Category Archives: Africa

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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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.

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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.

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Cameroon Approves the Creation of a National Immunization Trust Fund (NITF)

On October 7, 2010, Dr. Mama Fouda of the Cameroonian Ministry of Public Health, approved the creation of the National Immunization Trust Fund (NITF) as an alternative for sustainable immunization financing in Cameroon. This political commitment is the result of a comprehensive change on long term immunization financing, facilitated by the Sustainable Immunization Financing program at the Sabin Vaccine Institute and done with the helpful support of both the WHO, and UNICEF Cameroon.

The inception of this change began with the assessment of the main challenges of immunization financing in a December 2009 sub-regional meeting in in Dakar, Senegal. Resulting from the assessment, were the drafting of finding alternative solutions for immunization financing for participating countries: Cameroon, Mali, and Senegal. In a May 2010 following sub-regional meeting in Yaounde was opened by Dr. Mama Fouda, Parliamentarians, maires, and technical staff from the Ministries of Economic and Planning, Finance, and Decentralization, all worked together to formulate a recommendation to establish a National Immunization Trust Fund for each of the three countries.

A similar process started in the Democratic Republic of Congo (DRC); Parliamentarians and technical advisers from both Cameroon and the DRC agreed to engage in a Sabin SIF sponsored peer exchange. From September 11-15, Delegations from both countries met in Yaounde, Cameroon, to share their experiences. Despite GAVI’s fiscal support for immunization funds, the present government budget stands at less than 20% for these funds. Convinced that immunization is the best investment to achieve Millennium Development Goal 4 (reducing by 2/3 the rate of child mortality), all agreed to draft a “Call for Action” asking their government to address the problem of immunization financing, and to treat it as a development priority.

The Yaounde Call for Action was conceived and signed by the Honorable Gaston Komba, President of the Finance and Budget Committee of Parliament, as well as by Professor Lazard Kaptue, the General Secretary of the Association des Villes et Communes Unies du Cameroun, (who served as both the chairman of the May Sub-Regional meeting as well as for the Sabin sponsored Peer Exchange.) After discussions at October 1st’s ICCA Meeting, this document was then sent to the Ministry of Health for review.

Briefed by both the Honorable Gaston Komba and Honorable Amougou Mezang, the Minister of Health gave his final approval for the creation of the National Immunization Trust Fund on October 7, 2010. The Minister of Health asked that the EPI Team to work closely with the SIF program at the Sabin Vaccine Institute, as well as with the Legal Services department of the Ministry of Health to assist in the beginnings of drafting a law which would secure the establishment of a National Immunization Trust Fund in Cameroon.

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Senior Program Officer Helene Mambu-ma-Disu to Meet with Madagascar’s Minister of Health and EPI Manager this Week

This week, Senior Program Officer Helene Mambu-ma-Disu will be in Antananarivo to meet with Madagascar’s Minister of Health, Pascal Rajaonarison, as well as with their EPI Manager, Louis Rakotomarius. The purpose of this two-day series of meetings will be to discuss sustainable immunization financing for this SIF pilot country. Watch this space for a follow-up article describing the outcome of these discussions.

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