RWANDA EXPANDED PROGRAM OF IMMUNIZATION FINANCIAL SUSTAINABILITY PLAN SUMMARY

Transcription

1 RWANDA EXPANDED PROGRAM OF IMMUNIZATION FINANCIAL SUSTAINABILITY PLAN SUMMARY A. Description of the key objectives for the improvement and expansion of the program: - More energetic advocacy of and social mobilization for the program - Strengthening program logistics and equipment maintenance - Continuing the introduction of new technologies into the program - Improving the monitoring and tracking system with the aim of reducing the dropout rate - Developing the capabilities of staff involved in program activities - Taking control of waste management and disposal system in the context of injection safety. B. List of current program costs and sources of funding: 1. Reference year (2000): - Total cost: 2,219,108 USD - Financial coverage: a) Government of Rwanda: 1,364,562 USD b) GAVI: 0 c) WHO: 299,236 USD d) UNICEF: 542,725 USD e) Rotary: 7,097 USD f) Belgian Cooperation: 5,424 USD g) Other funding: 64 USD 2. Current year (2001): - Total cost: USD - Financial coverage: a) Government of Rwanda: 1,481,818 USD b) GAVI: 269,404 USD c) WHO: 160,661 USD d) UNICEF: 685,567 USD e) Rotary: 14,043 USD f) Belgian Cooperation: 5,424 USD g) Other funding: 64 USD 1

2 C. Forecast of resource shortfalls during the remainder of the period covered by the support given by the Global Alliance for Vaccines and Immunization and subsequently: 1. Period covered by the support given by the Global Alliance for Vaccines and Immunization ( ): - Total cost: 29,090,667 USD - Financial coverage: a) Government of Rwanda: 8,607,370 USD (30%) b) GAVI: 16,847,438 USD (58%) c) WHO: 426,437 USD (1%) d) UNICEF: 3,173,776 USD (11%) e) Rotary and Belgian Cooperation: 35,646 USD All of this funding is certain or probable. 2. Period after the period covered by the support given by the Global Alliance for Vaccines and Immunization ( ): - Total cost: 22,139,630 USD - Financial coverage: a) Government of Rwanda: 7,313,114 USD (33%) b) GAVI: 4,704,077 USD (21%) c) WHO: 259,673 USD (1%) d) UNICEF: 573,951 USD (3%) e) Rotary and Cooperation Belgian: 30,222 USD Uncovered balance: 9,258,593 USD D. List of strategic priorities of the financial sustainability plan. The list should be based on the diagnosis of the main financial challenges: There are 4 main objectives, each of which involves strategies to be implemented. Objective 1: To bring about an increase in the Government s financial contribution to the EPI by constantly presenting the case for the importance of the EPI in terms of general policy Objective 2: To increase the contribution from other donors (bilateral and multilateral cooperation) with the aim of closing the gap between needs and acquired resources and to reduce dependence on those donors by a greater diversification of sources of funding. Objective 3: To increase the sustainability of funding: Objective 4: To increase the efficiency of the program so as to improve the cost benefit ratio. Rwanda Financial sustainability plan

3 E. List of measures taken in the short and medium term to ensure financial sustainability: Prepare general information brochures on the EPI and distribute them to all governmental instances (Government and Ministries concerned, provincial and district authorities) Step up the information and awareness-building tours in the health districts (1 x / quarter) Launch of awareness-building campaigns in the press (TV, radio and newspapers) Organise a National Immunization Day Establish an objective for the budgetary commitment by the State Incorporate the FSP 1 of the EPI into the national health plan Publish a weekly review of information on the EPI for distribution to the members of the Government, to the ministries most concerned, to the members of the ICC, and to the international partners Organise an annual symposium on the EPI Try to expand the composition of the ICC by bringing in new members Distribute the general information brochures on the EPI to the members of the ICC and to other potential donors Distribute the weekly reviews of information on the EPI to the members of the ICC and to other potential donors Invite potential donors to the annual symposium on the EPI Make funding proposals to potential donors Involve donors to a greater extent in the medium- and long-term planning of EPI budgetary needs Try to obtain financial commitments of more than 5 years Set up coordination between the financial managers in the Ministry of the Health, the Ministry of Finance and the Ministry of Local Administration with the aim of improving the procedures for transfers of funds Help administrators and managers of health districts to anticipate and prepare the requests for funds they send to the central level better Improve the completeness and promptness of vaccination reports sent in by the districts Organise seminars for the supervisors of health districts with the aim of improving their skills in the collection, processing and analysis of data Upgrade the computing hardware for data processing at the central level Strengthen the WHO strategy on the policy for opened vials. 1 FSP: Financial sustainability plan Rwanda Financial sustainability plan

4 4.2.2 Verify the implementation of the new guidelines that have just been issued on stock management Ensure that auxiliary cold-chain technicians apply correctly the guidelines they were given at the time of the May 2002 seminar on cold-chain maintenance Make proposals concerning a strategy to motivate health staff with the aim of reducing staff churn Improve financial monitoring including monitoring at the time of the quarterly and half-yearly reviews of data: develop a financial component of monitoring alongside the technical component Ensure the effective establishment in the health districts of the maintenance units created after the seminar for auxiliary cold-chain technicians; introduce the control and monitoring system for these maintenance units Ensure the proper establishment of the decentralisation of stocks of spare parts Mobilise health promoters to a greater extent Raise the awareness of the grassroots political and administrative authorities Raise the awareness of other opinion leaders at the community level Raise the awareness of the IEC Focal Points 2 of the Ministries concerned. F. List of the indicators used to track progress made towards achieving the objectives of financial sustainability: The general information brochures on the EPI exist and have been distributed to all governmental instances (Government and Ministries concerned, provincial and district authorities) The reports of the quarterly awareness-building tours of the health districts exist and are available There is at least 1 annual press campaign involving the 3 media A National Immunization Day has been organised; the report exists and is available There is an objective for budgetary commitment by the State The FSP of the EPI has been incorporated into the national health plan A weekly review of information is being published and distributed The report of the annual symposium exists and is available There is at least one new member of the ICC each year. 2 IEC (Information Education Communication) focal points are resource persons for information, education and communication in the social ministries. Rwanda Financial sustainability plan

5 2.1.2 The general information brochures exist and have been distributed (cf distribution list) The weekly reviews of information exist and have been distributed (cf distribution list) Donors have been invited to the annual symposium (cf list of invitations and report of the symposium) Funding proposals have been sent out Donors are participating in the preparation of budgetary requirements planning including work done at the quarterly meetings of the ICC The funding proposals relate to funding periods longer than 5 years A written document laying down the procedures for transfers of funds has been produced following the coordination meetings organised with the Ministries concerned A workshop for health district administrators and managers is being organised once a year and includes a component on the management of decentralised funds Reports are more complete and deadlines are met: they reach the central level no later than the 15th of the following month The seminars on the SIS (Health Information System) for health district supervisors are held once a year New equipment has been purchased and is operational; ad hoc training courses have been given Written instructions relating to the policy on opened vials exist and have been sent out to all the districts (bis) A Monitoring of the policy on opened vials component has been included in the guidelines for supervision The Verification of stock management component has been strengthened in the guidelines for supervision missions of health districts The Verification of cold-chain maintenance component of the has been strengthened in the guidelines for supervision missions of health districts A document containing proposals on a strategy to motivate health staff has been produced in the Ministry of Health The content of the financial information section of the periodic reviews of EPI data has been strengthened The creation of Cold-chain maintenance units is verified during the supervision missions of the health districts (bis) A complete inventory is prepared at least once a year There are decentralised stocks in each health district A meeting monthly with health promoters is held in each medical establishment (Health centre and health district hospitals). Rwanda Financial sustainability plan

6 4.4.2 A quarterly meeting, financially supported by the EPI, is held in each health district with the grassroots political and administrative authorities A meeting with all the focal points of the ministries concerned is held at least once a quarter. Rwanda Financial sustainability plan

7 Section 1: General situation of the country and its health system 1.1 General context of Rwanda: Rwanda, a landlocked country, lies in the centre of Africa, or more precisely in the centre of the Great Lakes region. Bounded to the North by Uganda, to the West by the Democratic Republic of the Congo, to the South by Burundi and to the East by Tanzania, Rwanda has an area of 26,338 km², 17,758 km² of which is arable land. Essentially mountainous, Rwanda has a temperate climate; the average temperature is 18 C. Two rainy seasons (the major and the minor) and two dry seasons (the major and the minor) cover the crop year. Rainfall varies from 700 to 2,000 mm of water depending on the region. The country has 11 Provinces and the City of Kigali and is subdivided into 106 administrative districts. Each administrative district is in turn divided into sectors and the sectors into units. The total population of the country in 1999 was estimated to be 8.1 million inhabitants with a density of 307 inhabitants per km 2. The degree of urbanisation is still very low. With current reproduction rates, the women of Rwanda will give birth to 5.8 children during their reproductive life. However, despite the major upheavals that led to the population movements during and after the genocide, the total population in 1997 has exceeded that of after The genocide affected the demographic structure: 49% of the population is under 15, and there are more women than men (54% against 46%). With a high reproduction rate, a young population and a natural growth rate estimated at 2.8%, Rwanda will have more than 11 million inhabitants by This high population density exerts considerable pressure on the occupation of arable land, and the fall in incomes is contributing to an increase in impoverishment. Rwanda has one of the highest rates of infantile mortality: 107 children per 1,000 live births die after reaching their first birthday. Maternal mortality is still very high, 1,071 deaths per 100,000 births for the period The country is in a difficult economic situation 3. The indicator of this state of affairs is the relatively high proportion of people living below the poverty line. In 1997, the figure was 70% while it was only 40% and 53% respectively in 1985 and The decline in agricultural production and the global economic environment (including coffee prices) and also the consequences of the 1994 Genocide are probably among the root causes of this phenomenon. Gross national product (GNP) was 237 USD in 1999 (IPRSP, 2000). Agriculture contributes 47% of GNP, 91% of employment and 72% of exports. The industrial sector accounts for only 19% of GNP and employs less than 2% of the active population. The manufacturing and construction sectors account for 10% and 9% of GNP respectively. After a drop of 50% in 1994, GNP recovered progressively after the war (37% in 1995, about 10% a year between 1996 and 1998, and 6% in 1999), particularly after the considerable amounts of money injected into Rwanda by the international community immediately after the war. 3 This section of the text is based largely on the Interim Poverty Reduction Strategy Paper (2000), Ministry of Finance and Economic Planning, Kigali. Rwanda Financial sustainability plan

8 Expected growth is estimated at 8% per year for the next 15 years. Inflation has been contained during recent years (6.8% in 1998 and 2.4% in 1999). Low and only slightly diversified agricultural production, the cyclical droughts and famines that affect the country, growing unemployment, high transport costs, and environmental decline are all structural problems that have as their corollary dependence on the two main export products (coffee and tea), substantial export deficits (16 USD per capita on average, compared with 100 USD per capita in sub-saharan Africa), an imbalance between income and expenditure, and low private investment (8% of GNP in 1999). The Genocide of 1994 has also left a major heritage of difficulties that include: a considerable reduction in the number of adult men (34% of households are headed by women), a high proportion of orphans, many households without a solid abode, a reduction of small family farms, an increase in the prevalence of AIDS (violence, population movements, etc.), and disappearing human resources. 1.2 Health context: Since the 1980s, the Government of Rwanda has subscribed to the policy of primary health care as defined at Alma Ata. From 1985 onwards, taking on board the policy of decentralisation advocated at Lusaka, Rwanda stared its own thinking on the decentralisation strategies applicable to its health system. The process implemented will be limited to the health regions, which, because of their size, will never be totally operational. In February 1995, just after the genocide, the Ministry of Health, with the support of WHO, started on a health reform that would be adopted by the Government of National Union in March The declared objective of the new policy is to contribute to the well-being of the population by providing quality services that are acceptable and accessible to the majority of the population, and implemented with its full participation. To achieve these objectives, the reform is based on 3 main strategies: (1) use of the health district as the basic operational unit of the system, (2) the development of primary health care through its eight fundamental components, and (3) enhanced community participation in the management and funding of the services. After 5 years of implementation of this policy, 39 health districts are now functional to a more or less advanced degree. Most of the health infrastructure has been restored and equipped. 63% of the minimum package of activities developed from the components of primary health care has been achieved in all grassroots medical establishments. Thirty one (31) districts of the 39 in existence now have a functional hospital, and 90% of the complementary package of activities has now been achieved 4. Community participation is effective in 100% of the medical establishments of the primary and secondary levels, albeit with variable degrees of performance. To strengthen the commitment of the local communities, a vast network of health promoters has been set up throughout the country. Rwanda Financial sustainability plan

9 1.3 Organisational structure of the health system: The health system in Rwanda has a pyramidal structure with 3 levels: central, intermediate and peripheral. The central level includes the management offices of the Ministry of Health and the national referral hospitals. The intermediate level consists of the Provincial Management Office that includes health as part of its remit but has no care units. The peripheral level is represented by the health district, which consists of an administrative base, a primary referral hospital and health centres providing primary health care. The role of the central level is to draft the national health policy and also the strategies and plans for its implementation. It organises, coordinates and supports the intermediate and peripheral levels of the national health system in administrative, technical and logistical matters. Its role is also to monitor and evaluate the medical situation and to coordinate resources at the national level. The task of the intermediate level, which corresponds to the provinces, is to facilitate and guide the process of development of the operational level (health district), for which it provides administrative, logistics, technical, and policy supervision. The peripheral level is the operational unit of the district, consisting of an administrative base, a district hospital and the primary medical establishments, mainly the health centres. It deals with all the health problems of a well-defined population. With the participation of that population, it plans, coordinates and implements the health activities of its geographical area. At the level of the district structures, decisions are made collegially by a number of committees. The management structures of the district are the district health committee, the district foundation team, the hospital health committee, and the health committees of the health centres. The composition, role and remit of these committees have been defined. In order to provide clients with the best care possible, a referral-against-referral system is staged on 3 levels according to the technical skills required and the rational use of resources. 1.4 Decentralisation of the health services: As in most African countries, the process of internal reorganisation of the health system in Rwanda has been overtaken by administrative and policy decentralisation reforms that are causing upheavals in the institutional environment, leading to new relations with administrative authorities and political actors, and forcing the health sector to make considerable readjustments. As a prelude to the application of the decentralisation policy, the Government of Rwanda embarked on the implementation, starting in 2000, of measures to decentralise the budgets of peripheral services. This means that the credits of the decentralised services are managed by the province, which, in collaboration with those in charge of the services, should be able to ensure they are used properly. Since the decentralised services of the Ministry of Health, unlike those of the other ministries, already enjoy considerable management autonomy the context of the health system, the usefulness of considering the implementation of this measure is understandable. Consideration of measures to decentralise budgets is followed by an analysis of the administrative and policy decentralisation reforms from the point of view of their implications for the health sector. The analysis consists mainly of highlighting the issues of the expectations of the Rwanda Financial sustainability plan

10 various actors in the new context, and the identification of the challenges and opportunities accompanying the reforms. This is the framework within which the specific case of the mutualist health system will be examined to see where opportunities can be found in the decentralisation reforms to solve some of the problems arising from its development. The interest that the Ministry of Health and the various partners are showing in the question of decentralisation reforms is thus justified by a legitimate need to put the health sector in a comfortable situation that will enable it to take on board the various reforms in a stance favourable to the preservation of what it has achieved and the achievement of its objectives. Rwanda Financial sustainability plan

11 Section 2: Financial management The State s contribution to the operations of the Ministry of the Health is limited, remaining below the level of 4% of the national budget, which corresponds to about 1.25 USD per capita per year. According to the 1999 review of public expenditure, 60% of these funds go to the peripheral health services, 15% are allocated to the referral hospitals and 26% to the central and provincial services. Three quarters of the budget are devoted to providing services and no more than one quarter to administration. 80% of expenditure is made at the level of the health districts. It should however be noted that donors largely support the referral hospitals and the operation of the central level services. The population s average contribution to the operation of the public structures is 0.5 USD per year per capita 2. All in all, according to the estimates made in the context of the national health accounts, total contributions by the population (public and private services, traditional medicine) would be 1.5 USD to 2 USD per year per capita, which is a long way from the 5 USD per year per capita observed in sub-saharan Africa. The dependence of the Ministry of Health on external aid is considerable, because some 50 to 60% of the sector s financial envelope comes from international cooperation, compared with 20% for the Government and 30% for the population (1998 data). This dependence is tending to diminish, but to the detriment of the total envelope, which is due to fall from a little under 20 million dollars in 1998 to less than 10 million dollars in During the 1999 spending review, one study estimated that 8 USD per capita per year would be necessary to fund a capable district-based system while currently, adding up all the possible sources of funding, we arrive at a figure of only 3 to 4 USD per capita per year. The question of the long-term funding of the decentralisation policy is particularly acute today. The funds allocated by donors to the vaccination program are deposited directly into separate Ministry of Health accounts opened with the National Bank of Rwanda. Official signatories to these accounts are appointed by the Ministry of Health so that a withdrawal of funds requires at least two or three authorised signatures. Where the financial management of the funds allocated to the program is concerned, it can be seen, thanks to the advocacy and awareness-building efforts directed at the decision makers, that there has been some improvement in the process of budgetary decisions. However, there are still delays due mainly to administrative sluggishness; the problem becomes more acute where transfers to the peripheral structures are concerned. Management of the funds allocated by the Government and donors is transparent as far as possible. Use of the funds is justified in accordance with the accounting methods defined by the Ministry of Finance and is monitored by the auditors mandated by the Government (Office of the Auditor General). The financial partners of the program have a right of scrutiny in relation to the management of the funds allocated, and the Ministry of Health keeps them informed of the use of the funds, including by regular financial reports. When necessary, changes people want to make in the mechanisms for managing the funds are the subject of exchanges between the Ministry and its partners at the time of the half-yearly or 2 Partnerships for Health Reform & World Health Organization (2000) 1998 National health Accounts in Rwanda, Ministry of Health, Kigali. Rwanda Financial sustainability plan

12 yearly review meetings. The EPI Inter-agency Coordinating Committee is the preferred venue for this type of exchange. Purchases of equipment and other supplies for the program are made in accordance with the rules defined by the National Tender Board. For all purchases of an amount not exceeding 3 million Rwandan francs (about 6,000 USD), an internal commission of the Ministry of Health meets and, using clear and transparent procedures, examines the various offers. If the transaction is in excess of 3 million Rwandan francs, the transaction must be put out to public tender through the National Tender Board. Rwanda Financial sustainability plan

13 Section 3: Characteristics, objectives and strategies of the Program 3.1 Brief background of the EPI in Rwanda : The Government of Rwanda has made the fight against childhood diseases, particularly by prevention, one of its priorities. That is the context in which the Expanded Program of Immunization was created in 1978 to combat six vaccination-preventable diseases: tuberculosis, poliomyelitis, diphtheria, tetanus, whooping cough, and measles. The program had achieved major successes in vaccination coverage until just before the genocide that plunged Rwanda into mourning in From April 1994 to August 1994, practically all the activities of the EPI were halted throughout the national territory. The assets of the program were plundered and skilled human resources became very scarce. The program was re-launched in September 1994 by the Ministry of Health with the support of its traditional partners. The cold chain was restored and staff progressively established. The EPI is currently operational in all the medical establishments of the country. The results achieved during the past 5 years are by and large satisfactory. 3.2 Overall mission of the EPI: To improve the health of children by reducing infant and juvenile morbidity and mortality due to vaccination-preventable diseases. 3.3 General objectives: - To boost the services provided by the vaccination services so that they are of high quality and sustainable - To accelerate efforts to achieve the eradication of poliomyelitis, and the control and elimination of measles and neonatal tetanus - To introduce sustainably new vaccines and appropriate technologies into the national vaccination program. 3.4 Specific objectives: - To strengthen the national vaccination system so as to achieve by % vaccination coverage for all antigens, in all the health districts of the country, and to keep it above that level for subsequent years - To eradicate poliomyelitis by To eliminate maternal and neonatal tetanus by To bring about a reduction of morbidity and mortality due to measles to less than 0.01% per birth cohort by To make vitamin A supplement part of routine vaccination services in 100% of health districts by To ensure that medical establishments are in control of the aspects of injection safety management, including safe waste disposal, by 2004

14 . - To ensure the integration of active surveillance of the diseases targeted by the program and especially those targeted for eradication, control or elimination in 100% of health districts. 3.5 Strategies adopted to achieve the objectives: - Planning of action at both the national level and at that of the health districts - Development of the capabilities and continuous training of staff - Intensified advocacy, social mobilization and communication to change behaviour in favour of the program - Lobbying for political commitment at the highest level for the program - Strengthening of logistics, the supply system and quality of vaccines, and also of equipment maintenance - Management of the program: quarterly reviews, supervision visits, monitoring and evaluation. 3.6 Partnership: The program has had an operational Inter-agency Coordinating Committee (ICC) since The Committee is made up of the senior officers of the Ministry of Health, the funding partners of the EPI (WHO, UNICEF, USAID, Rotary International, ) and other parties interested in being part of the Committee. The ICC plays a technical role and one of advocacy in favour of the program. Its meetings are held regularly and are documented by minutes. The Committee is open to new members who demonstrate the intention of joining. The Ministry maintains regular and excellent relations with the representatives of the churches that manage almost 40% of the medical establishments in the country. A convention between the Government and the accepted parties is about to be made official. The various parties involved are regularly brought into strategic thinking either at the local level (where they form an integral part of the district foundation teams or the community management committees) or at the central level, at the time of coordination meetings or of the strategic workshops to which they are regularly invited. There is however no formalised coordination framework yet at the central level. Relations with the private and traditional sectors are very little developed. As to vaccination activities, the EPI has just established close relations with the private medical establishments of the city of KIGALI, by providing them in particular with vaccines and vaccination equipment free of charge whenever coldchain conditions so allow. The EPI is working in close collaboration with the other programs and divisions of the Ministry of Health, and also with the provinces and health districts. The program is also building up a partnership with the various ministries by requesting their support, especially at the time of national or local immunization days. Within the grassroots community, the program relies on the health promoters, whose assistance is increasingly appreciated, including help in reducing vaccination dropout rates.

15 3.7 The provision of vaccination services: Routine vaccination: Routine vaccination applies to children between 0 and 11 months of age. It also includes in its program the vaccination of pregnant women. As previously mentioned, the national vaccination program was disrupted by the war of However, the Government of National Union, in its efforts to reconstruct the country, has made the program one of its main priorities. The assessment of vaccination coverage carried out two years after the war showed that the rate of participation in initial vaccination was around 91%, but that the proportion of children who completed the recommended series of vaccinations (traditional vaccination calendar) was little more than 60% of the target. It goes without saying that to achieve the post-war level, enormous efforts and means had to be applied. According to an assessment of program performance carried out in September 1998, the major problems identified as obstacles to the proper operation of the program are the following: A reduction in the efforts to monitor and supervise the activities of the EPI at all levels A fall in the efforts to increase the awareness of parents of the need for several vaccination visits, resulting in a high dropout rate The use of sterilizable syringes for injections, which caused parents to lose confidence (problems associated with injection safety) Insufficient training of staff in EPI management at all levels and particularly at the peripheral level Weaknesses in the system of medical information Failure to control the target population variable, resulting in under- or over-estimates of the denominator A halting of outreach strategy activities, resulting in vaccination services becoming physically inaccessible in several parts of the country Failure to match the supply system to demand, resulting in frequent shortages of vaccines, vaccination equipment and fuel Inadequacy of the cold-chain maintenance service. Two years after these findings, the program has entered a phase of redynamisation thanks to the support of GAVI and the Global Fund for Children s Vaccines and also to the efforts made by the Government, especially in the purchase of vaccination equipment (autodestruct syringes and safety boxes) for all vaccination injections with the aim of protecting them. The GAVI funds have made it possible to re-launch the activities identified by the districts as likely to increase vaccination coverage rapidly. These include: ❾ The training of health workers in EPI management ❾ The holding of quarterly meetings to evaluate vaccination activities between district foundation teams and the holders of health centres ❾ Support for vaccination activities using the outreach strategy ❾ Support for supervision activities at all levels ❾ Support for monitoring activities based on the determinants of vaccination coverage ❾ The purchase of schedulers for the active search for dropouts

16 ❾ Support for updating the EPI target population by strengthening the work of health promoters in the field ❾ Involvement of the private sector in routine vaccination activities. Coverage 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Changes in vaccination coverage BCG DTP3 OPV3 MEAS TT2+ Antigens es: Sourc e: Ministry of Health/St atistics Division Avail ability and use of vacci natio n servic Vaccination services are completely integrated with the routine activities of the medical establishments. Over 90% of vaccinations are given under the stationary strategy. According to the survey of vaccination coverage carried out in 1999, the degree of accessibility of vaccination services, which shows up as the number of children that had received the first dose of DTP, was 93%. The survey showed the existence of dropout rates of 9% between DTP 1 and DTP 3 and 16% between DTP 1 and MEAS. With the support of the GAVI funds intended to strengthen the vaccination services, the Ministry of Health has put in place strategies aimed at reducing dropout rates, including: - An active search for dropouts through the health promoters - A monitoring system introduced at the level of the health districts. The system consists of: o correctly determining the denominator by monitored activity (reliable estimate of the target population) o estimating the availability of the resources necessary for the performance of vaccination activities o measuring geographical accessibility so as to be more familiar with people who have difficulties in attending vaccination services easily (planning of outreach strategies) o measuring the use of services o calculating the appropriate and actual coverage of the measures developed Introduction of new vaccines into the routine EPI:

17 Rwanda took the initiative, with the support of GAVI, of introducing new vaccines into its vaccination program starting in January The vaccination calendar has been supplemented by vaccination against hepatitis B and type B hæmophylus Influenzæ. These two new antigens have been associated with traditional DTP and are administered in the form of a pentavalent vaccine: DTP-HepB/Hib. This combined form has the advantage of limiting the number of injections per child and its incorporation into the program has not encountered any difficulties, since it has not disturbed the usual vaccination calendar. The vaccination calendar in effect in the country is as follows: Antigen Age at first dose Minimum interval between two doses Number of doses BCG At birth - 1 Polio At birth 4 weeks 4 DTP -HepB/Hib At 6 weeks 4 weeks 3 MEAS At 9 month/s - 1 TT First contact with the pregnant woman - 4 weeks between TT1 and TT2-6 months between TT2 and TT3-1 year between TT3 and TT4-1 year between TT4 and TT The cold chain: At the central level, cold-chain equipment consists of a positive cold chamber and also freezers and refrigerators. Current storage capacity is estimated to be insufficient to be able to store the vaccines required for a 6 months period, including the stock of new vaccines. The cold chamber, which survived the pillaging of the 1994 war and the fire of July 1998, is causing enormous maintenance problems and has to be replaced. The sustainability of the program requires continuous renewal of the cold-chain equipment not only in the EPI central warehouse but also at the level of the districts and health centres. An inventory of cold-chain equipment was brought up to date in November 2001 and provided important information on the type, age, operational status, and capabilities of the cold chain at various levels. After the operation, the following recommendations were made: ❹ ❹ ❹ ❹ ❹ ❹ Renovate the central level cold chamber Install fire-fighting equipment at the central EPI Renovate the electrical installations and the emergency generator of the central EPI Replace freezers and refrigerators more than 5 years old at each level Replace domestic freezers and refrigerators with appliances that are appropriate for vaccine storage (without CFC) Make spare parts available for the cold appliances available at each level

18 Action taken: - A contract for the renovation of the cold chamber has just been awarded to a local company after a tender put out by the National Tender Board. This will entail the renovation of the existing cold chamber, the installation of a new 30m 3 mixed (positive/negative) chamber, the installation of a fire-prevention system (extinguishers, lightning conductors, etc) and an emergency generator - Rotary International has just made a donation to the EPI consisting of cold-chain equipment (2 freezers, 5 large refrigerators, 15 small refrigerators, cool boxes, and spare parts for this equipment) - A plan for the renovation of peripheral level equipment is being finalised in line with the recommendations stemming from the inventory carried out in November The supply of vaccines and other supplies: Until now, UNICEF has been the exclusive supplier of the vaccines used in routine activities with the exception of the new vaccines provided by GAVI. The large increase expected in the budget allocated to the national vaccination program for 2003 will mean that routine vaccine requirements (with the exception of new vaccines) will soon be paid for entirely by the Government. It should be noted that the Government contributes to the purchase of vaccination equipment and has already released about 400,000 USD, thereby covering requirements for auto-destruct syringes for Injection safety The Government of Rwanda has adopted since 2001 the systematic and exclusive use of auto-destruct syringes and safety boxes both for routine vaccination and for all mass vaccination campaigns. An assessment of injection practices in the country was made only recently (August 2002). The results of that assessment enabled the drafting of a five-year plan of action to improve injection safety and risk-free disposal of injection waste in Rwanda. The activities scheduled in the plan include the training of health technicians in both the public and private sectors, the mobilisation of the community in injection safety matters, supplies of injection equipment and safety boxes, the construction of modern incinerators for each medical establishment, the construction of an equipment storage depot at the central level, monitoring and evaluation of activities, etc. The overall objective of the Ministry of Health in this area is thus to ensure that by 2003 all injections given are free of risk for the beneficiary, the care provider and the environment. The strategies for achieving that objective range from the choice of injection equipment, via the calculation of the necessary supplies, to methods for the safe destruction of sharps. Obviously the implementation of the plan requires the combined efforts of the Government and of the financial partners of the program.

19 3.7.2 Supplementary immunisation activities NIDs to combat poliomyelitis: Rwanda has been participating since 1996 in the global effort to eradicate poliomyelitis. From 1996 to 2002 the country ran successfully five rounds of National Immunization Days (NIDs) and two rounds of Local Immunization Days (LIDs). As can be seen from the graph below, coverage during those campaigns has grown progressively and has been kept above 95% in the last four years. This success is due mainly to the following factors: - social mobilisation supported at the highest political level - a multi-sectoral partnership - cumulative experience in the organisation of NIDs Changes in vaccination coverage of NIDs/LIDs/Polio, Coverage Coverage 1st round Coverage 2nd round Coverage Average (NID) (LID) Period As part of inter-country medical cooperation, the mass vaccination campaigns were often organised in synchronisation with the countries of the sub-region. Rwanda can now rely on good routine vaccination coverage, the fairly high number of NIDs/LIDs organised successfully, and the high standard of surveillance of acute flaccid paralysis (AFP) to be ready for 2005, the year for certification that poliomyelitis has been eradicated. If the epidemiological situation in the neighbouring countries does not compromise what has been achieved, Rwanda will not need to organise any more NIDs until just before the year of certification, i.e. in Strategies to combat measles: As part of the acceleration of efforts to control measles in Rwanda, a strategic fiveyear plan ( ) has been drawn up. The plan has been revised ( ) so as to bring it into line with current epidemiological realities and thus to take account of regional

20 orientations in the fight against measles. In addition to the strategies to step up routine vaccination activities, the country has always taken the opportunity offered by the NIDs to associate with them vaccination against measles and the administration of vitamin A. The campaigns of 1999, 2000 and 2001 targeted children between 9 and 59 months old. The plan is based on the following strategic components: - Running a nation-wide campaign in the first quarter of 2003 for all children from 9 months to 14 years of age - Increasing the coverage of routine vaccination against measles among children under one year of age in successive birth cohorts - Providing active surveillance based on cases - Providing proper care of all children with measles so as to minimise measles mortality. The strategies for implementing the plan will be based on stepping up advocacy and social mobilization, training of staff, communication to change behaviour, strengthening of logistics (transport and cold chain), multi-sectoral partnership, and community participation Strategy of the fight against NMT: The fight against maternal and neo-natal tetanus in Rwanda is centred around four major strategies: Strengthening of routine vaccination (TT) Identification of the areas at high risk from tetanus Organisation of mass vaccination campaigns for women of child-bearing age in high risk areas Stepping up active surveillance 3.8 Surveillance of diseases: Surveillance of the diseases targeted by the EPI is entirely integrated with general surveillance by the Ministry of Health. Three EPI diseases are on the list of alert diseases: measles, maternal and neo-natal tetanus, and poliomyelitis (AFP). Very recently, paediatric bacterial meningitis was added to the list with the aim of measuring the impact of the new vaccines on morbidity and the mortality attributable to haemophilus influenzae.

21 Number of cases of diseases targeted by the EPI recorded in medical establishments, from 1997 to 2001 Year Disease Measles MNT AFP Source: Annual report of the Ministry of Health Measles During 1998 and 1999, the incidence of measles was high not only among the infant and juvenile populations, but also among adults. The majority of cases were reported in the areas of the West of the country, where insecurity was rampant during that period. It was also during that period that a fall in vaccination coverage was observed. It should however be stressed that the introduction of the EPI has brought about a remarkable drop in the incidence of measles throughout the country as compared with the pre-epi period. In fact, the country experienced less than 1,000 cases in 2001, or a reduction of more than 95%. Case-based surveillance was introduced in the health districts in 2001 but is still very limited. A national public health laboratory that has been functioning for almost two years provides the analysis of samples and enables accurate confirmation of measles diagnoses. The collection of samples at the medical establishment level needs to be improved and strengthened. Priority activities include the training of staff, the supply of the necessary equipment and the introduction of a system for transporting samples Acute flaccid paralysis (AFP) Active surveillance of AFP started in May 1998 and has been established successfully in all the health districts of the country. Efforts will continue in this area to improve performance, particularly in health districts with a low rate of detection. Awareness-building meetings are organised at the district level with the aim of involving the community in active surveillance of AFP through the health promoters.

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23 Section 6: Strategic plan and indicators of the financial sustainability of the EPI: 6.1 General overview of the financial sustainability of the EPI: General structure of the costs of the EPI: Period : From 2000 to 2001, total expenditure rose by about 400,000 USD to reach 2.6 million USD - a growth rate of 18%. Over half of the increase was related to the purchase of vaccines and injection supplies. That was because of: - the growth of the population - the improvement in vaccination coverage. - the organisation of the National Immunization Days (in 2000, only Local Immunization Days took place; they relate to only certain of the health districts). Staff costs increased by 50,000 USD (+ 8%); this is partly explained by: - the automatic increase in salaries because of seniority and of incumbents regular performance in their posts - the raising of the level of skills of national staff, which has led to scale increases Period : In comparison with the previous year, there has mainly been an explosion of the costs of vaccines, particularly Pentavalent, the average annual cost of which is 3.9 million USD. That average annual cost accounts in itself for 1.5 times all vaccination costs in 2001 and is more than ½ of the costs for the period In total, the average annual costs of the EPI are thus multiplied by a factor of 2.8 as compared with the current year. If the cost of Pentavalent 5 is factored out, however, the total average annual cost is about 3.3 million USD - an increase of 27% over the total cost in 2001, which is a year without Pentavalent. And if it is assumed that the growth of expenditure is linear over the whole period, the annual rate of increase is about 9.5% a year, which can easily be explained by the rate of population growth, the improvement in vaccination coverage and the inflation rate Period : The findings are similar to those of the previous year: Pentavalent consumes a large part of the annual budget (more than 54%). But if Pentavalent is disregarded, the average annual cost of vaccination is about 3 million USD - a fall compared with the pervious period. This is explained by the fact that in 2003 and 2004 two vaccination campaigns have been scheduled, one against measles, the other against poliomyelitis, while for the period , other campaigns are 5 It might be objected to this reasoning that if Pentavalent is removed from the calculations, it should be replaced by another product to enable a valid comparison of the two periods. That substitution product is in fact the DTP that was used formerly and the cost of which is more than 10 x lower than that of Pentavalent; so ignoring this in the reasoning does not change matters fundamentally. Rwanda financial sustainability plan of the EPI Section

24 also planned, but their costs have not yet been determined. They are therefore not included in the budgets at this stage General structure of funding of the EPI and prospects during the period covered by the Global Alliance for Vaccines and Immunization and for the subsequent period: For the period 2000 and 2001, the Government of Rwanda s share of funding of all expenditure is about 59% of total expenditure. For the period , it falls to 28%. As in the case of the sudden increase in expenditure from 2002, this sharp fall is explained by the by the introduction of Pentavalent, the cost of which is covered in its entirety by the Global Alliance for Vaccines and Immunization. In reality, although the Government s relative share decreases, its contribution in absolute value increases: it is 2 million USD a year on average over the period , compared with its contribution for 2001, which is 1.5 million USD. In other words, if it is assumed that the growth of the Government contribution is linear, that would mean a rate of growth of more than 13% a year for 4 years, compared with For the period , its average annual contribution will continue to increase: it will be 2.4 million USD a year, which is almost double that of the reference year. It may therefore be stated that the Government s efforts to increase its contribution to paying for the costs of the vaccination programs are very considerable even though, in the tables, those efforts are somehow obscured by the overwhelming and new share represented by the purchase of Pentavalent and its funding by the Global Alliance for Vaccines and Immunization. This moreover poses a problem for future funding: who, in fact, will take over once the Global Alliance for Vaccines and Immunization ends its support? Given the high cost of Pentavalent, it would seem difficult to contemplate the Government s taking over from GAVI, and in any case not immediately. Indeed, if it wished to do so, it would have to increase by a factor of over 2.5 from 2007 the amount of its annual contribution to the costs of the EPI for that year. It seems difficult to envisage that at present. And there is nothing to suggest that other donors will take over for such high amounts. There is therefore a risk of finishing up in a blind alley. At worst, one could imagine dropping Pentavalent and going back to the old DTP. But that would of course mean a major loss of quality in therapeutic terms and in terms of ease of vaccination. Furthermore, it is not certain that DTP will still be available on the market in a few years time. To wind up this general overview, it may be said that, without Pentavalent, the financial sustainability of the vaccination program would have been almost completely ensured by the Government. Indeed, for the period , the average annual shortfall to be funded by other donors, disregarding Pentavalent and in a worst-case scenario (no contribution from UNICEF or WHO to operating costs), would have been only about 400,000 USD a year, or 13% of annual costs. One could be reasonably sure of being able to cover the deficit. The use of Pentavalent turns these prospects on their head and makes them much more gloomy. Rwanda financial sustainability plan of the EPI Section