TABLE OF CONTENTS. List of Abbreviations & Acronyms. Acknowledgement. Executive Summary. Introduction

Transcription

1 TABLE OF CONTENTS List of Abbreviations & Acronyms Acknowledgement Executive Summary Introduction Section I: Section II Impact of Country and Health System Context 1.1 Geography and Climate 1.2 Demographic Situation 1.3 Socio-economic background 1.4 Federal administrative structure 1.5 Ethiopian National Health Policy 1.6 The Health System 1.7 Organization of the Health System 1.8 Health Care financing 1.9 Total Health Expenditures 1.10 Functional distribution of expenditures 1.11 Government planning budgeting and reporting process Program Characteristics, Objectives and Strategies 2.1 Immunization Schedule 2.2 Supplemental Immunization Activities 2.3 Vaccine wastage 2.4 Future plan for EPI 2.5 The role of UN agencies and NGOS in the national immunization program Section III Pre-vaccine fund and vaccine fund year program costs and financing 3.1 Pre vaccine fund year (2001) expenditure and financing 3.2 Vaccine fund year (2003) expenditure and financing Section IV Future Resource Requirements and Program Financing / Gap Analysis 4.1 Projections of future program costs 4.2 Future financing for the immunization program, and funding gap analysis 4.3 Financial impact of selected alternative policy options to decrease program costs Section V Sustainable Financing Strategy, Actions and Indicators 5.1 Opportunities for financial sustainability: 5.2 Challenges of financial sustainability 5.3 Strategy for financial sustainability Mobilizing additional resources Increasing reliability of resources Improving Program Efficiency 5.4 Action Plan, monitoring process and indicators for FSP 1

2 Tables and Illustrations Tables: Table 1.1: Total and per capita health expenditure by major source classifications, 2000 Table 2.1 The national EPI schedule. Table 3.1 Past EPI expenditure by cost categories, , in US $ Table 4.1 Future program costs by cost categories, Table 4.2 Secure, and probable resources from different partners Table 5.1 Indicators for follow up of progress of implementation of the financial sustainability plan Figures Figure 1.1 Health care expenditure by source in Ethiopia Figure 1.2 Government health expenditure in Ethiopia Figure 1.3 Breakdown of PHC expenditures in Ethiopia Figure 2.1 Trends in immunization coverage in Ethiopia, Figure 2.2 Routine immunization coverage by regions Figure 3.1 Program costs (US$ millions) by category for in Ethiopia Figure 3.2 Financing sources for immunization in 2001 Figure 3.3 Financing sources for immunization in 2003 Figure 4.1 Projection of immunization costs by strategy, US$ millions, Figure 4.2 Secure and probable financing for immunization, US$ millions, Figure 4.3 Impact on total program costs, and funding gap of different new vaccine policy options 2

3 Acknowledgements The Federal Ministry of Health would like to take this opportunity to thank all partners particularly, UNICEF, WHO and World Bank for their technical and financial support to develop the Financial Sustainability Planning for Ethiopia (FSP). We extend our gratitude to all ICC members and technical group of the national immunization program for their active participation in the development of this important document.. 3

4 Abbreviations and Acronyms AD syringe AEFI AFP BCG CDC CIDA CHW CMH CSA DFID DPT EFY EPI FSP FMOH GAVI GDP HDI Hep B HEP HEW Hib HIV/AIDS HSDP ICC IEC JICA MDGs MNT MOFED MOH NGOs NHA NIDs NIP NORAD OPV PHCU RED RHB SDPRP SIAs SNIDs SNNPR SOS TFR TT UN UNDP UNICEF USAID WHO ZHB Auto-Distract Syringe Adverse Effect Following Immunization Acute Flaccid Paralysis Bacillus Callmunt Guirine Center for Diseases Control Canadian International Development Agency Community Health Workers Commission on Macroeconomics and Health Central Statistic Authority Department for International Development Diphtheria Pertussis and Tetanus Ethiopian Physical Year Expanded Program on Immunization Financial Sustainable Plan Federal Ministry of Health Global Alliance for Vaccines Gross Domestic Product Human Development Index Hepatitis B Health Extension Program Health Extension Worker Hemophilus Influenza type B Human Immune Virus/Acquired Immune Deficiency Syndrome Health Sector Development Program Inter Agency Coordinating Committee Information Education Communication Japan International Cooperation Agency Millennium Development Goals Maternal Neonatal Tetanus Ministry of Finance and Economic Development Ministry of Health Non Governmental Organizations National Health Account National Immunization Days National Immunization Program Norwegian Agency for Development Cooperation Oral Polio Vaccine Primary Health Care Unit Reaching Every District Regional Health Bureaus Sustainable Development Poverty Reduction paper Supplemental Immunization Activities Sub- national Immunization Days Southern Nations and Nationalities People Sustainable Outreach Services Total Fertility Rate Tetanus Toxoid United Nations United Nations Development Program United Nations International Children s Fund United States Agency for International Development World Health Organization Zonal Health Bureau 4

5 Executive Summary Introduction In order to control vaccine preventable diseases, the World Health Organization and member countries including Ethiopia have established the Expanded Program on Immunization (EPI). The Ethiopian EPI program was launched in 1980, with the objective to reach 100% coverage to all children under two by Progress in coverage has been slow and up know the Ethiopian EPI program has not achieved the target coverage. However, with the introduction of the two new approaches known as Reaching Every Districts (RED) and Sustainable Outreach Services (SOS) significant improvement has been documented in the last few years. Currently the national DPT3 coverage stands at 65%. The Health System The Ethiopian health system currently reaches about 61% of the population. There are too few facilities, particularly at the levels closest to the community, and there are long-term shortages of skilled human resources. The FMOH is responding to this recognized need through two major initiatives in the context of the Health Sector Development program: A plan for expansion of primary health facilities and staff, which will raise health coverage to 85% by The health extension program (HEP) institutionalizes the community health system. The Health Extension Workers (HEWs) are intended to be the main change agents for health in the community. Their primary task will be to mobilize and empower households and communities to take responsibility for their own health by involving them in the planning and execution of community health activities and services. HEWs, working with other community-based workers and supported by their local health center will be trained and equipped to provide a wide range of promotive and preventive services including provision of routine vaccines Health Care financing The health services in Ethiopia are financed from four main sources: Government (both federal and regional) Bilateral and multilateral donors (both grants and loans) Non-governmental organizations, and Private contributions, both from out-of-pocket payments and through private sector investment in health services The routine immunization program is funded primarily by the Government and partners like, UNICEF and Irish Aid. Whilst vaccines are financed by UNICEF and salaries by the government, funding for a number of other components such as cold chain equipment, transport, social mobilization and some operational costs have been made available by WHO and other donor agencies under the Polio eradication initiative. 5

6 Program characteristics, objectives and strategies The overall aim of the immunization program is to improve the quality and coverage of national immunization services. The Ethiopian EPI program focuses mainly on four objectives: Strengthening the immunization system: strengthen and optimize the delivery of sustainable, quality immunization services by increasing DPT3/ measles coverage to 95% by Introduction of new vaccines: it is planned to introduce Hepatitis B vaccine as monovalent in and Hib vaccine as pentavalent in The target is to achieve 95% coverage by Minimizing vaccine wastage: the wastage rate should be properly calculated and minimized by focusing on accurate forecasting and proper stock management, effective cold chain system and improvement in the ratio of children to vials opened. Accelerated disease control: accelerate effort to achieve polio eradication, measles control/ elimination, and neonatal tetanus elimination. Ethiopia has a five year EPI plan which was developed in The prime focus of the plan was to increase the coverage by 5% annually, and likewise decrease the vaccine wastage rate. Trends in immunization coverage in Ethiopia, % BCG DPT3 Measles * 2004 Year Supplemental Immunization Activities To reach the remote zones of the country and to synergize the routine immunization activity, supplemental immunization was introduced in Supplemental immunization was designed mainly for Polio and Measles and since 1999 SIA for MNT was also started. Note : * 2004 annualized report 6

7 Vaccine wastage Vaccine wastage is a problem in Ethiopia. At present the wastage rate is more than 65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT. It is due to poor planning of static and out reach sessions, lack of awareness of the community and poor management of the cold chain system and also the current policy which recommends to open a vial of vaccine, even for a single child and discard opened vials of BCG and measles after 6 hours or at the end of the session. Pre-vaccine fund and vaccine fund year program costs and financing 1 This section presents the review of the total program expenditure and financing from This is broken down by the program expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to costs for the program are also represented. Program costs (US $ million) by category $30.0 $25.0 $20.0 $15.0 $10.0 $5.0 Other optional information Other SIAs Measles Campaigns Polio Campaigns Cold chain equipment Other routine recurrent costs Personnel Injection supplies Traditional Vaccines $ Total expenditure on immunization activities in the country was at approximately 25 million US dollars in each of these years. Projection of future program costs and gap analysis Based on the program objectives and strategies, a costing is estimated for the future program costs and financing. By the year 2005 & 2006, the program costs are just over US$ 30 million. There is then a large increase to over US$ 60 million in 2007, with the costs being maintained at that level. 1 Pre-vaccine means before the GAVI fund was available and vaccine fund year is when the GAVI fund is available 7

8 The main cost driver from 2007 onwards is the new, pentavalent vaccine. This will cost the program over US$ 30 million each year. The share of the routine program costs to the total immunization costs in the country increases from just over 40% to 80% when the pentavalent vaccine is introduced. Future financing is either secure, or probable. Secure funding represents resources for which there is a very high certainty that will be available. These include resources from Government for health workers salaries, contribution to maintenance (based on present contributions), and estimated proportion for immunization of shared costs for building, personnel, and transport. In addition, secured resources include regular budget funds from WHO and UNICEF (up to the end of their present programs of work, 2005 for WHO and 2006 for UNICEF), and support to the program activities for 2004, and secured funding for 2005 from GAVI, USAID, Ireland Aid, Netherlands, DFID, Government of Japan, and a host of other partners. These funds are largely for the planned campaigns in 2005 (detailed breakdown of each partner s contribution in Annex 3). Secured funds represent only 18% of the total resource requirements from A series of resources have been classified as probable and these include: Continued support beyond the present agreed program of work for WHO and UNICEF (US$ 50,000 for WHO, and US$ 2,500,000 for UNICEF per year),this is still probable money as the country proposal for support is still to be submitted and approved Funds for SIA activities have always been mobilized in the past, and the respective SIA will not be done (so won't be a program cost) if funds are not mobilized. Inclusion of these probable funds reduces the funding gap to 40% of total resource requirements. Sustainable financing strategy The ultimate goal of the financial sustainability plan is "self sufficiency". The ultimate goal of the financial sustainability plan is Self Sufficiency. That is to be able to cover all costs related to immunization, including the purchase of vaccines and required logistics, personnel and operational costs, etc. However, for a country like Ethiopia, where the overall health expenditure is still at a lower level, the rational way of formulating the FSP will be mobilization and efficient use of domestic and supplemental external resources on a reliable basis to achieve the targeted goals of national immunization coverage. The central and regional governments have already started funding for about 15% of the total EPI program expenditure. In addition, the FMOH covers the taxation cost, which is estimated to be 18% of the total cost of injection material. This effort has to grow significantly, so that, at least by the year 2015 the government will be able to cover an additional 10% of the total cost for vaccines. The strategy for moving forward to financial sustainability plan will be on identifying key activities for sustainable financing, which include; Mobilizing additional resource: - From central and local governments - From private sector, civil societies and NGOs and -from funding agencies Increasing reliability of resources both governmental and external resource Improving program efficiency by; -minimizing vaccine wastage -improving EPI program management and - Maximum use of health extension program 8

9 INTRODUCTION In order to control vaccine preventable diseases, the World Health Organization and member countries including Ethiopia have established the Expanded Program on Immunization. The Ethiopian EPI program was launched in 1980, with the objective to reach 100% coverage to all children under two by In 1985, the target was reviewed to 75% coverage for the target age group was changed to under ones. However, progress in coverage has been slow and up to date the Ethiopian EPI program has not achieved the target coverage. Low coverage is an acknowledged weakness of the national EPI program. However, improvement has been documented in the last few of years, with the introduction of a new approach known as Reaching Every Districts (RED) and Sustainable Outreach Services (SOS) for immunization. The above two approaches were launched in 2003, to maximize the coverage and accelerate the effort of the national immunization program, so that, the country is able to achieve immunization goals set by United nations General Assembly special session to ensure 90% coverage at national level and 80% in all districts by the year This should support the country immunization. program achieve its expectations towards the achievement of the Millennium Development Goal. To this effect, in the last few years the national immunization coverage has shown significan improvement. Currently the national DPT3 coverage stands at 65%. As with other health services, immunization coverage varies significantly by region. Over 80% of children in, Tigray, Dire Dawa and Harari regions are immunized for DPT3 by age one, while the figure dramatically drops to less than 5% in Somali region. Immunization coverage rates in the three most populous regions -Oromia, Amhara and SNNPR has started picking up, but remains still low, to influence the national average. In terms of health financing and budget provisions, the government has taken steps to reallocate resources away from urban hospitalbased curative services towards more preventive and promotive care, targeting the rural population. The overall focus has been on communicable diseases, common nutritional disorders, environmental health and hygiene, safe and adequate water. The routine immunization program is funded primarily by the Government and its partners that largely channel their funds through UNICEF and WHO. Whilst the bulk of vaccine costs are financed by UNICEF and salaries by the government, funding for a number of other components such as cold chain equipment, transport equipment, social mobilization and some operational costs have been made available by WHO,UNICEF and other donor agencies under the Polio eradication initiative. 9

10 SECTION ONE Impact of country and Health System context Ethiopia 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 overall country situation including the budget and monetary developments, all of which have a bearing on public financing of health programmes. The section also covers Ministry of health priorities in terms of allocation of little resources, methods and procedures of budgeting, procurement, disbursing and reporting on the use of funds for immunization. 1.1 Geography and Climate Ethiopia is situated in the Horn of Africa. The total area of the country is around 1.1 million square kilometers, and it shares borders with Djibouti, Eritrea, Sudan, Kenya and Somalia. Ethiopia is a country with great geographical diversity, with topographic features ranging from 4,550m above sea level to 110m below sea level 2. More than half of the country lies above 1,500 meters. There are broadly three climatic zones: the Kolla, or hot lowlands, below approximately 1,500 meters, the Weyna Dega at 1,500-2,400 meters and the Dega or cool temperate highlands above 2,400 meters. In general the highlands receive more rain than the lowlands. The country is prone to recurrent droughts and famines. 1.2 Demographic Situation According to the 2004 mid-year population projection, the population of Ethiopia is approximately 71.2 million. 2 The average household size is About 85% of the total population is rural, making Ethiopia one of the least urbanized countries in the world. Only nine urban centres have populations of over 100,000, and Addis Ababa is the only urban centre with a population of over a million, accounting for 26% of the total urban population and 3.9% of the total population. At an annual growth rate of 2.9%, the total population is expected to reach 106 million by the year Rapid population growth exacerbates critical gaps in basic health services, especially when growth of the economy is low or per capita incomes are in decline. The average population density is 52.2 per square km, with great variation among regions. Population densities are highest in the highland regions and lowest in the eastern and southern lowlands. Most of the woredas along the borders of the country have densities of less than 10 persons per square km. 23.2% of the population is concentrated on 9% of the land area. 2 Central Statistical Authority (Ethiopia) and ORC Macro (2001). Ethiopia Demographic and Health Survey Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro. [EDHS 2000] 2 Central Statistical Authority (1994). The 1994 GC Population and Housing Census of Ethiopia: Analytic Report. Addis Ababa: Central Statistical Authority 3 EDHS 2000, ibid 4 Central Statistical Authority (1994). The 1994 GC Population and Housing Census of Ethiopia: Analytic Report. Addis Ababa: Central Statistical Authority 10

11 Roughly 50 percent of the land area represents sparsely populated areas with nomadic or seminomadic pastoral ethnic groups living in arid plains or in a semi-desert environment. The settlement pattern of the population and its density greatly affect the provision of health care, including the accessibility and utilization of existing health care facilities. About 17.5% of the population is aged less than 5 years, 43.5% of the population are under 15 years, 51.9% are between 15 and 59 years and 4.6 % are aged 60 years and above. Twenty four percent of the total population is women in the reproductive age group (15-49 years). The Ethiopian Demographic and Health Survey 2000 indicate a total fertility rate of 5.9 children per woman. Fertility is highest in the Oromia Region (6.4 births per woman) and lowest in Addis Ababa (1.9 births per woman). The level of fertility is significantly lower in urban (TFR of 3.3) compared to rural areas (TFR of 6.4). The general level of education has marked influence on the spread of diseases, the acceptability of health practices and utilization of modern health services. However the literacy status of the population is low. The adult literacy rate is 49% for males and 34% for females. The gross enrolment ratio in primary schools at national level is 64% (53% for girls). 5 Ethiopia is home to around 80 ethnic groups that vary in population size from more than 18 million to less than Christianity and Islam are the main religions, with 51% Orthodox Christians, 33% Muslims, and 10% Protestants, the rest following a diversity of other faiths. 1.3 Socio-economic background Ethiopia is one of the least developed countries in the world with an estimated annual per capita income of US$ 100. Forty seven percent of the total population lives below the poverty line. The 2003 UNDP Human Development Index (HDI) for Ethiopia stands at The socio-economic and health development of the country has been hindered by a combination of rapid population growth, poor economic performance and low educational levels. Economic performance, which in the 80s was characterized by low or negative growth rates in real GDP and per capita incomes, resulting from decades of civil war, drought and economic mismanagement, was reversed in the 90s. Over the decade, the Government initiated a comprehensive economic reform program which has had an important bearing on the development of the key socio-economic sectors including health. The new economic policy is aimed at establishing a market-based economic transformation and redirecting Government interventions to the development and strengthening of social services such as education, health, investment in roads and water resources. The policy environment created by the economic reform and macro economic stability helped address poverty in a comprehensive way through the adoption of the Sustainable Development and Poverty Reduction Program (SDPRP), which is now giving attention to poverty-related health program targets. The government is also committed to meeting targets set by global initiatives, notably the Millennium Development Goals (MDGs) and the recommendations of the WHO Commission on Macroeconomics and Health (CMH) aimed at strengthening the link between improved health and economic development. 5 Ministry of Education (2003). Education Statistics, Annual Abstract EC Addis Ababa: Ministry of Education 6 CSA (1998). 11

12 1.4 Federal administrative structure Ethiopia is a Federal Democratic Republic. It has a bicameral parliament: the House of Representatives, whose members are elected from the regions, zones, woredas (districts) and kebeles, and the House of Federation, whose members are designated from their respective regions. Administratively, there is extensive decentralization of service delivery, with relatively autonomous regions largely responsible for service delivery. These regions are subdivided in to further administrative units of zones, woredas and kebeles. At present the country has nine regional states and two City Administrations. The highest governing body of each regional national state is the Regional Council, which has elected members and is headed by a president nominated by the party that holds the majority of seats. The president is assisted by heads of various regional bureaus, including Health. Each region has its own parliament and is responsible for legislative and administrative functions except for foreign affairs and defense. The National Regional States and City Administrations are further divided into 75 zones, 580 woredas, and approximately 15,000 kebeles. There are also two zones and seven woredas designated as "special". These are medium sized towns or traditional sites of ethnic minorities. The woreda is the basic administrative unit and has an administrative council composed of elected members. The woredas are further divided into kebeles, representing urban dwellers associations in towns and peasant associations in rural villages. With the devolution of power to regional governments, public service delivery, including health care, has fallen largely under the jurisdiction of the regions. The approach has been to promote decentralization and meaningful participation of the population in local development program. For administration of public health care, there is a Regional Health Bureau (RHB) at the Regional level, and a Zonal Health Department (ZHD) at the zonal level. An increasing number of woreda health offices are currently being established, as it is expected that the zonal level will be phased out in favor of a strengthened woreda structure. Therefore, decentralization has brought an opportune moment for the EPI program as the implementing bodies (woreds) are more capable both politically and economically to play their own role in resource mobilization and allocation for immunization program in their own respective areas. Some regions and woredas have already started allocating budget for operational costs, and few have also started contributing for capital costs by procuring refrigerators. However contributions, for purchase of vaccines and injection materials by the regions and woredas are yet to be started. 1.5 Ethiopian National Health Policy Following the change of Government in 1991, a number of political and socio-economic reform measures were put in place. Two of these were the development and introduction of a new National Health Policy in 1993 and, in 1997, the formulation of a comprehensive rolling 20-year Health Sector Development Plan (HSDP). Both are the result of the critical assessment and analysis of the nature and causes of the country s health problems. The HSDP is now in its second period (HSDP II). The major foci of the health policy are democratization and decentralization of the health care system, development of the preventive, promotive and curative components of health care, assurance of accessibility of health care for all segments of the population and the promotion of participation of the private sector and NGOs in the health sector. 12

13 1.6 The health system The Ethiopian health system currently reaches about 61% of the population. There are too few facilities, particularly at the levels closest to the community, and there are long-term shortages of skilled human resources. The Federal MOH is responding to this recognized need through two major initiatives in the context of the Health Sector Development Plan: A plan for expansion of primary health facilities and staff, which will raise coverage to 85% by The health extension program (HEP): This institutionalizes the community health system. The Health Extension Workers (HEWs) are intended to be the main change agents for health in the community. Their primary task will be to mobilize and empower households and communities to take responsibility for their own health by involving them in the planning and execution of community health activities and services. HEWs, working with other community-based workers and supported by their local health center will be trained and equipped to provide a wide range of promotive and preventive services including provision of routine vaccines.the HEP is seen as an opportunity to strengthen all the health services for mothers and children at the community level. 1.7 Organization of the health system The Federal Ministry of Health, Regional Health Bureaus and Woreda Health Offices, depending on the level and type of health facility, shoulder responsibility for administration and operation of government health services. Other health institutions are owned and managed by private and non-governmental organizations. The national health policy emphasizes the importance of achieving access to a basic package of quality primary heath care services for all segments of the population, via a decentralized state system of governance. This package includes preventive, promotive and curative services. In order to attain this goal, HSDP I introduced a four-tier system for health service delivery. This is characterized by a primary health care unit (PHCU) comprising one health center and five satellite health posts, and the district hospital, zonal hospital and specialized referral hospital. A PHCU was planned to serve 25,000 people, while district and zonal hospitals are each expected to serve 250,000 and 1 million people respectively. The growing size and scope of the private health sector, both for profit and not-for-profit, offers an opportunity to enhance health service coverage and utilization, and HSDP has explicitly recognized the complementarities between the two sub sectors with the articulation of a strategy to promote the private sector in health care delivery. 1.8 Health care financing The health services in Ethiopia are financed from four main sources: Government (both federal and regional) Bilateral and multilateral donors (both grants and loans) Non-governmental organizations, and Private contributions, both from out-of-pocket payments and through private sector investment in health services. 13

14 1.9 Total health expenditures According to the second National Health Account (NHA), conducted using 1992 EFY data, the total health expenditure in EFY 1992 was estimated to be ETB 2.9 billion (355.5 million US$). The first NHA conducted using EFY 1988 data estimated the total health expenditures at ETB 1.45 billion or 230 million US$. The per-capita health expenditure has increased by about one dollar from 4.5 US$ to 5.6 US$ per person per year between the two time periods. Although the share of GDP allocated to health, at 5.5%, compares reasonably well with other low income countries, the per capita expenditure remains one of the lowest in the world and significantly lower than the US$12 that is the average among sub-saharan African countries. The global estimate of the minimum per capita expenditure for effective health care in developing countries is US$34. Therefore, there is a need for considerable increase in health financing in Ethiopia, combined from all sources, including making full use of the willingness of families to contribute financially to health care. Table 1.1 Total and per capita health expenditure by major source classifications, 2000 Source Amount in Birr Amount in USD Per Capita USD Percent Government 978,960, ,731, % Bilateral& Multilateral 471,443,092 57,178, % Households 1,057,826, ,297, % NGOs(local& international) 290,082,327 35,182, % Private 132,849,569 16,112, % Total 2,931,161, ,502, % Source: Ethiopia s second NHA draft report, 2003 Figure 1.1 Health care expenditure by source in Ethiopia, 2000 NGOs, 10% Private, 5%, Government, 33% Household, 36% External donors, 16% Source: Ethiopia s second NHA draft report,

15 The major source of funding for health in 2003 was households, which account for 36% of total health expenditures, but their proportional contribution has significantly declined from about 53% in Government financing from taxes, general revenue and loans stands next, covering 33% of total health expenditures. The rest of the world through bilateral and multilateral assistance comes third with 16%. Since financing from the rest of the world mostly comes through the government, the second round shows that about 50% of health expenditures are financed from public sources. The share of NGOs has also increased to about 10% from the previous 7%. In terms of per capita expenditures, households spend $2.02, government $1.87, the rest of the world $0.9, NGOs $0.55 and the private sector $0.25 US per person per year Functional distribution of expenditures Health expenditures are dominated by curative care. Pharmaceuticals consumed about 39% of total health expenditures. Curative care services took about 19% of total expenditures. Considering non-vaccine pharmaceutical expenditures and considering the rest as a part of curative treatment, the share of curative care increases to about 57% of total expenditure. Overall, expenditure on primary health care accounted for about 16%. Including immunization, sanitation, and environmental health functions that are categorized under health-related increases the share to 18%. The share of health administration stands at a reasonable level of 8%. Figure 1.2 Government health expenditure in Ethiopia, 2000 Curative care, 19% Environmental health, 1%, Training, 2% Drugs, 38% Capital, 15% Administration, 8% R&D, 1% PPHC, 16% Immunization cost, 1% Source: Ethiopia s second NHA, draft report, A breakdown of expenditure on PHC shows that in 2000, about 41% was spent on mother and child health, while 29% was used for expansion of primary health care and 12% for controlling communicable diseases. Other services like IEC, non-communicable disease control, sanitation and environmental health together consumed 18% of resources. 15

16 Figure 1.3 Breakdown of PHC expenditures in Ethiopia Others 18% MCH 41% Expansion 29% CDC 12% Source: Ethiopia s second NHA, draft Report, Government planning budgeting and reporting process The over all-financial planning, budgeting and reporting process follow the bottom up principle. The financial year starts on the eighth of July and ends on the seventh of July of the subsequent year. The Family health department, which is the main pioneer of the immunization activity, develops the annual plan of action with the budge in the beginning of the financial year. The higher bodies of the FMOH scrutinize the budget before it is submitted to MOFED for approval. MOFED scrutinizes further the budget according to the national plan, priority areas of the country and the available resources. There after, the annual budget for each sector will be allocated. MOFED presents the annual budget of each sector to the House of Representatives for final approval. Once the budget is known the finance division of the FMOH requests MOFED to release the monthly budget according to the plan of action of each department. Every month, the finance division of the FMOH reports back to MOFED, about every detail of all capital and recurrent expenses used by each department. Failure to adhere to this, the subsequent monthly budget of the FMOH may not be released. At the end of the year, MOFED sends its own auditors to FMOH to evaluate the over all annual budget utilization of the MOH. 16

17 SECTION Two Program characteristics, objectives and strategies 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. The overall aim of the immunization program is to improve the quality and coverage of national immunization services. The Ethiopian EPI program focuses mainly on four objectives: Strengthening the immunization system: strengthen and optimize the delivery of sustainable, quality immunization services by increasing DPT3/ measles coverage to 95% by 2009 Introduction of a new vaccine: it is planned to introduce Hepatitis B vaccine as monovalent in and Hib vaccine as pentavalent in The target is to achieve a coverage of 95 % by 2009 Minimizing vaccine wastage: the wastage rate should be properly calculated and minimized by focusing on accurate forecasting and proper stock management, effective cold chain system and improvement in the ratio of children to vials opened. Accelerated disease control: accelerate effort to achieve polio eradication, measles control/ elimination, and maternal and neonatal tetanus elimination To realize the above objectives, the national EPI program gives special attention to the following priority areas of interventions. Capacity building at all levels; including full involvement and maximum use of the health extension program. Conduct regular monitoring and supportive supervision; Improve the cold chain and vaccine management at all levels; Strengthen further the participation of NGOs and the private sectors in EPI activities Conduct social mobilization activities by using the existing community health workers and the newly coming HEWs, to create demand in the community for immunization; Facilitate participation of community leaders in mobilizing community and defaulter tracing to decrease drop -out rate; Implement Reaching Every District(RED) approach in all low performing regions and zones; Local resource mobilization 17

18 2.1 Immunization Schedule Immunization is mainly provided through state run health facilities and associated outreach activities. The national guidelines for EPI recommend that health workers should use every opportunity to immunize eligible children, and all eligible children attending outpatient clinics should be immunized according to the recommended schedule. Table 2.1 The national EPI schedule Vaccine Ages of administration Supplemental BCG/OPV0 at birth DPT1/OPV1 6 weeks DPT2/OPV2 10 weeks DPT3/OPV3 14 weeks Measles 9 months Vitamin A Tetanus for pregnant women first contact during pregnancy for TT1, after 4 weekstt2 and after 6 months TT3,T4 and T5 Ethiopia has a five year EPI plan which was developed in 2001.The prime focus of the plan was to increase the coverage by 5% annually, and likewise decrease the wastage rate. The graph below shows the actual rise in the immunization coverage since Figure 2.1 Trends in immunization coverage in Ethiopia, % BCG DPT3 Measles * 2004 Year Immunization coverage significantly varies by regions. The coverage ranges from DPT3 coverage of more than 80% in Tigray, Diredewa and Harari regions to less than 10% coverage in Somali and Afar regions. The most populous regions, like Oromia, Amhara and SNNPR have started showing an increasing trend; however, a lot has to be done from these regions to make a significant impact on the national coverage rate. Note : * First six month annualised 18

19 Figure 2.2 Routine Immunization coverage by regions ( ) % DPT1 DPT3 Measles Tigray Afar Amhara Oromia Somali B/Gumuz SNNP Gambela Harari Addis Ababa Dire-Dawa National Region 2.2 Supplemental immunization activities To reach the remote zones of the country and to synergize the routine immunization activity, supplemental immunization was introduced in Supplemental immunization was designed mainly for Polio and Measles and since 1999 SIA for MNT was also started. Polio supplemental immunization activity Ethiopia joined polio eradication efforts in 1996 by conducting supplemental immunization activities in 9 selected cities followed by full NIDs from 1997 to The number of children immunized increased from about 8 million in 1997 to 14 million in Today, Ethiopia has been polio free for three years, and AFP surveillance has achieved certification level standard. In 2003 SNIDs were conducted in areas poorly covered during previous NIDs. In 2004 SNID was also conducted in densely populated areas of central Ethiopia. and in Woredas bordering Sudan. The threat to the national polio eradication initiative is the risk of importation of wild polio from polio endemic countries. Measures are being under taken to prevent the threat of wild poliovirus importation. Measles supplemental immunization: Measles is a major public health problem in Ethiopia. Catch up measles supplemental immunizations have been conducted for children under 15 years of age in most parts of the country and more than 30 million children received supplemental doses. The plan is, to continue conducting the catch up immunization in the remaining parts of the country, and strengthen routine immunization at the same time. After 3 to 4 years, follow up campaign will be conducted in phases all over the country for children under five years of age. 19

20 MNT supplemental immunization: Neonatal Tetanus is one of the leading causes of mortality in infants less than one month of life. The national coverage of routine TT plus was too low to impact on the neonatal morbidity and mortality. The FMOH has therefore, decided to undertake Maternal & Neonatal Tetanus (MNT) elimination campaign using a high risk approach. In 1990, the FMOH in collaboration with UNICEF and other partners launched an accelerated maternal &neonatal tetanus elimination pilot project in Gedeo Zone of the SNNPRG. Based on the success of the pilot project in Gedeo Zone, a similar campaign for MNT was implemented in high risk zones of SNNPR, Tigray,Oromia and the Amhara regions. 2.3 Vaccine wastage Vaccine wastage is a problem in Ethiopia. At present the wastage rate is more than 65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT. It is due to poor planning of static and out reach sessions, lack of awareness of the community and poor management of the cold chain system and also is due to the current policy which recommends to open a vial of vaccine, even for a single child and discard opened vials of BCG and measles after 6 hours or at the end of the session. 2.4 Future plan for EPI The future plan of action for EPI implementation is structured in line with the recently developed child survival strategy and therefore, the EPI plan will mostly depend up on the new and innovative community health program, "the health extension program". Through the expansion of primary health facilities and training of more than health extension workers, it is planned to raise the health coverage to 85% by Although there are major barriers to overcome like, limited access to health facility, widespread shortage of skilled human resource and supplies for immunization activity at all level, the moment is right to scale up immunization activities in the country. Limited access will be addressed through the accelerated primary health service expansion program which is targeting at 85% access by 2009 and the health extension program addresses the human resource issue at the grass root level.therefore the future plan focuses more on increasing coverage and minimizing Wastage, by making maximum use of the health extension program. The over all EPI plan is to: Increase DPT3 by 5% annually and reach 95% coverage by the end of 2009 Increase Measles immunization coverage to 95% by 2009 Increase TT2 plus coverage to 80% in women of childbearing age, by 2010 and Reduce drop out rate of DPT1-DPT3 and DPT1-measles to less than 5% by 2007 Reduce preventable Adverse Events Following Immunization (AEFI) to very minimal Level by the year 2005 Reduce vaccine wastage rate drastically (BCG and measles to less than 20%, DPT, TT and OPV to less than 10%) By 2009 Rehabilitate the cold chain in line with the cold chain maintenance and rehabilitation plan by 2009 In line with the Health Extension Program implementation make sure that the health 20

21 extension workers are fully involved in the routine and supplemental immunization activity as of 2005 Increase the number of antigens provided to the population by introducing the pentavalent vaccine (introduce antigens for Hepatitis B and Haemophilus influenza type b) Strengthening both in service and pre-service training Mobilize both internal and external resource for EPI The national child survival strategy has recommended adding Hib vaccine to the traditional EPI program. The national plan is to introduce the Hepatitis B vaccine in and Hib vaccine as pentavalent in Expected future challenges of the national immunization program GAVI support for injection materials will expire in 2004.After that the government shall seek funding resources from partners to fill the funding gap for the cost of injection materials The country has planned to expand primary health facility and plans also to deploy a large number of health extension workers to the community which ultimately may increase the demand for immunization service and like wise increase the coverage. But mobilizing equivalent amount of resources to cover the rising capital, investment and operational costs will probably be a threat 2.5 The role of UN agencies and NGOs in the national immunization program UNICEF is the main source of funding agency for vaccine and some of the injection materials and may continue supplying vaccines in the future. Major funding for SIAs, AFP surveillance, short-term training, and injection supplies, cold chain and other operational cost came from USAID and the Japan government /JICA during the period of 2001 to The Irish government has been contributing for strengthening of the routine EPI program since In addition, the Irish government has supported the procurement of injection materials for After 2005, the fund for injection materials is not yet secured. About 15% of the fund used for polio campaign during the has come from CDC. WHO and UNICEF have been paying salary for most of the national EPI experts for the last three years. In addition, WHO has also supported short-term training, AFP surveillance, supervision and monitoring and other operational costs. The Rotary International, Netherlands, NORAD, CIDA, Belgium and DFID have also significant contribution in the funding of the SIAs and routine immunization program during the period of

22 SECTION Three Pre-vaccine fund & vaccine fund year Program costs and financing ( ) This section provides and analyzes basic information about the total cost of the national immunization program, broken down by core cost categories (vaccines, personnel, transport and others), and by funding source (government, international donors, and others) from 2001 (before any GAVI support was available) to 2003 (the first full year of GAVI support) This section presents the review of the total program expenditure and financing from This is broken down by the program expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to costs for the program are also represented. Routine recurrent expenditure represents those expenses for the routine program for activities that require regular input of funds (recurrent expenditure). On the other hand, routine capital expenditure represents the expenses on capital investments used for the routine program. Supplemental immunization activity expenditure relates to expenses incurred during the respective campaigns. Other information not included in these above categories is an estimate attributable to immunization activities for buildings, personnel and transport expenditure (as these are used extensively by other health related activities), disease surveillance costs, and costs for technical assistance from partners. Program costs for the above years are illustrated in figure 3.1 below. Figure 3.1 Program costs (US$ millions) by category for in Ethiopia $30.0 $25.0 $20.0 $15.0 $10.0 $5.0 Other optional information Other SIAs Measles Campaigns Polio Campaigns Other capital costs Cold chain equipment Vehicles Other routine recurrent costs Transportation Personnel Injection supplies Traditional Vaccines $ Total expenditure on immunization activities in the country was at approximately 25 million US dollar which is 0.35/capita per year. About 5% of the total government health expenditure goes for immunization services. Actual expenditure is illustrated in table 3.1 below 22

23 Table 3.1 Past EPI expenditure by cost categories, , in US dollars Cost Category Routine Recurrent Cost US$ (%) US$ (%) US$ (%) Vaccines (routine vaccines only) 1,853, % 2,109, % 2,239, % Traditional Vaccines 1,853,142 2,109,646 2,239,418 Injection supplies 555, % 1,079, % 1,335, % Personnel 1,972, % 2,018, % 2,044, % Salaries of full-time NIP health workers (immunization specific) 1,781,446 1,823,556 1,848,551 Per-diems for outreach vaccinators/mobile teams 190, , ,300 Transportation 2, % 29, % 56, % Fixed site and vaccine delivery 2,647 27,280 52,894 Outreach activities 175 1,808 3,505 Maintenance and overhead 1,085, % 1,151, % 1,205, % Short-term training 50, % 402, % 647, % IEC/social mobilization 23, % 90, % 82, % Supervision and Monitoring 74, % 1,074, % 614, % Other routine recurrent costs 154, % EPI reviews/surveys 154, Subtotal Recurrent Costs 5,772, % 7,955, % 8,227, % Routine Capital Cost Vehicles 10, % 70, % 122, % Cold chain equipment 777, % 825, % 865, % Other capital costs 10, % 10, % 24, % Subtotal Capital Costs 799, % 906, % 1,012, % Supplemental Immunization Activities Polio Campaigns 14,584, % 10,473, % 1,841, % Vaccines 3,337,560 4,365, ,027 Other operational costs 11,247,219 6,107,443 1,094,274 Measles Campaigns 911, % 3,191, % 8,857, % Vaccines 295, ,353 3,040,043 Injection supplies 61, ,966 1,931,656 Other operational costs 554,012 2,402,823 3,886,136 MNT Campaigns (CBAW) 1,813, % 2,625, % 814, % Vaccines 219, ,112 54,419 Injection supplies 202, ,257 58,073 Other operational costs 1,391,864 1,789, ,725 Subtotal Supplemental 17,310, % 16,290, % 11,513, % Shared cost and other optional information Shared Personnel Costs 849, % 866, % 873, % Shared Transportation Costs 14, % 47, % 62, % Building 389, % 397, % 405, % Other optional information 1,626, % 1,024, % 2,016, % Technical assistance 8,574 53,072 98,800 Disease surveillance 1,618, ,950 1,918,128 Subtotal Optional 2,880, % 2,335, % 3,359, % GRAND TOTAL 26,761,777 27,488,069 24,112,138 Routine (Fixed Delivery) 9,260,819 11,001,345 12,398,980 Routine (Outreach Activities) 190, , ,805 Supplemental Immunization Activities 17,310,012 16,290,252 11,513,353 23