Financial Sustainability Plan

Transcription

1 Republic of Yemen Ministry of Public Health & Population Primary Health Care Sector Expanded Program on Immunization Financial Sustainability Plan January 2005 Financial Sustainability Plan / Jan 05 /Yemen 1

2 Financial Sustainability Plan Yemen Acronyms Executive Summary Section 1 Impact of country and health system context on Immunization program costs, financing and financial management 1.1 Country profile 1.2 Macroeconomic performance 1.3 The health sector 1.4 Finance of the health system 1.5 Health planning & budgeting Section 2 Program Characteristics, Objectives and Strategies 2.1 Introduction 2.2 Program objectives and strategies 2.3 Organization of the EPI 2.4 EPI services and performance 2.5 EPI partners 2.6 Inter-agency Coordination Committee Section 3 Current Program Expenditure and Finance 3.1 Qualitative information prevaccine fund program 3.2 Sources of immunization funds 3.3 Current EPI funds 3.4 Trends in EPI expenditures 3.5 Basic analysis Section 4 Future Resources Requirements and Program Financing / Gap Analysis 4.1 Introduction 4.2 Major challenges facing expenditures and costs 4.3 Projection of resource requirements 4.4 Futures financing level projection and patterns 4.5 Gap estimates 4.6 Analysis of the gap Section 5 Sustainability Financial Strategy, Action and Indicators 5.1 Introduction 5.2 The main drivers of EPI cost Financial Sustainability Plan / Jan 05 /Yemen 2

3 5.3 Main EPI strengths 5.4 Main EPI weaknesses 5.5 Main opportunities 5.6 Main weaknesses 5.7 Main constraints and risks 5.8 Strategies towards sustainability 5.9 Short term changes 5.10 Medium term changes 5.11 Action plan 5.12 Discussion with EPI partners Section 6 Annex 1 Annex 2 Annex 3 Annex 4 Annex 5 Annex 7 Annex 8 Stakeholders comments Future resource requirements Secure funds Probable funding Secure and Probable funding Members of FSP committee Agenda of ICC meeting, Attendance, Minutes of the meeting Acknowledgment Financial Sustainability Plan / Jan 05 /Yemen 3

4 Acronyms 5YDP BCG CSO DHS EFARP EPI FSP GAVI GDP GNP GoY HBV HF HSR ICC IDA IMR JICA MDGs MoF MoPHP MoPIC MMR MNT NGOs NHA NIDs Penta PHC PHR+ PRS OPV SIAs SNIDs TT U5MR UN UNICEF USAID Vit A VP WHO Five-year Development Plan Bacillus Calmett and Guiran Central Statistical Organization District Health System Economic, Financial and Administrative Reform Extended Program on Immunization Financial Sustainability Plan The Global Alliance for Vaccines and Immunization Gross Domestic Product Gross National Product Government of Yemen Hepatitis B Vaccine Health Facility Health Sector Reform Inter-agency Coordination Committee International Development Agency Infant Mortality Rate Japanese International Cooperation Agency Millennium Development Goals Ministry of Finance Ministry of Public Health & Population Ministry of Planning and Development Maternal Mortality Rate Maternal & Neonatal Tetanus Non-governmental Organizations National Health Accounts National Immunization Days Pentavalent Vaccine Primary Health Care Partners for Health Reform plus Poverty Reduction Strategy Oral Polio Vaccine Supplementary Immunization Activities Sub-National Immunization Days Tetanus Toxoid Under-Five Mortality Rate United Nations The United Nations children s Fund United States of America for International Development Vitamin A Vertical Program World Health Organization Financial Sustainability Plan / Jan 05 /Yemen 4

5 Executive Summary Financial sustainability plan is an essential step to sustain and improve EPI program through this multiyear detailed plan, which will enable the program to know when it has adequate and reliable funding, combined with efficient use of resources. The plan will serve also as an advocacy tool for resource mobilization. Yemen faces serious economic and social challenges affecting the public health sector and its efforts to improve the general health situation nationwide. This country with its vast ancient history of civilization is reviving and its modern history has been a story of struggle towards prosperity. Much has been achieved but much more is expected. Human development is the ultimate goal and better health would be the choice. Since the start of its operation in 1978, the Expanded Program on Immunization (EPI) has expanded and currently offers its immunization services towards seven vaccinepreventable diseases. The last antigen to be introduced has been the hepatitis B vaccine since 1998, in addition to tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles which have been used earlier. The country has been polio free since 1998, and measles is still an endemic disease, while high risk approach is being used for achieving the MNT elimination. Major efforts are exerted to achieve the best use of resources. The program offers its services through the public health sector network through fixed, outreach and mobile services. The EPI strategy is to increase the coverage rates, which are currently around 78% for 2004, and ultimately reach the global goal. The pentavalent vaccine would be introduced in 2005 onwards. The program aims besides increasing the level of coverage of the pentavalent and OPV; to achieve a 60% coverage of TT+ for pregnant women by 2007, interruption of the indigenous measles virus and eliminating neonatal tetanus by the year Other objectives of the program are: sustaining the interruption of the polio virus and ensuring safe vaccination. Yemen is one of the least development countries and confronts a couple of challenges in various areas. In a couple of decades the economy as well as overall development has been growing but with a couple of periods of shortcomings. The major governmental revenue is from oil exports and although half of the population works in the agriculture sector their contribution to the overall economy is low. Most promising sectors in the future are fishery and tourism as well as boosting of the oil industry through exportation of gas reserves. Economic growth has been realized after public reform efforts in the mid nineties, but that had negatively affected the purchasing power of the local currency. A Poverty Reduction Strategy (PRS) was formulated to remedy the reform effects which had resulted in the fact that 42% of the population living under the poverty line. Within the PRS, more resource allocation to social sector has been emphasized on; namely health and education. The level of funding to the health system has not been substantial; the share of the MoPHP from the total government is 4.1 % which is 1.6 of the GDP. The aim is to increase this allocated share to 6% of the government budget and 2% of the GDP by the year The planning and budgeting process, currently carried in a decentralized manner, is early to evaluate. The major constraint Financial Sustainability Plan / Jan 05 /Yemen 5

6 in regard is the current line item budgeting which inefficient compared to activitybased budgeting. In mid 2004, the MoPHP has been restructured and a new PHC sector was introduced. The EPI lies within this sector and is receiving heightened attention. Within the overall Health Sector Reform Strategy of 1998, it was anticipated that the provision of accessible, affordable, quality and efficient services would be the ultimate aim. The DHS approach, which was prioritized by the ministry within the overall framework of decentralization, has delegated the planning and implantation role to a lower, more effective level. The districts plan for EPI services are among other services and much attention is to be directed towards raising their awareness and prioritization of immunization services. Nevertheless, the EPI remains as the governing body supervising, monitoring, supplying and ensuring nation-wide immunization goals are realized. The donor agencies namely; WHO and UNICEF have supported the EPI since it had commenced in 1978 and their input and commitment since then has been substantial. Other partner agencies have joined and currently the program receives support from the former two in addition to JICA, WB and USAID. The EPI provides its services through the public health facilities network with minimal involvement of the private sector. The total cost of the immunization program was (in US$ million) 17, 15.5 and 15.4 in 2001, 2002 and 2003 respectively which include also supplementary immunization activities. The decreases in the amount of funding from 2001 to 2003 (Pre-Vaccine and Vaccine Fund Year) is explained by the fact that supplementary immunization activities, which were conducted in 2001 and 2002 constituted the added amounts in the expenditure, rather than the cost of routine recurrent cost. Thus the total expenditure on Routine EPI cost, which was 13.6, 13.4, 14.3 US$ million in 2001, 2002 and 2003 respectively, is considered stable with a reasonable increase from year to year. It is worth to note that the GoY share of the cost of EPI increased from 72% in 2001 to 85% in 2003 while the rest was given by international partner agencies. The routine EPI cost per-child to be vaccinated with 3 doses of DPT3 was around US $ 30 in The cost includes every thing except the cost of the SIAs, while the average routine recurrent EPI cost per child was about US$ 17 for the period 2001 to Towards attaining the MDGs, major efforts need to be exerted in the field of maternal and childhood health. Immunization is the corner-stone to achieve reduction in childhood mortalities as well as deaths related to tetanus in the child-bearing age women. In an aim to achieve a universal coverage by immunization services EPI would be gradually increasing its coverage rates matched with increased future resources. On the short and mid term, the EPI will need to increase its staffing, replace its cold chain, train its manpower, enhance its vehicle fleet and strengthen its surveillance system. These objectives need to be carefully planned and complemented by committed financial resources. The support of GAVI began in the year 2002 and an agreement has been reached to stretch the support of introducing pentavalent vaccine to Nevertheless, predicting the required resources included the period from 2005 until the year 2013 because the first year of projection was considered 2004 in the spreadsheet tool. The year 2004 has been analyzed as current fund. Therefore all the projections is up till 2013 except the cost of pentavalent has been predicted up till 2014 since the Financial Sustainability Plan / Jan 05 /Yemen 6

7 government would start to pay 10% of the cost in 2006 with 10% increase every year. The total future cost of the program (2005 to 2013) amounted to US $ 327 million. Of this amount a total of US $ million is secure and probable through the GoY and EPI international partner agencies. This leaves the program with a funding gap of US $ 48.5 million which constitutes 15 % of the required funding. In depth analysis illustrates the fact that funding gap is most likely to occur towards the end of the planned period; the years 2010 until The reason behind this gap, is the fact that most of donors commitments are overseen for that forthcoming period. In addition to that the analysis illustrated that peaks of this gap would coincide with supplementary immunization activities such as campaigns in 2005 and 2008 in addition to the huge replacement of cold chain and vehicles in 2005 and The government share has been increasing annually from US$ 12.1 million in 2001 to US$ 13 million. GoY afford the total cost of vaccines (including HepB) for the last three years. With the introduction of the pentavalent, GAVI would support the cost of the vaccine with a complimentary annual increase of 10% in the GoY share towards the cost. By 2015, the government would be fully paying for the pentavalent vaccine. The governmental share of the cost of the vaccine amounts to around US $ 40 million through the period In addition to the vaccine cost, the government would and has been covering the program cost which includes operating costs and salaries and this situation is most likely to continue over the planned period. Towards sustainability of the process, the GoY contribution would amount to US $ 214 million which constitute 79% of the secure and probable fund and constitute 65% of the total cost for the period In a close overlook to the EPI plan, evidence suggests that the overall situation would be sustainable, given that the share of the gap from the total cost (17%) is due to the lack of knowledge of future resources beyond 2008 for many partners. Nevertheless, a couple of underlying risks may arise which are mostly beyond the control of the health system. Examples of such risks are; epidemics or disasters and most importantly the overall growth of economy and its alignment with the population growth as well as the dependency of the economic growth on oil production. On the other hand, a couple of opportunities are foreseen in the future which would have positive implications on the EPI plan. The heightened attention on MDGs and the fact that immunization activities are major interventions to achieve these goals raises hopes that EPI would receive its required funds. It is likely that several components of the EPI plan would be included in forthcoming donor programmes and projects. The main strategies of financial sustainability would encompass a) mobilizing additional resources (FSP advocacy, stretching the period of GAVI support of Pent up till 2014, increasing the number of ICC members, ensuring and maintaining the current support), b) improving the program efficiency (through reducing vaccine wastage and accomplishing the cold chain and vehicles replacement) and c) Increasing the reliability of the available resources (advocacy and training to local authorities). Therefore the EPI would need to focus on activities that build the local capacity such as training and staffing and capital replacement. This would be complemented by work in the political arena advocating for the financial sustainability plan to close the funding gap. Financial Sustainability Plan / Jan 05 /Yemen 7

8 Within this plan a couple of changes have been rationally proposed in an effort to establish a sequence and synergism in the approach. On the short term, the plans are to introduce the pentavalent in 2005 onwards as well as completion of major the cold chain and vehicle fleet replacement planned by Regarding EPI finance, an annual 10 % increase in governments share in the cost of the pentavalent is planned and an annual increase of 5 10 % in the EPI year budget is anticipated. The program would also be working on strengthening of its surveillance system and increasing its technical staffing. On the medium term the program would continue to build on the short term achievements such as the annual 10 % increase in government contribution towards the cost of the pentavalent and annual increase in the EPI budget. Subsequent cold chain and vehicle fleet replacement are planned to be ongoing process as required. Indicators of progress have been chosen to monitor implementing the strategies of financial sustainability. They are related to every strategy: 1) Annual increase of 5-10% of the governmental operational EPI cost. 2) Increase the donor support 3) increase number of the ICC members. 4) Wastage rate decrease of Penta to less than 10% by the year ) Increase the number of the new cold chain. 6) % of villages with access to vaccination services. 7) More than 90% of the EPI budget used for EPI activities. As a conclusion this Financial Sustainability Plan will serve as an advocacy tool and will be vital in mobilizing resources. With the strong government commitment and the partnership of the international agencies and using this detailed financial plan for mobilizing more resources it s expected that the financial gap would be closed. Financial Sustainability Plan / Jan 05 /Yemen 8

9 Section 1 Impact of country and health system context on Immunization program costs, financing and financial management This section gives a brief background on the performance of the country's economy, improvement efforts and an overview of the current economic performance and its key indicators. Future projections within the overall development framework are illuminated in addition to their impact on the health system as whole and the immunization program in particular. An overview of the health system is also given in this section mentioning the major characteristics of the national system coupled with indicators. It details the current reform efforts and its implications on the immunization program. The section gives a description of the health system finance, flow of funds and future projections given the ongoing reform and restructuring processes. The implications of the existing budgeting and planning system are clarified and their relation to the health system with emphasis on the immunization program. 1.1 Country Profile Yemen is situated in the southwestern corner of the Arabian Peninsula occupying an area of over half a million square kilometers. It is bordered by the Kingdom of Saudi Arabia to the north, the Arabian Sea and Gulf of Aden to the south, Sultanate of Oman to the east, and the Red Sea to the West. The natural topography of the country divides it into four major regions: costal, highlands, Tihama plateau and the eastern plateau in addition to many islands in the Arab and Red seas. Yemen has a population of 21,069,869 as of the year 2005 (based on estimations from the latest national population census in 1994) and they are spread over 122,000 settlements and villages. The population is predominantly rural where 76 % of the Yemenis live, and the under-15 age group represents 46.3 % of the population with a rapid annual growth of 3.5 %. Administratively, the country is divided into 22 governorates which are further divided into 332 districts each of around 45,000 inhabitants. The Yemeni society is labeled as traditional where the agriculture sector absorbs about half of the total work force. 1.2 Macroeconomic Performance Brief background Unity of both parts of the country in 1990 marked a new era in its history with an ambition that this step would accelerate economic development and growth as well as hopes of prosperity and stability. Nevertheless, burdens inherited from the newly Financial Sustainability Plan / Jan 05 /Yemen 9

10 established state and the aftermaths of the first Gulf war in the early nineties had its serious implications on the overall economic framework. The mid nineties witnessed economical stagnation, sharp decline in the Gross National Product (GNP) and devaluation of the local currency. In an effort to confront these economic imbalances, the government embarked on an Economic, Financial and Administrative Reform Program (EFARP) which commenced in These efforts where translated into two Five-year Developmental Plans which aimed at attaining economic stability, economic growth, raising incomes and creating new job opportunities. Both plans encompassed into consideration improvement of social services as an approach to achieve human development. Within the framework of the Second Five-Year Development Plan (5YDP) ( ) a Poverty Reduction Strategy was adopted to overcome the adverse effects of the reform. The population living in poverty is around 42% and the Poverty Reduction Strategy Paper (PRSP) intended to deal with the different dimensions of poverty Current situation The late nineties reform policies and measures have contributed to economic stabilization, liberalization of trade and private sector involvement in economic activity. There has been a 4.4 % increase in the economic growth rate, a drop in the inflation rate and stabilization of the foreign currency exchange rate. Despite the satisfactory performance of the economic reforms, it has resulted in several side effects. The devaluation of the purchasing power of the local currency, removal of subsidies and price hikes of commodities and basic services which were not coupled with a similar increase in the real wages of labor led to a negative affect on the living standards. Currently, Yemen is classified as one of the least developed countries and ranks 148 out of 175 countries on the UNDP Human Development Index (2003) with a per capita GDP of US$ 460. The country faces enormous economic and social challenges; among these are a couple of alarming gaps in a number of development indicators. The following table (1) demonstrates some of the major indicators: Table (1): Country indicators: Indicator 2003 Fertility rate 6.5% Annual population growth rate 3.5 % GDP per capita 460 US $ Foreign debts as % of GDP 56 % Unemployment 40% People living in poverty 42 % Illiteracy rates between females 73.5% Net enrollment in basic education 59.9 % Health care coverage 50 % Sources: MoPIC, Millennium Development Goals, 2004 MoPHP, Family Health Survey, Financial Sustainability Plan / Jan 05 /Yemen 10

11 Other development indicators: - Limited access to basic service. - Non-renewable water supply is dwindling at an alarming rate. - Half of the children under age of five are malnourished Future projections Oil revenues constitute the major contribution to the central state budget and it is the major export. The service sector comes second and fishery and tourism follow, which are two promising sectors although their current contributions to the economy are low. The dependency on the oil exports is a hazardous fact since it is liable to price fluctuations. Currently the Second 5YDP ( ) is in action as well as the PRS ( ). The developmental plans aim at achieving an annual economic growth of 7 % with emphasis on increasing resource allocation to social services and in particular those directed to the health sector. The next promising step is ongoing process of developing a Health Investment Plan to achieve the Millennium Development Goals (MDGs). This process began August 2004, guided by the Millennium Project (UN) and is expected to be finalized by the end of January This process would facilitate the national efforts of advocating for increased finance for the health system and in particular resources enabling the country to achieve its global commitment within the framework of the MDGs. Another adjuvant process complementing the above mentioned is the formulation of the Third Five-Year Development Plan, MDG based - PRSP oriented ( ) which is to take place from January until July of This plan would envisage the importance of Primary Health Care (PHC) provision as an approach for poverty alleviation. More resource allocation is expected since the forthcoming plan is receiving major consideration on the national level and from development partners. 1.3 Health Sector General Situation There have been major improvements in the general health situation in the last two decades with a remarkable increase in number of health facilities and health staff providing services as well as a moderate increase in the life expectancy at birth. Nevertheless the health status remains poor and health indictors are one of the least favorable in the Middle-east region. The disease pattern in Yemen describes the epidemiological and demographic changes taking place, with a high incidence and prevalence of communicable diseases such as Malaria, Measles, Tuberculosis and Schistosomiasis. The major causes of childhood mortality are infectious diseases such as diarrhea and acute respiratory illnesses as well as malnutrition. The alarming infant and child mortality rates in addition to maternal mortality are major challenges besides the emergence of noncommunicable diseases such as cardiovascular and renal diseases and cancers. Financial Sustainability Plan / Jan 05 /Yemen 11

12 These health problems are attributable to several factors such as low PHC coverage but other challenges lie beyond the reach of the health system such as; high malnutrition rates, high levels of illiteracy, as well as lack of safe water provision (30 % coverage). In the following table (2) are selective health indicators: Table (2): Selective health indicators Indicator 2003 Life expectancy at birth 60.4 Infant mortality rate 75 / 1,000 Child mortality rate 102/1000 Maternal mortality rate 366 / 100,000 Source: MoPHP, Family Health Survey 2003 The prevalence of childhood illnesses is one of the highest region-wide where onethird of the under-five deaths are attributable to vaccine preventable diseases. Measles remains a major problem as well as neonatal tetanus. Yemen is in its way to achieve polio eradication and efforts to increase routine immunization have resulted in a modest coverage rate of around 70% for those under the age of one year. The current situation requires increased financial and technical support to improve the extent of routine immunization and enhancement of the surveillance system Structure of the Ministry of Public Health & Population Ministry of Public Health & Population (MoPHP) is the major provider of health services thorough its network of health facilities in four levels; health units, health centers and district hospitals, governorate hospitals and specialized hospitals. Along with the public sector there is a widespread unregulated private health sector and health facilities run by NGOs. The Primary Health Care (PHC) has been the approach of the public health system since the early eighties; nevertheless it covers only 45% of the total population. By mid 2004 the MoPHP was restructured aiming at effective management of its various activities and ensuring synergy. A new sector for Primary Health Care translates the focus of the Ministry towards providing a basic package of essential services to the vast population and ensuring integrity of services in the field. The following diagram illustrates the new organigram: Financial Sustainability Plan / Jan 05 /Yemen 12

13 Ministry of Public Health & Population Donor Organizations and Agencies Planning Sector Curative care Sector Population Sector Primary Health Care Sector WHO UNICEF GAVI JICA WB USAID VP VP VP VP EPI Governorate Governorate Governorates District District District Immunization Activities HF HF The 'Expanded Program on Immunization' falls under the PHC sector among other vertical programs such as Malaria, Tuberculosis, Integrated Maternal & Childhood Illnesses, HIV/AIDS, etc. Provision of immunization services on the service level is conducted by the public health facilities free of charge Health Sector Reform The public health system by the late nineties experienced several shortcomings on different levels. On the level of service provision, financial and geographical inaccessibility, low quality of services and reduced efficiency has been the experience of the majority of health care clients. On the other hand, on the level of the health system, there has been evidence of low capacity in operational planning in addition to lack of managerial capacity and the absence of managerial tools such as supervision and monitoring systems. The MoPHP embarked on a reform program in 1998 recognizing the serious shortcomings of the existing health system. The reform comes within an overall context of public sector reform based on decentralization, democratization, civil service modernization, and financial restructuring. The long-term objectives of the process are to achieve universal access, equity, quality of services in addition to efficiency and financial sustainability. The key element of the reform envisages the establishment of the district health system where other elements such as decentralization, community participation and inter-sectoral cooperation could be realized. Among the elements of reform is the call for redefining Financial Sustainability Plan / Jan 05 /Yemen 13

14 the role of the public sector and encouraging the participation of the private sector as well as donor coordination. The implementation of the Health Sector Reform (HSR) has been challenging and progress has been achieved in selective elements of the reform namely; the District Health System (DHS) and decentralization. On the other hand, the immunization coverage was estimated to be 28% before the reform and current figures estimate a country-wide coverage of around 70% (latest EPI figures). The MoPHP is expected to conduct a comprehensive review of the health sector which would help in evaluation and development of the new sector vision. This is expected to take place in the period Jan Jul 2005 coinciding with the development of the Third 5YDP ( ) National Health Priorities The national health priorities are directed towards enhancing the PHC system, which is evident in introducing a sector for PHC in the new structure of the MoPHP and increasing central and governorates budget to PHC related activities. The EPI is one of the major programs in the PHC sector and immunization activities are considered the corner stone within the framework of services provision. During the last eight years there has been strong political support through the participation of the country's leaderships in various nationwide polio eradication campaigns and allocation of required budgets. The MoPHP is in the process of formulating a health investment plan by early 2005, towards achieving the health related MDGs targets. In the process of carrying out the needs assessment and list of interventions, immunization activities stand as the priority intervention to reduce infant and childhood mortalities. A subsequent effort would take place in the first half of 2005, to formulate the Third 5YDP ( ) which would be MDGs based PRSP oriented and would encompass the prioritization and significance of immunization activities within an integrated set of cost-effective package of essential services. 1.4 National Health Expenditures Finance of the health system The national health care system is heavily dependant on household financial contributions and direct provider payments. Based on the National Health Accounts (NHA) study of 1998, households contributed 57.3 % of the total health expenditures whereas the share of the Ministry of Finance (government revenues and tax-based funds) channeled through the MoPHP amounted to 28.5%. The following figure (1) shows the national health expenditures based on the source of funding: Financial Sustainability Plan / Jan 05 /Yemen 14

15 Figure (1): secure health expenditure Sources of Health Expenditure Ministry of finance 29% Household 57% Donors 8% public Firms 6% Source: National Health Accounts Report, The per capita spending on health was estimated to be US $ 20 (1998) which is way below the optimum recommended level of funding for a basic package of services, out of this amount the Government share is US$ 7. In spite the fact that cost sharing and nominal fees for services were introduced at all levels of service provision in the recent years, primary health care services remain to be free which include immunization services Trends in funds availability Given the fact that there are two major financing sources (the public sector and individual households) and the absence of a health insurance market augments the burden of households seeking health services and dealing with sudden health incidents. It also indicates the importance of attaining increased public funding spending as well as equitable distribution of these funds both in terms of services provided and geographical coverage. The health public spending has been slightly increasing annually but it is way below the optimum levels required to operate public health facilities and there activities as well as the increasing demands of the growing population. The current share of the public health system is 4.1 % of the total government budget which represents 1.6 % of the total GDP. The following table illustrates the changes in public health spending over the period of the last five fiscal years and correspondent changes as of share of the GDP. Table (3): Public health spending ( ) Year % of MoPHP expenditure as of the Govt. budget % of MoPHP expenditure as of GDP Source: Preliminary Data; Public Expenditure Review Health Sector Financial Sustainability Plan / Jan 05 /Yemen 15

16 Latest public expenditure analysis and annual budgetary data show that there has been a slight trend during the past couple of years towards increased expenditures in capital investment and highlighted the fact that a large share of the recurrent budget is consumed by tertiary level care. Other major allocative discrepancies are realized in the low amounts distributed as service operating expenses where evidence suggests that health facilities nation-wide are under funded as well as absorption of a high share of the budget towards salaries and wages for MoPHP staff which suffers from a high load of support staff against the technical health cadre Future of health sector funding It has been deemed in the Second 5YDP ( ) that there would be an increase in resources allocated to the health sector. The same commitment appeared in the PRSP ( ) where by the year 2005 it has been anticipated that the share of health expenditures in the government budget would increase to 6 % which would constitute 2 % of the national GDP. As explained above there has been an increase during the past years and these commitments are likely to be fulfilled. On the other hand, since the fiscal year 2003 there has been a separation of funds for PHC activities from the MoPHP budget and allocated amounts are expected to increase. Another major factor in regard is the recent introduction of the PHC sector which would ultimately facilitate and enhance increased funding Health Planning & Budgeting Planning and budgeting process Within the overall framework of decentralization, the budgeting, accounting and planning process has been decentralized to the level of governorates and districts which is then bottom-up consolidated to a national ministry budget / plan according to the local authority law no. 4 of The budgets on the district level are prepared by the district health office and discussed by the support committees formed by the Ministry of Finance (MoF). The plans and budgets are deemed to reflect the local community's needs and aspirations tacking into consideration their technical and absorptive capacity to implement these plans. The experience so far is that the allocated budgets by the MoF are based on historical estimates with slight annual incremental increases. The budgetary allocation does not employ any economic evaluation techniques to asses the financial and social viability of these health allocations neither does it allow the application of measures of horizontal and vertical equity Budget Execution and Funds Disbursement The system of budget execution and disbursement of funds is based upon a system of local accounting units, affiliated to the Ministry of Finance, each serving a governorate or a district. These accounting units act as sub-treasury in their area of Financial Sustainability Plan / Jan 05 /Yemen 16

17 operation and their role is to receive revenues and disburse funds according to the requests from the ministry's branch's which are governorate or district health offices. The budget categorization and itemization (salaries, goods & services, maintenance, capital investment, etc) does not facilitate efficient use of allocated resources neither does it respond to technical aspects of public health activities. Another shortcoming in the financial system is the usual delays in disbursement which hinders timely conduction of activities. In any given district, the district health office would apply for their recurrent and operating costs to conduct planned activities through requests conveyed to the accounting unit. It is upon the district health office to prioritize or include any PHC or immunization activities within its annual plan. Another financial asset to the district health system is the retention of revenues generated through user fees and the revolving drug fund which are mainly used to enhance quality of services and pay incentives. On the other hand, the central offices of the MoPHP retain direct control over capital investment funds which is disbursed according to annual nation-wide investment plans EPI Planning & Budgeting The process of planning and budgeting for the EPI is similar to the health sector process. It is worth to note that there are two procedures for disbursement of funds to cover immunization activities: a. The district health office, within its annual plan, requests the conduction of immunization activities from the accounting unit. Funds are disbursed and accounts are cleared on that level. Local authorities and district health offices decide upon the immunization activities and allocated resources. b. Most of the vertical programs (e.g. EPI) disburse their funds centrally to the assigned district health office according to nationwide plans. These health offices conduct the activities and clear vouchers with the related program according to a unified accounting system. The EPI program among others follows this method of disbursement of funds and the accounting system underlying in this case is activity-based disbursement which is deemed to be more efficient. Financial Sustainability Plan / Jan 05 /Yemen 17

18 Section 2 Program Characteristics, Objectives and Strategies This section briefly presents information on the EPI program, its aims and objectives as well as its ongoing strategies. An overview of the program achievements over the past recent years and future approaches is highlighted in addition to the related role of development partners. 2.1 Introduction The national Expanded Program on Immunization began its operation in 1979 as a vertical program within the structure of the MoPHP supported by WHO and UNICEF and others, and it continued as such until 1987 when it was integrated with PHC. Since its creation, six diseases have been targeted through vaccines namely; tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus and measles. In the year 1998, hepatitis B vaccine was introduced partially in some governorates as a pilot project and it was generalized to nationwide in the year Program objectives and strategies Program Objectives The overall aim of the EPI is to reduce the morbidity and mortality of vaccinepreventable diseases. To achieve this aim, the program objectives towards: - Increasing the scope of immunization coverage through several approaches. - Introduction of the pentavalent vaccine covering a wider scope of vaccinepreventable diseases. On the other hand, the program is governed by its five-year action plan ( ). The specific objectives of the program are: a) Introducing the Pentavalent vaccine in 2005 and achieving at least 80% coverage of Penta3/OPV3 by the year 2007 for children less than one year. b) Achieving 60% coverage for pregnant women with TT2+. c) Sustaining the interruption of polio virus. d) Interruption of the indigenous measles virus by the year e) Ensuring safe vaccination. f) Achieving the maternal neonatal tetanus elimination by the year Program Strategies Within the local context and resource limitations, the EPI faces a couple of challenges confronting its effort to achieve the above-mentioned objectives. Nevertheless, the Financial Sustainability Plan / Jan 05 /Yemen 18

19 program has formulated its own strategies which enable it of providing its crucial services and fulfilling the needs of the growing population. Several approaches and have been in place in addition to many other forthcoming ideas and strategies would enable the program of realizing its aim and objectives Immunization activities To ensure global coverage target by immunization activities, each health facility defines its target population within its catchment s area. The health facility plans and conducts its vaccination activities through three strategies: fixed, outreach and mobile services. Currently, there are 2347 governmental health facilities which provide permanent (fixed) vaccination services. The private health sector does not provide any routine vaccination services but they do take part during Polio campaigns. There is a hope that the increasingly growing sector will gradually be integrated into provision of PHC services. Every effort is exerted to ensure all public health facilities provide vaccination services. Social mobilization has effectively contributed to EPI activities and raised public awareness in services provided. The participation of the country s leadership and seniors in EPI campaigns had a positive influence. Several aspects need to be strengthened to assist the EPI of achieving its aim through the activities performed nation-wide. The program requires more financial resources to increase the scope and scale of services provided. On the other hand, staffing of additional number of qualified technical personal is crucial to ensure the effectiveness of services Immunization, Decentralization and Integration Within the framework of the decentralization policy, the responsibility of planning, implementing and monitoring immunization activities is performed at the level of governorates and districts under the supervision of the national immunization program. Bottom-up micro-planning process is under implementation in an effort to attain effectiveness and sustainability of the process. Decentralization within the District Health System approach has been in favor of the health system and has assisted in integration of PHC (of which EPI are the corner stone) at the service level. Supervision and support from the governorate health offices plays a major role in ensuring the appropriateness and effectiveness of conduction of these activities. It is early to evaluate the impact of decentralization process on immunization but it is evident that lower levels need to be strengthened in aspects such as training on planning, management, maintenance, etc Safety injection The governemnt has committed to WHO /UNICEF joint statment of 1999 on safety of injection. A proposal for safety injection has been attached to the strategic plan of action which was presented with the application to GAVI. Financial Sustainability Plan / Jan 05 /Yemen 19

20 EPI target diseases surveillance EPI target diseases surveillance system has improved in the last few years. AFP surveillance meets the certification standard but it s worth to note that it is positioned under the Epidemiology Department in MoPHP. Measles surveillance has been improving and there is a good coordination between EPI and the Surveillance Department aiming at revealing the actual measles situation in Yemen. Improving the other EPI target diseases surveillance remains a priority Immunization Schedule The EPI currently targets seven vaccine-preventable diseases and the target groups are children under one year and women in the childbearing age. With the introduction of the pentavalent in 2005, an additional antigen would be introduced (Hib B) and accordingly the immunization schedule for children would change. Routine vaccination of children: The objective of the EPI is to complete vaccination of children before their first birth day according to the following table: Table (4): Children vaccine schedule: Vaccine Age of vaccination BCG, zero dose of OPV Within the 1 st week of age DPT1/OPV1/HBV1* At 6 weeks of age DPT2/OPV2/HBV2 At 10 weeks of age DPT3/OPV3 At 14 weeks of age 1 st dose Measles/HBV3 & Vit A At nine months of age 2 nd dose Measles** At 18 months of age * HBV has been introduced in ** 2 nd dose of measles was adopted in Starting from early 2005, pentavalent will be introduced through the support of GAVI (introducing new vaccine) and the schedule will be as follows: Table (5): Children vaccine schedule (effective 2005): Vaccine Age BCG, zero dose of OPV Within the 1 st week of age Penta1/OPV1 At 6 weeks of age Penta2/OPV2 At 10 weeks of age Penta3/OPV3 At 14 weeks of age 1 st dose Measles & Vit A At nine months of age 2 nd dose Measles & Vit A At 18 months of age Financial Sustainability Plan / Jan 05 /Yemen 20

21 Tetanus vaccination for childbearing age women (15-45): The policy is to give all childbearing age women (age 15 to 45), tetanus vaccination with special attention on pregnant women. In addition to the routine vaccination conducted in the health facilities, Maternal & Neonatal Tetanus (MNT) campaigns are conducted in high risk districts. Table (6): Tetanus vaccination schedule childbearing age women Dose TT1 TT2 TT3 TT4 TT5 Schedule At the first contact After one month After six month After one year After one year 2.3 Organization of EPI National level The national EPI Director is responsible for design of immunization policies, coordinating immunization efforts, mobilizing government, international and public support and assisting in controlling of EPI-target diseases. Under the national EPI Director the program has a branch located in Aden Governorate and supervises and supports the southern and eastern governorates. The national EPI program is divided into two main sections: the technical section and finance/ administration section. Technical section: headed by the national EPI technical officer comprises the following units: 1- Operational unit: It consists of eight national operation officers, who are considered the continuous link between the EPI director and the governorates. They provide training and technical assistance to the governorates, in addition to supervision and monitoring the program progress. 2- Data management unit: A computerized information management unit, which collects and analyzes coverage data. Its tasks include monitoring the completeness and timeliness of activities as well as monthly feedback to concerned authorities at different levels. 3 Vaccines management unit: Responsible of receiving and storing all the vaccines and equipments of EPI. Its task includes supply and distribution of all vaccines and equipments to the governorates. 4- Cold chain repair and maintenance unit: Its responsibility is the repair and maintenance of all cold chain equipments as well as of training and follow up of the maintenance sub-workshops in the governorates. Financial Sustainability Plan / Jan 05 /Yemen 21

22 Finance and administration section: headed by the finance officer, who handles personnel, finance, budgeting, customs, transport (transport repair and maintenance) and clerical activities and is responsible of establishing appropriate office procedures for the EPI directorate Governorate level The Director General of Health Office at governorate level has the full responsibility and authority to plan, implement, monitor and supervise EPI activities in his governorate. The director of PHC, and EPI governorate supervisor, together with district supervisors, assist in carrying out these activities. The EPI related governorate health office staff is as follows: - PHC director - EPI governorate supervisor - EPI district supervisors - Health education officer - Statistical officer - Cold chain stores clerk - Cold chain repair, maintenance technician 2.4 EPI services and performance Routine immunization EPI activities, as measured by reported coverage, underwent gradual development until Reported coverage in 1990 for DPT 3/ polio 3 and measles immunization reached 84% and 74% respectively due to the conduction of national campaign supported by WHO and UNICEF. Due to discontinuity of support during the period the reported DPT 3/ Polio 3 coverage deteriorated to figures around 40%. In the year 1998, the coverage rate increased to 68% and continued to be in the range of the seventies until the year Additional resources and revitalization of the program contributed to this substantial increase during this period. Unfortunately the coverage declined in the years 2002 and 2003 to 68% and 65% respectively due to a management gap caused by the delay in government budget disbursement, especially after the government took over the responsibility of purchasing vaccines in Those management gaps have been overcome to a far extent, which has been reflected in an increase in the coverage rates to 78% for DPT3/OPV3 in 2004 Financial Sustainability Plan / Jan 05 /Yemen 22

23 Figure (2) % coverage of DPT3/OPV % coverage of DPT3/OPV Yemen j Source: National EPI Since the program commenced in 1979, UNICEF used to provide all the vaccines. The situation changed from 2002 onwards, when the government has undertaken the responsibility of vaccines budgeting and procuring through UNICEF. However, the government has been procuring the hepatitis B vaccine since its introduction in Polio Eradication Due to the success of the National Immunization Days (NIDs) conducted since 1996 through 2001; the country has become free of wild poliovirus since SNIDs have been conducted in the last few years and will be conducted according to the epidemiological data. Accordingly, Yemen presents its certification document to the regional certification committee every year. Plans has been prepared to conduct NIDs in 2005 to minimize or eliminate the risk of any importation Measles elimination Measles is endemic disease in Yemen and many outbreaks do occur every year. 3046, 1298, 928, 8536 measles cases have been registered in 2000, 2001, 2002 and 2003 respectively. The reason behind the 2003 increase in registered cases is improvement in the surveillance system. Mass campaigns have been conducted in 2001 for children from 9 months to 5 years and have resulted in 94% coverage. A second dose of measles vaccine was adopted in 2003; nevertheless coverage rates are still low. In the year 2005, a catch up campaign are planned in September to interrupt the circulation of indigenous virus. A funding proposal for the campaign has been presented to donors. Mass campaigns for children from 9 months to 5 years are to be conducted every 2-3 years according to epidemiological data. Measles surveillance system is improving but there still room for better achievement. Laboratory diagnoses started in 2003 and more samples have been tested ever since. WHO has supported in provision of laboratory materials especially the reagents. Financial Sustainability Plan / Jan 05 /Yemen 23