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.

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.

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.

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.

Revisiting Kenya’s First Parliamentary Briefing on SIF

On September 8, 2010, Parliamentarians met with Senior Program Officer Diana Kizza to discuss Sustainable Immunization Financing. Attending, were: Hon Dr. Robert Monda (Chair Health Committee), MP; Hon Dr Eseli Simiyu, MP; Hon Dr. Bori Khalwale MP; Hon Dr. Nuh Nassir, MP; Hon Fred Orita, MP; Hon Joseph O. Magwanga, MP; Mr. Salad (Clerk Health Committee) Parliament of Kenya; Prof (Dr) Fred Were, Kenya Paediatric Association; and Dr David Githanga, from the Kenya Paediatric Association.

The purpose of the September 8 meeting was to meet directly with the health committee, to divert its focus to immunization efforts in the country. Secondly, the goal was to address making immunization programs a priority through a variety of approaches; mostly through sensitizing the public and advocating for increased budget allocations for the health sector and thus immunization. With new and underutilized vaccines rapidly being introduced onto the market, it is becoming increasingly difficult to achieve full coverage: the rapidly growing cost of immunizing the population is threatened by the increasingly limited rate of committed financial sources.

Like other countries facing a similar dilemma, GAVI is unable to patch funding in order to support the introduction of new (and expensive) Pneumococcal Vaccine and Rotavirus vaccine. This alerting fact points to the urgent action needed by Kenyan leaders for planning to ensure that its population will be adequately protected against preventable, immunizable diseases.

Recently, a new Kenyan constitution was put into place. This offers a favorable window of opportunity for the development of a proposed law on immunization in Kenya; one that would bind the Government of Kenya at central and local levels which would protect funds for immunization and ensure immunization schedules. At this meeting, MPs suggested on drafting a bill which would help secure such actions, to begin immediately, by borrowing from the successes of the PAHO countries of South America, and employing the parliamentary department specialized in drafting legislation.

The Comprehensive Multi Year Plan (CMYp) was brought to the attention of the MPs, as they requested data which described the total amount going towards vaccines in Kenya; this review also addressing the obvious gaps. The planning and advocacy tool has recently been updated by the Ministry of Health for the 2010 – 2015 period. The recommendation of a policy brief, designed to address and illustrate funding challenges, as well as the total costs and gaps for procurement for new and underutilized vaccines be drawb. With new information on the availability of a CMYp, the parliamentarians (MPs) proposed a meeting with members of the Ministry of Health for elucidation on the Comprehensive Multi Year Plan, as well as a proposed immunization financing plan post 2015.

It was further proposed that the committee organize a core team which would include dedicated MPs which would demonstrate their commitment to immunization financing advocacy, thereby ensuring a high level advocacy campaign. The Health Committee was updated on the proposed March SIF colloquium where 12 African and 3 Asian countries will meet in Addis Ababa to share experiences on best practices on immunization financing.

The meeting was adjourned at 1220H with closing remarks from the Chair.

SIF’s Program Director Reflects on Public Health Initiatives in Asia

In our fifth post from our ‘Reflections from the Field’ series, our Program Director, Mike McQuestion, writes about his recent time spent in Asia as well as his thoughts on sustainable immunization financing initiatives in SIF’s three Asian pilot countries.

The three Asian SIF pilot countries could not be more distinct. In Cambodia, a rice growing culture has flourished for 2000 years in the Mekong River delta. Public health programs are just now starting to cut maternal and child mortality. Nepal is a polyglot of mountain and plain dwellers unexposed to the modern world until the late 1940s. Its health programs are also rapidly driving down mortality. Both countries are on track to make their MDG4 targets. Sri Lanka, in contrast, is a prosperous island with a diverse economy, high educational levels and a sophistocated public sector. Mortality has been low for decades. These contrasts aside, the three countries are pulling together to reach the sustainable financing goal. This was the theme of last week’s Third Sabin Asian Subregional Symposium on SIF.

Nigeria holds its First Briefing on Sustainable Immunization Financing

Some of the participants in Nigeria's first SIF parliamentary briefing, 29 Oct 2010, Abuja.

Sponsored by SIF Sabin, Nigeria held its first parliamentary briefing in Abuja, Nigeria today. It was chaired by the Executive Director of the National Primary Health Care Development Agency (NPHCDA) Dr. Muhammad Pate. The 32 participants included the Chairlady of the Senate Health Committee, Hon. Mrs. Dr. Iyabo Obasanjo-Bello, colleagues from the NPHCDA, WHO (including the Representative, Dr. Peter Eriki), UNICEF, USAID and Rotary International. The Chairman of the Board of the NPHCDA, His Royal Highness, Dr. Yahyah, was also in attendance, and the event was fully covered by the print and electronic media.

In his remarks, Dr. Michael McQuestion, the Director of the Sustainable Immunization Financing Program of the Sabin Vaccine Institute opined that although Nigeria is the thirteenth of the fifteen program countries, it has the potential to become the first to achieve Sustainable Immunization Financing. The country already funds over 70% of the routine vaccine costs, higher than any other country in sub-Saharan Africa. He emphasized the commitment of the SIF program to work closely with the NPHCDA and other stakeholders to achieve this in the near future.

In her remarks, the Chairlady of the Senate Health Committee, Hon. Mrs. Dr. Iyabo Obasanjo-Bello, apologized on behalf of her Senate colleagues, who could not attend because they had to travel outside Abuja to attend urgent political events. She emphasized that this is not a manifestation of lack of interest on their part, and assured all that the attendance will definitely be much better if the next event is organized at a more appropriate time.

Discussions after the presentations focused on the need to strengthen routine immunization activities; need for health systems strengthening, especially in the light of the introduction of additional, more expensive vaccines; need to introduce strategies and possibly legislation to “ring-fence” adequate funding for immunizations; and the significant contribution immunizations can make towards achieving the MDGs in Nigeria.

The symposium ended with a clear agreement by all that the good working relationship established between the various partners for immunization must continue and be strengthened. The process of information sharing, consultation, collaboration, and advocacy will definitely lead towards sustained immunization financing, thereby putting the country on the firm path towards achieving the MDGs.

For photos of this event, please visit our Flickr site here.

Sabin’s Communication Officer Writes About Recent SIF Phnom Penh Meeting

Our fourth post from our ‘Reflections from the Field’ series is written by Eteena Tadjiogueu, a Communications Associate here at the Sabin Vaccine Institute. While on her travels in South East Asia, she participated in SIF Sabin’s sponsored meeting in Phnom Penh dedicated to SIF and child initiatives. Here, she writes about her experience.

Last week I had the opportunity to participate in the two day “Third Sub-Regional Symposium for Parliamentarians on Child Health and Sustainable Immunization Financing” in Phnom Penh, Cambodia. It was my first time visiting South East Asia and my first opportunity to witness the work of the SIF program first hand.

Day one of the symposium was filled with highly informative presentations from parliamentarians from Cambodia, Sri Lanka and Nepal as well as representatives from UNICEF, World Bank and UNDP. The agenda really got interesting on the afternoon of day one when the delegates and I were placed into small working groups, comprised of representatives from each of the three countries, and asked to discuss challenges to budget preparation oversight or legislating for immunization and health.

Eteena Tadjiogueu, Sabin Communications Associate; Dr. Mike McQuestion, SIF Program Director; Dr. Devedra Gnawali, SIF Senior Program Officer; and Mr. Visal Uy, Cambodian Director of International Relations Division of the National Assembly (left to right); pose with the symposium organizers at the conclusion of the two-day meeting

My group discussed the budget preparation oversight process and came up with eight challenges that hindered the process. From the list of eight we drilled down to three main challenges, first and foremost being a limited budget to support health activities. Next we discussed several options to remedy our main challenge including the potential to develop a national immunization fund, increasing the amount of money allocated to the health budget by the national government, improving the economy through boosting agriculture exports, and financing health projects through taxes.The results of each working group were shared the following morning and then delegates were placed into three country-specific working groups to develop action plans that devised components of the “Phnom Penh Declaration.”

Similar to the Kathmandu Declaration, the Phnom Penh Declaration lists out specific actions that should be taken by parliamentarians, ministers of health and finance, and government officials to ensure immunization programs are sustainably funded. For instance, bullet point number one directly alludes to what my group discussed in calling for the ministers of finance and health to increase the national immunization budget. Other points, like requesting governments to create National Immunization Acts, were developed from the results of the working groups who discussed legislating for immunization and health.

The most exciting part of the symposium came on the last day and it certainly wasn’t because the event was drawing to a close! Instead, when I saw each of the participants armed with a copy of the Phnom Penh Declaration and fully aware of the upcoming SIF colloquium where they will have to report on their progress in front of the other 14 pilot countries, I was excited about the immense amount of opportunity for change that lays ahead.

SIF Program Director Dr. Mike McQuestion told participants during the closing session that he hoped in the coming months each of the delegates would continue to work as innovative groups. Based on my conversations with several delegates in my working group, and during coffee breaks, I have no doubt that they will and I believe that the conversations and presentations on sustainable immunization financing will be even more fascinating at the SIF colloquium.

Please join us for our next entry from this series when Director Mike McQuestion writes about his experience at this Sabin-sponsored symposium in Phnom Penh event. For additional photos, please visit the event album on Flickr

Second Day of Activities from the Third Parliamentary Symposium on SIF

Today marks the second day of the Third Parliamentary Symposium on Sustainable Immunization Financing (SIF) in Phnom Penh. Delegates from SIF pilot countries Sri Lanka, Nepal, and Cambodia will be discussing: Budget Preparation and Oversight; Legislating for Immunization and Health; and National Delegations’ Action Plans. All three countries will present their Action Plans and collectively discuss the adoption of a new Cambodia Declaration. To learn more about these two-day proceedings, please return to our blog next week for a field report from our Sabin SIF Program Director, Mike McQuestion.

Cambodian delegation prepares its action plan.

Third Parliamentary Symposium on Sustainable Immunization Financing Begins Today in Phnom Penh, Cambodia.

The Third Parliamentary Symposium on Sustainable Immunization Financing (SIF) begins today in Phnom Penh, Cambodia, lasting from October 21-22, 2010. Sponsored by the Sabin Vaccine Institute and hosted by the Government and Parliament of Cambodia, government representatives from Sri Lanka, Cambodia, Nepal, as well as representatives from the WHO, UNDP, UNICEF, and World Bank will be joining Director Mike McQuestion and Senior Program Officer Devendra Gnawali today to discuss these countries’ statuses in reaching sustainable immunization financing. Government representatives from each pilot country will summarize their achievements to date in reaching this initiative. Topics to be broached, will be: best practices in budgeting and legislation; best practices in advocacy; problem areas; goals; as well as varied and practiced approaches to sustainable immunization financing.

In both February and July of 2010, SIF Sabin sponsored two briefings in Asia. In February 2010, the First Asian Sub-regional parliamentary colloquium in Kathmandu, Nepal, produced the Kathmandu Declaration, which called for bigger national immunization budgets in SIF Sabin’s three Asian focus countries: Nepal, Cambodia, and Sri Lanka. In July 2010, a similar colloquium was held in Colombo, Sri Lanka; the output of this convening of nations was the Kathmandu to Colombo and Beyond Declaration, which called upon governments to find innovative ways in which to increase routine immunization budgets, also calling upon nations EPI managers to begin monitoring with fiscal findings and follow up reporting.

Nepal's RP Biccha calls for less donor dependence during panel discussion.

Today’s Third Parliamentary Symposium on Sustainable Immunization Financing will follow up on these prior achievements and explore viable initiatives in achieving sustainable immunization financing. A series of presentations will inform the next two days planned side meetings and scheduled workshops. These activities will offer Parliamentarians, as well as members from Ministries of Health and Finance from all three countries an opportunity to discuss varied proposed strategies, all of which will be analyzed in a peer review. Anticipated outputs will be work plans and refined approaches to progress monitoring. Collectively, participants will agree on a list of follow-up action items and activities which will help each focus country move closer to sustainable immunization financing.

All three SIF Asian pilot countries recognize that immunization is an effective and powerful public health tool; governments from Cambodia, Nepal, and Sri Lanka are working to reach Millennium Development’s Goal 4, Reducing Child Mortality, by 2015. The introduction and incorporation of new vaccines have greatly added to the cost of current immunization program needs; all three countries recognize that external donors such as GAVI, WHO, and UNICEF are increasingly unable to fill the the fiscal gap needed to ensure continued execution of national immunization program schedules. These are vital to maintaining herd immunity and protecting the public’s health from life-threatening and debilitating diseases. With Declarations such as the Kathmandu Declaration and Kathmandu to Colombo and Beyond Declaration, these three countries are collectively moving forward towards reaching their respective goals in independently achieving sustainable immunization financing via internally conceived strategies and programs. Sabin SIF is proud to be a part of this collective process and effort; by providing the context, agenda and platform for these dialogs to take place, each of these three countries is making undeniable advances towards sustainable immunization financing.