ZANZIBAR REVOLUTINARY GOVERNMENT MINISTRY OF HEALTH AND SOCIAL WELFARE

Transcription

1 ZANZIBAR REVOLUTINARY GOVERNMENT MINISTRY OF HEALTH AND SOCIAL WELFARE NATIONAL IMMUNAZATION PROGRAM FINANCIAL SUSTAINABILITY PLAN REVISED NOVEMBER 2003, ZANZIBAR

2 TABLE OF CONTENTS Content Page No. Table of contents ii Executive Summary.... iv Acknowledgement.... viii Abbreviations.. ix 1.0 COUNTRY AND HEALTH SECTOR CONTEXT 1.1 Country Profile National Health Policy and Other Reforms Overall Government reforms National Health Policy National Policy Reforms BUDGET PROCESS AND FINANCIAL MANAGEMENT 2.1 Phase I: Pre-budget Guidelines Phase II: Budget Preparation and Scrutiny Phase III: Budget Approval Phase IV: Budget Execution Disbursement of Funds Procurement of goods and Services Accounting Reporting Auditing PROGRAM CHARACTERISTICS, OBJECTIVES & STRATEGIES 3.1 Program Characteristics Immunization Coverage Vaccine Wastage Rate Immunization Technology and Antigen BASELINE AND CURRENT PROGRAMME COSTS AND FINANCING 4.1 Baseline Program Costs and Financing Patterns Current year costs and financing patterns 10 ii

3 5.0 FUTURE RESOURCE REQUIREMENTS AND PROGRAM FINANCING 5.1 Estimate of future resource requirements Projection of future financial levels and patterns Estimates of financing gap Risk assessment SUSTAINABILITY STRATEGY PLANS AND INDICATORS 6.1 Immunization Program Constraints Financial strategies and indicators Conclusions and Final Recommendations COMMENTS FROM STAKEHOLDERS 27 ANNEXES Annex A: Annex B: Annex C: Annex D: Programme characteristics, objectives and strategies baseline and current year programme costs Log frame of strategies and actions Advocacy messages for key actors iii

4 EXECUTIVE SUMMARY The immunization programme in Zanzibar has as its goal of reduction in morbidity and mortality due to vaccine preventable diseases. The programme s broad areas of activity are routine immunization service delivery, disease surveillance and supplementary immunization activities. In the recent past, Zanzibar has revitalized EPI, with improvements in the planning process, immunization coverage and in safety of immunization, as well as in strengthening community ownership and involvement, and the effective mobilization of funds for EPI. Year 2001/02 saw a switch from the use of sterilizable needles and syringes to use of auto disable syringes and needles, as well as in the introduction of DPT-Hep B combination vaccine into the immunization schedule. A new vaccine (Hib Vaccine) introduction is planned for the year 2005/06. This vaccine protects against the bacterium Haemophilus influenza, a major contributor to ill health and death in children under 5 years. The programme is operating in a general macroeconomic environment of low GDP per capita, with limited resources available to the government for health service delivery. The health sector receives on average 8% of the total Government resources, with the EPI programme at present receiving less than 1% of this. The EPI programme resources have in the recent past been limited. The total programme cost for the Financial Year 1999/2000 (excluding shared costs of USD$ 121,341) was USD$143,133, with a per capita cost of 0.16 USD. Of this cost, 34% (i.e. USD$ 48,665) was for operational cost 14% for capital cost (i.e.$ 20039) and 53% (i.e. USD$ 74,429) for supplemental immunization activities. Government contributed 17% (i.e.$ 24,333) to this cost, whilst developmental partners provided 83%. In 2001/02, the programme introduced the HepB vaccine in its schedule. The programme costs for this year (excluding the shares costs of USD$ 174,457) increased to USD$347,076 with a per capita cost of 0.36 USD. Operational cost accounted for 61% (i.e. USD$ 211,716) of the cost whilst 39% of the cost (i.e.$ 135,360) went to supplemental immunization activities. In this year, 2001/02 the government contribution reduced to 7% (i.e.$ 25,052) of the total programme costs with increase in the donor support to the programme, partly as a result of input of resources from the Global Alliance for Vaccines and Immunization. iv

5 Over the medium term (up to 2008/09), the total programme costs is expected to increase, with the increase partially attributable to population increase, and partially due to increase in immunization coverage, and the costs of the introduction of the new vaccines. The costs of the programme, by activity up to the year 2008/09 are illustrated in the graph below EPI programme resource requirements projections to the year 2008/09 1,000, ,000 SIA's 800, , , , , ,000 Routine capital costs Other recurrent costs Vaccines 200, , Year On average the government contribution during the Vaccine Fund period (i.e. 2003/ /06) is US$ 32,636 with peak of 8.1%( i.e. US $ 32,960) in 2004/05. Though the percentage government contribution declined compared to the pre-vaccine period, there is absolute increase in government contribution during the Vaccine Fund period. GAVI contribution during the Vaccine Fund period (2003/04) is 76% of the total EPI cost (i.e. US$ 1,242,957 ) The Government contribution during the post Vaccine Fund (2006/ /09 ) is estimated to increase to 56% (US$108,080) of the secured funds. Additional support for both the Vaccine Fund and post Vaccine Fund is expected from multilateral and bilateral organizations. The program will therefore be faced with a funding gap that increases from (US$110,305 in the year 2004/05 to US$778,051 by the year 2008/09. The total funding gap for the period from 2003/04 to 2008/09 is US$ 2,294,463 (50%) out of the required resources of US$ 4,544,409. This is depicted in the summary tables attached and the graph below. v

6 Funding gap for the immunization programme up to 2008/09 1,000, , , ,000 Unsecured funds 600, , , ,000 Secured funds 200, , / / / / / / / / 09 Year The programme has identified strategies to undertake to fill this funding gap. These are: 1. Mobilizing additional resources, 2. Improving the reliability of resources, and 3. Improving the efficiency of the programme. The programme will seek additional resources from the health sector, local Governments, private sector and bilateral and multilateral donors. The ability to raise the additional resources from Government is the key strategy. These additional resources will be mobilized, within scope of financial realities of the Health. From a present (2003/04) funding of under1% (US$$32,247) of the health sector resources, the programme shall seek an increase to 4% (US$233,459) of the health sector resources by 2008/09. In addition, improvements in programme efficiency shall be sought, with a planned reduction of vaccine wastage of DPT-Hep B from 20% during 2002 to 10% in These strategies shall each raise resources to fill the funding gap as illustrated in the graph below. Contribution to the funding gap from the different strategies 1,200,000 1,000, , , , , Year Remaining gap Mobilize private resources Additional donor support Increase multilateral contributions New GAVI application for Hib support Improved programme eff iciency Mobilize LG resources Mobilize additional Govt resources Total secured vi

7 The Inter Agency Coordinating Committee (ICC) will outlined the action plans for Financial sustainability for implementation. The ICC shall, on a quarterly basis, review progress on the action plan as presented by the financing sub working group, and plan for activities from the action plan to be completed in the coming quarter. A technical sub-working group from ICC (the Immunization financing working group) will follow up the day-to-day implementation of financial sustainability activities. This sub-working group made up of a maximum of eight people, will include representatives from the EPI, representatives from the technical organizations (WHO and UNICEF), the Ministry of Finance and three additional members chosen by the ICC. The financing sub working group shall meet on a monthly basis to review progress on expected activities, and plan for upcoming tasks On an annual basis, the ICC shall have a retreat to review progress on financial sustainability based on the agreed district and national based indicators, and will chart out the expected activities for the next year. Findings from this retreat shall form the basis for the reporting mechanism to GAVI on progress on financial sustainability. vii

8 ACKNOWLEDGEMENTS The Ministry of Health wishes to acknowledge with sincere gratitude the Financial Sustainability Task Force and others who in one way or another contributed to the development and finalization of the EPI Financial Sustainability Plan. The Task Force comprised of Dr Mohamed Dahoma, Ms Mwaka Said, Mr Habibu Chwaya, Mr Juma Rajabu, Mr.Idrisa, Abeid Ahamte, Mr.Yusuf Makame, Dr Cornelia Atsyor. The Ministry also acknowledges with gratitude the technical support on the FSP from Ms. B. Sakagawa, Mr. C.V. Maziwisa Mr.P.A.Ilomo and Dr H. Karamagi of AFRO-WHO. The support from WHO, UNICEF, and the GAVI Secretariat for their financial support of the FSP development process is much appreciated. Special thanks also should be given to the ICC members who provided comments on this document. Last but not least, thanks should go to Ms Amina Badri,the Secretary, for assisting with assembling this document. PERMANENT SECRETARY MINISTRY OF HEALTH AND SOCIAL WELFARE viii

9 Abbreviations AFP - Acute Flaccid Paralysis BCG - Bacillus Calmette Guerin BD - Becton Dickinson East Africa Operations CUAM - Italian Development Agency CHF - Community Health Fund DANIDA - Danish International Development Agency DFID - Department International Development DMO - District Medical Officer EPI - Expanded Programme on Immunization DPT- HB - Diphtheria, Pertussis, Tetanus and Hepatitis B DPT - Diphtheria Pertussis Tetanus EPI - Expanded Programme on Immunization GAVI - Global Alliance for Vaccine and Immunization GDP - Gross Domestic Product GFS - Government Financial Statistics GOZ - Government of Zanzibar HIPC - Highly Indebted Poor Countries IFMS - Integrated Financial Management System JICA - Japanese International Cooperation MCH - Maternal and Child Health MCHA - Maternal and Child Health Aid MDAs - Ministries, Departments and Agencies MOF - Ministry of Finance MOH - Ministry of Health MTEF - Medium -Term Expenditure Framework NIDs - National Immunization Days OPV - Oral Polio Vaccine PER - Public Expenditure Review PM - Programme Manager POW - Programme of Work PRS - Poverty Reduction Strategies RCCO Regional Cold Chain Officer RCHS - Reproduction and Child Health Services RHMTs - Regional Health Management Teams RMO - Regional Medical Officer SIA - Supplementary Immunization Activities SNIDs - Sub-National Immunization Days TFR - Total Fertility Rate TT - Tetanus Toxoid UNICEF - United Nations Children s Fund USAID - United States Agency for International Development US$ - United States Dollars WHO - World Health Organization ix

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11 1.0 COUNTRY AND HEALTH SECTOR CONTEXT 1.1 Country Profile Zanzibar, together with the Tanzania mainland, forms the United Republic of Tanzania and is situated south of the equator, along the Indian Ocean. It covers an area of approximately 2,642 sq. km s. It is made up of the two islands of Unguja and Pemba, each of an area of 1,658 and 984 sq km s respectively. It has an estimated population of 984,625 (2002) with a growth rate of 3.1 percent. The proportion of the population below the age of 15 years is estimated at about 47%. The population in the year age group is estimated at 49% with the remaining 4% covering those above the age of 65 years. Administratively, Zanzibar has 5 regions and 10 districts, with each district sub divided into divisions and wards. Decision making is still largely controlled by the Ministry of Health, though it is in the process of deconcentrating power to the districts. Significant progress has also been made in the macro economic stabilization, which has facilitated positive economic growth in recent years. Overall the GDP growth has steadily risen from 3.0% in 1997 to 5.3% in The GOZ predicts that, by year 2005, the economy will grow at a rate of 6.7%. The exchange rate was 890 Tanzania shillings to the dollar (rate in 2002). The health status of Zanzibar and Mainland Tanzania s population is considered to be among the lowest in African countries with similar economic characteristics. In recent years, infant mortality in Zanzibar increased by 10%, from 88 (1996 TDHS) to 99 per 1,000 births (1999 CRHS). The Government of Zanzibar (GOZ) has recognized the need to address the health status of women and children and has begun to implement several health sector reforms and initiatives aimed at improving the health of its population. Reforms include the development of a health sector strategic plan, emphasis on decentralization, and the preparation of a poverty reduction strategy paper. Zanzibar has pledged to achieve Millennium Development Goals in health, articulated as: Reducing the under-five mortality rate by two-thirds between Reducing by three quarters the maternal mortality ratio between Halting and reversing the spread of HIV/.AIDS by 2015 Halting and beginning to reverse the incidence of malaria and other major diseases by

12 1.2 National Health Policy and Other Reforms Overall Government reforms From the late 1980 s, the GoZ undertook reforms in line with the market based Government reforms that were ongoing internationally. These have been civil service reforms, political reforms and economic/financial reforms. These shape the structures and processes used for Health Service Delivery in Zanzibar National Policy Reforms Prior to the 1964 revolution, health service delivery was mainly oriented to curative services and centralized in urban areas. Efforts to decentralize basic health services, started immediately after the revolution. Management structures for the MOH have been deconcentrated through the creation of zonal and district health management s. However, financial decision-making and budgeting decisions continue to be made at the national level in the Ministries of Finance and Health. Decentralization policies were also included in both the Vision 2020 and Zanzibar s poverty reduction strategy framework. The GOZ has developed a Poverty Reduction Plan (ZPRP) since This plan has included health related issues such as those aimed at improving the health of women and children by reducing mortality rates to ensure longer survival. The plan also has immunization related indicators. With this plan, it is expected that resources to the health sector will be increased (pg 48 of ZPRP) Specific actions under the objective of improving the health of women and children Improving MCH and reproductive health services. Increasing vaccination to cover all children less than five years of age. Creating equal opportunities of access to basic and essential quality health care. Increasing the focus on strengthening management financing of the overall health care system. Reducing the morbidity and mortality resulting from human exposure to environmental hazards. Despite these reforms, Zanzibar s health system faces a number of challenges to improving and strengthening its immunization program. These challenges include limited government contribution to the immunization program and heavy donor dependency to implement the program and inadequate human resources both in terms of capacity and staffing. 2

13 1.2.3 National Health Policy Zanzibar National Health Policy emphasizes the need to promote the health status of women and children. As part of this policy, the Government of Zanzibar has developed a health sector strategic plan (HSSP, year 2001 to 2006) that aims to make institutional and structural changes to improve existing organizational structures, management systems and capacities so that the health system can better address the health needs of the population The goal of the Zanzibar Health Sector Policy is to: improve and sustain the health status of all Zanzibar people by ensuring that vulnerable groups i.e. those at risk particularly the poor women of child bearing age, children, the disabled and elderly have access to high quality health care services. (See also The Eleven reform areas identified in the HSSP in Box 1.) Box 1: Eleven reform areas identified within the HSSP Improvement of organization and management of health services Human resource development; Strengthening health service delivery; Health sector financing and mobilization of resources; Research development; Legislation; Pharmaceuticals, medical supplies and equipment; Secondary and tertiary referral hospitals; Public and private partnerships; Social services/welfare; and Donor coordination. The Immunization Program is geared at achieving the above-mentioned vision and aims to protect the majority of children and women against vaccine preventable diseases. The EPI program is housed within the Directorate of Preventive Services (DPS) in the Ministry of Health. The EPI program is tasked with providing vaccinations to children and mothers in order to prevent communicable diseases. Two zonal and ten district management s implement the immunization program. EPI services are provided free of charge and is the responsibility of the zonal and district management s. The national level provides logistics support and technical input for the zones and the districts. No changes to the current management and governance system are planned. 3

14 2.0 BUDGET PROCESS AND FINANCIAL MANAGEMENT The financial year in Zanzibar is from the month of July to June the next year. The Government of Zanzibar commences the Public Expenditure Review process and the Medium Term Expenditure Framework process of budgetary planning in the Financial Year 2003/04. The table below highlights key macro economic figures for GoZ. Table 1: Key macro economic indicators for Zanzibar, 2001/02 (millions of Tanzanian shilling) Planned Received EPI programme 60,000 2,000 MOHSW 5,463,027 3,410,087 Total Government 67,402,560 Budget and expenditure Proportion of resources EPI to MOH 1.1% 0.1% received MOH to Govt 8.1% The health sector receives approximately 8% of the total government budget. Of this, the EPI programme received below 1% of the health budget, and expenditure. Funds from the recurrent budget are used for the operational costs of running the EPI programme, such as building maintenance, salaries, etc. The government budget process and financial management has four phases namely, pre- budget guideline phase, budget preparation and scrutiny phase, budget approval phase, and budget execution phase. 2.1 Phase 1: Pre-Budget Guideline This phase is involves the review of the past macroeconomic performance in areas of policy targets, economic growth, inflation, government finance, monetary and credits development, exchange rate and external sector. It is at this stage that global resource allocation to sectors, Ministries and departments are made. Both the macroeconomic review and projections provide important inputs to the budget guidelines. For the immunization program, this stage may serve as an entry point for soliciting resources by making sure that the program requirements are reflected in the health budget. The Ministry of Finance and Economic Affairs (MOFEA) is responsible for financial planning, monitoring and evaluation of the government structure in Zanzibar. Funds from the MOFEA are channelled to the Ministry of Health through the recurrent and development budgets.. Funds from the recurrent budget are used to pay for general operating costs of the EPI program such as salaries, building and fuel costs. The government development budget supports projects that receive significant partner (donor) support. The EPI program is one of five prioritized programs of the Ministry of Health and Social Welfare (MOH-SW) that are funded through the development budget. Funds from the development budget are used to pay for specific operating costs of the EPI program excluding salaries. 4

15 2.2 Phase II: Budget Preparation and Scrutiny The issuing of budget guidelines triggers this phase. The government planning and budget cycle starts in January/February of each year. The MOFEA, in collaboration with the Zanzibar Revenue Board, identifies and forecasts the overall governmental expenditures for the coming fiscal year based on collected revenues. The MOFEA and the Revenue Board then set budgetary guidelines and ceilings for each ministry. The MOH-SW uses these annual guidelines and the budget ceiling provided by the MOFEA to prepare its annual budget proposals. These plans are reviewed by the MOFEA s directors and if necessary, returned to MOH-SW for revisions. 2.3 Phase III: The Budget Approval The revised proposals are then submitted to the principal secretaries in the MOFEA for approval. The principal secretaries examine and adjust the plans and allocations prior to forwarding them to the Revolutionary Council for preliminary endorsement. The total budget proposal is then sent to the Committees of Finance and Economic Affairs of the House of Representatives for review and authorization before being presented at the House of Representatives budget session. 2.4 Phase IV: The Budget Execution This stage involves disbursement of funds, procurement of goods and services, accounting, reporting and auditing. The phase may also serve as an avenue for the monitoring and tracking of the program resource inflows and expenditure Disbursement of Funds In reality, implementation of the EPI program is significantly affected by low and slow disbursement of funds. The reasons why the EPI program does not receive all of its approved funds have been attributed to inaccurate revenue forecasting as well as administrative and logistical problems related to collecting projected revenues Procurement of Goods and Services Government funds are mainly utilized to procure supplies for the program and the procurement has to follow the laid down procedures.. All vaccines and injection supplies are currently procured through UNICEF Accounting The financial transactions of the government are done through the exchequer systems and IFMS. All revenue collection, payments, issuing of cheques, expenditures and procurement commitments are managed though the IFMS. Immunization Program financial transactions for all monies budgeted on the Government budget are also accounted through the exchequer and IFMS Reporting The planning unit of the MOH-SW prepares physical and financial reports on quarterly and annual basis and forwards them to the MOFEA. These reports describe the activities of the program that were funded under the development budget during that period. 5

16 2.4.5 Auditing Internal auditors in the MOH-SW and MOFEA external auditors conduct accounting and auditing of the EPI program. During the fiscal year, the government will introduce the PER/MTEF system of planning and accounting in order to create better accountability of government and donor funds. The financial challenges that the immunization program faces are highlighted in Box 3 below. Box 3: Financial challenges facing the Immunization Program For long periods of time, very little surplus revenue has been available to finance development expenditures. Dependence on general tax revenues is evidence that health sector financing is heavily influenced by the overall performance of the public economy and on total government revenues. Actual EPI program needs are much higher than what is planned and provided for in the EPI program budget. This situation hinders the effectiveness of the program to meet its planned objectives. Irregular disbursal of funds from the treasury to the MOHSW has undermined the capacity of the ministry to effectively manage its resources. A centralized financial management structure weakens the capacity of other levels of the ministry, especially at the district and community levels for effective and efficient planning and management of resources. The EPI program is highly donor dependent on most program inputs such as capital equipment and vaccines and injection supplies. At lower levels of the health system, financial and budgeting capacity needs strengthening. 6

17 3.0 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES 3.1 Program Characteristics The Zanzibar EPI Program s goal is to decrease morbidity and mortality caused by vaccine preventable diseases. The program s broad areas of activity are routine service delivery, disease surveillance and supplemental immunization to eradicate polio, control measles and eliminate neonatal and maternal tetanus. Specific descriptions of program performance and targets have been addressed at length in the GAVI application, inception report and multi-year strategic plan. Updated national and district immunization coverage information for is located in Annex A. It is expected that the EPI program will be able to meet its coverage targets if all resources requested by the EPI program are provided. However, if funding is not available, experience has shown that it will be difficult for the program to reach these targets. The five-year Strategic Plan has highlighted plans for implementing program improvements and these are highlighted in Box 4 below. Box 4: Plans for Implementing Program Improvements Improving district micro planning, Increasing community ownership and involvement, Supporting outreach immunization and supervision, Effective mobilization of funds for EPI. Introduction of a new injection safety policy, which replaces sterilizable syringes with AD syringes and needles and requires injection equipment to be disposed of safely Immunization Coverage The DPT3 immunization coverage rate as of 2001 was 83%. This has changed from a rate of 84% in 1999 and 81% in Since the development of the strategic plan, the EPI program has identified a need for funds for transportation to reach populations in difficult to access regions. In Pemba, for example, there are about 22 small islands which will either require funding for the purchase of two small fiberglass boats with outboard motors for reaching these islands or funding for hiring small boats when needed. The immunization program has faced financial constraints in the past, notably since 1996 when bilateral support for the immunization program ended. If the EPI program does not receive the funding that it needs, EPI staff will focus on activities where funding is available. During funding shortages, routine immunizations continue, but supplementary immunizations are temporarily suspended. 7

18 3.1.2 Vaccine Wastage Rate The EPI program calculates the vaccine wastage rate by including all types of wastages, i.e. discarding open vials, freezing, broken and missing vials. The program s goal is to reduce wastage for all types of wastage. As part of its wastage policy, EPI program staff will focus on reducing vaccine wastage at the national and district levels. Once wastage has been reduced at these levels, they will work to reduce wastage at the lower levels i.e health centre and community levels. The wastage rate for all antigens ranged from 25-60% in 2000 but shown signs of decreasing in 2002 (15-49%). See Table 2 below. The decrease in vaccine wastage has occurred primarily as a result of implementation of the multi-dose vial policy in It is expected that wastage rate will continue to fall to reach the target rate of 15%. Table 2: WASTAGE RATE (%) BY ANTIGEN Antigen BCG OPV DPT (Hep B) Measles TT New Immunization Technology and Antigens The program introduced DPT-HB in 2001 and plans to introduce DPT-HB-Hib by 2005/06 FY. DPT-Hib vaccine will be introduced to achieve an expected coverage rate of 90% for all antigens for all districts by The Hib disease burden rapid assessment conducted in October, 2001 suggested that there is a great need of Hib vaccine to be introduced in the routine immunization schedule. The assessment revealed that, Meningitis based estimates (lower end) of 15,000 cases with 2,500 deaths per year, Meningitis based estimates (high end) of 18,000 cases with 3,000 deaths per year. Child Mortality based method of 19,000 cases with 3,300 deaths per year. To address injection safety, EPI has introduced the auto disable syringes in place of sterilizable needle and syringes. Other measures undertaken to improve injection safety include sensitization, education of health workers, and the construction of incinerators in all district hospitals. All of these measures have cost implications. 8

19 4.0 BASELINE AND CURRENT PROGRAMME COSTS AND FINANCING Before 1996, Zanzibar s major EPI financial partners were bilateral organizations such as DANIDA, CUAM (Italy), and multilateral organizations such as WHO and UNICEF. Since 1984, CUAM and DANIDA fully supported all program developmental costs including logistics for vaccine purchases and distribution of cold chain equipment, human resource development, and transport for program management such as supervision and office operations. DANIDA s average annual contribution over was approximately US$250,000. During the years prior to 1996, GOZ supported program infrastructure and staff remuneration. UNICEF and WHO provided technical support such as specification of EPI vaccines and equipment and technical materials. After 1996, bilateral donors, CUAM and DANIDA, ended their support of the EPI program in Zanzibar. To make up for the shortfall, increased support from the government and multilateral organizations (WHO and UNICEF) was provided to the program. As of 2002, WHO and UNICEF provide funds for disease control initiatives to address measles and polio, support routine immunization through the provision of vaccines and cold chain equipment, and provide technical support for capacity building. However, this support is inadequate to cover all program needs and often leads to shortages of vaccines and fuel for cold chain and supervision. Some additional funds and in-kind donations from the private sector are mobilized through the ICC. Funding sources include ECOTEC, a British petroleum company that supplies fuel and kerosene during NIDs, local Rotary Clubs and private business institutions. 4.1 Baseline Program Costs and Financing Patterns The pre vaccine fund year for which accurate data is available for the immunization program is 1999/00 and for the purpose of this exercise, this will be the baseline year. The programme costs are illustrated in Annex B table 1.1. The total expenditure during the period for the immunization program was $143,133. These costs represent both the operating, and capital costs of the programme. Inclusion of shared costs such as personnel for EPI raises the total programme costs to US$ 264,474. The categorization of these costs (without the shared costs) is shown in the diagram below; Financial Year 1999/2000 major cost categorization for the EPI programme 9

20 Vac cines 16% SIA's 52% Ot her recurrent cost s 18% Rout ine capit al cost s 14% The bulk of the programme costs were due to the supplemental immunization activities for polio and measles that were carried out then. The other cost components; the routine capital, vaccine costs and other routine recurrent costs were approximately of the same amount to the programme. Of these programme costs, the Government contributions represented 17% of the total costs. Inclusion of the shared costs rises the Government contribution to 48% of the total costs Expenditures for 2001/02 (Current Year) The programme expenditures are detailed out in Annex B, table 1.2 for the year 2001/02. The total expenditure for the immunization program was US$347,076. If shared personnel costs are included, the total cost of the program would be $521,532. The categorization of these costs (minus shared costs) is shown below. Financial Year 2001/02 major cost categorization for the EPI programme 10

21 Vac cines 16% SIA's 39% Rout ine capit al cost s 0% Other recurrent costs 45% There is a marked increase in the proportion of routine operational costs as compared to the previous year. This is largely attributed to the operational costs incurred during the introduction of the new vaccines. Comparison of the different donors over the two years is presented in the diagram below. Relations of funders for the EPI programme, 2000/01 and 2001/02 400, ,000 Cost (USD) 300, , , ,000 GAVI Mulitlaterals Bilaterals Government 100,000 50, Year We see the overall increase in the programme costs in the year 2001 as compared to the year While the government contribution is largely the same, it reduces in proportion to the total costs to 7%, down from 17%. An increased number of bilateral governments were offering support to the programme, shown by the marked increase in bilateral support. Support from the multilaterals (represented by the UN agencies) was on the whole similar. We see the introduction of GAVI funds reflected. 11

22 5.0 FUTURE RESOURCE REQUIREMENTS AND PROGRAM FINANCING: 5.1 Estimates of future resource requirements Estimates of future resource requirements have been derived using projections of the program objectives which were described in Section 3. The projections are calculated using the multi-year financing plan that was developed as part of the program s Multi-Year Strategic Plan. Projections of resource requirements, future funding levels and patterns, and estimates of financing gaps have been developed based on the two funding periods, the GAVI/Vaccine Fund period 2001/ /06 and the Post Vaccine Fund period 2006/ /09. For each of the period, projections of resource requirement have used one scenario which is to introduce DPT-Hib in 2005/06. Also the projections for future funding have used one option which assumes GAVI Vaccine Fund is used over a period of 5 years (2001/ /09). This is summarized in the diagram below. EPI programme resource requirement projections to 2008/09 1,000, ,000 SIA's 800, , , , , ,000 Routine capital costs Other recurrent costs Vaccines 200, , Year From the above, there is an increase in the programme costs over the years, with two peaks at the periods when the HepB is introduced 2002, and again when the Hib vaccine is expected to be introduced 2005/06 FY. The causes for the cost increases include the increase in the birth cohort, and strategies for increased coverage and new vaccine introduction. The new vaccine introduction leads to the highest increase in programme costs, with the result that the vaccine cost increasingly becomes the cost driver for the programme. 12

23 The table below is a breakdown of the expected program requirements for specific line items for 2002/ /09. Operational Cost Vaccines 204, , , , , , ,578 Vaccines (traditional 6 antigens) 41,370 38,790 39,952 42,385 43,657 44,923 46,226 Vaccines (new and underused vaccines) 162, , , , , , ,352 Injection supplies 25,007 24,984 25,733 27,299 28,119 28,119 28,119 Personnel (salaries) 5,899 5,899 5,899 9,000 9,000 9,000 9,000 Transportation 10,000 9,500 9,500 9,500 9,500 9,500 9,500 Cold chain maintenance and Overhead 47,387 21,150 15,150 5,899 5,899 5,899 5,900 Kerosene/gas 6,400 6,400 6,400 6,400 6,400 6,400 6,400 Short-term training 55,500 4,000 6,800 72,204 IEC/Social mobilization 8,000 8,000 8,000 8,000 8,000 8,000 8,000 Monitoring and surveillance 46,626 11,274 10,206 10,206 10,206 10,206 10,206 Other operational costs 43,801 46,198 50,148 67,804 73, Sub total operational costs 453, , , , , , ,927 Capital costs Vehicles 28,000 28,000 Cold chain equipment 58,628 16,698 17,109 24,665 22,221 22,221 22,221 Other capital investments 3,720 Subtotal capital costs 86,628 44,698 17,109 24,665 22,221 22,221 22,221 Supplementary Immunizaiton Activities (polio and measles) Subtotal SIA's 163, , ,423 TOTAL COSTS 703, , , , , , ,148 Optional information Shared personnel costs 102, , , , , , ,101 Suubtota; optional information 102, , , , , , ,101 GRAND TOTAL (with optional information) 805, , ,880 1,022, , , ,249 Note: Breakdown of the Supplemental Immunization Activity costs was not feasible due to data gaps The total programme requirements for the period 2002/03 to 2008/09 including the shared personnel costs are USD$ 5,962,230, of which USD$ 2,075,785 are required for the period 2002/03 to 2004/05, while USD$ 3,886,445 are required for the period 2005/06 to 2008/ Projections of Future Financing Levels and Patterns: Projections of future financing during the GAVI/Vaccine Fund period (2001/ /06) and after the GAVI/Vaccine fund period (2006/ /09) were calculated based on the programme strategies and available information on the funding levels from both the government and development partners. Government funding is based on the present level of support, adjusted for population growth. 13

24 Future funding can only be estimated for the multilateral partners, and is based on present and past programme support. The estimates of the secured funding are shown below. Funding Source 2003/ / / / / /09 Government 32,000 32,960 33,949 34,967 36,016 37,097 GAVI/Vaccine Fund UNICEF 95,000 50,000 30,000 30,000 30, WHO 50,000 30,000 30,000 30,000 30, *The support from GAVI/Vaccine Fund for the 2006/07 was unspent balance from the year 2001/02. Based on the distribution of funds from GAVI/Vaccine Fund, Zanzibar will get US$ 2,075,213 for the period of 5 years (2001/ /06). This is 6.9 percent of the total available from GAVI/Vaccine Fund for both Tanzania Mainland and Zanzibar. 5.3 Estimates of Financing Gap The following of diagram shows estimates of the financing gap for the period of 2001/ /09 based on the scenario and option discussed above. Funding gap for the EPI programme, up to 2008/09 1,000, , , ,000 Unsecured funds 600, , , , ,000 Secured funds 100,000 The funding gap in US$ / / / / / / / / 09 Year Projected 530, , , , , ,148 req. Secured Funds 420, , , ,967 96,016 97,097 Funding 110, , , , , ,051 gap *The projected resource requirement does not include the optional information on shared costs of personnel for the period of 2003/ /09. 14

25 The program is faced with a total funding a gap of US$ 2,294,463 (50%) out of the 4,544,409 US$ it requires over the period of 2003/ /09. This gap does not include the personnel shared cost of USD$ 612,606 over the same period We see the presence of a funding gap even before the introduction of the Hib vaccines, which significantly increases over the years following its introduction. 5.4 Risk Assessment It should be noted that, this gap is large because of the difficulty in knowing resources available far into the future, from whichever source. As a result, a number of persons/organizations that will be investing in the programme then are not included in the secured funds. The aim is to illustrate the level of uncertainty in funding the programme objectives, as opposed to illustrating programme under funding. The major source of secured funds is the GAVI resources, as illustrated in the diagram below. Secured programme funds by source, 2001/02 to 2008/09 900, , , , , , , ,000 Others (DANIDA, Irish Aid, USAID) WHO UNICEF GAVI/Vaccine Fund 100,000 Government / / / / / / / / 09 GAVI/Vaccine Fund support is the most secured source of funding for the VF period. The government financing is dependent on the actual allocation in respective years. These commitments depend on the outcome of negotiations and prioritization through the PER and MTEF processes. Since the government budget is calculated in Tanzania shillings any exchange rate fluctuation will affect contribution levels. The present programme strategy as outlined in section 3 and in the EPI Multi Year Plan presents the most cost effective use of the government s resources, and leads to the highest reduction in both mortality and morbidity for the particular conditions for which vaccines are being provided. 15

26 6.0 SUSTAINABILITY STRATEGIES PLAN AND INDICATORS 6.1 Immunization Program Constraints In the implementation of immunization activities, there are various constraints, which affect the performance and sustainability of the program. These constraints include: (i) (ii) (iii) (iv) (v) (vi) (vii) Inadequate funds for funding all planned activities. Delays in disbursement of funds from both government and Development Partners Sometimes the program is faced with a problem of receiving fewer funds as compared to pledges from different sources.. Delays in the procurement process affect the implementation of program activities. Delays in honouring pledges lead to funds being frozen and therefore affecting the program performance. Lack of adequate and qualified health staff especially at the facility district level, leads to poor forecasting and inefficient handling of vaccine supplies. This is one of the reasons for high wastage rate, which at 2002 stands at 20 percent for DPT-HB. Failure to realise additional resources as projected in the financing strategies described below under section 6.2. Failure to increase efficiency especially in reduction of wastage rate to 10% from the current rate of 20% of DPT-Heb prior to the introduction of new vaccine. 6.2 Financing Strategies, Indicators and action plan To address the financing gap illustrated in section 5.3 above, the FSP Task Force has developed a series of financing strategies and indicators to help address current and future financing needs. The strategies are designed to mobilize existing and additional resources, ensure reliability of resources and increase the efficiency of resources. Some specific strategies include: (1) Assuring mobilization of adequate resources; (2) Assuring reliability of resources, and (3) Increasing the efficiency of the EPI program 16

27 Mobilizing additional resources The strategies and actions to be used by the programme to mobilize additional resources are varied. These additional resources shall be sought from government (both central and local), private sector and donors. The programme shall institute a number of activities to ensure these resources are achieved each year, and are reflected in the MTEF. These are outlined in the log frame that is Annex C. They are presented within the text that follows Additional central Government resources The resources sought have to fit within the financial realities of the sector, and so amounts sought shall be based on proportions of the sector budget, as opposed to basing them on the overall needs of the programme. Central Government funding for the EPI programme is presently at US$ 13,500. This amount is very small, compared to the impact socially, economically and politically of the programme for the Government and communities. As such, the programme shall, within the financial realities within which the sector operates, and keeping in mind the needs of other health sector programmes, shall strive to have an increased resources through a gradual increase in its proportion of the health sector resources. This increase shall be sought in the medium to long term to ensure it has limited, or no impact on other Ministry of Health programme or activity budgets. The programme shall seek to receive 4% of the health sector expenditure by the year 2008/09 incrementally as is illustrated in the table below. Incremental resources from Government, 2003/04 to 2008/09 (US$) Govt health budget/expenditure 5,863,000 6,033,027 6,207,985 6,388,016 6,573,269 6,763,894 Proportion of health to EPI Govt budget 0.6% 1.0% 1.5% 2.0% 3.0% 4.0% Amount 32,247 60,330 93, , , ,556 Incremental amount on secured funds ,370 59,171 92, , ,459 The ability to achieve these resources from Government will greatly impact on the ability of the other strategies to realise the expected resources. Additional local Government resources The local Government s are resource constrained, and rely largely on resources from the central Government for their activities. However, some programme activities can be funded locally, particularly those relating to the usually funded activities for local Governments. The activities relate to social mobilization of communities for routine EPI activities. In the long term, the programme shall seek to shift 50% of the resources being spent on social mobilization to the local Governments. This shift shall be phased to ensure lessons learned are taken up in the most cost effective manner, and the local Governments are only able to take up these costs based on their capacities. The strategy shall be to have 25% of these costs transferred to the local Governments in the Financial Year 2004/05, 40% in the FY 2005/06 up to 50% beyond 2006/07. 17

28 The expected resources mobilized are illustrated in the table below Incremental resources from Local Governments, 2003/04 to 2008/ Social mobilization/kerosene resources 14,400 14,400 14,400 14,400 14,400 14,400 Proportion to LG's 0% 25% 40% 50% 50% 50% Incremental amount from LG's - 3, , , , , To mobilize additional Government (central and local Government) resources requires a plan focused at the key stakeholders responsible for resource allocation for the programme. These stakeholders include both technical and political actors, for which key advocacy messages shall be synthesized and presented in a brief (Annex D). The message from the programme to the political actors shall focus on the possible political dividends of the strategy (the strategy involves the first introduction of new vaccines in 20 years), its relation to the ruling part manifesto and the social implications of not being able to implement the strategy. These actors shall be: - The Office of the President, State House from whom the programme would benefit from a clear message of support for the strategy (particularly relating to introduction of Hib in 2005) - The office of the Prime Minister for advocacy within Government, - The Parliament for wider political support for the strategy An information memorandum shall be prepared and presented to the Government of Zanzibar highlighting the EPI strategy, with its financial feasibility to achieve government endorsement for the strategy. This shall make resource mobilization less difficult. The technical actors include persons from the Ministries of Health and Finance. These include: - Minister of Health and Social Welfare for top level political support in the sector, and to the wider Government - Ministry of Health and Social Welfare Permanent Secretary for support from the top most key technical officer in the ministry - Ministry of Health and Social Welfare Director, preventive services who is the head of the directorate - Ministry of Health and Social Welfare Director, policy and planning - Ministry of Finance and Economic Affairs health technical officer - Ministry of Finance and Economic Affairs Directors of planning and budgeting For these technical actors, the focus of the advocacy shall be on highlighting the financial feasibility of the strategy, and the lack of impact on other programmes, sectors and the overall macroeconomic framework of the country. Also highlighted 18

29 shall be the availability of funding in the short, medium and long term, the impact of the strategy on disease burden, and the implications of not implementing the strategy. Included in the advocacy shall be actors at the regional and district level, where the advocacy focus shall be on the feasibility of the strategy, and their required activities in support of sub national resource generation efforts. Resources from private sector The private sector includes the private for profit actors, and the Non Governmental Organizations. A number of these have the potential to support specific programme activities, but require to be provided with the appropriate message and strategies for collaboration. The NGO actors include humanitarian organizations, while the profit sector includes the large actors in the commercial sector like the communication and beverage companies. Actions relating to these include initial identification of the appropriate actors to target. The programme shall identify 2 to approach in the 1 st year, starting with a humanitarian organization to understand the approach before contacting a commercial company. For each, background information is first required relating to estimates of the organizations advertising/support budget and activities it has supported in the past. The particular activities it could support are then identified within the programme activities. Before contacting each, it is important to have a brief that highlights: - Proposed areas of collaboration with the organization, - Resources sought - Benefits of the collaboration to the organization - Benefits of the collaboration to the EPI programme and the Ministry of Health and Social Welfare - Social benefits (to the community) of the collaboration The resources sought from these shall be conservative, as it is a new sphere of operation for the programme. As such, amount sought shall be limited at an equivalent of 50% of the social mobilization costs, starting from 30% in 2004/05 to 40% in 2005/06 and finally 50% in 2006/07. The expected resources are illustrated below. Incremental resources from private sources, 2004/05 to 2008/09 (US) MOBILIZE PRIVATE RESOURCES Social mobilization resources 14,400 14,400 14,400 14,400 14,400 Proportion to private sector 30% 40% 50% 50% 50% Incremental amount from private sector 4,320 5,760 7,200 7,200 7,200 Additional resources from present EPI donors The programme has a number of donors presently supporting its activities. These are the multilaterals WHO and UNICEF, and one bilateral donor, GAVI. It is only 19