FINANCIAL SUSTAINABILITY PLAN FOR THE IMMUNIZATION PROGRAMME IN ZAMBIA

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1 The Government of the Republic of Zambia FINANCIAL SUSTAINABILITY PLAN FOR THE IMMUNIZATION PROGRAMME IN ZAMBIA

2 The Government of the Republic of Zambia thanks all the persons whose support has made the production of this document possible. Copies of this document, and the excel templates used to derive estimates for costs and disease outcomes are available on request 2

3 Table of contents EXECUTIVE SUMMARY i SECTIONS 1. FINANCIAL AND HEALTH SECTOR BACKGROUND Country profile Macroeconomic performance review Public service reform programme and the health sector reforms National health expenditures 6 2. PROGRAMME CHARACTERISTICS, OBJECTIVES & STRATEGIES Programme targets Support to EPI through developmental partners Programme performance Limitations facing the immunization programme Inputs required to implement the programme improvements BASELINE AND CURRENT YEAR PROGRAMME COSTS Programme expenditure in the year Programme expenditure in the year FUTURE COST REQUIREMENTS AND PROGRAMME Future programme costs Availability of funds for the programme Possible programme options available 27 3

4 5. SUSTAINABLE FINANCING STRATEGIES ACTIONS & INDICATORS Opportunities for financial sustainability Challenges to financial sustainability Strategy for financial sustainability COMMENTS FROM STAKEHOLDERS ANNEXES 38 Annex 1: Funding categorisation, , Zambia 38 4

5 List of tables and figures Tables No. 1 Key macroeconomic indicators as a proportion of GDP, Zambia, Trends in health expenditure in Zambia, Immunisation targets, Vaccine wastage rates 13 5 Programme funding by source, Programme funding by source, Future programme costs by category, 2003 to 2012, Zambia 24 8 Annual funding situation for Zambia EPI programme, 2003 to Impact on funding gap of different options, 2003 to Indicators for follow-up of process in achieving of strategies for financial sustainability 36 Figures 1 Organogram for the central level health sector 4 2 Total EPI programme costs from different sources of funds for Zambia in compared with Contribution to the programme costs, 2000 and 2002, Zambia 21 4 Costs for the immunisation programme for different cost categories 22 5 Future EPI programme costs in Zambia, 2003 to 2012 compared with and 2002 by category 6 Zambia EPI programme funding sources and gap, 2003 to Impact on funding gap of different plausible scenarios 28 5

6 Acknowledgements The planning process for financial sustainability has been long and tedious. It would not have been possible to complete this work without the collaborative efforts of the many partners that were involved in the preparation of the financial sustainability plan (FSP). In the first place we are grateful for the leadership provided by the Ministry of Health and the Central Board of Health. We would like to thank members of the task force on the financial sustainability plan; Mrs Stephanie Angomwile (Ministry of Finance and National Planning), Mr. Mwele A Mukobe, Ms. Leo Chivundu, Mrs. Euphrasia Mtonga (Ministry of Health), Mr. Killion Ngoma, Dr. Mary Katepa-Bwalya (Central Board of Health), Dr. Sitali Maswenyeho (ZIHP/USAID), Mr. Flint Zulu (UNICEF), and Dr. Mutale Mumba (WHO). We would also like to acknowledge the input from Dr. Adiele Onyeze (WHO), Dr. Birthe Locatelli-Rossi (UNICEF), and Mr. N Chikwenya (Ministry of Health), and Mr. Bonah Chitah (Central Board of Health). We are grateful to members of the Interagency Coordinating Committee (ICC) for the support during preparation of the document and endorsement of the FSP. We wish to thank the Resource Allocation Sub-committee of the Health Sector Committee for reviewing the FSP and providing useful comments. The collaborating partners took time to provide useful comments and advice in the preparatory stages and these include WHO, UNICEF, DFID, JICA, ZIHP, USAID and World Bank. In the same vein we gratefully acknowledge the comments from Dr. G Carlsson (DANIDA Advisor, Central Board of Health). Last but not least we wish to acknowledge the invaluable support provided by Dr. Humphrey Karamagi (WHO/AFRO) and Ms. Lidija Kamara (WHO/HQ). 6

7 Abbreviations AIDS BCG CBoH DfID DHMT DPT EPI EU FSP FY GAVI GDP GNP GRZ HCC Hep B Hib HIPC HMIS HSSC ICC IMCI JICA MoFNP MoH MoU MTEF NGO NIDS OPV PHC PHO SWAp TT UNICEF US$ USAID VF WHO Acquired Immuno Deficiency Syndrome Bacillus Callmete Guerine (Vaccine for Tuberculosis) Central Board of Health Department for International Development (UK) District Health Management Team Diphtheria-Pertussis-Tetanus vaccine Expanded Programme on Immunisation European Union Financial Sustainability Plan Financial Year Global Alliance for Vaccines and Immunisation Gross Domestic Product Gross National Product Government of the Republic of Zambia Health Center Committee Hepatitis B Haemophilus influenzae type b Highly-indebted poor countries (debt relief initiative) Health Management Information System Health Sector Support Steering Committee Inter-agency Coordinating Committee Integrated Management of Childhood Illnesses Japanese International Cooperation Agency Ministry of Finance and National Planning Ministry of Health Memorandum of Understanding Medium-Term Expenditure Framework Non Governmental Organisation National Immunisation Days Oral Polio Vaccine Primary Health Care Provincial Health Office Sector-Wide Approach Tetanus Toxoid vaccine United Nation s Children Fund United States Dollars United States Agency for International Development Vaccine Fund World Health Organisation 7

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9 Executive Summary This Financial Sustainability Plan (FSP) for immunisation assesses the key challenges facing the immunisation programme in Zambia, and describes the Government s approach to mobilising and effectively using financial resources to support the medium and long term programme objectives. The Ministry of Health of Zambia, through the Expanded Programme on Immunisation, is committed to provision of cost effective immunisation services to the whole target population. As a result, a plan has been adopted to improve service delivery for routine vaccines, offer supplemental immunisation for low coverage vaccines, and introduce new vaccines. In the recent past, the coverage for all antigens has increased, supplemental immunisation activities are regularly carried out. In addition, new vaccines are planned for introduction to the population, with a vaccine for Haemophilus influenzae type b (Hib) to be introduced in the year 2004, and one for Hepatitis B (HepB) in All these activities have significant cost implications. These activities are being carried out in a general context of an overall relative economic stability in the country as a result of sound macro-economic policies, supported by a broadening tax base. The current policy environment in Government is directed by poverty reduction strategies, implemented through a Medium Term Expenditure Framework, a process just being introduced in the Government. There is a high level of political commitment for Immunisation at the highest levels of Government. However, the rate of growth of the economy has been low over the past few years, with a result that all public sectors are underfunded. A number of key macroeconomic indicators have been registering negative growth. The Global Alliance for Vaccines and Immunisation (GAVI) began supporting the immunisation programme in the financial year 2001/02. This support has so far been for strengthening the immunisation delivery system that includes 3 years support for injection safety materials. Support will be provided for introduction of the Hib and HepB vaccines equivalent to 5 years post introduction. As the GAVI support is limited in time, the programme, finds it necessary to review its financial situation with an aim to illustrate, over the short to medium term, the financial challenges facing it, and highlight plausible strategies to maintain financial sustainability. 9

10 During the financial year 2000 prior to any support from GAVI, the immunisation programme cost a total of USD $2,981,984. This cost rose to USD $5,322,867 in the next financial year 2002/03, representing a 79% increase. This increase was largely a result of increased Supplemental Immunisation Activities, and cold chain investments. Additional resources were through the multilaterals (WHO and UNICEF) for the SIA s, and JICA for the cold chain investments. Continued increases in the programme costs are expected, particularly after the introduction of the new vaccines, with the total cost expected to rise to USD $ 9,177,410 by Annual programme costs are illustrated below EPI programme costs, Zambia, 2000 to ,000,000 12,000,000 Supplement al Immunizat ion Activities 10,000,000 Routine Capital Cost 8,000,000 6,000,000 Other routine recurrent costs 4,000,000 New vaccines 2,000, Traditional vaccines The increases in cost of the programme are driven by: 1. Introduction & integration of additional vaccines in the immunisation programme, 2. High population growth rate with a larger cohort of infants each year requiring immunisation services, 3. Strategies adopted to increase vaccination coverage to the targets in the 5 year plan. As a result of these increasing costs, the programme is faced with a substantial funding gap. This is illustrated below 10

11 Funding availability and gap, Zambia, ,000,000 12,000,000 10,000,000 8,000,000 6,000,000 Funding gap (total) Secure Funding 4,000,000 2,000, Up to 52% of the required programme resources between 2003 and 2012 are unfunded. It is unlikely that the Government will be able to afford to fully fund the programme when the support from GAVI ends in 2006/07. There are 4 plausible options that the programme can adopt based on the major contributors to programme costs. These are: 1. The use of the DPT-HepB-Hib pentavalent vaccine, which is the preferred option 2. Use of DPT with Hepatitis B tetravalent vaccine as one injection, 3. The use of DPT alone, or 4. The absence of Supplemental Immunisation Activities. The funding gap over the period will reduce to zero if the programme maintains its present approach with no new vaccine addition. It reduces from 52% to 45% without the SIA s, and down to 20% with no Hib vaccine. However, this reduction in the gap for all the strategies differs in different years, implying based on the present activity, there would be some years with high funding gaps while others would have surplus funds. Three strategies are to be employed to maintain, and increase programme funding during and beyond this period: 1. Mobilising additional resources (from local and external sources) 2. Ensuring increased reliability of resources, and 3. Improving the efficiency of the programme to free up some resources. 11

12 Additional resources from Government will be sought from the district allocations retained at the central level for drug purchases. These additional resources shall act in a two fold manner; the help reduce the funding gap, and aid in advocacy when mobilizing the resources from the other actors. In the longer term, the programme shall seek financial autonomy from the Ministry of Health, to aid resource mobilization in line with programme activities as is done with the Malaria and HIV/AIDS programmes. Further resources will be sought from local Government s (for IEC and social mobilisation activities), private sector (for vaccine purchases), multilateral and bilateral donors. The ICC shall be expanded to include any new financial donors (including from the private sector) that are mobilized as a result of this strategy. The Health Sector Support Steering Committee ( HSSSC), which is the main coordinating mechanism for the SWAp, will be the body through which advocacy for resource mobilisation through the SWAp baskets, particularly and the central and district levels shall be used. Regarding resource reliability, the programme shall ensure that its needs as outlined in this FSP are included in the MTEF estimates, and annual Ministry of Health plans. This shall be a result of active review of activities and costs of the programme annually before the MTEF ceilings are determined. In addition, the programme resources shall be protected within the Government, and sector budgets to ensure allocated resources are received by the programme. The programme seeks to ensure resources available are used in the most efficient manner. Vaccine wastage rates shall be monitored, and strategies implemented for its continued reduction. Maximisation of opportunities to offer services at static units shall be ensured, without compromising coverage. In addition, efficiency of outreach sessions shall be ensured, with monitoring of numbers of children immunised at each outreach session. The programme, to ensure they are carried out appropriately, shall monitor each of these strategies. 12

13 Section 1. Financial and health sector background Zambia is confronted with multiple economic, social and geographical natural complications, which render allocation of resources to particular programmes such as immunization very competitive. This section gives us a complete panorama of the recent Zambian economic performance including the budget, external and domestic debt situation, AID and monetary developments, all of which have a bearing on public financing of health programmes. The Section also looks at the current wave of Public Service Reforms (PRP) vis-àvis the health sector reforms that are being implemented in the country. A thorough analysis of whether they have improved the financing process of health programmes as to attain equity distribution of resources to all public health institutions. The section also covers Ministry of health priorities in terms of allocation of thin resources, methods and procedures of budgeting, procurement, disbursing and reporting on the use of funds for immunization Country profile Zambia is located in Southern Africa, and covers an area of 752, 614 square km. It is bordered by Zimbabwe in the South, Malawi in the east, Angola in the west and Tanzania in the north. From the 2000 census, the present population (2003) is estimated at 9,872,000 million persons, of which 51% are male and 49 % female. The annual population growth rate is estimated at 2.9 %. The majority of the population (62 %) live in rural areas. The crude birth rate is births per 1,000. The national literacy rate is estimated at 63 % for males and 50% for females. The country is divided into nine provinces, with 72 districts. Although Zambia is endowed with abundant water resources, it is mostly in the Northern part of the country. Zambia has untapped mineral wealth, a varied biodiversity and climatic conditions generally favourable to agriculture. The economy is largely based on copper mining and agriculture, with potential in tourism, energy and industry. In the late 1960s Zambia was the third largest copper producer in the world, after the United States and the Soviet Union. World copper prices collapsed in 1975 which had a devastating effect on Zambia s economy. Even so, Zambia still receives most of its foreign earnings from copper, and there is some optimism about the future of the industry, which was privatized in the 1990s Macroeconomic performance review The Government of Zambia uses the Millennium Development Goals (of which immunization service coverage is but one) as part of the guiding principles for its long-term national development framework. The prerequisites for the attainment of MDGs include economic 13

14 growth, good governance, and peace and security, all of which are key activities Government strives for. The macroeconomic growth and stability is key towards attaining these goals by During the period , macroeconomic policies have been aimed at achieving macroeconomic stability while the targets have largely been premised on increased investment in agriculture, mining, manufacturing and tourism. The GNP per capita is 320 US$.Other key macroeconomic indicators over the past 3 years are illustrated in figure 1 below. Table 1: Key Macro economic indicators as a proportion of GDP, Zambia, Indicator Value by year (projected) Economic growth (%age) Budget performance as % of GDP Domestic expenditure as % of GDP Grants as % of GDP Budget deficit (%age) Foreign financed capital as % of GDP End year inflation outturn (%age) Debt service as % of GDP External debt stock (billions of USD) <7 Domestic debt (billions of Zambian Kwacha) 2,525 3,021 3,639 Low economic performance seen in 2002 was mainly due to the inadequate rainfall that characterized the 2001/2002-agriculture season. Domestic revenue was generally within expected targets. On the other hand, expenditure overruns persisted, were offset by lower expenditure on capital and HIPC financed expenditures. Nevertheless, in line with Government commitment to provide adequate resources to the social sectors, all budgeted amounts from domestic resources for education, health and water and sanitation were disbursed. However, the budgeted amounts were still lower than the benchmarks agreed upon with the cooperation partners. The reduction in the budget deficit is due to the significant growth recorded in foreign financed capital. Following the reaching of the decision point under the Heavily Indebted Poor Country (HIPC) Initiative in 2000, Zambia reduced its debt servicing payments during the period from the potential US $600 million to US $140 million per year. However, while measures to reduce the stock of external debt received wide support from creditors, there was little support for efforts to dismantle domestic debt. Consequently, domestic debt has risen to unsustainable levels. During the period under review, monetary policy has had two broad objectives. These have been the reduction of inflation and the sustenance of financial system stability. The high inflation levels seen have largely been due to high money supply growth, mainly due to Government borrowing, the depreciation of the Kwacha, and occasional shocks such as the effects of drought and rising oil prices. The country completed preparing the Poverty Reduction Strategy Paper (PRSP) in As contained in the HIPC Decision Point document, Zambia was expected to implement the programme for at least one year before reaching completion point. To develop a broader development agenda, Zambia also prepared the Transitional National Development Plan (TNDP). Zambia was 14

15 expected to reach the HIPC completion point in December However, due to the slippages particularly with regard to the civil service wage bill, the country is on a Staff Monitored Programme (SMP) which is a basically a prerequisite for the PRGF. The Government also started the implementation of the Medium Term Pay Reform Strategy (MTPRS) in order enhance civil service pay including health workers. This strategy will continue over the medium term. By end 2002, as a share of GDP, releases on poverty reduction programmes were equivalent to 0.68 percent, compared to the target of 2.59 percent. The lower than programmed expenditure was due to budgetary constraints during the year. The projected poverty reduction expenditure stands at 1.39 percent of GDP by 2003, compared to the target of 2.07 percent. Regarding external financing, in 2002 development partners pledged US $1.3 billion for the period By the end of 2002, Zambia received a total of US $595 million (16.34 percent of GDP) out of US $687 million (18.86 percent of GDP) external assistance, pledged for the year. Of the programmed external assistance of US $777 million (20.65 percent of GDP) for 2003, only US $191 million (5.08 percent of GDP) had been disbursed by June This makes planning and implementation of programmes very difficult. The less than programmed disbursements were due to Zambia s failure to successfully implement the Poverty Reduction Growth Facility in 2003, on which most bilateral and multilateral donors and creditors base their support to Zambia Public service reform programme and the health sector reforms Ministry of Health structure The government s vision has been to provide all its people equitable access to cost-effective quality health care. To realize this vision, it embarked on health sector reform in 1992, of which the main thrust was to decentralize and delegate the planning, management and decision-making of health services to the health boards and restructuring of health delivery systems. The process of restructuring culminated in the formation of the Central Board of Health (CBOH), the District Health Boards (DHBs) and the Hospital Management Boards (HMBs). There are now 72 DHBs and 20 HMBs which are operational. The Ministry of Health is now responsible for policy and strategic directions for the health sector, while the CBOH is the national administrative agency for the overall technical management of health services and interpretation and implementation of health policies. The district health system and hospitals are run by the DHBs and HMBs respectively, whose members the Minister of Health appoints. The role of the Ministry of Health is now to formulate health policies, which regulate the entire health sector. The organizational structure at the central level is illustrated in figure 1. The Central Board of Health, through the provinces, has the responsibility of translating and implementing government health policies. It operates through the programmes. The districts are commissioned by the Central board of Health to provide health services. 15

16 Figure 1: Organogram for the central level Health Sector Statutory Boards FUNCTIONAL RELATIONSHIP OF THE HEALTH DELIVERY SYSTEM Ministry of Health Central Board of Health APPENDIX A General Nursing Council Medical Council National Public Health Regulatory Authority Pharmacy & Poisons Board Hospital Boards 2nd & 3rd Level Central Board of Health Provincial Health Offices District Health Boards District Hospitals MoH Functions Policy formulation Legislation Resource Mobilization Finance and Budgeting External Relations Monitoring & Evaluation of CBOH Bilateral & Multisectoral Collaboration Strategic Planning Advocacy Health Centres Health Posts Voluntary Providers Private Providers CBOH Functions Commissioning of Health Services Development of Support Systems Interpretation of legislation & Policy Monitoring & Evaluation Public Health Promotion By the mid 1990 s, the country accelerated the implementation of all reform programmes in the public sector following the adoption of the Structural adjustment programmes. This public service reform programme is implemented in all Ministries and provinces with an aim to improve Government capacity to analyse and implement policies and perform its appropriate functions; to effectively manage public resources; and to make public service more efficient and responsive to the needs of the country s population. The key reforms were related to: 1. Organizational changes, with decentralization of service delivery to provinces and districts that started in 1991 and led to restructuring of the different levels of service delivery, and 2. Management changes, key of which was the introduction of Sector Wide Approaches (SWAps) in Donor Coordination 16

17 The Ministry of Health plays the leading role in the coordination of partners involved in the health sector. The key approach to donor coordination is built on the sector-wide approaches (SWAps), which emphasize pooling of government and donor funds, and from which from the National Health Sector Strategic Plan ( ) is financed. A good example of this approach is the district basket, which supports the delivery of the basic health care package by providing unearmarked funds directly to District Health Management Teams. Moves are under way to expand the basket concept to the wider health sector. There are still, however, some discussions on how the latter can be achieved. The full implementation of SWAps in the sector would call for donors adopting common systems such as disbursement, monitoring and reporting, and each donor would not necessarily know what their funds were used for. It calls for full trust on either side. The other donors not placing their resources in the common basket participate in the SWAp through ensuring that the activities they fund fall within the agreed sectoral priorities. These donors include the multilaterals WHO and UNICEF, JICA, and USAID as the major ones. These are also the main EPI donors. Up to 50 60% of resources from the cooperating partners, and 50% of GRZ z resources are channelled to the district and health centre levels. The balance of resources is made available for use at all levels. The basket funds are managed through CBoH and MoH, in consultation with the Health Sector Support Steering Committee (HSSSC), which is chaired by the Permanent Secretary, MoH. The utilisation of funds in the basket is reflected in the MoH and CBoH annual plan. The shift under SWAps to common working arrangements ensures longer time horizons of commitments for external support through an MTEF. The MTEF is currently at the stage of stakeholder input. Currently the basket is being expanded in order to include hospitals human resource and drug supplies. Other cooperating partners allocate their funds to the MOH on a project implementation basis Competing Programme Priorities The Ministry of health articulated a policy and strategic plan in the year These were developed, and are implemented under the SWAp framework. The key priority programmes outlined in the policy and strategic plan are: HIV/AIDS, Tuberculosis, Malaria, Reproductive Health, Child Health, Oral Health, Mental Health and Environmental Health. These activities are implemented in an integrated manner, with different packages defined for community, health post, health centre, district level, and second and third level hospitals. Nonetheless the district is the key intervention level The state of poor health is in part due to the HIV/AIDS epidemic and also to the high level of poverty. In 1999, the estimated Disability-Adjusted Life Expectancy 17

18 (DALE) for Zambia was 30.3 years. 1 There are only three countries out of 191 WHO Member States that have a lower value of DALE than Zambia: Malawi (29.4 years), Niger (29.1 years) and Sierra Leone (25.9 years). This is indeed a serious state of affairs that needs to be addressed vigorously. In the same year (1999), more than one million people were estimated to be HIV-positive, with a prevalence rate of 19.7% in the sexually-active population group. 2 Urban areas, however, had a much higher prevalence rate (28.7%) than rural areas (13.6%). Women tend to be infected at a younger age than men and at higher rates. Trends in infections are, however, promising as in 1994 the seroprevalence rate in the year age group was 28% while in 1999 it had decreased to 15%. The incidence of illnesses associated with HIV/AIDS has been increasing. Tuberculosis cases have increased; in the 1970s the reported incidence was /100,000; it is now estimated to be above 500/100,000. It is reported that around 30% 40% of the HIV-positive people die of TB (MOH estimates). The National Tuberculosis Control Programme needs to be revived. While the supply of anti-tb medicines has significantly improved in the last year following some years of serious shortages, the revival of the directly-observed treatment, shortcourse (DOTS) strategy has been very slow. WHO and several other partners have teamed up to assist the national authorities to revive the implementation of DOTS in the country, and there are signs that, with the commitment recently shown by the government, the roll out can be successfully speeded up. Up to 10% of the outpatient visits to hospitals are due to sexually transmitted infections (STIs), (3% being women and 7% men). Women are showing lower figures of STI because they are usually asymptomatic. Malaria is acknowledged as the number one public health priority (burden of diseases), mainly because of the difficulty of documenting HIV/AIDS-related deaths. Malaria constitutes about 15% of maternal deaths, and 30% of hospital admissions countrywide. The level of parasite resistance to chloroquine has been rising and is now estimated at about 30% in some parts of the country. As a result, a consensus has recently been reached to change to a first-line combination therapy. More sulfadoxine-pyrimethamine will be made available to health facilities with immediate effect, and, during the interim, a move will be made to change to an artemisinin-based combination drug as the first-line drug. This transition will take a few years but the authorities have adopted the policy in this regard. 1.4 National health expenditures With a per capita GNP of less than $400, the resources available for health are limited. According to an analysis conducted by some European donors during a joint identification and formulation mission, the resources that could be mobilized by the public health care system amounted to $10.5 per capita in 2000 and were expected to grow to $14.9 per capita in 2001, inclusive of HIPC 18

19 resources. Assuming that the conditions of the floating endpoint for HIPC were met, the mission assumed that the public health sector envelope could be increased by as much as 30% over the years 2001 to These estimates include resources from both the government and donors available to the Ministry of Health. The contribution of the private sector to health expenditure will be revealed by the National Health Accounts that are under way, but it is estimated that 38% of the total health expenditure comes directly from households in the form of out-of-pocket payments Trends in funds availability Government health expenditure include what is spent on health services by the public sector namely the ministries of health, community development and social services, defence, education, home affairs, agriculture and cooperatives and Office of the Vice president under disaster and mitigation unit. The trends in health expenditure as a share of total discretionary expenditure since 1999 are illustrated in table 2. Table 2: Trends in health expenditure in Zambia; Health expenditure (K bn) Health expenditure (USD) Total Discretionary expenditure (K bn) 1, , , ,500.4 Total Discretionary expenditure (USD) Health/Total Discretionary expenditure Health expenditure/gdp In nominal terms health expenditures have over the time been growing at an average of 25% per annum. In real terms however, health expenditure have been declining. Over the same range of time, real expenditures declined by an average of 1.6% per annum. Comparison of the total health expenditures to the GDP and the total Government expenditure over the same time shows that as a percentage of GDP, total health expenditure rose from 5.2% to 6.4% in the previous year. Government expenditure stood at 14% in Government expenditure on health decreased in the following years to about 10%, but has steadily increased to about 13%. Government expenditure on health services as a percentage of total Government spending is around 55% while cooperating partners provide 45% Trends in flow of funds. A wide range of organizations; cooperating partners, private and NGOs finance the health sector in Zambia. In the public sector the main financier is the Ministry of Finance and National Planning (MOFNP). MOFNP disburses finances to the Ministry of Health (MOH), Ministry of Education for the School of Medicine, defence force medical hospitals through the Ministry of Defence and such other government ministries and agencies. 19

20 Fund flowing through the MOH are further disbursed to the affiliate institutions and agencies, namely the Central Board of Health, District & Hospital Boards Statutory Boards and Bodies, and also to the mission hospitals to support their operational costs through the umbrella body, the Christian Health Association of Zambia (CHAZ). Timeliness of funds disbursement in the districts has improved with the SWAp process Private Sector Contribution to the Health Sector The comparative expenditure analysis of the private and public sectors shows that: Firstly, the private sector is predominantly in the Lusaka and Copperbelt provinces with well over 95% of the practitioners located in these two geographical areas and serving coverages of some 2.5 million people or 25% of the population. Secondly, the expenditures of households on the private sector compared with the sources of funding from the Government of the republic of Zambia (GRZ) to secondary level services and are about 50% of GRZ funding to primary health services. The major expenditures items in the private sector are personnel expenditures that take up 50% and the drugs and medical supplies take up about 30% of the total health expenditures in the private sector. Capital expenditure is low at 5-6%. The proportion of medical doctors in the private sector is about 33%. There however is an element of double counting as some doctors are running or practicing in some clinics while maintaining public sector employment or engagement Planning Process and Budgeting The planning process Information on the implementation of the action plan and expenditure of the board is reported to Central Board of Health through the Provincial Health Office (PHO) through the quarterly financial and progress reports. It is the responsibility of the Executive Director or District Director of Health in accordance with quarterly deadlines provided by CBoH to promptly submit these reports to the board for approval before submission to the PHO The PHO will review the reports and in accordance with quarterly deadlines submit to the CBoH. The CBoH then scrutinizes the reports and necessary recommendations are made to the Health Sector Committee that meets quarterly to decide on funding for each board. At the moment a condition for funding districts is that the district has completed and submitted satisfactory quarterly reports. The other condition is that planned activities have been carried out. When a district is approved for funding, CBoH will release money on monthly basis 20

21 The basis for funding and implementing district health activities is the district plan. The procedure to prepare the district health plan is administered by the DHMT based on the annual planning guidelines, which include indicative planning figures, provided by CBoH and the Planning Handbooks. The planning process begins at the lowest levels of the health care system through the Health Centre Committees. The involvement of the community is gained through the membership of representatives of the Neighbourhood Health Committees on the Health Centre Committee. The DHMT discusses the plans together with the institutions concerned. The final inclusion of the level plans into the district health plan is the responsibility of the DHMT It is the responsibility of the health board to ensure that expenditures are within the approved plans and budget and that appropriate procedures are followed. In all its procurement transactions, the board must ensure transparency and accountability. All procurements must be done in accordance with the Zambia National Tender Board Act, CAP 394 and its subsequent subsidiary legislation (Tender Regulations). Expenditures are approved at different levels depending on the amount of funds. The higher the amount, the higher the authority required to approve the funds Sources of Funding The district receives its funding from the following major sources Grants from donors and Government from the SWAp basket, Donations in kind (drugs, equipment etc from cooperating partners, NGOs and Govt) Cost sharing fees Self generated funds The amount of money to be received by individual district boards depends on the size of the population, the number of beds and is weighted against population density, fuel prices in the district, availability of banking facilities and the disease pattern in the district Reporting System Every quarter the management team prepares a report consisting of two major parts A financial report stating the income and expenditure for the quarter A progress report stating what activities took place, the constraints encountered during the quarter and resolutions proposed It is an important task of the board members to analyse and discuss the reports with respect to Finance Planned activities versus implemented activities Development over time, e.g. progress as compared to last quarter and last year towards achieving the set targets Deviations from the plans, the reasons for need to modify the plan, implications for next year s planning 21

22 Section 2. Programme Characteristics, Objectives and Strategies INTRODUCTION This section provides basic information about the scale, scope, performance, management and future plans of the national immunization programme, highlighting the specific types of improvements that are to be achieved over the planning horizon of approximately five to seven years. It contains quantitative and qualitative information about programme performance and targets, information about possible change in programme objectives in light of financial constraints, some data from the district level, and information about the roles and responsibilities of partners in immunization financing, service delivery and other aspects of the programme. 2.1 Programme targets The Expanded Programme on Immunization (EPI) in Zambia commenced in 1975, and in 1984 the Ministry of Health adopted the goal of Universal Childhood Immunization. This meant that all children aged zero to 5 years should receive BCG, OPV, DPT and measles vaccines according to schedule or soon thereafter. Although all children up to 5 years are eligible for vaccination, the priority, however, is for all children to receive all doses before the first birthday. Since 1997 Vitamin A supplementation was given to all children aged between 6 months and 59 months during the NIDS. Vitamin A became integrated into the routine EPI services in the year 2000 for all children aged 6-59 months. Immunizations sessions are supposed to take place at all health facilities with a refrigeration facility for vaccine storage. The main objectives of the immunisation programme over the next few years are: 1. To increase routine immunization coverage for all childhood EPI antigens (BCG, measles, OPV3, DPT3) to 90% by 2004, and maintain this level, 2. To increase TT2+ coverage (or protected pregnancy) in pregnant women to 60% and maintain this level, 3. To sustain and attain all targets for AFP surveillance and initiate an integrated surveillance system through the HMIS, 4. To follow up on implementation of the Vaccine Independence Initiative, 5. To improve the quality of immunization services, especially as regards injection safety, 6. To conduct a comprehensive review of the EPI programme and develop a multi year plan in 2004, 7. To phase in new antigens into the immunization programme. 2.2 Support to EPI through developmental partners 22

23 The Vaccine Independence Initiative aimed to increase ownership of the immunisation programme by Government through progressive uptake of the costs of vaccine purchase over time. It was envisioned that the Government would take up 10% of the vaccine costs each year starting in 2000 up to the year 2010, when Government would take up all vaccine costs. However, support from Government only commenced in Apart from funds from the Vaccine independence Initiative, the programme receives funding and programme support from key partners including, GAVI, UNICEF, WHO and JICA. UNICEF provides support for the process of vaccine procurement, WHO supports direct technical support to the programme, in addition to SIA s and personnel for surveillance staff, JICA supports Cold Chain infrastructure support and funding for BCG vaccines as part of the routine vaccination programme, and GAVI provides support for new and under-used vaccines, immunization systems strengthening and injection safety. Immunisation service provision in Zambia has been boosted by support from the Vaccine Fund since The total support expected from GAVI and the Vaccine Fund is USD 36,991,000, for a five-year period. The support includes support for injection safety for 3 years, with support of USD 743,500. Districts have been trained and Auto-Disable syringes will be introduced into routine immunization in all health facilities by the third quarter of Details regarding plans for injection safety are provided below. 2.3 Programme Performance The Zambian Immunisation programme is known for its sustained high levels of immunisation coverage. Since the introduction of the Health Management Information System (HMIS) in 1998 it has been easy to collect district specific coverage data, which are then used to monitor, low performing districts. It has been evident however, that the high coverage s that many districts report are probably due to undercounting of the denominator. For instance the administrative estimate of the national DPT3 coverage for 2000 was 92% but a cluster survey found the coverage to be 75.5%. Some of the reasons advanced for this scenario are omission of certain doses like DPT1, 2 and booster on the tally sheet, and unreliable population estimates. The national census of 2000 has however; done little to remedy the situation as most of the districts have contended that the population figures from the census were lower than expected. There is need for cluster surveys, especially for the districts in the north of the country where the population denominators from the census are highly disputed to derive better estimates of the target population. Due to the unreliability of administrative coverage figures, a cluster survey was conducted in 2001 to ascertain the coverage in Based on the findings from the cluster survey the following targets were set for the immunisation programme: Table 3: Immunisation Targets Year

24 Births 479, , , , , ,950 Surviving infants BCG No. % 427, , , , , , , , , , , ,946 92% 94% 95% 96% 97% 98% DTP3 No. ((+Hib(+HepB)) 348, , , , , ,742 % 76% 78% 80% 85% 88% 90% Measles No. 366, , , , , ,702 TT2+ % No. % 85% 87% 89% 92% 94% 96% 323, , , , , ,727 All these targets were set based on surviving infants. 75% 77% 80% 83% 86% 88% The targets are admittedly ambitious and achieving them will be unattainable without seriously addressing some of the problems highlighted below. These targets accordingly need to be reviewed so that realistic increases are projected after taking the prevailing conditions into account. Regarding new and under-used vaccines, the proposal for the pentavalent vaccine was approved by GAVI in April However, the introduction of the pentavalent vaccine has been postponed to 2005 due to the GAVI vaccine supply crisis that occurred in Meanwhile, GAVI has approved plans for Zambia to introduce DPT+Hib in January 2004, with a view to switching to pentavalent in Zambia is yet to put together a formal child health policy or specific immunization policy document. Nonetheless the Ministry of Health adopted World Health Organisation (WHO) recommendations on childhood immunizations when it revised the vaccination manual in1992. The vaccination manual has been revised again to incorporate new vaccines and recent modifications in vaccine schedules, new technologies such as vaccine vial monitors (VVMs), Auto-Disable (AD) syringes, injection equipment, CFC-free refrigerators and Open Vial Policy. 2.4 Limitations facing the immunisation programme It is generally accepted that vaccine wastage rates are very high in many districts. Efforts must therefore be made to address this issue especially that the newer vaccines are very costly. There are no recent data on wastage rates for specific antigens however; data from the EPI Review of 1997 are indicated in table 4 below. Table 4: Antigen Vaccine Wastage factors Wastage Rate estimates

25 1 BCG 79.3% 70% 2 DPT 55.5% 25% 3 OPV 62% 25% 4 Measles 69.8% 40% 5 TT 82.4% 45% The high wastage rate was mainly due to the supermarket approach and frequent sessions. In the supermarket approach a vaccine vial was opened without regard to number of children present. Additionally Zambia was following the policy of discarding open vials at the end of each session. The open vial policy has now been introduced and the multi-dose vial policy is currently being introduced to address this high wastage rate. Other attempts are being made to reduce wastage through training in vaccine management and cold chain improvement. Other problems facing the Immunisation Programme include: 1. Inadequate numbers of qualified staff especially in rural areas 2. High attrition of trained personnel due to resignations, transfers, ill health and death 3. Absence of regular training on EPI 4. Weak supervision of EPI activities at provincial and district levels 5. Inconsistent outreach services due to inadequate funding which leads to failure to implement all planned immunisation activities 6. Weak vaccine and logistics management at provincial and district levels leading to stock outs and high wastage rates 7. Inadequate functional cold chain equipment in districts and health centres 8. Inadequate government spending on vaccines and donor dependency 9. Failure to set correct priorities in some districts 10. Low community participation in immunisation activities 11. Shortage of transport and lack of suitable transport like four wheel drive vehicles and powered boats in some cases 12. Questionable coverage data due to unreliable population figures and use of wrong denominators 13. Unsafe injection practices in routine immunisation 14. Improper disposal of medical and injection waste With support from GAVI and its local partners a number of these problems are being addressed as explained below: 1. Revision of the Manual: The vaccination manual has been revised with help from WHO, UNICEF and the Zambia Integrated Health Programme (ZIHP/USAID). 2. Training: Training for master trainers on Injection Safety and Revised EPI Guidelines was conducted in February It is expected that all districts and health facilities will have trained their staff by third quarter of This training has included staff from the Ministry of Health, 25

26 Training institutions, NGOs, regulatory bodies and private institutions. Most of the funding will come from the GAVI ISS funds. 3. Staff Posting and Retention: The Ministry of Health has reintroduced central posting of staff to ensure equitable distribution of trained personnel. Additionally, the government is devising ways of improving the package for health workers in a bid to retain them. Retention of health workers remains one the biggest challenges facing the immunisation programme and health service delivery in general. 4. Replacement of Cold Chain equipment: in August 2002, the Japanese International Cooperation Agency (JICA) provided new cold chain equipment to districts satisfying approximately 55% of the total requirements. Furthermore, UNICEF has also supplied some districts with cold chain equipment 5. Revision of data collection tools: Tally sheets have been revised to include the missing doses of antigens and have been disaggregated into the under one and above one age groups. This should help to correct the issue of denominators. 6. Injection Safety: Training on injection safety has already started in readiness for the introduction of safe injections into routine immunisation. GAVI has already started delivering AD syringes and injection equipment including safe waste disposal boxes. The ministry is currently mobilising funds to construct and rehabilitate incinerators in districts. 7. Monitoring and Supervision: The Ministry plans to strengthen supervision for the central level up to facility level. This is being done partly by strengthening micro planning at district level and facilitating supervision from the central level. 8. Increased Government spending on Vaccines as part of the Vaccine Independence Initiative: The Government commitment for the year 2003 has been to a minimum of ZMK 200, 000,000 (approx. USD 50,000) towards the purchase of vaccines. It is expected the contribution will rise to ZMK 1,000,000,000 (approximately USD 200,000) by December Inputs required to implement the programme improvements New staff Staffing levels in health institutions is critical as some of the technically highly qualified personnel have left for greener pastures. The loss of EPI trained staff because of HIV/ AIDS related illness, voluntary and early retirements, retrenchments have created a big gap in the overall management of programmes. This gap has made it difficult for the strained staff to effectively deliver quality services according to expected standards and targets. 26