Sierra Leone Adopts “Reach Every District” Strategy to Increase Immunization Coverage

Sierra Leone moved closer to achievement of both the Global Immunization Vision and Strategy and Millennium Development Goals related to poverty-reduction and improved health outcomes when the nation adopted the “Reach Every Child (RED)” approach to healthcare last fall.

In 2002, the World Health Organization (WHO) developed RED in response to stagnating immunization coverage throughout the African continent. The RED approach focuses on improving immunization coverage by concentrating attention on district level healthcare facilities, and stressing the importance of collecting data and monitoring progress.
Sabin Senior Program Officer Dr. Clifford Kamara facilitated a lecture on ToT for 22 health personnel during a RED training workshop sponsored by Sabin, WHO, and UNICEF. The workshop provided attendees with insights on how to utilize effective planning and monitoring and evaluation techniques for immunization and maternal and child health interventions. The 22 health personnel, who represented each of Sierra Leone’s 13 districts, will in-turn train other health workers and ensure that the RED approach is widely implemented.

Participants in the RED training developed five key recommendations at the conclusion of the meeting, including a focus on training health workers whose primary focus is maternal and child health, mobilizing resources to ensure that the RED approach is effectively implemented, and empowering “district health sisters” to be responsible for training health workers and monitoring the implementation of RED.

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National immunization trust fund emerges in Nepal

As 2010 comes to a close, Nepal is eyeing the establishment of a national trust fund as a way to ensure sustainable financing for its national immunization program. The groundwork for this important step was laid over the year by a host of stakeholders. Several preparatory meetings brought together Ministry of Health and Ministry of Finance officials with parliamentarians and private sector leaders to discuss the options.

The Nepalis developed the trust fund concept in league with their Cambodian and Sri Lankan counterparts. Threes sub-regional parliamentary briefings, supported by Sabin, were held in Kathmandu (9-11 February), Colombo (15-16 July), and Phnom Penh (21-22 October). In February, the parliamentarians adopted the “Kathmandu Declaration”, in which they committed to work for sustainable immunization financing for Nepal. UNICEF/Nepal has played an important role, first by co-sponsoring some of the briefings, then by providing technical support to the Nepali parliamentary and governmental counterparts. In the July Colombo briefing the delegates exchanged more information and generated the “Kathmandu to Colombo and Beyond Declaration”, which called upon all three governments to find innovative ways to increase routine immunization budgets. The Declaration also called on national immunization program managers to begin monitoring and reporting program expenditures along with coverage and surveillance data. At the meeting in Phnom Penh, the countries elaborated lists of short-term actions they will take to move them closer to the sustainable immunization financing goal. Again the delegates produced a “Phnom Penh Declaration”, this time highlighting the urgency of achieving the Millennium Development Goals and asking for in-year reporting from the ministries to parliament on immunization program performance. With these elements in place- policy directives, better reporting, a sense of urgency- the trust fund becomes feasible.

Throughout 2010, the Rotary Clubs of Nepal also played a key role in turning the country into an SIF champion. The clubs set up and capitalized a precursor fund, assessing each member US$80 to get it started. The Rotarians had participated in national SIF briefings in June and October. Today there is consensus that achieving sustainable immunization financing will require attracting more domestic resources from national business/corporate houses. The fund will allow firms to demonstrate their corporate social responsibility while accruing tax breaks. The goal is to establish a fund independent of the current external partner pooled funding arrangements for immunization. All contributions received will be seed money. The interest income from the seed money will be provided to the government to procure vaccines. As soon as the government establishes a legal mechanism, the partners agreed, ownership of the trust fund will be shifted to the government. The growing number of new stakeholders puts pressure on the government to speed up the process of creating the national immunization trust fund. At a brainstorming meeting on 28 December, members of the Rotary Club of North Kathmandu announced they had so far contributed NRs 137350 (about US$1900) to the interim fund.

Legislative work is also required to set up a trust fund. In a series of recent meetings, senior officials from health, finance and planning ministries have taken on the task of crafting a “National Immunization Act” to support the national immunization trust fund. The Ministry of Health has inserted these two activities into its annual program. The plan now awaits the approval of the National Planning Commission. These institutional innovations demonstrate the important effects new domestic and legislative stakeholders can have on the highest policy levels of government.

Among senior officials crafting the trust fund are Hon. Dr. Chet Raj Pant of the National Planning Commission; Mr. Vidyadhar Mallik, Vice-chairman of the Nepal Poverty Alleviation Fund; and, from the Ministry of Health, Dr. YV Pradhan, Director General of Department of Health Services; Dr. RP Bichha, Director of Child Health Division; Mr. KB Chand, Chief EPI Section; and Dr. Padam Bahadur Chand, Chief of the Policy, Planning and International Cooperation Division. Also involved are officials from the Parliament Secretariat; a representative from Ministry of Finance; representatives from WHO, UNICEF, Rotary and others.

The Nepalis are currently studying immunization laws from three Latin American countries (Bolivia, Costa Rica and Paraguay). The laws have been effective. Latin American governments now finance over 95% of their national immunization budgets. Their view is that the Immunization Act and Immunization Trust Fund must be developed simultaneously. The next step is for the Ministry of Health to win approval from the Cabinet of Ministers. This will require advocacy at the highest level. The team is forming a Technical Working Group to work on this task. The group will bring together immunization experts, legal officers and others high level officials to prepare a justification for why the Act and the Fund are necessary. Assuming they succeed, another high level meeting will take place with the Secretaries of Finance, Health and Law & Justice.

The Nepali delegation is expected to present their immunization trust fund case study at a Parliamentary Colloquium on Sustainable Immunization Financing, which SIF is organizing in Addis Ababa the last week of March 2011. Similar immunization trust funds are being organized by parliamentary and government counterparts in DR Congo and Cameroon. Mali, Senegal and Sri Lanka are also studying the idea. The Nepali case will be the first to demonstrate how a poor country can nevertheless make headway on the path to sustainable immunization financing.

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Progress in the review of Uganda’s health legislation

One of the achievements of the discussions with medicines taskforce of the Ministry of Health and Civil Society Organizations, which are strongly involved in advocacy for Medicines, is a current effort by SIF to perform a legal audit and analysis of the current legal framework on immunization. This effort, which was initiated in September 2010, will provide a legal opinion on the existing options for adopting a legislation of regulation pertaining to immunization in Uganda. The product of the assignment should be able to guide an advocacy plan to use the public health legal regime and human rights based approach to influence funding for immunization and national action on the current challenges of the immunization programs in Uganda.

So far, a national survey at different levels of the implementation process of immunization, beginning at the national level, distribution, district, and ending at the local government level, was conducted. Findings of the survey have been presented at the National Health Review Meeting in November and new strategies for the next phase of the planning cycle HSSP III (2011 – 2014) have been discussed and formulated.

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Lessons Learnt Through Peer Exchange on Performance Based Budgeting Practices: Case Study from Liberia, Sierra Leone and Uganda

by SIF Senior Program Officer, Cliff Kamara
The Sustainable Immunization Financing Program of the Sabin Vaccine Institute had another opportunity to share experiences during the WHO/ AFRO Annual Regional Conference on Immunization in Ouagadougou 6th – 8th December, 2010. Peter Sam-Kpakra, Senior Assistant Secretary for Donor-funded Projects in Sierra Leone’s Ministry of Finance and Economic Development, presented a paper outlining the lessons learnt when he and Bernard Jappah of Liberia’s Ministry of Finance conducted a Peer Exchange visit to Uganda, another SIF program country. Uganda is recognized as a country with best practices as far as budget reforms are concerned; these include performance based monitoring of immunization and other health programs.

Hosted by the government of Uganda, Peter and Bernard familiarized themselves with innovative financial management practices during a two day visit to the Ministry of Finance and the Ministry of Health of Uganda. Lessons learnt include the benefits of signing performance-based contracts, with the disbursement of subsequent allocations based on satisfactory program execution/ performance. The government of Uganda also front loads program in the event of delayed donor funding, thereby averting the delays in the implementation of planned activities. As opposed to Liberia and Sierra Leone, the budget monitoring process is formalized, and is the responsibility of a well established unit staffed by relevant specialists.

Peter described how on return to Liberia and Sierra Leone, he and Bernard are currently applying the lessons learnt in their respective Ministries of Finance. In Liberia, Bernard is introducing health sector budgeting, as compared to ministerial budgeting; in Sierra Leone, Peter is strengthening the recently introduced performance-based financing in the Reproductive and Child Health Program, where immunization coverage is the main indicator for monitoring performance.

Clearly, it was agreed that Peer Exchanges on topical issues can play a vital role in sharing experiences and learning between SIF program countries. Whilst monitoring the introduction and implementation of the best practices seen in Uganda by Peter and Bernard, the SIF will continue to organize other Peer Exchange visits between program countries, with the firm belief that this is a fast method of introducing innovative practices that can contribute meaningfully towards achieving the overall goal of sustainable immunization financing.

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DR Congo and Cameroon delegations present SIF work at the WHO/AFRO Annual Regional Conference on Immunization

Here in the second day of the WHO/AFRO Annual Regional Conference on Immunization in Ouagadougou, Burkina Faso, participants heard how the Democratic Republic of Congo and Cameroon are working together to develop sustainable immunization financing plans. Representing the DRC delegation were Hon. Gregoire LUSENGE KAKULE, Member of Parliament, and Mr. Andre BONA KABAMBA, Chef de Division Unique in the Ministry of Finance. Representing Cameroon were parliamentarian Hon. Gaston KOMBA and EPI finance officer Sylvain BRICE BANELA. Also attending were Sabin’s Senior Program Officers, Dr. Helene MAMBU-MA-DISU, who is based in DRC, and Jonas MBWANGUE, who is based in Cameroon.

In his presentation, Hon. LUSENGE described how a team from WHO, UNICEF and GAVI came to Kinshasa in April 2009 to assess the country’s immunization financing situation. That year DRC’s immunization program was almost entirely donor-dependent. The government had allocated just US$777,609 for the approximately $90m program. In September 2009, Sabin organized the first in a series of parliamentary briefings in Kinshasa. For the first time, said Hon. LUSENGE, the parliamentarians saw how immunizations are given in this vast country of 445 ethnic groups. What alarmed them most was the program’s high donor dependency.

The members of the National Assembly’s Health Commission immediately became immunization advocates.

During the 2010 budget hearings they demanded and got specific immunization line items added to the budget, allowing them to track budget execution. And they convinced the government to push its EPI investment up to $6.4m. But progress eluded them. Most of the 2010 government funds were never disbursed. Worse, vaccine coverage fell from 83% to 69% due to staff turnovers and lackluster performance.

The solution that occurred to the MoF’s BONA KABAMBA was to develop a national immunization trust fund. To be financed by a new tax on cell phone calls, private sector donations and external immunization partner contributions, the fund would be governed by a quasi-public board. Bypassing the Treasury would eliminate the cash rationing problem. The EPI would have to demonstrate its performance to the fund directors in order to qualify for each budgetary tranche.

As BONA KABAMBA puts the finishing touches on the proposal, the MPs on the Health Commission are rallying their fellow parliamentarians, five key ministries and the country’s eleven provincial governors and provincial assemblies to support the proposed fund.

Meanwhile, a similar advocacy process is underway in nearby Cameroon. Both countries are developing national immunization trust funds. In his presentation, Hon. KOMBA described a Sabin-sponsored visit by the DRC delegation to Yaounde last September. The peer exchange allowed LUSENGE, KABAMBA and DRC EPI Manager Raymond CAMBELE to compare notes with their Cameroonian peers. The teams continue to collaborate as they advance their innovative financing projects.

The funds will be broadly similar, however, Cameroon’s will take advantage of the country’s fast-moving decentralization program by ensuring that municipalities (mairies) also contribute to the fund. An expert committee, added Hon. KOMBA, will oversee technical aspects of the program. A permanent secretariat will ensure the new funding streams are used as efficiently as possible.

Much work remains to be done before the funds are operational. Feasibility studies must be completed and both packages must ultimately be passed into law. Afterwards several participants congratulated the delegations for their pathbreaking work. It was the first time parliamentarians had ever attended an ARCI meeting.

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Another ‘Reflections From the Field’ Entry from SIF Program Director, Mike McQuestion

Here at the WHO African Regional Conference on Immunization in Ouagadougou we heard today about new polio outbreaks in DR Congo, Uganda and Kenya. Since September, there have been around 1,000 cases in DR Congo and neighboring Republic of Congo (Brazzaville). Most of the cases have been in young adults. Case fatality rates are around 40-50%. Many adults, the data tell us, were susceptible. They were never vaccinated and never encountered the wild poliovirus as children. When high vaccine coverage is not maintained, susceptible pool in each birth cohort. The epidemic happens when there are enough susceptible to permit the poliovirus to transmit. The outbreak is a sobering reminder that once polio transmission is interrupted, countries must keep their polio vaccine coverage levels above 80%. That requires a well functioning, adequately resourced routine immunization program. Reacting to the presentation this morning, Hon. Grégoire LUSENGE KAKULE, a Member of Parliament from DRC and Sabin peer exchanger to this meeting, vowed to investigate the situation in his constituency and to report his findings to his fellow National Assembly Health Commissioners.

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“Reaching Every Child in the African Region with Immunization” – ARCI/ARICC meeting in Ouagadougou, December 6-9, 2010

On December 6-9, 2010, the WHO will host ARCI/ARICC meetings in Ouagadougou, Burkina Faso. The Sustainable Immunization Financing (SIF) Program at Sabin will host and oversee a Parallel 3 Session dedicated to Immunization Financing. Representatives from five of SIF Sabin’s pilot countries will be presenting and reporting on a variety of aspects relating to sustainable immunization financing.

Results that have been achieved to date in Africa to improve routine immunization coverage, eradicate polio as well as reduce measles morbidity and mortality, are impressive. A lot of goals remain to be achieved; among them, is the increase in national resources, the introduction of new evidence-based vaccines, as well as the creation and improvement of national legislation for national immunization efforts. With these goals in mind, the parallel 3 Session will address such issues as the dissemination of performance-based budgeting practices and the establishment of emergent National Immunization Trust Funds. These presentations will inform the attendees on the various facets of these initiatives, promoting collective dialog on how to address the challenges unique to developing nations, and helping countries reach sustainable immunization financing for vital-to-public-health immunization programs.

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