Kingdom of Cambodia. Financial Sustainability Plan for Immunization Services

Transcription

1 Kingdom of Cambodia Financial Sustainability Plan for Immunization Services Submitted to GAVI November 2002

2 Table of Contents I. Country and Health Sector Context... 3 Government Health Expenditures... 6 Reforms in the Health Sector... 7 Donor Funding of the Health Sector... 8 II. Immunization Budget Process and Financial Management... 8 Budgeting Process... 8 Financial Management and Disbursement III. Program Characteristics, Objectives and Strategies Current Situation Current Objectives and Strategies IV. Baseline and Current Program Costs and Financing V. Future Resource Requirements and Program Financing VI. Sustainable Financing Strategic Plan and Indicators Opportunities Challenges Strategies and Actions Strategic Plan VII. Stakeholder Comments Signatures Annex A: Reported Coverage Rates by Province This document is supplemented by GAVI required FSP Table 1.1, 1.2, 2.1, and 2.2 provided as an attachment. 2

3 Acronyms ADB Asian Development Bank ADD Accelerated Development District AFP Acute Flaccid Paralysis AusAID Australia Agency for International Development BCG Bacille Calmette-Guerin CBAW Child Bearing Age Women CG Consultative Group COCOM Coordinating Committee CPA Complementary Package of Activities CVP/PATH Children s Vaccine Program at PATH DHS Demographic and Health Survey DTP Diptheria, Tetanus, Pertussis ESAF Enhanced Structural Adjustment Facility GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product HC Health Center ICSC Immunization Coordination Sub-Committee IEC Information Education and Communication IMF International Monetary Fund ISS Immunization Services Strengthening JICA Japan International Cooperation Agency MCH Maternal and Child Health MDVP Multi-Dose Vial Policy MOEF Ministry of Economy and Finance MOH Ministry of Health MPA Minimum Package of Activities MTEF Medium Term Expenditure Framework NGO Non-governmental Organization NIP National Immunization Program NNT Neonatal Tetanus OD Operational District OPV Oral Polio Vaccine PAP Priority Action Plan PHD Provincial Health Department PROCOCOM Provincial Coordinating Committee RH Referral Hospital SIA Supplemental Immunization Activities SWIM Sector Wide Management TT Tetanus Toxoid TWG Technical Working Group UNICEF United Nations Children s Fund VF Vaccine Fund VVM Vaccine Vial Monitor WHO World Health Organization 3

4 Executive Summary The immunization program in Cambodia seeks to improve child survival and child health by controlling, eliminating, or eradicating all vaccine preventable diseases targeted by the NIP. The key program objectives are: Raise coverage for all NIP antigens among children under 1 year of age to 80% in a minimum of 50 of 73 ODs by the year 2002, and all ODs by 2005 Maintain capability for rapid detection and containment of any imported wild poliovirus until the time of global eradication Achieve neonatal tetanus elimination by 2005 Effectively control measles as a public health problem by 2005 Effectively control Vitamin A deficiency as a significant health problem by 2005 Reduce Hepatitis B carriage associated with transmission in children, and morbidity and mortality due to other illnesses for which the introduction of new vaccines and technologies is feasible and practical Ensure that all immunizations are given safely and with potent high quality vaccine Improve the efficiency of vaccine delivery and usage The total cost of the immunization program for 2001 was $3.61 million (see Table 1.1), compared with total estimated costs of $4.73 million in 2002 (see Table 1.2). For 2002, government funding comprises 28% of the cost of immunization services. The following table shows trends in government and donor funding for 1999, 2001, and Trends in Government and Donor Funding (US$) Increase from 2002/1999 Gov t Funds* 380,010 1,176,284 1,329, % GAVI/VF support 0 157, ,571 N/A Other Donor Funds 1,567,540 2,280,088 2,718,449 73% Total 1,947,550 3,613,372 4,734, % * includes estimate of costs of personnel and of HC outreach activities costs, including per-diem for HC staff to go to villages, which represents the biggest share of the Government contribution since Costs of the immunization program are projected to increase over the next seven years. While secured and probable financing for 2003 covers nearly the full projected cost for 2003, the financing gaps are quite large after In 2006, after the last year of GAVI/VF support for vaccines, secured and probable financing are projected to cover 54% of the projected costs, and drops to 29% of projected costs in At least part of the reason for this large gap is that neither donors nor government officials can commit to funding so far out into the future. Even costs that have historically been paid by certain donors or by the government budget cannot be considered secure because of the length of time into the future. A graphical depiction of future financing is shown below. 4

5 Projections of NIP Financing (US$) 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000, Gap Poss External Poss. Gov't Prob. External Prob. Gov't Secure External Secure Gov't Cambodia will pursue six key strategies to close the funding gap, as shown below, together with illustrative actions to improve sustainability and appropriate indicators to measure progress. Strategies Illustrative Actions* Overall Indicator(s) Increase national government financial contribution to NIP Increase provincial level expenditures for NIP Increase donor funding for NIP Provide reliable funding for immunization at all times Reduce vaccine wastage Improve efficiency of outreach sessions Set targets for government commitment for the next three years with all ICSC members On a targeted basis, work with provincial authorities to ensure greater funding access for primary health and other social sectors NIP Manager/TWG to advocate for increased funding Explore mechanisms to alleviate MOEF cash disbursement issues Evaluate other vaccine handling and storage solutions Maximize number of children vaccinated at each session with improved social mobilization Nat l Bud Exp on NIP GDP-debt service Nat l budget NIP exp Total MOH budget Prov Bud Exp on NIP Total NIP Expenses Donor Actual Exp (prev yr) Proj Need Proj Natl Exp Mechanisms exist to ensure cash is available when needed for key NIP activities (Y/N) Wastage rate (%) of DTP/Hep B combo vaccine DTP3 coverage rate (%) in 5 selected provinces where outreach is the dominant mode of service delivery * This list of actions is illustrative and does not represent the full array of activities proposed see Section VI for full discussion of activities. 5

6 I. Country and Health Sector Context Cambodia is a country of 13 million people. It is a low income country, with per capita GDP of $260 (2000). It has poor health indicators: life expectancy at birth is 54 years for men and 58 for women, the infant mortality rate is 95 per 1,000 live births, and the maternal mortality rate is estimated to be 437 per 100,000 live births as estimated in the 2000 Cambodian Demographic and Health Survey (DHS). Since 1998, when a new coalition government was established, Cambodia has enjoyed both political stability and economic growth. Economic growth has hovered around 5% per year since 1999, while inflation has remained low. Foreign investment has not returned to the levels seen in the early 1990s, partly due to weakness in the other Asian economies following the 1997 financial crisis. The government has committed itself to fiscal reforms including strengthening revenue collection, demobilization of the military, and increased investment in social sectors. Government Health Expenditures As part of the government fiscal reforms, there have been remarkable increases in government health expenditures. The Ministry of Health (MOH) expenditures from are shown in the table below. MOH Expenditures Year Expenditures (million riel) Percent Increase Per Capita Exp. (US$) ,366 $ ,808 35% $ ,294 28% $ * 171,700 32% $3.26 Source: MOH * Budgeted expenditures In 2002, the MOH budget represents 10.9% of total government planned budget. On a per capita basis, health expenditures have more than doubled between 1999 and Continued increases in the MOH budget are planned, with the projected budget for 2005 estimated to be 300,256 million riel, representing 12.8% of projected government expenditures. While the health sector is a high priority for the government, total government health expenditures remain low as a percentage of GDP. Projected expenditures for 2002 represent 1.2% of GDP, and planned increases will bring that measure to 1.8% of GDP in The reason MOH expenditures are such a large portion of the government budget, while remaining a small percent of GDP is because of the low government revenue collection rate. Strengthening revenue collection is one of the key areas for fiscal reform. Any further substantive increases in the MOH budget would depend on the government s ability to further raise revenue, as it is unlikely that 6

7 the MOH budget would continue to expand beyond 12 13% of government expenditures. Though there is always room for improvement, the government demonstrates a strong commitment to public health. Reforms in the Health Sector The health sector in Cambodia has been undergoing substantial development and reform in three main areas organizational, financial, and human resources development since the mid-1990s. In 1996, the Health Coverage Plan was approved, which divided the country into 24 provinces with Provincial Health Departments (PHD), and 73 operational districts (ODs). The OD has two levels of service delivery facilities, the health center (HC) and the referral hospital (RH). Under this system, 940 HCs are to be established providing the Minimum Package of Activities (MPA), with 68 referral hospitals providing the Complementary Package of Activities (CPA). In 2000, it was estimated that 55% of Cambodians had access to primary level health services, defined as living within 10 kilometers, or a two hour walk of a HC. Approximately 80% of the planned HCs are currently in place and functioning. Along with development of the health infrastructure, there have also been financing, budgeting, and management reforms. Reforms include adoption of a financing Charter defining the framework for introduction of user fees, new budgeting mechanisms, and donor coordination mechanisms, as well as increases in staff salaries. The impact of new budgeting mechanisms is discussed in Section II. User fees have been formally approved in 128 HCs (as of Sep 2000), although many more are charging fees without formal approval. Health facilities are allowed to use 49% of the fees collected to supplement staff salaries. Staff salaries are extremely low, in the range of $15 - $30 per month, but recently approved increases should increase salaries 15% - 30% per year on average for the next few years. Despite these increases, salaries are still low compared with acceptable living wages, and the potential earnings in private practice. Staff have strong incentives to spend time at their private practice or to provide curative services which bring in user fees. Since immunizations are free, there may not be very strong motivation for staff to make immunizations a high priority. The donor coordination mechanisms such as the Coordinating Committee (COCOM) and Provincial Coordinating Committee (PROCOCOM) have been successful in improving technical and programmatic coordination, but have not dealt adequately with coordination of financing. To improve financial coordination, a sector-wide management (SWIM) system is under development, whereby donors and the government could commit funding to an agreed upon set of goals and strategies but without basket funding. The health sector in Cambodia is also characterized by a high degree of decentralization. In 2001, 56% of the MOH expenditures went through the PHDs, including drugs that are centrally procured for use at lower levels. The PHDs, the provincial Governors, the provincial finance departments, and the provincial treasuries are all involved in decisions 7

8 on the level of funding to support health services at RH and HC levels, where service delivery occurs. The PHD and OD play an important role in ensuring that funds for outreach are disbursed, and can commit additional funds to support outreach and other activities. Donor Funding of the Health Sector Since its Enhanced Structural Adjustment Facility (ESAF) negotiated with the International Monetary Fund (IMF) in 1999, Cambodia has rebuilt its relationships with the donor community. Although Cambodia has set a broad agenda of reforms, progress has been slow. Donors expressed concern at the 2002 Consultative Group (CG) meeting regarding lack of progress in many areas including forestry management, the legal and judicial reforms, the lack of regular access to budget of the social sector ministries and corruption control. Nonetheless, donor financial commitment remains high, with pledges of aid totaling $635 million, exceeding both the government request ($484 million) and 2001 assistance ($560 million). The government also requested that donors make pledges for the next three years, which did not happen. During that meeting, however, the donors made clear that unless reforms progressed, and the 2003 elections are free and fair, future aid would decline. Of total public sector health expenditures, 66% of funds are from external sources. The table below shows the breakdown of external and government funding for the last several years. As a percentage of total funding, the government contribution has been stable. Breakdown of Gov t and External Funding for Health Year Percent Gov t Percent External % 77% % 71% % 66% Source: MOH The Ministry of Health (MOH) finalized its Health Sector Strategic Plan for in August With the new strategic plan in place, the MOH is well-positioned to discuss donor commitments for the sector to support the strategic plan. II. Immunization Budget Process and Financial Management Budgeting Process The process of budgeting for the NIP is complex because there are multiple funding sources, each with their own budget horizon and procedures. This is further exacerbated by the multiple budgeting mechanisms within the MOH. The service delivery costs for the routine program (ice, transport and per diem for outreach) flow through provincial 8

9 budgets, and the central NIP management team is not responsible for monitoring or distribution of those budgets. Provincial and OD budgets are managed by various budgeting mechanisms, all of which have deficiencies. In addition to the multiple funding sources and government budgeting mechanisms, the different national programs often using external funding do not coordinate their provincial inputs and activities. Even the three units of the NIP do not always plan activities and budgets in an integrated fashion, although efforts are made to increase integration within the NIP. Lastly, there is a culture of over-budgeting requests for government funding since there is a tendency to receive less than the budgeted amount. As a rule, under the traditional budget mechanism, which is still applied in 17 ODs out of 73 and for some centrally purchased items, MOH expenditures are pre-audited by the Ministry of Economy and Finance (MOEF), requiring substantial paperwork and approval before release of funds. This approval goes through the Provincial Governor s office, the finance department and the Treasury, which not only takes a long time, but also provides opportunities for leakage of funds. In order to compensate for these issues, several alternative or pilot funding mechanisms have been established in many districts and provinces. These alternative mechanisms include the Accelerated District Development (ADD) system in 33 ODs, the Priority Action Program (PAP) in 7 Provinces (21 ODs), and contracting out in 2 ODs under the Asian Development Bank s (ADB) current health project. Until this year, the 33 districts under the ADD system were provided advances directly by the central finance department of the MOH, bypassing the provincial level, and ensuring greater access to funds at the OD level. The ODs would be advanced funds, provide reports to the central MOH who was then reporting to the MOEF substantiating expenditures, and their imprest account would be replenished based on the level of expenditures. Data showed that ADD districts accessed a larger portion of their budgeted funds, and may have had higher health facility utilization rates. Beginning in 2002, however, the procedures were revised and ADD districts also receive their funding through the Provincial Treasury. It is unclear how the new procedures will impact funding access. The PAP was introduced in seven provinces in 2000 as another mechanism to ensure timely funding of health activities. These provinces receive quarterly advances to cover their operating budgets. PAP funding was originally proposed to flow directly to ODs, but instead funds are disbursed through the Provincial Treasury to the PHD. Generally, the procedures for the PAP are perceived to be complex and vary from one province to the other, however, PAP provinces have been able to access a larger share of their budgeted funds, compared with the other funding mechanisms. The budgeting done at the central NIP includes only activities or expenses carried out by the central level. Such activities include monitoring from the central level, surveillance, supplemental immunization, training, and information, education and communication (IE&C). One key operational cost of the routine program costs of outreach activities are included in provincial budgets. 9

10 Of the centrally funded activities, the activities for the coming year are presented and discussed in the ICSC meetings. Some donors, such as AusAID and JICA under its Grant Aid facility operate on multi-year budget cycles (2-3 years), so their commitment may be known in advance. Other donors can only confirm a portion of their funding in the beginning of the year., The full funding is often not confirmed until mid-year. In some cases, if funding is not identified, activities may be postponed. Budgeting for capital expenses, such as cold chain equipment or vehicles is done at the central level, and plans for upgrading such equipment is based on a combination of need and funding availability. The service delivery costs of the routine program (primarily ice and outreach related costs) are in principle fully funded through the provincial budgets. The ODs and PHDs are given a total budget annually, using a funding allocation formula based on population and utilization rates. Thus, the ODs and PHDs can prepare their budgets, which must include funding for outreach activities, for which there are specific guidelines regarding the number of outreach sessions to be held (based on the number of villages) and the set per diem, transport, etc. allotted for each session. While in principle these activities are fully funded by government funds, problems arise because of irregularities in funding disbursements, a problem pervasive across all government ministries. The Cambodian government has finalized its first Medium Term Expenditure Framework (MTEF) for the period for four ministries, including MOH. The MOH has developed its MTEF for a longer period ( ) to fit with the Health Sector Strategic Plan. The MTEF exercise has potentially many benefits, including providing indications of overall MOH budget, fostering increased coordination within the MOH between Dept of Finance and Dept of Planning, and generating improved data on donor funding. All these areas will benefit the NIP in its budgeting and financing efforts. Financial Management and Disbursement The problems in financial management and disbursement of government funding affect immunization services particularly acutely. The basic problem is that government cash disbursement is exceptionally slow throughout the first half of the year, so many facilities do not have funds for required operating costs. For example, approximately 14% of the annual provincial health budgets had been disbursed from January June For the last several years, approximately 30-50% of the annual budget is released in the last quarter of the year, and PHDs and ODs rush to spend the funds by the end of the year. This problem is particularly important for the NIP because the beginning of the year is the dry season, and the best time to immunize. However, staff may not travel to conduct outreach because funding is not available. Reduction in outreach during the dry season has significant impact on immunization rates, since the majority of routine immunization is conducted during outreach sessions. It is difficult for the NIP and even for the MOH to have significant impact on the overall MOEF cash management systems. Instead, the most expedient solution to this problem has been to find alternative funding for outreach services, particularly during the first 10

11 quarter when there is potentially high impact. One alternative is identifying donor funding to support outreach during the first quarter, as partially done over the last several years using UNICEF and other partner funds. It has been agreed that GAVI/VF funding will be used to support outreach activities in the first quarter of Further decision on the longer term support for outreach through the NIP will be taken after evaluation of the impact of such support on coverage rates. The management and disbursement of funding at the central level is quite different, and generally simpler. Management of donor funding is very straightforward although some donors provide funding through the MOH, while others provide funding directly to the NIP. All donors require a request or proposal of activities, upon which donors release funds to an account at the MOH or directly to the NIP. Once funds are with the MOH, the NIP managers can obtain the funds with minimal procedures. GAVI/VF ISS funds are accessed the same way, based on a workplan pre-approved by the Immunization Coordination Sub-Committee (ICSC) Technical Working Group (TWG) and the Director General for Health. No one has expressed problems with accessing funds. Depending on the source of funding, reports of expenditures are submitted to the MOH, or directly to the donor providing funds. Expenditure reports for GAVI/VF funds are reconciled within the NIP, without outside review. Expenditures funded by the national budget are handled through the national Maternal and Child Health (MCH) program, which oversees the NIP program. Due to the problems with MOEF cash disbursements, however, it is difficult for the MCH program to commit to funding at the beginning of the year. Some activities are funded on an ad hoc basis over the course of the year, depending on the funding availability at the MCH. In this situation, financial management is relatively simple, but the problem of MOEF cash disbursements affects the NIP s ability to appropriately plan at the beginning of the year. In summary, the budgeting and financial management procedures currently in place make it difficult for the NIP to effectively manage their financing. Although financing of the NIP supplies (vaccines, syringes, and to some extent cold chain) is partly in place by the beginning of the year, there is uncertainty regarding available funding for many other important activities. For example, budgets for social mobilization, training, or monitoring are not fully defined and available at the beginning of the year, and can only be conducted if adequate funding is identified. While the NIP and the ICSC TWG has a good record of finding the required funds during the course of the year, this system does not reinforce the goal of improving the NIP s ability to plan and prioritize activities taking into account financial considerations. 11

12 III. Program Characteristics, Objectives and Strategies Current Situation The NIP seeks to improve child survival and child health by controlling, eliminating, or eradicating all vaccine preventable diseases targeted by the NIP. The current structure of the central NIP consists of three units: 1) service delivery; 2) logistics, training, and information, education and communication (IE&C); and, 3) surveillance. There is an NIP Manager who reports to the Director of MCH for administrative purposes, and to the Director General for Health on all technical and programmatic matters. Under the NIP Manager are three Deputy Managers, overseeing the three units. This management structure was established in 2000, and a recently conducted functional analysis to review the human resources needs and current use should lead to a process of better defining and integrating the individual functions of these three units to achieve the common program goals most efficiently. In addition to the ICSC, which includes a broad range of stakeholders, there exists a TWG overseeing the NIP. Representatives of UNICEF, WHO, CVP/PATH, and NIP staff participate in the TWG, which meets biweekly to ensure coordination of ongoing activities. Broader programmatic issues are brought before the ICSC, which meets at least quarterly to undertake critical decisions. The current immunization schedule for children is shown in the table below. Immunization Schedule for Children Age of Infants Type of Vaccine At birth BCG, OPV, HepB* 6 weeks OPV1, DTP1 or DTP-HepB1 10 weeks OPV2, DTP2 or DTP-HepB2 14 weeks OPV3, DTP3 or DTP-HepB3 9 months Measles Reported routine coverage for all antigens increased in 1999, reversing a three year decline (see figure below). Since 1999, coverage has increased moderately for all antigens, except for TT2+ in pregnant women, which has had more significant coverage increases. Coverage rates by province are shown in Annex A. There are discrepancies between reported coverage data and the DHS data. For example, in 1998 and 1999, the reported DTP3 coverage was 64%, while the 2000 DHS survey of children months showed coverage of 49%. One of the key objectives of the NIP is to increase coverage to 80% for all antigens in all districts by The flat coverage of the last 2-3 years is of concern because total funding for immunization services has actually increased over this period. At the same time, development of the health infrastructure continues, which should support immunization. Some investigation to see whether the operational funds required at the service delivery 12

13 level are accessible, and whether health staff are conducting outreach activities are being implemented (as part of regular post-activities assessments) to evaluate reasons for the flat coverage rates. Reported Immunization Coverage Rates % 80% 70% 60% 50% 40% 30% 20% 10% 0% BCG OPV3 DPT3 Measles TT2+ PW Major achievements of the NIP were interruption of wild poliovirus as well as successful measles and neonatal tetanus control activities. Cambodia was certified polio-free in Cambodia must continue surveillance for acute flaccid paralysis (AFP), and maintain high OPV3 coverage until global eradication of polio is achieved. Ongoing rigorous surveillance and periodic supplementary immunization activities (SIA) are required ensure that Cambodia remains polio free. One of the key weaknesses of the current program impacting financial sustainability is high vaccine wastage. The financial impact of vaccine wastage will be magnified once DTP/Hep B is introduced nationally since it is a much more expensive vaccine relatively. Wastage rates over the last five years for each of the antigens is shown in the next table. There is no overall trend in wastage, and no particular indication of decreases in wastage. Based on initial reports, the DTP wastage rate declined significantly for 2001 (which may be partly a result of shifting from 20 dose vials to 10 dose vials early in the year), but the magnitude of the reduction is surprising and the data must be reviewed. 13

14 Reported Vaccine Wastage Rates * 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% BCG OPV DPT Measles TT *The decline in the wastage rate for DTP for 2001 is not yet confirmed. With the phased-in introduction of DTP/Hepatitis B vaccine, the NIP aims to evaluate new measures for reducing vaccine wastage through improvements in vaccine handling and storage through deployment of new cold chain equipment at HC level and improvement in social mobilization. Staff training on implementation of the Multi-Dose Vial Policy (MDVP) is also planned as a measure to reduce vaccine wastage. Routine services in Cambodia rely on outreach delivery. Delivery of outreach services is a key component of the overall health plan, and there are central level guidelines on how often outreach is to be conducted, the types of services to be provided, per diem to be paid to staff for outreach, etc. Since the health infrastructure is relatively new, and in many areas still under development, it is unrealistic to expect quick transfer of patients to fixed services. Improving the efficiency and effectiveness of outreach services can impact both the NIP coverage and its sustainability. Current Objectives and Strategies The following table presents the current NIP objectives, and the key strategies being pursued to achieve the objectives. 14

15 NIP Objectives and Strategies Objective Raise coverage for all NIP antigens among children under 1 year of age to 80% in a minimum of 50 of 73 ODs by the year 2002, and all ODs by 2005 Maintain capability for rapid detection and containment of any imported wild poliovirus until the time of global eradication Achieve neonatal tetanus elimination by 2005 Effectively control measles as a public health problem by 2005 Effectively control Vitamin A deficiency as a significant health problem by 2005 Reduce Hepatitis B carriage associated with transmission in children, and morbidity and mortality due to other illnesses for which the introduction of new vaccines and technologies is feasible and practical Ensure that all immunizations are given safely and with potent high quality vaccine Improve the efficiency of vaccine delivery and usage Key Strategies Expand of cold chain to include refrigerators at HC level Increased social mobilization Staff training Introduction of birth registries Incentives for community workers Integration of NIP within health services delivery system Strengthening budget support for outreach Maintain excellent AFP surveillance Maintain high OPV3 coverage, particularly in areas prone to importation Conduct periodic supplementary immunization Strengthen NNT surveillance Increase TT coverage for CBAW Improve clean delivery practices and increase utilization of ANC Implement activities targeting age groups other than CBAW Increase public awareness of NNT Maintain rigorous measles surveillance and outbreak response procedures Increase and maintain measles vaccine coverage 90% Conduct SIA as necessary Reduce disability and mortality by providing Vit A during outbreak investigations Improve coordination with Nutrition department for Vitamin A distribution during SIAs Include Vit A distribution during measles outbreak investigations Phased introduction of DTP-HepB vaccine Develop and implement social mobilization plan, staff training, communication/advocacy plan Trial, document and implement methods to reduce vaccine wastage Monitor and evaluate implementation and impact Phased introduction of AD syringes for routine immunizations Continued use of ADs for SIAs Use of potent, high quality vaccines Strengthened cold chain, including refrigerators in HCs Improved system for monitoring AEFI Improve vaccine efficiency during outreach, through implementation of open vial policy and more effective outreach activities Reduce vaccine wastage by disseminating open vial policy, examining vial size impact, and identifying other operational solutions (waterproof bags, sealable containers to store vaccines, etc) Refine vaccine procurement to incorporate new requirements such as waterproof labels, VVMs, etc. 15

16 The strategic plan for achieving the NIP objectives is challenging, and NIP activities have increased over the last two years in order to meet these objectives. These increased activities translate to significant additional funding requirements for the NIP for example, surveillance for NNT and measles began in 1999, TT and measles SIAs are planned for the next several years, and Hep B vaccine is being phased in country-wide. Further increases in inputs will be required, particularly to support additional activities aimed at increasing coverage rates. Funding from the VF will help to fill this gap, but increases in donor and government funding will be required if the NIP is to fulfill its strategic objectives. IV. Baseline and Current Program Costs and Financing The total cost of the immunization program for 2001 was $3.61 million (see Table 1.1), compared with total estimated costs of $4.73 million in 2002 (see Table 1.2). The bulk of the increased costs are due to increases in SIA expenditures (+$650,000) and increases in expenditures for capital equipment (+$250,000). The total cost of the program has increased significantly over the last few years the last estimate of NIP costs estimated program costs of $1.95 million in Both donor and national budget funding have increased significantly to cover increases in the NIP expenditures. The following table shows trends in government and donor funding for 1999, 2001, and Trends in Government and Donor Funding (US$) Increase from 2002/1999 Gov t Funds* 380,010 1,176,284 1,329, % GAVI/VF support 0 157, ,571 N/A Other Donor Funds 1,567,540 2,280,088 2,718,449 73% Total 1,947,550 3,613,372 4,734, % * includes estimate of costs of personnel and of HC outreach activities costs, including per-diem for HC staff to go to villages, which represents the biggest share of the Government contribution since The overall trend in funding for the NIP is very positive, but it may be difficult for donors to sustain such high increases in the future. There is optimism regarding increases in government funding because of planned increases in the health budget over the next three years. 16

17 V. Future Resource Requirements and Program Financing The projections for NIP costs from are included in Tables 2.1 and 2.2. A summary of projected costs and financing is presented in the table below. Potential programmatic and strategic changes to the NIP have not been incorporated because none are planned as of now. However, there is preliminary discussion of potential programmatic changes such as including a second dose of measles, which would increase the costs of the NIP. Such changes to the program would not be implemented for several years, and would only be introduced if funding could be generated. Given the uncertainty of potential program changes, cost projections are only presented for the current program. Summary of NIP Projected Costs Operational Costs 3,784,666 4,995,613 6,161,959 7,160,139 5,400,290 5,751,669 6,604,023 Capital Costs 1,518,115 1,047, , , , , ,156 Total Costs 5,302,781 6,043,176 7,067,124 7,478,930 5,744,848 6,506,103 7,396,179 Secured Financing* 1,606,831 2,387,268 2,548, ,336 28,348 32,600 37,490 Probable Financing 3,655,893 3,185,718 2,676,332 3,936,047 1,640,166 1,714,770 2,077,183 * Secured financing primarily consists of projected GAVI contribution, with a small portion being MOH staff salary. Costs of the immunization program are projected to increase over the next seven years, with some fluctuation from year to year due to SIAs that may be conducted for example, projections through 2006 include costs for polio, measles, and tetanus campaigns. While secured and probable financing for 2003 covers nearly the full projected cost for 2003, the financing gaps are quite large after In 2006, after the last year of GAVI/VF support for vaccines, secured and probable financing are projected to cover 54% of the projected costs. In 2007, that gaps increases further, and secured and probable funding only covers 29% of projected costs although it should be kept in mind that that probable funding is not secure. At least part of the reason for this large gap is that neither donors nor government officials can commit to funding so far out into the future. Even costs that have historically been paid by certain donors or by the government budget cannot be considered secure because of the length of time into the future. A graphical depiction of future financing is shown below. 17

18 Projections of NIP Financing (US$) 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000, Gap Poss External Poss. Gov't Prob. External Prob. Gov't Secure External Secure Gov't As the graph shows, the total funding that is secure and probable declines over time, most notably after 2007, with the end of GAVI/VF support. Although there is some real risk to financing, part of the risk shown in this graph is due solely to the length of forward time commitment. As time goes on, donors will have better estimates of their budget for Cambodia, which will bring some of the possible financing to the probable category. Increases in government financing are another source of financing to reduce the gap. It is the goal of the ICSC to identify funding sources to fill the gap as quickly as possible, even if funding is not secured. VI. Sustainable Financing Strategic Plan and Indicators Opportunities Stable economic growth Cambodia anticipates stable economic growth in the next 3-5 years. Increased government revenues The MOEF has committed to increasing government revenues through better enforcement of tax laws and strengthening tax and customs administration. Increased funding for the MOH The planned increases in the MOH budget total 75% from The NIP needs to position itself to take advantage of increased funding. MOH Commitment The MOH has increased funding for the NIP over the last three years. Strong donor support Overall donor support to Cambodia has been growing, and the government seeks to maintain good donor relationships. Improvement in the health infrastructure A better functioning health system should increase access to services, and consumer trust in the system. Availability of the Vaccine Independent Initiative as a cost-effective mechanism to buy vaccines. 18

19 Challenges The NIP relies heavily on donor support. There is low public awareness of the need for immunizations, and low demand for services. The government s cash disbursement system needs to be adapted urgently to provide funding during the first quarter of the year the best season for delivery of immunization services. The vaccine wastage rates are high (selected wastage rates BCG 84%, OPV 52%, measles 68%). While outreach is an important mode of service delivery, it is not conducted very efficiently and results in a relatively high cost for service delivery in relation to fixed post delivery, which should be the medium to long term delivery strategy. Strategies and Actions Strategy 1: services Increase national government financial contribution to immunization Over the last two years, the MOH has increased its funding to the immunization services with total government funding for 2002 representing 28% of the immunization expenditures. However higher contributions from the MOH budget will be needed. Given the planned increases in the MOH budget over the next few years, there is opportunity to increase funding to the NIP without adversely impacting other health needs. Specific actions to be undertaken are: 1) recommend a target level of government commitment for the next three years with all ICSC members; 2) lobby the MOH decisions makers to discuss this recommended increased commitment; 3) if needed, some partners could facilitate the discussion of the MOH with the MOEF. Strategy 2: Increase provincial level expenditures for immunization services A significant portion of the MOH budget flows through the provincial level by the provincial treasuries. While there are specific guidelines regarding how to budget for certain activities, such as outreach, there is flexibility within the budget, particularly with the ADD and PAP mechanisms. Increased funding commitment from the OD or provincial level can take the form of either increased budget to support immunization activities, or protected funding priority to immunization activities when funding from the MOEF is limited. The NIP should advocate for increased and/or more reliable funding at the provincial level through senior level forums such as the CG meetings of donors. More political pressure to ensure that provinces provide adequate funds for primary health services, including outreach is needed. Coordinating advocacy efforts directed toward the provincial authorities will be challenging since there are 24 provinces in Cambodia. Some external donors provide significant funding across social sectors in certain 19

20 provinces. There may be targeted opportunities for some donors to provide work with provincial level authorities to ensure greater access to funding for social sectors, and primary health care in particular. Also important is to develop broad support and demand for immunization from a broad range of constituents, including women s groups, community development groups, private sector, etc. Some areas that may be appropriate for increased provincial level support include staff training, accounting skills development for request/liquidations of ADD and PAP budget, regular access to outreach budget, increased transport costs for hard to reach villages, or social mobilization to increase coverage rates. Even if the provinces do not provide more funds for immunization, it would be a great benefit if provincial treasuries could play a role to alleviate the funding shortage in the first quarter of the year, which has very adverse effects on coverage rates. Strategy 3: Increase donor funding for immunization While total donor funding for the immunization program has increased in the last few years, further increased funding will be needed in order to meet the increasing cost of the program. New donors will need to be identified beyond the traditional NIP donors in Cambodia. The nature of support will vary from donor to donor. For example, a bilateral donor is undertaking a program to support primary health care services in 16 focus districts. While EPI is implicitly supported through this program, the NIP may be able to work closely with that donor to ensure that specific activities are funded and that immunization target indicators are met. In this scenario, a donor may not actually be committing any additional funds, but instead efforts are made to ensure that already committed funds are used more effectively to improve immunization coverage. In other cases, the NIP would be requesting that donors commit additional funds to support NIP activities. The NIP Manager will need to work closely with members of the TWG to advocate for increased funding with all current and potentially new donors, including NGOs. Improved reporting on the expenditures of the NIP activities supported may be helpful to donors. Developing proposals directly or through partners including funding needs for proposed activities and expected results will be useful in advocacy efforts. Strategy 4: Increase reliability of funding for immunization at all times The most important financial management issue impacting immunization rates is the lack of reliable funding during the first part of the year. The cause of the problem rests largely with cash management within the MOEF, although there are structural changes included in the financial and administrative government reforms that target this problem. It is unlikely that the MOH and NIP will be able to make any immediate changes to ensure timely cash disbursements. For the time being, in order to achieve the NIP objectives, it will be important to develop solutions that can circumvent the cash flow issue. 20

21 Several potential solutions should be explored: 1) coordinate the available funding from UNICEF and NGOs to support outreach activities especially in first quarter and in Chapter 11 ODs and complement these resources by using GAVI/VF ISS funds to support outreach activities; 2) establish a mechanism for donors to exchange funding commitments with the PHD or OD, whereby donors could fund outreach activities in the first quarter in exchange for commitments from provinces to fund other activities in the last quarter; 3) with the MOH Department of Finance, explore the feasibility of provinces delaying expenditure reports for fourth quarter funding by one quarter so that year-end funds could be used for first quarter outreach activities; 4) develop a lending mechanism whereby provinces could borrow funds for outreach in the first quarter, to be repaid sometime later when funding is more readily available. All of these solutions could lead to higher immunization coverage and more effective use of funds. There are external donors who are positioned to support some of these initiatives, although there is the risk that outreach activities become dependent on donor funding. Further discussion within the ICSC is warranted. Another issue for the NIP is the lack of funding over which the NIP has complete discretion to program as needs arise. All of the sources of NIP funding require that funds be expended within a specific timeframe for specific activities. Because of these requirements, there is never any funding available in event of emergency the NIP must go without or mobilize funds on an emergency basis. Better planning within the NIP may help to avoid such situations. Strategy 5: Reduce vaccine wastage As part of the effort to introduce DTP/Hep B vaccine nationwide, there has been much focus on efforts to lower the vaccine wastage rate. The strategies pursued include both national level policy issues and local level logistics and vaccine handling issues. Two national policy issues include broader implementation of the MDVP for both fixed and outreach sessions following deployment of the new cold chain equipment at HC level, and potential savings from new vaccine presentations. Training of health staff will ensure that MDVP is implemented appropriately. The NIP would like to examine the potential effect of new vaccine presentations to lower wastage, including single dose or 5-dose presentations. The financial impact is particularly important for DTP/Hep B vaccine, since it is relatively more expensive. Further analysis is required to see how these presentations could impact total vaccine cost, and to see whether they are available through GAVI/VF. The logistics and vaccine handling issues are addressed through testing solutions to install new fridges at HC level to avoid freezing vaccines, labels falling off vaccines, and water entering the vaccine vials. These strategies are being implemented in the pilot province and will be evaluated for effectiveness, and to see whether they warrant national adoption. 21

22 Strategy 6: Improve efficiency of outreach sessions Outreach services are the primary service delivery mode for immunizations. Because of the health infrastructure in Cambodia is so new, it will take some time to transition people away from outreach to fixed delivery. In the meantime, it is important to make outreach services as effective and efficient as possible, since they represent a large part of the operational costs of routine services. The strategies to improve outreach services include maximizing the number of children immunized at each session and exploring adoption of the multi dose vial policy during outreach. Some activities being implemented to increase the number of children immunized per session include introduction of a birth registry to ensure reaching all newborns and pregnant women, providing incentives to motivate health workers, and mobilization of the targeted population through existing community structures as Village Development Committees, Feedback Committees, village volunteers, traditional birth attendants, local political leaders, etc. Providing better transport (motorbikes) will allow health workers to travel within villages more easily, reducing the number of missed children. Improving social mobilization efforts to increase awareness of the importance of immunization will also increase the number of children at outreach sessions. Implementation of the multi dose vial policy should reduce vaccine wastage associated with outreach delivery, but further discussion on its feasibility is required. Strategic Plan A summary of the strategies proposed and actions to be taken is shown in the following table. A preliminary timeframe for completion of the actions is also shown, along with indicators to be used to measure progress toward objectives. 22

23 Objective/Strategies Actions Objective: Mobilize adequate resources Increase national government financial contribution to NIP Increase provincial level expenditures for NIP Increase donor funding for NIP Objective: Increase the reliability of resources Provide reliable funding for immunization at all times Objective: Increase efficient use of resources Reduce vaccine wastage Improve efficiency of outreach sessions Set targets for government commitment for the next three years with all ICSC members Identify ICSC member(s) to meet with the MCH Director and Director General for Health to discuss increased commitment Ensure that high priority is given to the NIP within the Master Plan for Health, and that appropriate indicators for immunization coverage are targeted Advocate for increased and/or more reliable funding at provincial level at CG meeting On a targeted basis, work with provincial authorities to ensure greater funding access for primary health and other social sectors NIP Manager/TWG to advocate for increased funding Prepare reports of expenditures, activities and results Prepare proposals for new activities and expected results Explore mechanisms to alleviate MOEF cash disbursement issues Train staff to implement WHO MDVP Analyze impact of new vaccine presentations Evaluate other vaccine handling and storage solutions Maximize number of children vaccinated at each session with improved social mobilization Introduce birth registry to access all newborns Evaluate impact of incentives to community workers Implement MDVP as appropriate during outreach Preliminary Timeframe Dec 2002 and ongoing evaluation Dec Mar 2003 and ongoing 2003 and ongoing Mar 2003 and ongoing Mar 2003 and ongoing Jan/Feb 2003 Dec 2002 Mar 2003 Jun 2003 Jun 2003 and ongoing Pilot underway Sep 2003 Mar 2003 Overall Indicator(s) Nat l Bud Exp on NIP GDP-debt service Nat l budget NIP exp Total MOH budget Prov Bud Exp on NIP Total NIP Expenses Donor Actual Exp (prev yr) Proj Need Proj Natl Exp Mechanisms exist to ensure cash is available when needed for key NIP activities (Y/N) Wastage rate (%) of DTP/Hep B combo vaccine DTP3 coverage rate (%) in 5 selected provinces where outreach is the dominant mode of service delivery 23