THE KINGDOM OF LESOTHO MINISTRY OF HEALTH AND SOCIAL WELFARE FINANCIAL SUSTAINABILITY PLAN FOR THE EXPANDED PROGRAMME ON IMMUNIZATION

Transcription

1 THE KINGDOM OF LESOTHO MINISTRY OF HEALTH AND SOCIAL WELFARE FINANCIAL SUSTAINABILITY PLAN FOR THE EXPANDED PROGRAMME ON IMMUNIZATION December 2004 i

2 CONTENTS Acknowledgements Abbreviations and acronyms Executive summary I ii iii Section 1: Impact of country and Health System context Introduction Economy Health Sector Policy Framework Health context Financing Health Care Future Prospects for Health Care Financing Budgetary process and financial management 4 SECTION II: Programme characteristics, objectives and strategies Programme characteristics EPI coverage, EPI Review Multi year plan Programme targets for future years EPI programme financing 12 Section III: Pre Vaccine Fund and Vaccine fund year programme costing and financing Pre-vaccine fund year (2001) and vaccine fund year (2003) expenditure Pre vaccine fund year (2001) and vaccine fund year (2003) financing 15 Section IV: Future resource requirements, financing and funding gap analysis 17 Section V: Sustainable financing strategies, actions & indicators Opportunities and challenges to financial sustainability in Lesotho Opportunities Challenges Alternative policy scenarios Strategies and actions for financial sustainability Mobilizing additional resources Improving reliability of resources Improving programme efficiency Implementation and follow up of financial sustainability strategies 30 Section 6: Stakeholder comments 31 i

3 TABLES AND ILLUSTRATIONS Tables Table 1.1 Key health and demographic indicators for Lesotho Table 2.1: Immunization schedule in Lesotho Table 2.2: Coverage for routine vaccinations, Table 2.3 Key programme strategies, and inputs to implement the MYP Table 3.1: EPI expenditure by category in Lesotho, USD, and Table 4.1: Programme costs by cost categories, in USD Table 4.2: Secure, probable and funding gaps for the EPI programme, Table 5.1: Cost, programmatic and disease burden implications of different Policy options for Lesotho Table 5.2: Total programme costs, available resources, and Funding gaps for the period in Lesotho Table 5.3: Financial sustainability actions and monitoring indicators Figures Figure 2.1: Trends in EPI coverage from Figure 3.1: Trends in past programme costs by cost category, in USD millions Figure 3.2: Financing sources for immunization in USD, Figure 3.3: Contribution to programme expenditure by partner for Routine recurrent, capital and SIAs for Lesotho, Figure 4.1: Future programme costs by categories, USD millions Figure 4.2: Routine costs per DPT3 child for immunization in Lesotho, USD millions Figure 4.3: Secure/probable funding, and funding gaps for Immunization in Lesotho, USD millions Figure 5.1: Impact of different policy alternatives on overall cost, And funding gap for immunization, ii

4 ACKNOWLEDGEMENTS The Ministry of Health & Social Welfare wishes to thank its partners including members of the Interagency Coordinating Committee for their inputs in the compilation of this document. Special mention goes to the Ministry of Finance & Development planning for their supportive role in facilitating the implementation of this Financial Sustainability Plan. i

5 ABBREVIATIONS AND ACRONYMS AD AEFI BCG CBR CDC CHAL DCI DT DPT DTP-HepB-Hib EPI FSP GAVI GOL HC HepB Hib HPSU HSA ICC IMR ISS JICA LHWP LRA MMR MOFDP MOHSW MTEF MYP NGO OPV PHC PRSP SACU SIA USD UNICEF VAT VVM WHO Auto Disable Adverse Events Following Immunization Bacillus Calmette Guerine Crude Birth Rate Centre for Disease Control & Prevention Christian Health Association of Lesotho Development Cooperation Ireland Diphtheria and Tetanus Diphtheria, Pertussis and Tetanus Pentavalent vaccine Expanded Programme for Immunization Financial Sustainability Plan Global Alliance for Vaccines and Immunizations Government of Lesotho Health Center Hepatitis B Haemophilus influenzae type b Health Planning & Statistics Unit Health Service Area Interagency Coordinating Committee Infant Mortality Rate Immunizations Services Support Japan International Corporation Agency Lesotho Highlands Water Project Lesotho Revenue Authority Maternal Mortality Rate Ministry of Finance & Development Planning Ministry of Health and Social Welfare Medium Term Expenditure Framework Multi Year Plan Non Governmental Organization Oral Polio Virus Primary Health Care Poverty Reduction Strategy Paper South Africa Customs Union Supplemental Immunization Activities United States Dollar United Nations Children s Fund Value Added Tax Vaccine Vial Monitor World Health Organization ii

6 Preamble This Financial Sustainability Planning document was developed based on targets and known activities for the years Ideally the plan should have been developed in unison with the multi year plan for the coming years in order to ensure that all planned activities are accounted for and captured in the costs. It is possible that the costs presented here will change as planning for the future is further developed. The FSP is intended as interactive document that should be revisited and revised periodically. iii

7 EXECUTIVE SUMMARY Increasing poverty, declining public health expenditure and the AIDS pandemic are currently the greatest threats to the survival of children in Lesotho. Vaccine preventable diseases, including tuberculosis, malnutrition, diarrhoea, acute respiratory infections, pregnancy related complications and AIDS continue to contribute significantly to the disease burden in children. As one of the key social sectors, the health sector assumes high priority in the government fiscal policy with the total health budget ranging between 7% and 7.5% of total government expenditure. On average, the total health expenditure in the country represents 6.1% of GDP, with over 50% of the health expenditure coming from Government. One of the key government priorities in the next three years is to reduce the debt burden. This focus limits the potential for allocating additional funds to the social sector including health and therefore immunization initiatives. Though immunization has been identified as a priority area for intervention, competition for resources with other priorities will remain a reality. The Expanded Programme on Immunization in Lesotho was established in The programme aims to ensure that vaccines are available to the population for the traditional six preventable diseases of Tuberculosis, Diphtheria, Whooping Cough, Tetanus, Polio and Measles, including Hepatitis B, introduced into the programme in 2003 with GAVI support. Although reported vaccine-preventable disease morbidity and mortality is currently low in Lesotho, there are challenges in assessing the true impact of the National EPI. A programme multi year plan (MYP) was developed in 2001 for the period of The key objectives of the plan include: a) To achieve increased immunization coverage to at least 80% immunization coverage for all antigens by b) Introduction of Auto-Disable syringes (AD) in routine immunization services c) Detect one case of Acute Flaccid Paralysis (AFP) per 100,000 population of <15 years age in each HSA per year until the country is certified Polio free d) Collect blood specimens from all suspected Measles cases for laboratory confirmation e) Reduce the number of Neonatal Tetanus cases to less than one case per 1,000 live births in each district As of December 2004 some of these objectives have been met. The AD syringes are now in use for all vaccines provided through the EPI programme. AFP surveillance is of certification level. Blood specimens for measles cases are being collected and sent to the lab for confirmation. Number of neonatal tetanus cases is below one case per 1,000 live births, although it is not clear if this is due to absence of disease or insufficient surveillance. Other objectives have not yet been met. Routine immunization coverage is still below the objective of 80% for all antigens. Vaccine management is still very weak. Transportation and supportive supervision of HSAs and health facilities is still inadequate. iv

8 Future programme targets and new activities The target coverage for BCG and DPT3 for the years is 86%, and the target coverage for measles for the same years is 90%. The wastage targets for are 40% wastage for BCG by the year 2008, 30% for measles by the year 2006, and 20% for OPV and Pentavalent (DTP-HepB-Hib) by the year The programme also intends to introduce Hib vaccine in combination with DPT and HepB in This new vaccine will significantly increase the cost of the EPI programme, as the vaccine is many times more costly than the traditional vaccines. For the years 2006 to 2011, GAVI will support the costs of the new vaccine after which time the government will assume responsibility for those costs. Finally, nationwide measles follow up campaigns are planned for 2007 and These campaigns require intense inputs in terms of planning, human resources, and funds. Programme financing In 2001 the programme required approximately USD 1 million to operate. This increased to USD 1.8 million in 2003, the first year of GAVI support. This near doubling in expenses is primarily due to the nationwide measles campaign that was carried out in The increased strength of the local currency, from 10.4 Maloti: USD1 in 2002 to 7.6 Maloti: USD1 in 2003 also led to an apparent increase in costs of some cost categories particularly the personnel costs. Financing for these programme expenditures came from a series of sources as illustrated below. Financing sources for immunization in USD, $1. 6 $1. 4 $1. 2 $1. 0 JICA thru UNICEF $0. 8 $0. 6 WHO $0. 4 $0. CHAL CDC Development Cooperation Ireland UNICEF GAVI - Vaccine Fund Sub-national Gov. 2 National Government $ The Government provides the bulk of the programme expenditure. This represents the large impact of expenditure due to shared inputs (shared personnel, transport and buildings), and personnel costs for the programme. When shared costs such as personnel and building overhead are excluded, the percentage of the programme costs covered by government reduces to about 25% in Future cost projections Estimates of future programme costs were derived for the planned activities and recurrent costs of the programme v

9 Future programme costs by categories, USD millions $6.0 Other optional information Other SIAs $5.0 M easles Campaigns Polio Campaigns $4.0 Other capital costs Cold chain equipment $3.0 $2.0 $1.0 $ Vehicles Other routine recurrent costs Transportation Personnel Injection supplies New and underused vaccines Traditional Vaccines In 2004, the high programme costs are maintained as in 2003, at approximately USD 2 million due to additional SIAs. In 2005, the costs will reduce, but increase again in 2006 to over USD 2.5 million due to the planned introduction of the Pentavalent vaccine. Costs further increase in 2007 due to the measles campaign that will be carried out then, before settling back at approximately USD 2.5 million. Significant increases in costs are again seen in 2011, corresponding to the next measles SIA. Funding gaps begin to become significant in 2006, increasing dramatically in 2007, and remain high. Dramatic increase in the funding gap is seen again in Secure/probable funding and funding gaps for immunization in Lesotho, USD millions $6.0 $5.0 Funding Gap $4.0 CHAL CDC $3.0 JICA thru UNICEF Ireland Aid $2.0 UNICEF WHO $1.0 $ GAVI - Vaccine Fund Sub-national Gov. National Government vi

10 Strategies to cover programme costs in the years, Three strategies were explored in order to cover the funding gap in future years: Mobilizing additional resources; Improving the reliability of its resources; Improving programme efficiency. In addition, different programme scenarios which would reduce immediate programme cost were also explored, including their possible implications on programme effectiveness. Mobilizing additional resources The programme shall seek additional resources from Government, by ensuring its costing and financing information is included in the new MTEF. In addition, the programme shall seek additional resources from its partners. There shall be targeted resource mobilization form specific partners, based on the respective cost category for which funds are required, and the priorities of the partner. The publicity of the programme shall be increased among potential funders, with the programme achievements and financial situation elaborated. Improving reliability of resources As mentioned above, the programme shall ensure its requirements are included in the Government s/health sectors MTEF estimates. This provides a sectoral framework into which costing and financing estimates are elaborated on a 3 year rolling framework. In addition, the programme shall seek to ensure its partners (including Government) are always aware of how the resources are utilized in the programme, and avoid situations where funds are not committed because previous ones were not appropriately accounted for. Improving programme efficiency The programme shall seek to ensure the finances it has, or is able to mobilize, are utilized in the most efficient manner, with the best possible outputs derived from these funds. As mentioned in the beginning of this section, there are a number of issues that lead to inefficiencies, both within the wider Ministry of Health (such as inadequate transport facilities, or low numbers and skills of health workers), or in the EPI programme (such as vaccine wastage, and poor maintenance of equipment). Implementation and follow up A series of actions and indicators were developed for monitoring implementation of the financial sustainability strategies. The Ministry of Health, through the ICC shall be responsible for implementation and follow up. A technical sub working group (FSP team) shall follow up on a regular basis, on behalf of the ICC, the implementation of the actions required to attain financial sustainability. An action plan shall be elaborated by this team. On an annual basis, the ICC and other stakeholders shall meet to review progress based on the indicators used and actions expected, and adapt the financial sustainability strategies and actions for the coming year based on the issues in the previous year. Outputs from this meeting shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability (required with the Annual Performance Report) vii

11 Section 1: Impact of country and Health System context 1.1 Introduction The Kingdom of Lesotho is a small mountainous country of 30,355 square km totally enclosed by the Republic of South Africa. The country has had a stable government since independence in Topographically the country is divided into 4 zones: Lowlands comprising areas below 2,000 m altitude; Foothills which lies between 2,000 and 2,300 m altitude; Mountains where altitude exceeds 2,300 m; Senqu River Valley. A large percentage of the country population is located in the highlands, and foothills. The country enjoys a temperate climate with 4 distinct seasons. The annual rain fall ranges from 50cm to 150cm with the exposed mountain slope receiving most of the rain. The rainy season commences on October and ends in April although some rain and snow may occasionally fall in winter (June- August) period. The winter temperatures fall below the freezing point, whereas summer temperatures may exceed 30 c in summer especially the lowlands. 1.2 Economy Lesotho s currency, the Maloti, is linked to the South African Rand on a one to one ratio i.e. one Maloti is equal to one South African Rand. In 2002, the Maloti was valued at 10.4 to 1 USD. This reduced to 8.4 Maloti to 1USD in 2003 and further reduced to 6.5Maloti to 1USD in Lesotho s economic growth rate has been relatively strong in recent years, estimated at 3.5% in Several factors however have negatively affected the economy in recent years. The Lesotho Highlands Water Project (LHWP) created a great deal of employment in the construction sector, and the completion of this project in 2002 led to a decline in construction jobs. There has also been a reduction in miners remittances and South African Customs Union (SACU) revenue. Other factors impeding economic growth include political upheavals in 1998, decreased volumes of external assistance, restructuring of key government institutions, repayment of the commercial loans for LHWP, and recent government spending on famine. While industry is a well developed sector in Lesotho, much of the population relies on subsistence farming for its survival. Challenged with sustaining this favorable economic growth rate, Lesotho explored alternative sources of revenue collection, and has recently exploited strategies for improving revenue collection through implementation of the Revenue Policy by the Lesotho Revenue Authority and introducing the Value Added Tax (VAT). The government also intends to increase national productivity, generate job opportunities and implement prudent fiscal strategies for good financial management and maintenance of sustainable fiscal balances. 1

12 1.3 Health Sector Policy Framework The health sector policy derives directly from the broad government objectives outlined in the Vision 2020 and PRSP. The priority areas for the Health Sector include child survival, which incorporates immunization, nutrition, as well as reproductive and maternal health. Other factors that impact on child survival include access to clean water and sanitation, increased employment opportunities and increased literacy/education. As part of an effort to promote efficiency, the Ministry of Health & Social Welfare (MOHSW) embarked on a Health Sector Reform programme in The reform initiative is geared towards rationalizing existing management systems and implementing effective guidelines and protocols so that basic service delivery standards are met efficiently. Health sector reform incorporates restructuring of all the elements of the sector including those related to control and management of pharmaceuticals, human resources, infrastructure development and institutional management capacity for the health sector. Primary Health Care remains the cornerstone of service delivery therefore the Ministry has also undertaken to define the essential services package, which incorporates all the elements of PHC. Hence immunization coverage remains one of the crucial indicators for effectiveness of the health sector. The MOHSW has commenced piloting a decentralization programme as a priority within the ongoing Health Sector Reform programme. This initiative will be piloted in three of the ten administrative districts of Lesotho. It is anticipated that with a more decentralized planning and budget systems the resources for the Expanded Programme on Immunization (EPI) will be distributed more timely and be controlled at implementation level. Health service delivery is provided through geographically demarcated 18 Health Service Areas (HSAs) of which a hospital is the focal point. Another important initiative being undertaken is the development of a Medium Term Expenditure Framework (MTEF), which facilitates the important link between priorities and the budget. The MTEF utilizes a three year budgeting approach and is intended to simplify and improve allocation and spending of the budget. The processes for institutionalising a three-year MTEF started in 2001 but it is expected that this process will become fully effective starting FY 2005/06. The EPI is currently budgeted for under the MOHSW Family Health Division cost centre thus resources allocated to this programme are submerged into the Family Health Division budget. 1.4 Health context Increasing poverty, declining public health expenditure in real terms, and the AIDS pandemic are currently the greatest threats to the survival of children in Lesotho. Infant and under five mortality rates have increased by 33 percent and 38 percent respectively to 80/1000 and 113/1000 live births over the past 5 years. Disease conditions such as tuberculosis, malnutrition, diarrhoea, acute respiratory infections, pregnancy related complications and AIDS, continue to contribute significantly to the morbidity and mortality patterns in children. Although vaccine preventable diseases such as measles, diphtheria, tetanus, peruses and polio have been contained due to sustained high immunization coverage of the early 1980s, there is a threat of these diseases re-emerging in epidemic proportions due to the declining coverage witnessed in the 1990s. 2

13 Table 1.1 Key health and demographic indicators for Lesotho Indicator Value Source Population 2,333,846 Population data sheet: 2002 Infant mortality rate 80/1000 Population data sheet: 2002 Maternal mortality rate 419/100,000 LDS,2001:Vol 1 Crude birth rate 30/ Census Life expectancy Females : 40.8* 56.3 Population data sheet: 2002 Males : 39.1* 48.7 Access to health Urban : 35% Rural : 11% CWIQ 2002 * includes the estimated impact of HIV/AIDS 1.5 Financing Health Care As one of the key social sectors the health sector assumes high priority in the government fiscal policy with the total health budget ranging between 7% and 7.5% of total government expenditure. On average, 82% of the total Health & Social Welfare budget comes from the government while the other 18% is from external sources. The average per capita government expenditure on health is USD while as a percentage of GDP total health expenditure is on average 6.11%. In 2003 total health expenditures represent 6.4% of the GDP of the country. Of these health expenditures, 57% was from the Government of Lesotho (GOL), with the remainder from partners, and households. Government tax funding plays a significant part in the financing of service delivery. Patient user fees are the most prominent form of health financing but this revenue is reverted to the Central Treasury at the Ministry of Finance & Development Planning and thus does not add direct value to the Health Sector. Non-for-profit health providers are an exception to this procedure. Although a patient user fee exemption system is in place, the systems for this are still underdeveloped. Exemptions are granted on the basis of socio-economic status, type of illness as well as patient demographic details. Existing budgeting systems do not provide sufficient detail to allow for a precise analysis on how the resources allocated to the health sector are used to fund the EPI. 1.6 Future Prospects for Health Care Financing One of the key government priorities in the next three years is to reduce the debt burden, which currently rests at 3%. This focus limits the potential for allocating additional funds to the social sector including health and therefore immunization initiatives. The expectation is that over the period 2005/08, public expenditure will be targeted at high priority activities as identified in the Poverty Reduction Strategy Paper (PRSP) and enhancing operational efficiency. Though immunization has been identified as a priority area for intervention, competition with other priorities such as HIV/AIDS and the treatment of the related opportunistic infections will remain a reality. The implication is that to ensure sustainable provision of immunisation services great effort has to go into ensuring efficient use of scarce resources by adopting the most cost effective strategies and the health sector will need to undertake aggressive resource mobilisation strategies for the EPI programme. 3

14 1.7 Budgetary process and financial management The GOL budget cycle runs from April to March of the following year. The MOHSW at present enjoys a budget outturn of 101% (MOFDP data for 2003/04) for the recurrent budget and on average 70% for the capital budget. This disparity between approved budget and actual expenditure is mainly due to inefficient financial management systems where financial reporting is not adequately linked to physical progress reports. Moreover disbursement mechanisms tend to be very long and tedious such that at a particular point in time it is difficult to say exactly how much has been spent or committed. The end result of this is that by end of year the MOHSW still has some outstanding debts, which have to be financed through the new budget, because of the cash accounting approach used by government. These factors impact greatly on resources actually available for use in a given year and on how these resources are used. The capital budget is prone to under-spending. The reason for this is that much of what is termed capital budget is in fact recurrent in nature but is called capital because it is donor funded and this includes some of the funding for EPI. The main reason for underexpenditure of the capital budget is the lack of absorptive capacity which can be attributed partly to the vertical administrative planning of programmes such as EPI. In this vertical system, planning and budgeting for all programmes (EPI, Reproductive Health, Disease Control, etc.) takes place at the central headquarters level for the district level. The lack of capacity to coordinate and manage planning processes and implementation of these plans and budgets mean that even when resources are available, more often than not they do not reach the intended beneficiaries at the district level. In fact, budgets often get as far as the central programme and have to be returned at the end of the financial year as they have not been spent. The current initiatives towards decentralisation and rationalisation of role and responsibilities between the central and district level should go a long way in improving this situation. 4

15 SECTION II: Programme characteristics, objectives and strategies 2.1 Programme characteristics The Expanded Programme on Immunization (EPI) in Lesotho was established in It is placed at the central MOHSWSW headquarters level, within the Family Health Division. The EPI aims to ensure that vaccines are available for the population for the traditional six preventable diseases of Tuberculosis, Diphtheria, Whooping Cough, Tetanus, Polio and Measles, as well as Hepatitis B. The six traditional vaccines have been provided by the programme since its inception in 1979, while Hepatitis B was commenced in 2003 with the support of GAVI/vaccine fund. The Hepatitis B vaccine is presently provided as a monovalent vaccine. The immunization schedule in the country is illustrated in Table 2.1 below: Table 2.1: Immunization schedule in Lesotho Period Vaccine Doses per Antigen At birth BCG, OPV weeks DPT1, HepB 1, OPV weeks DPT2, HepB2, OPV weeks DPT3, HepB3, OPV3 1 9 months Measles 1 18 months DT& Measles booster dose 1 The schedule includes booster doses for Diphtheria, and Tetanus vaccines provided as a DT vaccine. To be able to ensure provision of these antigens, EPI utilizes the MOHSW organizational structures. Health workers, especially those at the health facilities, ensure services are adequately provided to the population. At present, the coverage achieved for the respective antigens, with wastage rates over the past few years is illustrated below. 5

16 2.2 EPI programme coverage and wastage, Figure 2.1 shows the trends in coverage as derived from administrative data Figure 2.1: Trends in EPI coverage from EPI coverage from 1981 to Table 2.2: Coverage and for routine vaccinations, Coverage Antigen BCG 70% 73% 79% DPT 3 65% 73% 83% Tetanus (TT) N/A* N/A N/A Measles 56% 66% 73% Polio 3 (OPV) 64% 70% 83% HepB 3 N/A N/A 17% DT N/A N/A N/A *N/A Not applicable BCG OPV3 DPT3 Measles The EPI coverage estimates, based on the Ministry of Health annual report data, is high, with the decline observed during the 1990 s having been reversed at present. It has been acknowledged that there is high antigen wastage. However, there are limitations to quantifying the extent as a result of limited resources for data collection and analysis. In 2003, it was found that 3000 doses of Measles antigen had expired. Furthermore, the standard 20-dose BCG vial is rarely utilized optimally as very few of the health care delivery facilities will have more than 20 births a day. Instances of antigen expiry as a result of a short shelf life have been attributed to distribution logistics of the vaccines to Lesotho. Stock outs due to administrative restructuring within procurement units also occurred. Since 1996 no case of acute poliomyelitis has been reported. Neonatal tetanus has been kept below 1 per 1000 births, but there are sporadic cases of measles. 6

17 2.3 EPI Review 2001 To review challenges facing the programme in its activities, an EPI review was carried out in Field visits conducted during this 2001 review revealed a general picture of an overall decline in the quality of EPI management, such that the considerable potential among junior staff is being undermined by the failure by senior staff to set rational priorities and act upon them. On the one hand, Health Centres have been supplied with high-quality vaccination and cold chain equipment, and the high quality of nurses basic training ensures that their vaccination technique is generally good. Furthermore, sufficient vaccines are donated annually to fully vaccinate every Basotho infant and woman of child-bearing age. However, Health Centre staffs are losing motivation due to lack of support and feedback from their HSA Primary Health Care (PHC) teams and, in some areas, frequent rotation of posts. Supervisory visits are increasingly rare and lack technical depth, such that staffs feel neglected. Outreach visits to remote villages are increasingly being cancelled, in part due to lack of transport as a result of poor logistical management and unclear priorities, but also due to the absence of support from HSA PHC teams. In several cases, Nursing Assistants are staffing Health Centres alone. The review noted that there had been a high quality of vaccines and injection equipment delivered consistently over the 3 years prior to the review. However, it also highlighted the following key issues that are hindering achievement of the programme objectives: 1. General decline in the quality of EPI management 2. Rational priorities not being established and followed through 3. Lack of motivation of peripheral level staff and little support including supervision from the central level. 4. Cancellation of outreach visits due to lack of transport and/or staff. 5. No updated EPI policies on new innovations or initiatives. 6. Health centre staffs have not received any training in vaccine management, setting targets, monitoring of immunization drop outs and on injection safety. Recommendations from the review included: 1. The national EPI policy should be revised with the inclusion of modern EPI theory and practice. 2. Include modern theory and practice of cold chain and operations management, EPI service delivery, monitoring and evaluation of routine vaccination coverage, and EPI disease surveillance in basic training curricula for nurses and, where appropriate, for environmental health officers. 3. Comprehensive, high-quality in-service training, supervision and monitoring of EPI activities at all levels should be carefully designed at national level and implemented at HSA and health facility levels. 4. Implement the WHO multi dose policy in order to reduce vaccine wastage. 5. The refrigerated vaccine delivery vehicle should be utilised more effectively. Routine orders for vaccines should be delivered to each of the HSAs regularly. This will eliminate the need for the HSAs to rely on ambulances to fulfill this function when the latter are traveling to Maseru. 6. Training at all levels of the cold chain and vaccine management is a priority. This should include, among other things, the VVMs, the shake test for toxoids, and overall vaccine management through the use of stock cards and order forms that make provision for the supply of correct diluents with the relevant vaccines. 7. Training of health workers should be intensified at both HSA and facility levels on national EPI goals, basic data management, including how to calculate and 7

18 monitor routine vaccination coverage and dropout rates, and EPI disease surveillance, including how to detect, investigate and report suspected cases of vaccine-preventable diseases, collect specimens for laboratory confirmation, and respond to outbreaks. 8. HSA PHC teams should revise and disseminate maps and age-specific catchment population profiles, to permit effective monitoring of vaccine coverage, dropouts and disease trends at health facility and HSA levels. 9. Community Health Workers village health registers should be used by all health facilities for estimating their catchment population, tracing defaulters and monitoring coverage. 10. The Health Education Programme in the MOHSW should develop a national health education policy. 11. Health workers should be trained in the use of EPI education materials and how to explain them clearly to community members. 12. All information, education and communication (IEC) materials, both visual and audiovisual, including those that are self-generated, should be developed according to the needs of target groups in the community and should be pretested. The programme is, as part of its future activities, aiming to ensure these issues are appropriately addressed in order to meet the programme goals and mandate. 2.4 Multi Year Plan A programme multi year plan (MYP) was developed in 2001 for the period of , and highlights the key programme objectives as to: a) Strengthen immunization systems b) Increase immunization coverage in the kingdom of Lesotho by 5-10% point over the next five years so that at least 80% immunization coverage for all antigens achieved by 2005 as set by WHO African Regional Office (WHO-AFRO) c) Improve transport situation in all HSAs and national level (procurement of EPI vehicles) d) Introduction of Auto-Disable syringes (AD) in routine immunization services e) Institute the system of reporting all serious adverse events following immunizations (incorporate AEFI into routine reporting system) f) Detect one case of AFP per 100,000 population of <15 years age in each district (HSAs) per year until the country is certified Polio free g) Collect blood specimens from all suspected Measles cases for laboratory confirmation h) Reduce the number of Neonatal Tetanus cases to less than one case per 1,000 live births in each district i) Increase awareness and build ownership of the programme that will positively bring the desired impact 8

19 The respective strategies to ensure these objectives are implemented, together with required inputs are outlined in the Table 2.3 below. A new multi year plan for the years 2006 to 2011 will be developed in Table 2.3 Key programme strategies, and inputs to implement the MYP OBJECTIVES STRATEGIES INPUTS REQUIRED TO IMPLEMENT STRATEGIES Strengthen systems immunization Increase immunization coverage in the kingdom of Lesotho by 5-10% point over the next five years so that at least 80% immunization coverage for all antigens achieved by 2005 as set by WHO- AFRO Improve transport situation in all HSAs and national level (procurement of EPI vehicles) Introduction of Auto- Disable syringes (AD) in routine immunization services Institute the system of reporting all serious adverse events following immunizations (incorporate AEFI into routine reporting system) Training of health workers and supervisors on managerial skills in EPI at both HSA and facility levels Strengthening and inclusion of current EPI policies and practices in pre-service institutions Timely ordering of adequate vaccines, cold chain equipment and other supplies in collaboration with potential partners and donors Development of the national health education policy and publication of improved EPI promotional materials Solicit adequate funding from collaborating partners and donors for procurement of vaccines Enlist government commitment on contribution towards procurement of vaccines Train health workers on Multi-Dose Vial Policy(MVDP) and interpretation of vaccine vial monitor Solicit funding from collaborating partners and donors Enlist support from government and ICC Solicit adequate funding from collaborating partners and donors Enlist government support for sustainable procurement of AD syringes Train health workers on safe injection practices Absence of circulation of indigenous wild Polio virus for at least a three year period during which surveillance activities have been maintained at the level of performance needed for certification National certification committee in each country has validated and submitted the documentation required by the regional certification commission Appropriate measures are in place to detect and respond to importation of wild Polio virus Trainers, training manuals and materials Printing and distribution of EPI Policies Training on logistics management Adequate advocacy and communication about EPI in all levels Training on financial management Quarterly review on the status of the funds and feed back on expenditure to the partners Additional personnel at central and HSA level Ensure annual plan of action includes transport requirement over the next 5 year period Annual requirement of AD syringes for 5 year period Weekly active search of suspected AFP cases Identification and training of the NTF Quarterly review meetings with focal points 9

20 Table 2.3 (continued) Key programme strategies, and inputs to implement the MYP OBJECTIVE STRATEGIES INPUTS REQUIRED TO IMPLEMENT STRATEGIES Detect one case of AFP Train one Disease Surveillance Focal Point in each Identification of focal per 100,000 population of admitting hospital people at all HSAs <15 years age in each Improve knowledge and skills of health workers in district (HSAs) per year surveillance activities through trainings, refresher Active response team until the country is courses and meetings certified Polio free Institute aggressive AFP surveillance with involvement of all health workers and communities aimed at detecting all cases of AFP and perform adequate clinical and epidemiological investigation. Intensify active search for AFP cases in all admitting hospitals and other health facilities by reviewing their records for the following: Poliomyelitis, Acute flaccid paralysis, transverse myelitis, Gullain-Barre syndrome, paraplegia, quadriplegia, Encephalitis and non bacterial meningitis Rapid and active response to potential outbreaks through investigation,proper reporting and documentation of all AFP cases Review of all AFP cases at 60 days with only one stool specimen collected or whose stool specimens Collect blood specimens from all suspected Measles cases for laboratory confirmation were taken after 14 days of onset of paralysis Train one Disease Surveillance focal point in each admitting hospital Improve knowledge and skills of health workers in surveillance activities through trainings, refresher courses and meetings Map and line-list measles cases at all levels for easy identification of high risk areas Use available data of monthly suspected measles cases to identify areas that have circulation of Measles virus Intensify laboratory diagnosis of suspected Measles cases Conduct outbreak response immediately after laboratory confirmation Intensify active search for all suspected Measles cases in all admitting health facilities by reviewing their records Funds to conduct trainings on reporting electronically for HSAs as well as funding to procure electronically communication Printing of guide lines manuals Reduce the number of Neonatal Tetanus cases to less than one case per 1,000 live births in each district Intensify immunization of all child bearing age group (15-49 years) with Tetanus Toxoid Active social mobilization team 10

21 As of December 2004 some of these objectives have been met, and some are still outstanding. The AD syringes are now is use for all vaccines provided through the EPI programme. AFP surveillance is of certification standard. The 2002 implementation of the WHO-AFRO Integrated Disease Surveillance & Response (IDSR) strategy has been instrumental in addressing AFP and Measles surveillance objectives. Blood specimens for measles cases are being collected and sent to the lab for confirmation. Number of neonatal tetanus cases is below one case per 1,000 live births, although it is not clear if this is due to absence of disease or insufficient surveillance. Other objectives have not yet been met. Routine immunization coverage is below the objective of 80% for all antigens. Vaccine management is restricted. Transportation and supportive supervision of HSAs and health facilities is still inadequate. 2.5 Programme targets for future years The programme has set ambitious goals of increasing routine coverage and reducing vaccine wastage in the coming years. According to the multi year plan, coverage for all antigens should be at least 80% by the year Further improvements beyond this are expected. The target coverage for BCG and DPT3 for the years is 86%, and the target coverage for measles for the same years is 90%. The targets for wastage also call for marked improvements. The targets for call for a reduction of wastage to 40% for BCG by the year 2008, 30% for measles by the year 2006, and 20% for OPV and Pentavalent by the year These goals will require a significant improvement in vaccine management in the short term. In addition to these targets for coverage and wastage, the programme also intends to introduce Hib vaccine in combination with DPT and HepB in This new vaccine will significantly increase the cost of the EPI programme, as the vaccine is many times more costly than the traditional vaccines. For the years 2006 to 2011, GAVI will support the costs of the new vaccine (Hib portion of the Pentavalent vaccine), after which time the government will assume responsibility for those costs. Effective introduction of the new vaccine will also require concerted efforts in training, surveillance, and assessment. Finally, nationwide measles follow up campaigns are planned for 2007 and These campaigns require intense inputs in terms of planning, human resources, and funds. In order to meet the coverage and wastage targets for the coming years, successfully introduce the Pentavalent vaccine in 2006, and implement the planned measles SIAs, the EPI programme will require significant improvements in staff capacity, planning, training, and supervision at the national, district, health service area, and health facility level. It is quite likely that these improvements will require additional funds. 11

22 2.6 EPI programme financing The EPI works with the following service delivery partners, all of whom have been supporting the programme for more than five years: 1. Christian Health Association of Lesotho (CHAL) 2. NGO Red Cross 3. Maseru City Council 4. Maseru Private Hospital 5. Military Hospital 6. Government Hospitals Other partners are providing financial and technical support to the EPI programme. These include: 1. GAVI 2. Development Cooperation Ireland (DCI) 3. JICA 4. UNICEF 5. WHO The support from these partners shall be elaborated in the coming section. 12

23 Section III: Pre Vaccine Fund and Vaccine fund year programme costing and financing We present a review of the costing and financing situation for the EPI programme in the year prior to receiving any support from GAVI/the vaccine fund, 2002, and in 2003-the first full year of GAVI support. This is broken down by programme expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to the expenditure of the programme (proportion of shared buildings, transport and personnel expenditure by sector) are also included in the costing. Routine recurrent expenditure represents those expenses for the routine programme for activities that require regular (annual) input of funds. On the other hand, routine capital expenditure represents the expenses on capital activities by the programme. SIA expenditure represents expenses on the supplemental immunization activities carried out by the programme. The total costs for the programme are illustrated in figure 3.1 below (details in table 3.1) Figure 3.1: Trends in past programme costs by cost category, in USD millions $2.0 $1.8 $1.6 $1.4 $1.2 $1.0 $0.8 $0.6 $0.4 $0.2 $ Other optional information Other SIAs M easles Campaigns Polio Campaigns Other capital costs Cold chain equipment Vehicles Other routine recurrent costs Transportat ion Personnel Injection supplies New and underused vaccines Traditional Vaccines 13

24 Actual expenditure in each of these years is represented in table 3.1 below. Table 3.1: EPI expenditure by category in Lesotho, USD, Cost Category Routine Recurrent Cost USD (%) USD (%) USD (%) Vaccines (routine vaccines only) 50, % 51, % 92, % Traditional Vaccines 47,380 49,063 78,554 New (HepB) and underused (DT) vaccines 3,055 2,519 14,110 Injection supplies 20, % 24, % 19, % Personnel 183, % 158, % 218, % Salaries of full-time NIP health workers 70,355 63,243 85,483 Per-diems for outreach vaccinators/mobile teams 113,291 95, ,484 Transportation 1, % 1, % 1, % Fixed site and vaccine delivery 1,204 1, Outreach activities Maintenance and overhead 163, % 167, % 171, % Short-term training 24, % 34, % 35, % IEC/social mobilization 26, % 34, % 38, % Supervision, Monitoring and Disease Surveillance 7, % 8, % 72, % Other Outreach costs (excluding per-diems, transport and ice) 19, % 3, % 0 0.0% Other routine recurrent costs 14, % 41,132 14,094 Annual cost for hiring aeroplane 14,094 14,094 14,094 Other communication costs 0 27,038 0 Subtotal Recurrent Costs 511, , ,509 Routine Capital Cost Vehicles 19, % 19, % 10, % Cold chain equipment 25, % 30, % 40, % Other capital costs % 1, % 2, % Subtotal Capital Costs 44,912 51,899 52,592 Supplemental Immunization Activities Measles Campaigns 0 0.0% 0 0.0% 628, % Vaccines ,382 Injection supplies ,375 Other operational costs ,851 Subtotal Supplemental ,608 Shared cost and other optional information Shared Personnel Costs 255, % 215, % 301, % Shared Transportation Costs % % % Building 197, % 201, % 205, % Subtotal Optional 453, , ,875 GRAND TOTAL 1,009, ,828 1,852,584 Routine (Fixed Delivery) 876, ,495 1,090,392 Routine (Outreach Activities) 132,965 99, ,584 Supplemental Immunization Activities ,608 14

25 Pre-vaccine fund year (2001) and vaccine fund year (2003) expenditure Table 3.1 shows that the programme cost approximately 1 million USD in The recurrent programme largely drives these costs, with costs for personnel as the largest single expenditure category (18% of total programme costs by EPI personnel, and 25% by contribution from other shared personnel). Vaccine expenditure contributes a small proportion (5%) of the overall expenditure. However, by the year 2003, the first full year with GAVI support, we see the programme expenditure almost doubled. This increase is largely a result of: 1. The increased strength of the local currency, from 10.4 Maloti to 1 USD in 2002, to 7.6 Maloti to 1 USD in this leads to an apparent increase in costs of some cost categories, particularly the personnel costs 2. Introduction of new activities. Most prominent is the measles campaign in The HepB antigen was also introduced in the same year. This however leads to a marginal increase in the total programme costs as it was introduced towards the end of the year (October 2003). The main expenditure driver is the SIA (over 30% of total costs), with the personnel costs reducing in their share of the total costs. However, vaccine expenditure still represents only 5% of the total programme costs. Pre vaccine fund year (2001) and vaccine fund year (2003) financing Financing for these programme expenditures came from a series of sources. These are illustrated in figure 3.2 below. Figure 3.2: Financing sources for immunization in USD, $1.6 $1.4 $1.2 $1.0 $0.8 $0.6 $0.4 $0.2 $ CHAL CDC JICA thru UNICEF Ireland Aid UNICEF WHO GAVI - Vaccine Fund Sub-national Gov. National Government 15

26 The Government provides the bulk of the programme expenditure. This represents the large impact of expenditure due to shared inputs (shared personnel, transport and buildings), and personnel costs for the programme. Some programme activities relating to maintenance and overheads were under funded, with funds made available not enough to cover the estimated total maintenance and overhead expenditure. A review of these funding sources for the pre-vaccine fund, and vaccine fund years without the optional information (shared costs above) is illustrated below. Figure 3.3: Contribution to programme expenditure by partner for routine recurrent, capital and SIAs for Lesotho, JICA thru UNICEF 18% Ireland Aid 11% UNICEF 6% CHAL CDC 4% 0% WHO 20% National Government 41% Sub-national Gov. 0% GAVI - Vaccine Fund 0% JICA thru UNICEF 18% Ireland Aid 4% UNICEF 11% CDC 8% CHAL 1% WHO 13% National Government 26% Sub-national Gov. 0% GAVI - Vaccine Fund 19% The national Government is the main source of funding for the specific cost categories for immunization in 2001, contributing over 40% of the total costs. WHO represented the second major source of funding then, followed by JICA (through UNICEF). Government resources were largely for personnel (salaries and per diems), with some additional funds for transport. On the other hand, the partner support is used for other operational programme activities. JICA funds were largely used for vaccine purchases, while WHO was supporting a series of programme operational expenditures, particularly disease surveillance and training activities. Development Cooperation Ireland (Ireland Aid) support is largely for SIAs. UNICEF funds are largely for training, social mobilization, monitoring and supervision. By the year 2003, the programme financing changed, due to the changed programme activities. GAVI/vaccine fund resources are now seen, due to the introduction of the new vaccine, safer injection materials, and immunization services support (ISS). In addition, new partners for the SIAs are seen, such as CDC. As a result, the proportion of Government funding in relation to total routine programme, and SIA costs reduced to 25%. In addition, UNICEF (and JICA funds) is increasingly taking on the costs associated with vaccine clearance and transportation, a responsibility that should be for Government resources. 16