficiaries who correctly identify EPI diseases and know the EPI immunization schedule
Strategies
• Availability of vaccines, injection equipment, cold chain (CFC free) equipment and other supplies through mobilization of funds from government and other partners.
• Revision and update of MCH/EPI service guideline.
• Update of MCH staff and cold chain officers skills in the EPI policies (e.g. safety of injections, cold chain maintenance, multi-dose vial policy Vaccine vial policy etc) and to incorporate EPI into pre-service curriculum.
• Increase of vaccination coverage in inaccessible areas through involvement of local government, communities, and
• Support the district capacity in micro planning and advocate for prioritising EPI in district plans.
• Increase community involvement and demand for EPI services through advocacy of community and opinion leaders, sensitisation of caretakers on the importance of vaccination, and quality improvement of immunization services
• Provide evidence-based information towards the introducing additional vaccines into immunization services.
