Proceedings of the second sabin colloquium on sustainable immunization financing (sif) fv

PROCEEDINGS OF THE SECOND SABIN COLLOQUIUM ON SUSTAINABLE IMMUNIZATION FINANCING (SIF) DAKAR, SENEGAL 5-6 AUGUST, 2013

Acknowledgements Funding for the SIF Program is provided by generous grants from the Bill & Melinda Gates Foundation and the GAVI Alliance.

The SIF Program receives guidance from a Partners Group whose members include the World Health Organization, UNICEF, the GAVI Alliance, the World Bank and the Bill & Melinda Gates Foundation.

The Sabin Vaccine Institute thanks the UNICEF Office for West and Central Africa for supporting the participation of several delegates and for the active participation of their staff in the Colloquium.

Several individuals provided logistic and media support, including Alexa Bednarz (Bill & Melinda Gates Foundation), Caitlin Garlow (Sabin) and Brian Shaw (Sabin).

Simultaneous interpretation was provided by Vidya DIAITE and Associates.

Photographs were created by Clement Tardiff.

The Colloquium would not have been possible without the invaluable support of the Ministry of Health and Social Assistance and the Ministry of the Interior, Government of Senegal.

This report was prepared by the Sabin SIF team: Khongorzul Dari, Ciro de Quadros, Devendra Gnawali, Clifford Kamara, Diana Kizza Mugenzi, Helene Mambu-Ma-Disu, Jonas Mbwangue, Mike McQuestion, Alice Nader, Mariya Savchuk.

Washington, DC USA 20 September 2013

Executive Summary On 5-6 August 2013, 59 delegates from 17 countries, convened in Dakar, Senegal for the second Sabin Colloquium on Sustainable Immunization Financing (SIF). They represented ministries of finance, ministries of health, other government ministries concerned with immunization financing and parliaments. Joining them were 35 counterparts from global immunization partner agencies WHO, UNICEF, the GAVI Alliance, the Bill & Melinda Gates Foundation and the Sabin Vaccine Institute. Participants spent two days in small groups and plenary sessions, examining their countries’ immunization budgets, legislation, and advocacy strategies. A highlight was a poster session where delegates assessed each others’ immunization financing innovations. Each country delegation drafted action points that will help them achieve sustainable immunization financing by 2015.

Assessment of the peer review results and country action points show that most of the SIF Program countries have made significant progress since the first Colloquium, which took place in Addis Ababa in March 2011. A summary of Colloquium proceedings and results follows.

Day One During a kick-off immunization finance and budget panel, delegates from nine countries shared insights into how their countries are financing their immunization programs and how effective advocacy efforts have been in this area. They reported generally increasing national immunization budgets. They described the roles ministries, parliaments and subnational government entities play in the budget process. They described innovations, such as results-based budgeting, national immunization funds and “sin taxes” to finance immunization. Future financing was a concern, particularly among delegates from countries about to graduate from GAVI grant eligibility, even before they have managed to introduce the newest (pneumococcal and rotavirus) vaccines.

Besides financing and budgeting, legislation is the second focus of SIF Program work.

During the second legislation panel, delegates from 9 countries pointed out that preparing immunization legislation forces government ministries and parliaments to come togethersomething seldom or never done in many countries. It forces the institutions to reconceptualize complex issues such as how best to fiscalize sub-national government

investments in health and immunization and how to harmonize federal and sub-national health laws. Some countries already have public finance control mechanisms in place which can easily encompass new immunization line items and fund operations. The cases show that the legislative process is usually long and arduous and is often interrupted by overriding events. Access to laws from other countries and peer exchanges, particularly through Sabin-organized legislative review workshops, have helped some delegates move their processes along.

Panelists identified a series of specific themes and best practices:

Nearly all the countries have organized parliamentary and public forums (briefings) to explain to the benefits of investing in immunization. These sensitization events greatly facilitate subsequent votes on the draft immunization laws once they are submitted to Parliament.

Panelists felt that establishing a network of like-minded parliamentarians in each country is essential to focus the dialogue with government and to ensure intra-parliamentary continuity on immunization-related issues. A parliamentary forum compensates for high MP turnover and provides necessary logistical and administrative support for the elaboration and implementation of immunization legislation.

All of the countries represented are currently developing immunization laws or updating existing ones. In most cases, freestanding bills are being written. This has been a slow process.

In some cases, panelists agreed, time can be saved if immunization legislation can be tacked onto existing laws.

Panelists agreed that “sin taxes� can be used to generate revenues earmarked for immunization and for health in general. They felt there should be a concerted effort to tax at least cigarettes and alcohol- two products that negatively affect population health. Immunization financing, should be included in the category of binding and mandatory (statutory) state budget expenditures.

A number of countries are working on legislation that will, inter alia, establish national immunization funds. Questions arose on: how will the fund be managed? What measures can be taken to ensure sound, efficient management? The questions remain moot because no funds have yet been implemented.

After the panels, delegates participated in a poster session where countries assessed each others’ new or planned immunization financing practices. Each poster followed a standard format, which included graphs of immunization financing trends, advocacy action points which had been set out by delegates to the previous Addis colloquium and bullet points describing the featured financing or legislative innovation. Delegates and their SIF Program counterparts prepared the posters together prior to the Colloquium. Forty-four

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delegates from all seventeen countries participated in the poster session. Each rater was randomly assigned three countries to evaluate. Peer assessments took place in two consecutive 45-minute rounds, each with peers from half the countries rating the other half.

Using a standard assessment guide, raters examined the posters and asked presenters to describe the innovative practices their governments and parliaments are developing, or have developed, to move their countries closer to the sustainable immunization financing goal. The results provide a description of some of the new practices countries are developing to more fully finance, and ultimately to own, their national immunization programs.

Raters most often classified the new practices as budget-related (26%), financial (10%), advocacy-related (6%), legislative (3%) or some combination of the four areas (54%).

Seventy-five percent of the practices were happening at national level, 18% at subnational level and 4% at international level. They appear to be developing in gradual fashion; at this point, few are fully institutionalized.

The subjective ratings showed that raters tended to agree most on four items: how the practices were conceptualized in the countries; which practices are leading to greater country ownership; which practices are most likely to succeed and; which practices might succeed in their own countries. Each of the four appears to tap a distinct dimension of the innovativeness construct. Well conceptualized innovations, for example, are not necessarily those leading to country ownership, nor are they likely transferrable to other countries. Whether relatively wealthy or relatively poor, raters decided, a country can innovate to improve immunization financing.

To finish Day One, participants were divided into six small groups to reflect on what they had shared and to analyze specific immunization financing issues. Three groups focused on finance/budget and oversight themes while the other three groups looked at legislative themes. A nominal group technique was used. Each participant reported a problem or challenge he or she considered important for immunization financing. Facilitators listed these. In the ensuing discussion, the number of problems was reduced to just a few and participants brainstormed possible solutions for each. Selected problems and proposed solutions are presented below.

The three finance/budget groups lamented the absence of actual cost and expenditure data from which to estimate forward budgets. (Proposed solutions: Conduct costing studies, analyze program costs)

A second problem was a general lack of budgeting and financial management skills on the part of EPI teams. (Proposed solution: Build financial management capacity through training and assigning skilled staff to EPI teams).

There is a general lack of budget transparency: financial and budgetary information is not being shared within or across public institutions.

Program financing, participants agreed, is highly dependent on external funding (Proposed solutions: identify new domestic revenue sources, improve tax collection, pass legislation ringfencing immunization funding) Ministries of finance are not helping enough to find new financing sources (Proposed solution: approach, engage ministries of finance) Vaccine costs are high and rising (Proposed solutions: pooled procurement arrangements, independent study of vaccine markets) Immunization budget disbursements are often delayed (Proposed solution: establish a buffer fund) Expenditures are not tracked, analyzed (Proposed solutions: establish budget monitoring (resource tracking) and reporting procedures, analyze expenditures as part of performance appraisals (including sub-national levels), improve management information systems) There is not enough coordination, transparency and accountability among public institutions (Proposed solutions: expand Interagency Coordinating Committees (ICCs) to include more national institutions; publish tax revenues and link them to immunization expenditures; perform timely internal and external audits) The three legislative groups identified 24 problems affecting legislative action for sustainable immunization financing. Among them:

Insufficient political commitment to universal immunization, all three groups felt, is a root problem. The availability of external immunization funding delays legislative action (state dependence). (Proposed solutions: evidence-based advocacy targeting both senior government officials and MPs; public information campaigns to raise demand, create political pressure for immunization; field visits by key decision-makers) The complex, ponderous legislative process itself is a significant barrier. With legislation, there is a tension between specificity (harder to pass, more effective) and generality (easier to pass, less effective). In some countries, governments and parliaments have little or no prior experience creating legislation together. Both sides lack the resources needed to properly legislate.

(Proposed solutions: Insert immunization into existing health laws where possible versus writing a free-standing immunization bill; organize occasional briefings where government officials and

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MPs come together to discuss the legislation; arrange more capacity building for parliaments and training for MPs; continue international peer exchanges) Government officials and parliamentarians do not know enough of the facts on immunization and immunization financing to take action. Investment cases for immunization are not made.

(Proposed solution: provide regular reports on the immunization program to key decisionmakers covering both immunization financial and technical indicators).

Day Two Day Two began with reports from the six small groups, which generated a lively Q&A session. A panel composed of partner agency counterparts followed, focusing on the Global

Vaccine Action Plan and how countries can leverage the innovations presented on Day One to meet selected GVAP strategic objectives. In this second Q&A session, the delegates stressed the importance of working together to achieve the GVAP objectives. They reinforced the need for each country to determine its own immunization priorities and for the external partners to shift their practices to fully support country ownership. Other GVAP-related issues addressed included: the need for more certainty on the price of the newer vaccines; the relationship between the various reports currently produced by the countries (JRF, GAVI Annual Report, National Health Accounts) and how they will contribute to the annual GVAP reporting process; and the need for faster technology transfer in Africa especially for vaccine production.

The 17 country delegations spent most of the afternoon of Day Two working in small groups. Each group developed a set of short- and medium-term action points, which delegates will strive to implement to achieve the SIF objective. The delegates then reconvened and presented their plans in plenary.

Thirteen out of the seventeen countries were represented in both the Addis and Dakar Colloquia. Analyzing the two sets of action points for the thirteen countries, five common themes emerge. Most frequent in both sets are legislation and advocacy activities.

Financing is next, followed by financial management and organizational changes within the EPI program .

Five of the thirteen countries (Liberia, Madagascar, Nepal, DRC, and Sri Lanka) formulated financing action points in both Colloquia. The comparison shows that the countries remain most strongly committed to their legislative work and to developing their own advocacy capacities.

Looking ahead, six countries (Cameroon, Madagascar, Mali, Nepal, Senegal, Vietnam) set action points in Dakar relating to GVAP implementation.

Their country action points completed, delegates next discussed, and ultimately adopted, the Declaration of Dakar. Drafted by an ad hoc delegate committee, the Declaration captures the key issues discussed throughout the Colloquium. It sets targets for developing more financing, budgetary and management best practices for immunization programs and calls for more south-south exchanges of these practices. The Declaration exhorts countries to fully implement GVAP. Delegations selected one delegate each to sign the Declaration.

The Colloquium finished with a posttest and closing remarks from the global immunization agency counterparts and the Director General, Ministry of Health and Social Welfare, Senegal.

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Contents Objectives of the Meeting ......................................................................................... 9 Agenda ................................................................................................................ 10 Participants ........................................................................................................... 10 Proceedings .......................................................................................................... 10 Day One ............................................................................................................. 10 1.1 Audience polling ........................................................................................... 10 1.2 Opening comments ....................................................................................... 12 1.3 Panel discussions.......................................................................................... 14 1.4 Poster session .............................................................................................. 25 1.5 Small groups .............................................................................................. 32 Day Two ............................................................................................................. 35 2.1 Partners on the Global Vaccine Acton Plan ....................................................... 35 2.3 Country action points .................................................................................... 38 2.4 Declaration of Dakar ..................................................................................... 39 2.5 SIF mini-course scholars ............................................................................... 40 2.6 Closing ceremony ......................................................................................... 40 3 Evaluations .................................................................................................... 41 ANNEXES: .......................................................................................................... 43

Objectives of the Meeting To bring together parliamentarians and their key governmental counterparts from 17 countries to share and assess experiences and best practices for sustainable immunization financing.

To enable delegates to peer review their work in the areas of financing, budgeting, advocacy and legislation using a standard methodology.

To enable national delegations to formulate new advocacy action points that will lead to sustainable immunization financing by 2016.

Ciro de Quadros addressing the delegates at the opening ceremony of the Colloquium.

"We’re at a pivotal moment in history, where we have the opportunity to create change like never before.�

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Agenda The Colloquium agenda is presented in Annex A.

Participants The Colloquium was attended by 94 participants, of whom 59 were country delegates and 35 were global immunization partner agency counterparts. Among the country delegates, 25 represented ministries of health, 12 represented ministries of finance, economy and budget and 20 were parliamentarians. Participants were well versed in immunization matters. Seventy-three percent of participants had personally participated in either a polio or measles campaign. Seventy-eight percent had worked on some phase of their national immunization program budget cycles. Sixty-four percent had participated in a previous Sabin SIF-organized event.

The list of participants is presented in Annex B.

Proceedings Day One 1.1 Audience polling The Colloquium began with a pretest in which the audience was polled on a range of items related to immunization and immunization financing.

Participants scored relatively well on a series of knowledge items relating to immunization, public institutions and public finance concepts. The majority was familiar with Millennium Development Goal #4 (reduce child mortality by two-thirds). Seventy-five percent knew that the cost of fully immunizing a child will soon approximate US$60. Equal proportions of participants understood the term absorptive capacity and were familiar with the World Bank’s Public Expenditure and Financial Accountability (PEFA) framework. Over 90%

correctly identified the three basic functions of parliament (oversight, representation, legislation).

Several attitudinal items were also measured. Their pre- and post- responses tended to vary. In the posttest, participants were more likely to agree or strongly agree that governments should only introduce a new vaccine if it has been shown to be cost effective. Eighty-five percent strongly agreed that any public program, immunization included, must be shown to be effective and efficiently managed. In comparison, 63% felt so in the pretest. Participant confidence in the programs evidently increased. In the pretest, only 7% of participants believed that lower income governments would be fully or nearly fully immunizing their routine immunization programs in five years’ time. In the posttest, this proportion increased to 20%. In the pretest, only 27% believed that polio eradication will be achieved in the next 3-5 years; in the posttest the proportion increased to 40%.

Pre- and posttest results are compared in Annex C.

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1.2 Opening comments The program opened with comments by counterparts from the partner agencies formally engaged in the SIF Program. Representing the World Health Organization, Dr Oladapo Walker, Coordinator of the WHO/AFRO Inter-country Support Team for West and Central Africa (WHO/AFRO/IST/WCA), outlined the strategic immunization goals adopted by the African Regional countries for 2009-15, emphasizing the need to increase vaccine coverage and eradicate polio. Immunization is one of the most cost-efficient interventions in public health, he added, and this provides another rationale for countries to continue investing in their immunization programs. WHO shares the SIF Program vision of countries ultimately self-financing their immunization programs, commented Dr. Walker. The countries will leave here with a stock of best practices to draw from as they work toward sustainable immunization financing.

Mr Santiago Cornejo, Director of Immunization Financing at the GAVI Alliance, recognized the progress made by the countries since the First SIF Colloquium (held in March 2011, Addis Ababa). He noted that GAVI supports SIF Program engagement in three countries. A second grant to add four more countries is in process, he added.

Begun in 2000, GAVI is dedicated to saving young lives by bringing newer and underutilized vaccines to every country. Looking ahead, there will be even more powerful vaccines but these will be even more costly. Reflecting on the Latin American experience, where countries today are financing over 95% of their immunization program needs, Cornejo challenged the African and Asian countries represented to do the same.

Ms. Molly Abbruzzese, Program Officer for Global Health Vaccine Delivery at the Bill & Melinda Gates Foundation, noted her foundation’s continuous support for the Sabin SIF Program. The first SIF grant was awarded in 2008. A second grant will support the Program through 2015. The Foundation is impressed with the innovative work the SIF countries are doing on immunization financing, commented Abbruzzese. Achieving sustainable immunization financing, she added, will also help the countries achieve Millennium Development Goal #4 (reduce child mortality by two-thirds) and Global Vaccine Action Plan Strategic Objective # 1 (all countries commit to immunization as a priority).

Mr. Thomas O’Connell, Senior Health Specialist, Economics and Finance, UNICEF, New York, described how UNICEF is working in tandem with governments to ensure that

vaccines reach every child. This imperative corresponds to GVAP Strategic Objective #3: The benefits of immunization are equitably extended to all people. One aspect of this work is to track resources to identify bottlenecks, which often occur at sub-national levels.

UNICEF and SIF are increasingly collaborating with countries in this area, noted O’Connell.

Dr. Ciro de Quadros, Executive Vice President of the Sabin Vaccine Institute, thanked the host country, Senegal, for its hospitality and recognized Senegal’s Minister of Health and Social Welfare, Her Excellency Prof. Awa Marie Coll, for the important leadership role she continues to play in global health. A lot has happened on the global immunization front since the first Sabin Colloquium in Addis, he observed. In two short years, further progress has been made against polio. The global community came together to chart the Decade of Vaccines and gave birth to the Global Vaccine Action Plan. Countries are spending more on immunization. Advocacy is becoming a core function of immunization programs. We are at an exceptional historic moment, remarked de Quadros, when representatives of several public institutions (MOH, MOF, Parliament) from 17 countries can come together with partners in order to discuss and analyze, not just the technical but also the financial performance of their immunization programs. The financing and legislative work about to be showcased is an indication of bigger things to come. De Quadros urged all the countries to continue to implement GVAP and to take to heart one of its guiding principles: “country ownership”. The strongest expression of country ownership, he added, is to achieve sustainable financing for national immunization programs, i.e., to increase immunization budgets and become independent of external partner financing. In the coming three years, Sabin expects to see at least six countries graduate from the SIF Program. We can already look beyond SIF, declared de Quadros.

He challenged the countries represented at the Colloquium to take up the leadership role in GVAP. Dr. Pape Amadou DIACK, Director General of Health, Ministry of Health and Social Welfare of Senegal, thanked Sabin and welcomed the country delegations on behalf of Minister Prof. Awa Marie Coll. Senegal considers the issue of immunization financing a priority, he said. The country will increase its immunization investments when it introduces pneumococcal vaccine later in 2013. Dr. DIACK reminded the audience that immunization is one of the universal tools for combating deadly diseases, thanks to which smallpox has been, and polio will soon be, eradicated. Immunization is a very costeffective intervention, he added, that can help countries attain their Millennium Development Goals, especially MDG4. Dr. DIACK recalled that the first SIF Colloquium

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established the framework to help countries overcome the challenges and increase the financing available for immunization. Sustainable immunization financing is also among the GVAP strategic objectives. Accomplishing it requires the active collaboration of all actors, especially parliamentarians, he stressed. With that, the Secretary declared the Second SIF Colloquium open and conveyed his wishes for a productive meeting.

Dr. Papa Amadou Diack, Director General, Ministry of Health and Social Welfare, Senegal, addressing the delegates at the opening ceremony of the Colloquium.

1.3 Panel discussions The colloquium began with “back to back� panel discussions on financing/budgeting and legislation for immunization. All 17 participating countries were represented on one of the panels.

1.3.1 Immunization financing and budgeting (Moderator: Jonas MBWANGUE)

Panelists included: Cameroon (Mr. Djoulde Maina, Ministry of Health), DRC (Mr. Jules Baganda, Ministry of Budget), Indonesia (Hon. (Dr.) Nova Riyanti Yusuf, Parliament), Kenya (Dr. Dominic Mutie, Ministry of Health), Mongolia (Dr. Delger Munkhbat, Ministry of Health), Sabin Senior Program Officer Jonas Mbwangue addresses the delegates at the Colloquium.

Republic of

Congo/Brazzaville (Hon Pascal Leyinda, Parliament), Sierra Leone (Dr. Sartie Mohamed Kenneh, Ministry of Health and Sanitation), Sri Lanka (Hon. (Dr.) Ramesh Pathirana, Parliament), Vietnam (Dr. Duong Thi Hong, Ministry of Health).

The focus of this discussion was government action on immunization financing. The panel began with an introductory question: Has the national immunization budget increased in your country?

Republic of Congo/Brazzaville There has been a slight increase in the immunization budget. Immunization remains one of the national development priorities. An immunization law has been drafted in order to secure the funds allocated to immunization financing, especially in light of the imminent departure of GAVI. Local communities are closely involved in immunization financing.

Local elected officials participate in routine immunization and mass immunization campaign activities. The private sector is also increasing its involvement as a result of their social corporate responsibility policies.

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Cameroon As a result of sustained advocacy efforts, much of it with Sabin’s support, a “resultsoriented culture” has emerged around the immunization program. The government contribution to the immunization budget has almost doubled since 2008. New revenue sources for the program are being identified. There have been institutional and legislative reforms. Performance-based budgeting has been introduced and applied to the immunization program. A decision has been made by the government to create a Health Fund for health with a separate window for immunization. However, the main problem remains sluggish disbursement of the immunization budget.

Sri Lanka Country ownership of immunization is evident in Sri Lanka. The government finances all the country’s vaccines, except pentavalent, which is co-financed with GAVI. The immunization budget has doubled since 2005 and is set to double again with the

introduction of newer vaccines. The government has established a vaccine budget line item.

Modalities for engaging the private sector are being developed.

Kenya The country has a very strong parliamentary health committee and a vibrant civil society that is interested in immunization. These factors facilitate the elaboration of the immunization budget and its approval by the Ministry of Finance. An immunization advocacy group is emerging in the National Assembly. Advocacy groups are also emerging at the county level. These decentralized groups will ensure that the budget allocated to immunization is used exclusively for that purpose. Kenya has not had problems with budget disbursement, however, the amount of funds allocated for the immunization program is inadequate. The ministry of health is investigating approaches to immunization resource tracking.

Vietnam The country has enacted a Law on Combating Preventable Diseases, which provides for free and compulsory vaccination. Immunization is a national priority. The government is committed to fully fund the EPI. There was a 30% increase in the EPI budget from 201112 but the budget remained static in 2012-13. This budget will again increase next year, partly to meet GAVI co-financing commitments. Provincial governments also contribute to the financing of vaccination. The government is developing new resource tracking approaches for the immunization program.

Mongolia The country’s EPI has shown impressive results since 1996. In 2011, the country introduced the latest new vaccine with government funding and co-financing from GAVI. Since 1923, the country has had a legal framework favoring

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immunization. By law, immunization is mandatory for every child, with sanctions placed on any dissenting family. Linked to the 1923 Act are 11 regulatory documents which relate to immunization financing. A national immunization fund provides ring-fenced financing for immunization.

DRC There is a parliamentary group for immunization. Vaccination is one of the priority activities in the National Plan for Health Development (PNDS), which established a close relationship between the financing of the health system and the funds allocated to immunization. Prior to the Addis symposium, immunization funds were comingled in the same budget line with pharmaceuticals and medical products. Two years later, the Ministry of the Budget created separate budget lines for vaccines and immunization campaigns. For now, the priority is to secure the immunization funds and ensure that they are spent on vaccination activities. This is what the parliamentary group for vaccination is striving to achieve through its active oversight role. A new public finance reform law incorporates results-based budgeting/management for all government programs. The country is making efforts to buy all of its traditional vaccines with national funds. There is still the question of how to ensure that the provincial governments also commit funds for vaccination in their budgets, especially to pay for transportation of vaccines to immunization sites. New approaches to decentralized resource tracking are under discussion.

Sierra Leone With the support of Sabin and WHO, the Parliament has been getting progressively more involved in the immunization budget process. This has led the government to increase funding for the immunization program. Advocacy activities are conducted at national, county and district levels. This work involves various actors. Awareness about immunization financing is increasing and local committees for vaccination are being established. The major challenge at the district level is how to track immunization expenditures. Some cold chain improvements have been financed with local resources.

Indonesia Immunization is a priority in the country’s medium- and short-term MDG plans. Federal health budgets are generally sufficient. In 2012, the country spent an estimated US$11.50 per infant on immunization compared to $1.50 in 2006. The main challenge is

decentralization. The decentralization law provides that each district contribute 2% of its budget for health activities. There is no mechanism to assure these budgets are adequate and well executed and that, within them, immunization is adequately resourced. The central government plays a technical monitoring role. Vaccine procurement is carried out by the central government. The main sustainable financing strategy is a universal health coverage program, which emphasizes prevention and includes vaccination. It will be launched in 2014.

Summary Panelists shared insights into how the countries finance the programs and how effective advocacy efforts have been in this area. They reported generally increasing national immunization budgets.

They described aspects of their budget processes, focusing on the respective roles of ministries, parliaments and subnational government entities. They described innovations such as results-based budgeting, national immunization funds and “sin taxes� to finance immunization. Future financing was a concern, particularly among delegates from countries about to graduate from GAVI grant eligibility even before they have managed to introduce the newest (pneumococcal and rotavirus) vaccines. Following a lively Q&A session, panelists identified two overarching themes: Governments need to work more on financing preventive and not just curative health programs; Governments must put in place effective monitoring (resource tracking) mechanisms to ensure sustainable financing for immunization.

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1.3.2 Immunization legislation (Moderator: Helene MAMBU-MA-DISU) Panelists included: Cambodia (Hon. Ouk Damry, MP), DR Congo (Hon. Gregoire Lusenge, MP), Liberia (Hon. William Dakel, MP), Madagascar (Hon. (Dr.) Aro Tafohasina, MP), Mali (Hon. Fanta Mantchini, MP), Nepal (Mr. Komal Prasad Acharya, Ministry of Health), Nigeria (Hon. Adebenga Sefiu Kaka), Senegal (Hon. Alfa Balde, MP), Uganda (Hon. Oleru Huda, MP).

In this discussion, panelists highlighted a range of issues relating to immunization legislation from a parliamentary perspective. Both legislative work and the provisions of pending laws were described.

Cambodia The National Assembly is leading a legislative project which will hopefully culminate with a new immunization law, to be passed in 2014. Work was delayed by national elections earlier this year. Involving all concerned ministries in the project has been challenging. Insufficient parliamentary resources for preparing and processing the legislation is a second limiting factor.

Madagascar After delegates participated in a Sabin-organized legislative workshop last year, they proposed a new national immunization law. The centerpiece of the law is the creation of a national immunization fund. The proposed law is under discussion with the Ministry of

Health. Revenue provisions have yet to be defined. The project has been delayed by impending national elections.

DRC A national immunization bill has been prepared and is ready to be introduced to Parliament. The bill contains explicit revenue provisions. Immunization will be financed through a larger health fund financed by a new mobile phone tax and mining royalties.

Lines of credit will be extended to the provinces to fund local immunization activities. The latter provision requires each of the eleven provincial parliaments to pass supporting legislation.

Liberia A Sabin-sponsored MP peer exchange with Uganda last year helped galvanize interest in Congress to take legislative action on immunization. A draft immunization bill is circulating. For the past few years, MPs have been advocating with the Minister of Health for increases in the proposed national immunization budget. MPs have also requested a line item in the health budget for immunization, which will be visible to them as they oversee its execution.

Mali A parliamentarian network on immunization was formed and has been building support among the National Assembly for a new immunization law. The Assembly has endorsed the project. MPs are working with the Minister of Health to define the financial provisions

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of the bill. Given the parliamentary initiative, the Ministry of Health is soon expected to issue a decree regarding immunization financing.

Nepal An expert committee has been advising the Ministry of Health on a proposed national immunization bill. Drawing from existing laws in Costa Roca, Mongolia and elsewhere, a working group of this committee has drafted the bill’s provisions. The central innovation is a new public-private immunization fund. Private donations to the fund will be matched by the government. The Ministry of Finance has endorsed the fund and has increased the national immunization budget by 7%. The bill is expected to pass shortly after a new parliament is elected in November 2013.

Nigeria There is high-level support for immunization in Nigeria. The government increased its federal immunization budget from N2.5b (US$15.5m) in 2011 to N6b ($37.3m) in 2013.

Government and parliament have put forth a constitutional amendment which will guarantee immunization (and other basic health services) as a right of citizenship. Twenty of 36 states have so far ratified the amendment.

Senegal The country is increasing its health investments. The federal health budget rose from CFA80b (US$162m) in 2009 to CFA100b ($203m) in 2013. An immunization bill has been

drafted and is in circulation. It provides for earmarked immunization funding from several revenue sources (regular allotments, “sin taxes� on alcohol and tobacco, a new mobile phone tax). The bill also provides for private sector and local government involvement in immunization financing.

Uganda A parliamentary immunization network was formed in 2012.

Working closely with government counterparts, MPs drafted and introduced a national immunization bill to parliament. Civil society and local governments have been widely engaged in drafting the bill. The President has expressed his support for the concerted effort to take ownership of the country’s immunization program.

Summary The Q&A following this panel elicited a number of points. Most countries, observed one delegate, are increasing their immunization financing despite their lack of up-to-date immunization laws. Other delegates pointed out that preparing immunization legislation forces government ministries and parliaments to come together- something seldom or never done in many countries. It forces the institutions to reconceptualize complex issues such as how best to fiscalize subnational government investments in health and immunization and how to harmonize federal and subnational health laws. Some countries already have public finance control mechanisms in place which can easily encompass new immunization line items and fund operations. The cases show that the legislative process is usually long and arduous and is often interrupted by overriding events. Access to laws

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from other countries and peer exchanges, particularly through Sabin-organized legislative review workshops, have helped some delegates move their processes along.

Panelists identified a series of specific themes and best practices. These are described below.

Immunization forums Nearly all the countries have organized parliamentary and public forums (briefings) to explain to the benefits of investing in immunization. These sensitization events greatly facilitate subsequent votes on the draft immunization laws once they are submitted to Parliament. Consulting the public through forums has also proven to be an important step in the legislative process.

Parliamentary networks Panelists felt that establishing a network of like-minded parliamentarians in each country is essential to focus the dialogue with government and to ensure intraparliamentary continuity on immunization-related issues. A parliamentary forum compensates for high MP turnover and provides necessary logistical and administrative support for the elaboration and implementation of immunization legislation. Bills are moving faster in countries with such parliamentary networks. In Mali, 68 of 147 MPs belong to that country’s parliamentary immunization network. Uganda’s network currently numbers 180 MPs.

Purpose of immunization bills All of the countries represented are currently developing immunization laws. In most cases, freestanding bills are being written. This has been a slow process. In some cases, panelists agreed, time can be saved if immunization legislation can be tacked onto existing laws. In some countries, the existing health laws deal solely with epidemic disease control. MPs in those countries can argue that immunization is a tool to fight epidemics. Another angle is needed for the more complex laws seeking to institute national immunization funds. In such cases, provisions are needed to ensure fund proceeds are earmarked for vaccine procurement and for vaccination activities.

Revenue sources Panelists agreed that “sin taxes� can be used to generate revenues earmarked for immunization and for health in general. They felt there should be a concerted effort to tax at least cigarettes and alcohol- two products that negatively affect population health.

Immunization financing, felt the panelists, should be included in the category of binding and mandatory (statutory) state budget expenditures.

National immunization funds A number of countries are working on legislation that will, inter alia, establish national immunization funds. Assuming the legislation is enacted, asked one delegate, how will the fund be managed? What measures can be taken to ensure sound, efficient management?

The questions remain moot because no funds have yet been implemented.

1.4 Poster session Methods Posters were used to present and assess each country’s innovative immunization financing practices. Each poster followed a standard format, which included graphs of immunization financing trends, advocacy action points

25 Sabin Vaccine Institute

which had been set out by delegates to the previous Addis colloquium and bullet points describing the featured innovation. Delegates and their SIF Program counterparts prepared the posters together prior to the Colloquium. Forty-four delegates from all seventeen countries participated in the poster session. Each rater was randomly assigned three countries to evaluate. Peer assessments took place in two consecutive 45-minute rounds, each with peers from half the countries rating the other half.

Using a standard assessment guide, raters examined the posters and asked presenters to describe the innovative practices their governments and parliaments are developing, or have developed, to move their countries closer to the sustainable immunization financing goal. New practices were classified in terms of functional area (finance, budget, legislation, advocacy), developmental mechanism (top-down, bottom-up, third party), duration (less than one year, 1-2 years, 3 years or more), level (international, national, subnational), the institutions involved (government, legislature, non-governmental) and current level of development (talking about, being tried, becoming institutionalized, fully institutionalized). Raters also evaluated a series of ten subjective Likert-scored items, ranging from whether they thought the new practice is properly conceptualized to whether the practice would succeed in the rater’s own country. The ten subjective Likert-scaled

items are described in Table 1. Raters assigned each item a score of 1-5, with 1 being “No chance”, 2 “Not likely”, 3 “Unsure”, 4 “Likely” and 5 “Almost certain”. To conclude the assessment, raters jotted down recommendations for the presenters. A total of 110 standard assessment forms were completed. Data were entered into Stata and analyzed by the SIF Program staff. Results are summarized below. Detailed results for each country are presented in Annex D.

Results Raters most often classified the new practices as budgetrelated (26%), financial (10%), advocacyrelated (6%), legislative (3%) or some combination of the four areas (54%). Seventyfive percent of the practices were happening at national level, 18% at subnational level and 4% at international level.

The practices tended to originate in top-down fashion (78%) with 14% emerging from the bottom-up and 4% originating through outside organizations or institutions. Eighty percent of the innovations involved more than one public institution. As expected, the ministries of health were most frequently involved (83%), followed by parliaments (59%) and ministries of finance (28%). Among non-government institutions, community service organizations, such as Rotary clubs, participated in 30% (34/110) of the innovations. The private business sector was active in 12% of the innovations with civil society and other groups accounting for 25%. Sixty-three percent of the practices (69/110) began within the past 1-2 years with the remainder beginning 3 or more years ago. The raters determined that 16% of the new practices (17/110) were already fully institutionalized, i.e., they were no longer innovations but now routine. Most (53%) of the innovations, however, were classified as in the process of becoming institutionalized. Another 17% (19/110) were considered to be in trial phase while 8% were still under discussion with no action as yet.

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Inter-rater reliability is a concern for data such as these. Different numbers of raters rated each case. Rather than agree on the underlying concepts, raters likely differed in the ways they assessed a given country’s innovation. They may have interacted differently with the same informant. Language barriers, presentation styles and so on are other sources of error in the ratings. The intra-class correlations measure how similarly (reliably) the raters rated each item for each country. The ICCs are relatively low, ranging from 0.56 (likely to succeed) to 0.26 (sustainable).

To aid index construction, each item was rescaled in the interval (-2,2). The six items with the highest ICCs were then used to make an innovativeness index. Factor analysis revealed that four items made the best index: concept, owner, likely and own_likely (alpha=0.73). The dataset was then collapsed, generating mean values for the index and the four index items for each country (n=17).

The country means were then ranked from lowest to highest. A rank of 1 indicates the least innovative country; a rank of 17 indicates the country judged most innovative. The ranks and mean scores of the four Likert items, and of the index, are shown in Table 2.

There is considerable variation across the four items. Republic of Congo and Mali, for example, were ranked lowest and second highest on the concept item but their ranks are nearly reversed on the own likely item. Only five countries are ranked consistently in the lower or upper half of the distributions for all four items (Nepal, Indonesia, Kenya, Cameroon, Sri Lanka). Raters judged Sri Lanka to be the most innovative country overall.

In Figure 1, the innovativeness index ranks are plotted against the countries’ 2011 gross national income ranks. Countries in the top quadrants have the highest innovativeness scores; countries in the right quadrants had the highest GNIs in 2011. The pattern shows that innovativeness does not depend on GNI.

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20

Fig. 1. Innovativeness vs GNI ranks, Dakar Colloquium

Sri Lanka

15

Kenya Cambodia Cameroon Mongolia DRC

10

Sierra Leone Uganda Madagascar Vietnam Senegal Nigeria

5

Rep Congo Mali Liberia Indonesia

0

Nepal

0

5

10 2011 GNI rank

15

20

Discussion The poster assessment exercise was motivated by organizational change and institutional innovation theories.

Standard poster and review formats were used. The results provide a description of some of the new practices countries are developing to more fully finance, and ultimately to own, their national immunization programs.

Most of the innovations are happening at national level. They appear to be developing in gradual fashion; at this point, few are fully institutionalized.

The subjective ratings showed that raters tended to agree most on four items: how the practices were conceptualized in the countries; which practices are leading to greater country ownership; which practices are most likely to succeed and; which practices might succeed in their own countries. Each of the four appears to tap a distinct dimension of the innovativeness construct. Well conceptualized innovations, for example, are not necessarily those leading to country ownership, nor are they likely transferrable to other countries (Table 2).

Whether relatively wealthy or relatively poor, raters decided, a country can innovate to improve immunization financing. This is a welcome finding.

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There are a number of important limitations in this analysis. The posters and assessment guides were not pretested. Important concepts were likely omitted. The presenters were not necessarily personally involved in the practices they presented. In several instances, language limited comprehension. Raters noted there was no presenter for one of the countries.

Assessments for that country are entirely based on the poster contents. Additionally, the delegates were not sufficiently oriented to the methods used. Some raters clearly misunderstood some of the concepts they were measuring. Not all raters completed all three assessments assigned to them. Time allotted for the review may have been insufficient. Finally, there may also have been self-selection bias. The 44 peer assessors were a possibly nonrandom subsample of the 70 delegates participating in the Colloquium.

1.5 Small groups To finish Day One, participants were divided into six small groups to reflect on what they had shared and to analyze specific immunization financing issues. Three groups focused on finance/budget and oversight themes while the other three groups looked at legislative themes. A nominal group technique was used. Each participant reported a problem or challenge he or she considered important for immunization financing. Facilitators listed these. In the ensuing discussion, the number of problems was reduced to just a few and participants brainstormed possible solutions for each. Participants in each group elected rapporteurs to present their results on Day Two. Results are summarized below. Annex E lists verbatim the problems and proposed solutions from all six groups.

Budget and finance The three budget/finance groups identified and analyzed ten specific problems affecting immunization financing and budgeting.

Two groups treated problems pertaining to budget formulationhow immunization budgets are actually prepared.

Participants lamented the absence of actual cost and expenditure data from which to estimate forward budgets. (Proposed solutions: Conduct costing studies; analyze program costs) EPI teams, some felt, lack sufficient budgeting skills. (Proposed solution: Build financial management capacity through training and assigning skilled staff to EPI teams.)

There is a general lack of transparency: financial and budgetary information is not being shared within or across public institutions.

Budgets are formulated independently of policy documents, Medium Term Expenditure Frameworks (Proposed solution: Ministries of health organize internal arbitrage processes.)

Related to this is a lack of involvement of ministries of finance in preparing the immunization budgets. (Proposed solution: Expand the process to include more stakeholders.)

Approved budget amounts are often far less than the amounts requested.

All three groups considered resource mobilization problems.

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Program financing, participants agreed, is highly dependent on external funding (Proposed solutions: Identify new domestic revenue sources; improve tax collection; pass legislation ring-fencing immunization funding.)

There is little or no domestic private sector financing for immunization (Proposed solution: Approach, engage private sector.)

Ministries of finance are not helping to find new financing sources (Proposed solution: Approach, engage ministries of finance.)

Vaccine costs are high and rising (Proposed solutions: Pooled procurement arrangements; independent study of vaccine markets.)

Likewise, all three groups analyzed problems related to immunization budget execution.

Half of the problems fell into this domain.

Immunization budget disbursements are often delayed (Proposed solution: Establish a buffer fund.)

Approved immunization funds are sometimes allocated elsewhere Expenditures are not tracked, analyzed (Proposed solutions: Establish budget monitoring (resource tracking) and reporting procedures; analyze expenditures as part of performance appraisals (including sub-national levels); improve management information systems.)

There is not enough coordination, transparency and accountability among public institutions (Proposed solutions: Expand Interagency Coordinating Committees (ICCs) to include more national institutions; publish tax revenues and link them to immunization expenditures; perform timely internal and external audits.)

Legislation In all, the three legislative groups identified 24 problems affecting legislative action for sustainable immunization financing.

Insufficient political commitment to universal immunization, all three groups felt, is a root problem. The availability of external immunization funding delays legislative action (state dependence). (Proposed solutions: Evidence-based advocacy targeting both senior government officials and MPs; public information campaigns to raise demand, create political pressure for immunization; field visits by key decisionmakers.)

Political instability and weak economies are perennial hindrances.

Two groups identified the complex, ponderous legislative process itself as a significant barrier. With legislation, there is a tension between specificity (harder to pass, more effective) and generality (easier to pass, less effective). In some countries, governments and parliaments have little or no prior experience creating legislation together. Both sides lack the resources needed to properly legislate.

(Proposed solutions: Insert immunization into existing health laws where possible vs writing a freestanding immunization bill; organize occasional briefings where government officials and MPs come together to discuss the legislation; arrange more capacity building for parliaments and training for MPs; continue international peer exchanges.)

Government officials and parliamentarians do not know enough of the facts on immunization and immunization financing to take action. Investment cases for immunization are not made. (Proposed solution: Provide regular reports on the immunization program to key decision-makers, covering both immunization financial and technical indicators.)

Day Two 2.1 Partners on the Global Vaccine Acton Plan

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Following the small group rapporteur presentations from Day One, Day Two continued with a panel of external partner representatives (WHO, UNICEF, Bill & Melinda Gates Foundation, GAVI Alliance, Sabin). The theme of the panel was “Leveraging SIF country innovations for the Global Vaccine Action Plan.”

2.1.1 Representing WHO/HQ, Dr. Miloud Kaddar outlined the origins, objectives and structure of the GVAP. In May 2012, the World Health Assembly passed Resolution A65/22, officially endorsing the Decade of Vaccines (DoV) Global Vaccine Action Plan. The GVAP lays out a set of guiding principles and strategic objectives through which 94 countries will meet the challenge set by Bill Gates in the 2011 Davos Summit to bring lifesaving vaccines to every household by the year 2020 (World Health Organization 2012).

The GVAP is a product of an intense, year-long consultation and planning process which involved some 1100 individuals at global, regional and country levels. Besides speeding technological progress and saving lives, GVAP implementation will bring about a number of important structural changes affecting how immunization programs are financed, managed and delivered. By the year 2020, country investments in immunization will increase and their dependency on external financing will decrease. Sustainable financing and delivery strategies will be institutionalized. Equity in immunization access will be achieved; every household will be reached and will understand the value of immunizations. Immunization legislation will be updated or created. New stakeholder groups will be engaged in all facets of the programs. In signing Resolution WHA65/22, ministers of health agreed to report their progress annually, beginning in 2014. The countries represented in the Dakar Colloquium are ideally positioned to lead the GVAP, commented Kaddar.

2.2.2 Representing UNICEF/NY, Mr. Thomas O’Connell shared several field-level innovations countries have developed with UNICEF to strengthen immunization program implementation. Of particular interest are new approaches and technologies that increase immunization equity- one of the GVAP strategic objectives. In some countries, for example, provincial- and district-level managers are using smart phones to follow vaccine shipments, avoid stockouts, send and receive reports and control their operational budgets. In the Gambia, the EPI cold chain is operated by a private firm with good results.

In Chad, a private firm handles sharps and waste disposal for the EPI. These and similar cases have revealed some new best practices. Much has been learned about these new public-private partnerships. Legislative mechanisms must be established to permit

ministries of health to sign contracts and maintain partnerships with the private sector.

Returning to an earlier theme, O’Connell described how UNICEF is actively developing new resource tracking modalities for sub-national (health district) users.

O’Connell recently inventoried over a dozen resource tracking projects proposed or underway worldwide. Resource tracking is an area where innovations such as those presented here yesterday will greatly contribute to GVAP. 2.2.3 Speaking for the Bill & Melinda Gates Foundation, Ms. Molly Abbruzzese described how GVAP is stimulating innovations to improve the performance of national immunization programs. Through SIF and a host of other programs, the Foundation is investing heavily in GVAP. She congratulated the delegates for their Day One presentations and urged them to keep developing innovations that will secure the GVAP goals and objectives.

2.2.4 Also a GVAP Leadership Council agency, the GAVI Alliance sees the effort as a vehicle for speeding up the introduction of new and underutilized vaccines. GVAP demands that countries optimize their immunization programs and that they report annually what they are investing in immunization, commented Mr. Santiago Cornejo. GAVI will continue its grant making for vaccines and for immunization program strengthening, however, countries will ultimately decide how many lives will be saved. It will depend on the investments they make in their programs and their commitment to meeting the GVAP goals and objectives.

Representing Sabin, Dr. Ciro de Quadros summarized the discussion and exhorted the countries to move away from the current paternalistic paradigm to one of country ownership. This Colloquium is a watershed moment in this paradigm shift, he added.

Sabin is sparing no effort to support GVAP. But GVAP is merely a vehicle. The countries are the drivers.

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A lively exchange of opinions followed in the Q&A session. Delegates stressed the importance of working together to achieve the GVAP objectives. They reinforced the need for each country to determine its own immunization priorities and for the external partners to shift their practices to fully support country ownership. Other GVAP-related issues addressed included: the need for more certainty on the price of the newer vaccines; the relationship between the various reports currently produced by the countries (JRF, GAVI Annual Report, National Health Accounts) and how they will contribute to the annual GVAP reporting process; and the need for faster technology transfer in Africa, especially for vaccine production.

Parliamentarians expressed their desire to continue acting collectively to meet the SIF objectives. They asked for more tools for analyzing and defending immunization budgets.

Several delegates stressed the crucial importance of increasing the involvement communities in all facets of immunization through civil society organizations and their elected representatives. Financing must come from collective and not individual resources (i.e., federal, state, local budgets, insurance funds and other public sources). Moreover, this funding must be sustainable.

With sustained political will it will be possible to reach the goal of immunization independence.

2.3 Country action points The 17 country delegations spent most of the afternoon of Day Two working in small groups to develop short- and medium-term action points which they will follow in order to advance their SIF projects and ultimately achieve the SIF objective. The delegates then reconvened and presented their plans in plenary. The action points are listed in Annex F along with the earlier action points generated in the 2011 Addis Colloquium.

Thirteen out of the seventeen countries were represented in both events.

The Addis delegates generated a total of 46 action points. Of these, 48% (22/46) have been accomplished, 43% (22/46) have been partially accomplished and 4% (2/46) have not been implemented.

The Dakar delegates, in comparison, generated 78 action points. Of these, 41 points were generated by the thirteen countries represented in Addis.

Analyzing the two sets of action points for the thirteen countries, five common themes emerge. Most frequent in both sets are legislation (Theme 1) and advocacy activities (Theme 2). Financing (Theme 3) is next, followed by financial management (Theme 4) and organizational changes within the EPI program (Theme 5).

Five of the thirteen countries (Liberia, Madagascar, Nepal, DRC, and Sri Lanka) formulated finance (Theme 3) action points in both Colloquia.

The comparison shows that the countries remain most strongly committed to their legislative work and to developing their own advocacy capacities.

Looking ahead, six countries (Cameroon, Madagascar, Mali, Nepal, Senegal, Vietnam) set action points in Dakar relating to GVAP.

2.4 Declaration of Dakar The country action points completed, delegates next discussed, and ultimately adopted, the Declaration of Dakar (Annex G). Drafted by an ad hoc delegate committee, the Declaration captures the key issues discussed throughout the Colloquium. It sets targets for developing more financing, budgetary and management best practices for immunization programs

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and calls for more south-south exchanges of these practices. The rationale is to fully implement GVAP. Delegations selected one delegate each to sign the Declaration.

2.5 SIF mini-course scholars In preparation for the Colloquium, delegates were invited to take an online SIF minicourse, which features selected readings in English and French. The names of four delegates who passed the SIF mini-course quiz were read in plenary: Olalekan Olugbenga Olubajo, NPHCDA, Nigeria John B. Sumo, Member of Parliament, Liberia Raphael NUNGA MATADI, Ministry of Health, DRC Aguissa Mohamane MAIGA, Ministry of Health, Mali Upon returning home, all participants were encouraged to take the SIF mini-course at their leisure. The course is available in English and French here: http://www.sabin.org/programs/sif/sif-library.

All those who pass the quiz will receive a certificate of completion.

2.6 Closing ceremony Final remarks were delivered by Dr. Pape Amadou DIACK, Director General, Ministry of Health and Social Welfare, Senegal, and Dr. Ciro de Quadros. Dr. DIACK congratulated the participants for their hard work and evident enthusiasm. Senegal is pleased to be a part of this movement, he said. The country will certainly do its part to secure a sustainably financed immunization program and looks forward to future interactions with other countries engaged in this important work. Ciro de Quadros summarized the two days, describing them as an unprecedented expression of the countries’ collective commitment to owning and optimizing their national immunization programs.

3 Evaluations Sixty-three participants completed a standard evaluation form for the Colloquium. Of these, 51 (81%) were country delegates, 10 (16%) represented global immunization partners and 2 (3%) represented other institutions.

The Colloquium received generally positive reviews. Ninety-two percent (54/59) felt the agenda was apt for the task of peer reviewing their national SIF work. Eighty-four percent felt two days duration was sufficient time to complete the agenda.

Over 90% found each of the Day One panel discussions (finance/budget, legislation) informative.

Fifty-eight percent (29/50) of the delegates thought the time allotted to review the posters was sufficient. Only 22% (2/9) of the partner agency counterparts shared that view.

Reflecting on the small group sessions on Day One, 95% (56/59) agreed or strongly agreed that bottlenecks and problems affecting immunization financing were identified and solutions to those problems proposed in their groups. An equal proportion felt the groups gave them the chance to brainstorm and share ideas with their peers.

Asked whether they learned anything new about institutional innovations for immunization financing, 95% (58/61) answered in the affirmative.

The partner-led GVAP panel on Day Two was judged to be informative by 93% (55/59) of the participants.

Reflecting on their countries’ action points, 94% (46/49) of the delegates felt the exercise succeeded in setting out useful goals for the coming two years.

All but one participant said they would advise their colleagues to participate in the next Sabin SIF Colloquium.

Assessing other points, 75% (36/48) of delegates agreed or strongly agreed that their countries are on track to achieve the 2020 GVAP strategic objectives. In contrast, only

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33% (3/9) of partner agency counterparts felt this was true. The difference was statistically significant (Fig E1).

Asked whether their countries would achieve the SIF objective by 2015, 59% (30/51) of delegates agreed or strongly agreed that they would (Fig. E2).

ANNEXES: Annex A – Agenda Annex B – List of Participants Annex C- Comparison of pretest and posttest responses Annex D – Peer Evaluations of Country Posters Annex E – Thematic group reports Annex F – Country action points Annex G – Declaration of Dakar

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Annex A: Agenda for Colloquium on Sustainable Immunization Financing (SIF) II 5-6 August 2013

Day 1 – Monday, 5 August 2013 Time

Theme

7:00-8:00

Registration

Speakers

Location Room B/C12

Dr. Pape Amadou DIACK, Director General of Health, Ministry of Health and Social Welfare, Senegal

8:00-8:30

Welcome and opening ceremony

Dr. Ciro de Quadros, Sabin Vaccine Institut, USA

Room B/C12

Dr. Oladapo Walker, Coordinator, Inter-Country Support Team, West and Central Africa (WHO/AFRO) 8:30 – 8:45

8:45 – 9:15

Audience polling/Pre-test Overview of SIF Program results to date and review of country action points from the 1st SIF

Mike McQuestion (Sabin)

Room B/C12

Sabin

Room B/C12

Colloquium held in March 2011

9:15 – 10:00

Panel on financing/budgeting for immunization: What innovations are underway to track expenditures, meet Global Vaccine Action Plan reporting benchmarks and assure increasing national immunization budgets?

Case studies and best practices

10:00-10:15

Discussion

10:15-10:45

Coffee Break

10:45-11:30

Panel on immunization legislation: How are governments and legislatures working together to assure sustainable immunization financing? Case studies and best practices

SIF Country Delegates Mr. Djoulde Maina, Cameroon Hon. Pascal Leyinda, Congo/Brazzaville Hon. (Dr.) Ramesh Pathirana, Sri Lanka Mr. Jules Baganda, DR Congo Hon. (Dr.) Nova Riyanti Yusuf, Indonesia Dr. Dominic Mutie, Kenya Dr. Delger Munkhbat, Mongolia Dr. Sartie Mohamed Kenneh, Sierra Leone Dr. Duong Thi Hong, Vietnam

Room B/C12

Room B/C12

SIF country delegates *Hon. Ouk Damry, Cambodia *Hon. Gregoire Lusenge, DR Congo *Hon. William Dakel, Liberia *Hon. Dr. Aro Tafohasina, Madagascar *Hon. Fanta Mantchini, Mali *Mr. Komal Prasad Acharya, Nepal *Hon. Adebenga Sefiu Kaka, Nigeria

Room B/C12

*Hon. Alfa Balde, Senegal *Hon. Oleru Huda, Uganda 11:30-11:45

Discussion

11:45-12:45

Round One peer assessments (poster session)

12:45-14:00

Lunch

14:00-15:00

Round Two peer assessments (poster session)

15:00-15:30

Coffee break

15:30-17:00

18:00 – 20:00

Group work: challenges, bottlenecks and strategies to overcome them (3 groups on finance/budget/oversight, 3 groups on legislation)

Room B/C12 Group A (9 SIF countries presenting their posters)

Group B (8 SIF countries presenting their posters)

Small groups

Rooms: B02; B08; C02; C08

Cocktail Reception

Day 2 – Tuesday, 6 August, 2013 Time

Theme

8:30-8:45

Report on Day 1

8:45-9:45

Panel of small group discussants: What is working, what is still needed to achieve sustainable

Speakers Ciro de Quadros Plenary

Location Room B/C12

Room B/C12

immunization financing 9:45-10:15 10:15-10:30

Plenary discussion; Q&A

Room B/C12

Coffee break

10:30-11:30

External partners panel Theme: Leveraging SIF country innovations for the Global Vaccine Action Plan

11:30-12:00

Plenary discussion; Q&A

12:00-13:30

Country group work: Action points, way forward

13:30-14:30

Lunch

14:30-15:45

Countries present their action points

15:45-16:00

Coffee break

16:00-16:30

Plenary discussion; Q&A

16:30-17:00

Audience polling/post-test

Miloud Kaddar (WHO) Thomas O’Connell (UNICEF) Santiago Cornejo (GAVI) Molly Abbruzzese (BMGF) Ciro de Quadros (Sabin)

Room B/C12

Room B/C12 Small groups

Rooms: B02; B08; C02; C08

Plenary

Room B/C12

Room B/C12 Mike McQuestion (Sabin)

Room B/C12

Dr. Pape Amadou DIACK, Director General of Health , Ministry of Health and Social Welfare, Senegal 17:00-17:30

Summary and final remarks

Dr. Ciro de Quadros, Sabin Vaccine Institute, USA Dr. Oladapo Walker, Coordinator, WHO/AFRO Inter-

Room B/C12

Country Support Team, Central and West Africa Mr. Thomas O’Connell, Senior Health Specialist, Economics and Finance, UNICEF Mr. Santiago Cornejo, Director of Immunization Financing, GAVI Alliance Ms. Molly Abbruzzese, Program Officer for Global Health Vaccine Delivery, Bill & Melinda Gates Foundation

Annex B: List of Participants

Country

Title

Name of Participant

Institution

Email Address

Ministry of Mr.

Ngwen Ngangue

Economy, Planning and Regional

ngwenn@yahoo.fr

Development Cameroon

Ms. Mr. Hon.

Mr.

Mali

Mr. Hon. Dr.

Democratic Republic of

Mr.

Marie Yvonne Facksseu Maina Djoulde Emmanuel Norbert Amougou Mezang Sidibe Mahamadou Aguissa Mohamane Maiga Fanta Mantchini Diarra Nouhoun Kone Benjamin Bantulugi Feruzi

Ministry of Finance

facmy@yahoo.fr

Ministry of Health

mainadjoulde@yahoo.fr

National Assembly

amougoumezang2003@yahoo.fr

Ministry of Finance, Budget

m_sidibe86@yahoo.fr

and Economy Ministry of Health

aguissamaiga01@gmail.com; amagaml@yahoo.fr

National Assembly

fantandiarra2006@yahoo.fr

Ministry of Health

nkone63@yahoo.fr

Ministry of Health

benferuzi@gmail.com

Congo

Dr. Mr.

Audry Wa Kamba Mulumba Jules Kanki Baganda

Ministry of Health

audrywakamba@yahoo.fr

Ministry of Budget

julbag2002@yahoo.fr

Directorate of Mr.

Raphael Matadi Nunga

Studies and Planning of the

rafmatnunga@yahoo.fr

Ministry of Public Health

Hon. Hon. Hon. Congo-Brazzaville

Hon.

Gregoire Kakule Lusenge Gregoire Kiro Celestin Bondomiso Pascal Alain Leyinda

National Assembly

coingbra@yahoo.fr

National Assembly

gregoirekiro@yahoo.fr

National Assembly

celestin.bondomiso@gmail.com

National Assembly

apleyinda@yahoo.fr

National Assembly

herinalinjaka@gmail.com

Ministry of Health

rakotomariuslouis@gmail.com

Aro Tafohasina Hon.

Herinalinjaka Rajoelina

Madagascar Dr.

Louis Marius Rakotomanga

Ministry of Finance Mr.

Sam Morris Aruma

& Economic

samaruna2003@yahoo.com

Development

Sierra Leone

Sierra Leone's Hon.

Veronica Sesay

Parliamentary Heath Committee

sesayveronica@gmail.com

Dr. Mr. Liberia

Hon. Hon.

Sartie Mohamed

Ministry of Health

sartie69@yahoo.co.uk;

Kenneh

and Sanitation

sartiekenneh@gmail.com

John Barclay

Ministry of Health

Sumo

and Social Welfare

William Varney

House of

Dakel

Representatives

Johnson Toe Chea Olalekan

Dr.

Olugbenga Olubajo

House of Representatives

jsumo001@luthersem.edu wvdakel@yahoo.com jhnsnchea@gmail.com

National Primary Health Care Development

leks_olu1@yahoo.co.uk

Agency National Primary

Dr. Nigeria

Emmanuel

Health Care

Adebayo Abanida

Development

drabanida@gmail.com

Agency National Primary Dr.

Ado Jimada Gana

Health Care

Muhammad

Development

dradojg@yahoo.com

Agency Hon. Mr. Nepal

Mr. Mr.

Adegbenga Sefiu

Senate Committee

Kaka

on Health

Kedar Prasad Paneru Komal Prasad Acharya Giri Raj Subedi

Ministry of Finance

askgbenga14@yahoo.com kppaneru@gmail.com

Ministry of Health

acharyako@hotmail.com

Ministry of Health

subedi.giriraj@gmail.com

Ministry of Ms.

Bola Kan

Economy and Finance

Dr.

Morn Chheng

Ministry of Health

bkan@otatreas.us; kan_bola@yahoo.com chheng_morn@yahoo.com

National Assembly,

Cambodia Hon.

Damry Ouk

Commission on

damryouk@gmail.com

Legislation and Justice National Assembly Mr.

Visal Uy

of the Kingdom of

uyvisal7@gmail.com

Cambodia Dr. Sri Lanka Hon. Dr.

Paba Palihawadana

Ministry of Health

Ramesh Chaminda

Parliament of Sri

Bentota Pathirana

Lanka

Robert Mayanja

Ministry of Health

paba@health.gov.lk ramesh.pathirana@yahoo.com mayarobe@yahoo.com

Parliament of the Uganda

Hon.

Huda Oleru

Republic of

holeru@parliament.go.ug

Uganda Mr. Dr. Kenya Hon.

Ishmael Mweru Magona Dominic Mbullah Mutie

Ministry of Finance

ishmael.magona@finance.go.ug

Ministry of Health

dmutie_dvi@dfh.or.ke

David Eseli Easel

National Assembly

Simiyu

of Kenya

eselidoc@yahoo.com

Ms.

Mongolia

Esther Sharon Wagithi

Ministry of Finance

davidgithanga@gmail.com;

Association

david@githanga.org

David Githanga

Mr.

Munkhbat Delger

Ministry fo Health

Bayanselenge

Parliament of

Tsagaan Zangad

Mongolia

Mr.

Enkhbold Amjaa

Mr.

Nguyen Van Quyet

swayeki@treasury.go.ke

Kenya Paediatric

Mr.

Hon.

sharon.wanyeki@gmail.com;

munkhbat@moh.mn; poj_mm@yahoo.com bujinb@gmail.com

Ministry of

azzaya.l@mta.mn;

Taxation

enxhbold777@yahoo.com

Ministry of Finance

nguyenquyetgg@gmail.com

National Institute

Vietnam Dr.

Duong Thi Hong

of Hygiene and

hong_epi@yahoo.com

Epidemiology Hon. Hon. Ms. Indonesia Dr.

Soepriyatno

House of

Sardjono Askani

Representatives

Nova Riyanti Yusuf Tini Suryanti Suhadi Theresia Sandra Diah Ratih

soepriyatno1@yahoo.com

House of

nova.riyanti@dpr.go.id;

Representatives

aspirasi@novariyantiyusuf.net

Ministry of Health

tinisuryanti@gmail.com

Ministry of Health

tsandra_dratih@yahoo.com; t.sandra.d.ratih@gmail.com

National Mr.

Pungkas Bahjuri

Development

Ali

Planning Agency (BAPPENAS)

pungkas.ali@bappenas.go.id

Dr.

Ndiaye Mamadou

Ministry of Health and Social Action

mamamorph@yahoo.fr

Ministry of Ms.

Ndeye Maye Diouf

Economy and

mayediouf@hotmail.com

Finance

Senegal Hon.

Alfa Balde

National Assembly

alfamere@yahoo.fr

Dr.

Oumy Seck

Ministry of Health

docoumise@yahoo.fr

Dr.

Amy Lo Ndiaye

Ministry of Health

mmendiaye_2005@yahoo.fr

KANCO-Kenya

Mr.

Jack Ndegwa

KANCO-Kenya

jndegwa@kanco.org

ASADI-Kenya

Dr

Christian Acemah

ASADI-Kenya

cacemah@nas.edu

NITAG-Nigeria

Dr.

Mobolaji Odubanjo

NITAG-Nigeria

dodubanjo@nas.org.ng

GAVI

Mr.

Santiago Cornejo

Ms.

Molly Abbruzzese

Ms.

Alexa Bednarz

Mr.

Gene Bartley

Dr.

Miloud Kaddar

Mr.

Alexis Satoulou

WHO-IST-WCA

satouloua@bf.afro.who.int

Dr.

Oladapo Walker

WHO-IST-WCA

walkero@who.int

Bill & Melinda Gates Foundation

World Health Organization

GAVI-Genève (Headquarters) BMGF-Seattle (Headquarters) BMGF-Seattle (Headquarters) BMGF-Kenya WHO-Geneva (Headquarters)

scornejo@gavialliance.org molly.abbruzzese@gatesfoundation.org alexa.bednarz@gatesfoundation.org gbartley46@gmail.com kaddarm@who.int

Ms. Mr. Dr. Dr. Dr.

UNICEF

Sabin Vaccine Institute

Masembe Vuo Yolande Terry Hart Farba Lamine Sall Aliou Diallo Alimata Jeanne Diarra-Nama

WHO-RDC

masembey@cd.afro.who.int

WHO-Senegal

tjh0203@gmail.com

WHO-Senegal

sallf@sn.afro.who.int

WHO-Senegal

dialloali@sn.afro.who.int

WHO-Senegal

diarraal@who.int

Ms.

Asmaniar Saleh

WHO-Indonesia

salehas@searo.who.int

Mr.

Alexis Satoulou

WHO-IST-WCA

satouloua@bf.afro.who.int

Dr.

Oladapo Walker

WHO-IST-WCA

walkero@who.int

Mr.

Thomas O'Connell

Dr.

Abderrahmane BA

UNICEF-RDC

abba@unicef.org

Dr.

Djariatou Sow Sall

UNICEF-Senegal

dssall@unicef.org

Dr.

Jerome Pfaffmann

UNICEF-Senegal

jpfaffmann@unicef.org

Dr.

Bibata Pare

UNICEF-Senegal

bpare@unicef.org

Dr.

Caroline Damour

UNICEF-Senegal

cdamour@unicef.org

Dr.

Guido Borghese

UNICEF-Senegal

gborghese@unicef.org

Dr.

Ciro de Quadros

UNICEF-New York (Headquarters)

SABINWashington

toconnell@unicef.org

ciro.dequadros@sabin.org

(Headquarters) SABINDr.

Mike McQuestion

Washington

mike.mcquestion@sabin.org

(Headquarters) SABINMs.

Mariya Savchuk

Washington

mariya.savchuk@sabin.org

(Headquarters) SABINMs.

Alice Abou Nader

Washington

alice.nader@sabin.org

(Headquarters) Mr.

Brian Christopher Shaw

SABINWashington

brian.shaw@sabin.org

(Headquarters) SABIN-

Ms.

Caitlin Garlow

Washington

caitlin.garlow@sabin.org

(Headquarters) SABIN-Nepal, Dr.

Devendra Gnawali

Cambodia, Sri

devendra.gnawali@sabin.org

Lanka SABIN-Mongolia, Dr.

Khongorzul Dari

Indonesia,

khongorzul.dar@sabin.org

Vietnam Dr.

Dr.

Helene MambuMa-Disu Clifford Kamara

SABIN-DRC, Congo, Madagascar SABIN- Sierra Leone, Liberia,

helene.mambu@sabin.org; heledisu@yahoo.fr cliff.kamara@sabin.org

Nigeria

Arnold & Porter LLC

Ms.

Diana Kizza

Mr.

Jonas Mbwangue

Mr.

James Joseph

SABIN-Uganda, Kenya SABIN-Cameroon, Mali, Senegal PORTER

diana.kizza@sabin.org jonas.mbwangue@sabin.org James.Joseph@APORTER.COM

Annex C: Comparison of Pretest and Posttest Responses 1.) Under their MDG (Millennium Development Goals) Commitments countries should aim to reduce child mortality by: 1. Under their MDG (Millennium Development Responses Goals) Commitments countries Pre-Test (Aug. 5th) Post-Testby: (Aug. 6th) should aim to reduce child mortality Two Thirds Choices Percent One third 23% Two thirds 47% One thirdThree 5% (n=3) 30% Total 100%

Count Percent 11 5% 22 64% 23% (n=11) 14 30% 47 99%

Count 3 36 17 56

47% (n=22) Two thirds

64% (n=36) 30% (n=14) 30% (n=17)

Three quarters

Pre-Test (Aug. 5th) N=47

Post-Test (Aug. 6th) N=56

2.) By 2015, the estimated cost per child fully immunized will be about:

Responses Pre-test Post-test 14% 7 3% 2 2. By 2015, the estimated cost per child fully immunized about:51 $60 75% 38will be86% 12% 6 10% 6 51 59

US $10 US $60 US $100

14% (n=7) US $10

3% (n=2) 75% (n=38)

US $60

US $100

86% (n=51) 12% (n=6) 10% (n=6)

3.) During 2011-2012, the proportion of routine Pre-test (Aug.5th) Post-test (Aug. 6th) immunization program costs financed by the governments of Responses N=51 N=59 Pre-Text True 35% 18 False 65% 34 52

Post21% 79%

12 46 58

3. During 2011-2012, the proportion of routine immunization program costs financed by the governments of low income countries decreased: True

35% (n=18) True

21% (n=12)

65% (n=34) False the term absorptive capacity refers to: 4.) In public finance, the proportion of a budget that is actually utilized the proportion of a budget the ability of a government

Pre-Text (Aug. 5th) N=52

79% (n=46)

Responses Pre-Test

Post-Test

79% 42 75% Post-Text (Aug. 9% 5 6th) 11% N=586 11% 14% 53

43 6 8 57

4. In public finance, the term absorptive capacity refers to: the proportion of a budget that is actually utilized 79% (n=42)

the proportion of a budget that is actually utilized

75% (n=43) 9% (n=5)

the proportion of a budget that is actually disbursed

11% (n=6)

11% (n=6) 5.) How the many diseases have immunization programs ability of a government 14% (n=8) eradicated totodate? collect revenues None One Two Five

Pre-Test (Aug. 5th) N=53

Responses Pre-Test Post-Test 6% 3 11% Post-Test (Aug. 65% 32 6th) 73% 27% N=57 13 12% 2% 1 4% 49

6 41 7 2 56

5. How many diseases have immunization programs eradicated to date? One

None

6% (n=3) 11% (n=6) 65% (n=32) 73% (n=41)

One

Two

Five

27% (n=13) 12% (n=7) 2% (n=1) 4% (n=2) Pre-Test (Aug. 5th) N=49

Post-Test (Aug. 6th) N=56

6. What are the three basic functions of parliament:

6.) What are the three basic functions ofOversight, parliament:representation, legislation Responses Pre-Test Post-Test Regulation, 4% 2 3% 4% (n=2) Regulation, Enforcing laws, 3% (n=2) taxation, elections developing infrastructure, 2% 1 3% Oversight, representation, 95% 52 93% Enforcing laws, 55 2% (n=1) developing infrastructure, 3% (n=2) providing services

2 2 55 59

95% (n=52) 93% (n=59)

Oversight, representation, legislation

Pre-Test (Aug. 5th) N=55

Post-Test (Aug. 6th) N=59

7. GVAP stands for: Global Vaccine Action Plan

Global Vaccine Alliance Plan

10% (n=5) 0% (n=0) 82% (n=41)

Global Vaccine Action Plan 7.) GVAP stands for: Governmental Vaccine Action Plan Global Vaccine Global Vaccine Governmental

90% (n=9) Responses

8% (n=4) 10% (n=1) Pre-Test (Aug. 5th) N=50

Pre-Test Post-Test 10% 5 0% 82% 41 90% Post-Test (Aug. 8% 4 6th) 10% N=10 50

0 9 1 10

8. The World Bank PEFA framework refers to: Public Expenditure and Financial Accountability 8.) The World Bank PEFA framework refers to: Responses Proportion of Expenditures Programs Proportion Everywhereof Expenditures Financed Annually Public Expenditure

Programs Everywhere Failing Acutely

Pre-Test 11% 11% (n=6) 0% 21% (n=12) 89%

6 0 47 53

Post-Test 21% 2% 78%

12 1 45 58

0% (n=0) 2% (n=1) 89% (n=45) 78% (n=47)

Public Expenditure and Financial Accountability

Pre-Test (Aug. 5th) 9.) A government should not introduce a newN=53 vaccine if the cost of introducing that new vaccine exceeds its potential economic benefits.

Post-Test (Aug. 6th) N=58 Responses

Pre-Test Post-Test Strongly agree 23% 11 32% 18 9. A government should not introduce a new Agree 25% vaccine12if the cost 29%of introducing 16 that new vaccine exceeds its potential economic benefits.

Not sure 2% 1 9% 5 Disagree 29% 14 21% 12 Strongly disagree 21% 10 23% (n=11) 9% 5 Strongly agree 32% 48 56 (n=18)

25% (n=12) 29% (n=16)

Agree Not sure

2% (n=1)

9% (n=5)

Disagree

Strongly disagree

21% (n=12) 21% (n=10

9% (n=5)

10.) Any public health program, immunization included, Pre-Test (Aug. 5th) must be shown to be efficiently managed and effective (have

N=48

29% (n=14)

Post-Test (Aug. 6th) Responses N=56

Pre-Test Post-Test Strongly agree 63% 34 85% 47 Agree 30% 16 15% 8 10. Any public health program, immunization shown to be 0 Not sure 0%included,0must be0% efficiently managed and effective (have 6% impacts) in3order to0% justify a Disagree 0 budget increase.

Strongly disagree 2% 1 0% 0 54 63% (n=34) 55 Strongly agree 85% (n=47) Agree

30% (n=16) 15% (n=8)

0% (n=0) 0% (n=0) 6% (n=3) Disagree 0% (n=0) 2% (n=1) 11.) Five years from now, most and middle-income Strongly disagree 0%low(n=0) Not sure

countries will be financing all or nearly all of their routine

Responses Post-Test (Aug. 6th)Post-Test Pre-Test Strongly agree 7% N=55 4 20% 11 Agree 33% 18 27% 15 Not sure 33% 18 33% 18 Disagree 25% 14 16% 11. Five years from now, most low- and middle-income countries will be financing 9 Strongly disagree 2% 1 4% 2 all or nearly all of their routine immunization program budgets.

55 55

Pre-Test (Aug. 5th) N=54

Strongly agree

7% (n=4) 20% (n=11) 33% (n=18)

Agree

27% (n=15) 33% (n=18) 33% (n=18)

Not sure

25% (n=14)

Disagree Strongly disagree

16% (n=9) 2% (n=1) 4% (n=2) Pre-Test (Aug. 5th) N=55

Post-Test (Aug. 6th) N=55

12. Parliamentarians and other elected officials have important roles to play in national immunization programs.

12.) Parliamentarians and other elected officials have important roles to play in national immunization programs.

Strongly agree Strongly agree Agree 20% (n=11) Agree 19% (n=10) Not sure Disagree 0% (n=0) Strongly disagree Not sure 4% (n=2) Disagree Strongly disagree

Responses Pre-Test 79% 20% 0% 0% 2%

0% (n=0) 0% (n=0)

2% (n=1) 0% (n=0) Pre-Test (Aug. 5th) N=56

44 11 0 0 1 56

79% (n=44) 77% (n=41)

Post-Test 77% 19% 4% 0% 0%

41 10 2 0 0 53

Post-Test (Aug. 6th) N=53

13.) Country Ownership will help ensure that my country fully finances it’s immunization program in the long run:

Responses

13. Country Ownership will help ensure that my country fully finances it’s Pre-Test Post-Test immunization program in the long run:

Strongly agree Agree Not sure Strongly agree Disagree Strongly disagree Agree Not sure

73% 25% 2% 0% 25% (n=14) 0%

24% (n=12)

40 14 1 0 0 55

67% 24% 10% 0% 0%

34 12 (n=40) 73% 5 67% (n=34) 0 0 51

2% (n=1) 10% (n=5)

Disagree

0% (n=0) 0% (n=0)

Strongly disagree

0% (n=0) 0% (n=0) Pre-Test (Aug. 5th) N=55

Post-Test (Aug. 6th) N=51

14. Poliomyelitis will be eradicated in the next 3-5 years.

27% (n=15)

Strongly agree

40% (n=21)

14.) Poliomyelitis Agree will be eradicated in the next 3-5 years.

Strongly agree Not sure Agree Not sure Disagree Disagree Strongly disagree Strongly disagree

7% (n=4) 6% (n=3) 0% (n=0) 0% (n=0) Pre-Test (Aug. 5th) N=56

23% (n=13) 21% (n=11)Responses Pre-Test 27% 23% 43% 7% 0%

Post-Test 15 40% 13 33% (n=17) 21% 24 33% 4 6% 0 0% 56

Post-Test (Aug. 6th) N=52

43% 21 (n=24) 11 17 3 0 52

15. I am a: (multiple choice) 15.) I am a: (multiple choice) Ministry of health official Ministry of health official FinanceFinance ministryministry official official Parliamentarian External partner agency Other Parliamentarian

Responses 27% (n=15) (percent) (count) 27% 15 16% (n=9) 16% 9 25% 14 23% 13 25% (n=14) 9% 5 Totals 100% 56

External partner agency Other

23% (n=13) 9% (n=5)

16. I have helped to: (select all that apply, multiple choice) Prepare a national immunization budget 16.) I have helped to: (select all that apply) (multiple choice) Approve a national immunization budget Prepare aExecute nationala national Approve a national budget immunization Execute a national Prepare thePrepare cMYP the cMYP All of the above None of the above All of the above

10% (n=6)

None of the above

10% (n=6)

25% (n=16) 17% (n=11) Responses

Totals

(percent) (count) 25% 16 17% 11 10% 6 19%19% (n=12) 12 19% 12 10% 6 19% (n=12) 100% 63

17. I have participated personally in a polio eradication, measles or other vaccination campaign day (“Special Immunization Activity”):

Yes

73% (n=44)

17.) I have participated personally in a polio eradication, measles or other vaccination campaign day (“Special Immunization Activity”): (multiple choice) 20% (n=12) Responses No (percent) (count) Yes 73% 44 No 20% 12 7% (n=4) Not sure Not sure 7% 4 Totals 100% 60

18. I have participated in a previous Sabin-sponsored briefing or peer exchange.

64% (n=36) 18.) I have participated in a previous Sabin-sponsored briefing or peer exchange. (multiple choice) Yes Responses (percent) (count) Yes 64% 36 No 36% 20 Totals 100% 56

36% (n=20)

No

Annex D: Peer Evaluations of Country Posters 1) Preliminary peer assessment report: Cambodia Seven peer reviewers analyzed Cambodia’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Cameroon (2), Kenya (2), Senegal, and two unidentified reviewers. Their responses are summarized below.

1. In the presenters’ words, what problem or opportunity does the innovation address?

Needs legislation Started a national immunization law, good links among MoH, MoF, and parliament; decreasing government share of immunization funding Policy on vaccination Adopt a law; increase resources The financing of immunization Legislation is finalized and led by MoH

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): The law A draft was elaborated for parliament Take responsibility To create a tri-fund of parliament/NGO/Gov

1. Outline of variables reported by the 7 peers evaluating Cambodia’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

began

how_advanced

1.

2.

3.

4.

5.

fin+budget finance budget finance fin+budget

nat+subnat missing national missing national

MoH+MoF+elect MoH MoH+elected MoH+elected MoH+MoF

bottom-up top-down bottom-up top-down outside group

missing 1-2 yrs 1-2 yrs 1-2 yrs 3+ yrs

tried talking about becoming inst talking about becoming inst

6.

7.

fin+budget budget

national nat+subnat

MoH+MoF MoH+MoF+elect

top-down bottom-up

3+ yrs 1-2 yrs

talking about becoming inst

2. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

The draft law is currently that of the ministry of health Sensitize the population Focus on reducing disparities and increase local and government funding There should be more firm proposal on the financing aspect

2) Preliminary peer assessment report: Cameroon Six peer reviewers analyzed Cameroon’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: DRC (3), Liberia (2), and Uganda. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Financing, deal with the private companies, telecoms Application on technical aspects of vaccination; financing methods; need for a contingent legal framework for vaccination; bottom up process; legal project still getting started Financing immunization and drafting law By addressing private enterprise Law on vaccines not yet written Technical application: vaccination obligatory (update law); method of enforcement

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Legislation-top down; advocacy, top down Technical framework and operational costs of vaccination Legal framework constrained for co-opting people for immunization 3. Outline of variables reported by the 6 peers evaluating Cameroon’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechan~m

began

how_advanced

8.

9.

10.

11.

12.

fin+budget fin+budget fin+budget budget fin+budget

national national national national national

MoH+MoF MoH MoH+MoF MoH+MoF MoH+MoF+elect

top-down top-down top-down top-down top-down

1-2 yrs 1-2 yrs 1-2 yrs 1-2 yrs missing

becoming inst becoming inst talking about becoming inst becoming inst

13.

fin+budget

national

MoH+MoF+elect

top-down

1-2 yrs

becoming inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Needs to explain to the Ministry of Finance that the intention is not to drive away tax money to finance immunization Increase budgetary support for the immunization program With determination success is assured bring in private sector, pass the law Find innovative financing within parafiscality

3) Preliminary Peer Assessment Report: Democratic Republic of Congo (DRC) Fourteen peer reviewers analyzed DRC’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Sierra Leone (3), Kenya (3), Cameroon (2), Madagascar (2), Sri Lanka (2), Nigeria, and an unidentified reviewer. Their responses are summarized below.

1. In the presenters’ words, what problem or opportunity does the innovation address?

Government must start buying vaccines MP network since 2009 Key sectors: mines, telecommunication, imports linked to vulnerable residents Insufficient funds available for vaccination Resource tracking and advocacy Vaccine procurement, after 2012 the country has been paying for its vaccines and drafting immunization law Draft legislation on immunization Draft law on

immunization, increase national budget for immunization co-financing regularized Principal sectors; mines; mobile phones; health damaging products Historical legislative framework being put in place part financing the cost of traditional vaccines Lack of support Pass the law, increase the budget Sustainable financing, resource tracking Continue to improve the national budget, government immunization 1. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Peer exchange with Cameroon Financing streams from DRC’s natural wealth Great advocacy to increase the execution of the transfers to the national budget Legislating for immunization is an initiative of parliament and will be implemented through the support of MoH. Necessary to advertise the value of immunization, champions: MPs National government started buying vaccines in 2012 (traditional vaccines), first time to do so.

Innovation is started; going top down; strong mobilization Parliament – driving Awareness creation and gathering support Involved all the concerned players, stakeholders Increased by members of parliament; Parliamentary Network on Immunization; progressing well Drafting 7 laws since one year; MoH initiated

2. Outline of variables reported from 14 peers evaluating DRC’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

function

level

government

mechanism

began

how_advanced

14.

15.

16.

17.

18.

fin+adv budget budget budget budget

national national national national national

MoH+MoF+elect MoH+MoF+elect MoH+elected MoH+MoF+elect MoH+elected

bottom-up missing top-down top-down top-down

3+ 3+ 3+ 1-2 1-2

yrs yrs yrs yrs yrs

becoming inst missing becoming inst becoming inst fully inst

19.

20.

21.

22.

23.

fin+adv fin+bud+leg+adv other fin+bud+legis finance

national national national national nat+subnat

MoH MoH+MoF+elect MoH+MoF MoH+MoF MoH+elected

top-down top-down top-down top-down top-down

3+ 3+ 3+ 3+ 3+

yrs yrs yrs yrs yrs

becoming becoming becoming becoming becoming

24.

25.

26.

27.

28.

fin+budget budget fin+bud+legis other fin+bud

national national missing national national

MoH+MoF MoH+MoF+elect MoH+MoF MoH+MoF+elect elected

top-down top-down top-down top-down top-down

1-2 1-2 1-2 1-2 1-2

yrs yrs yrs yrs yrs

talking about becoming inst becoming inst missing becoming inst

inst inst inst inst inst

3. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Need to involve provincial government Relieve the barrier against vaccination Need to work for funding and to enact legislation To secure funding and source of financing immunization Strengthen the working group

to support the law, monitor management and secure funding for vaccination The legislation should be drafted in such a way that it is enforceable and its implementation involving key players in immunization Scale up process Focus on real, actual allocation and not what is planned; DRC can do more; oil companies should contribute more A good innovation which, once institutionalized, will be foolproof Continue to advocate finalizing draft legislation

4) Preliminary Peer Assessment Report: Indonesia Three peer reviewers analyzed Indonesia’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Kenya (2), and an unidentified reviewer. Their responses are summarized below.

1. In the presenters’ words, what problem or opportunity does the innovation address?

All vaccines and logistics are funded by central government, operational costs are covered by the local government, Indonesia has a Health Act where 5% of the national budget goes to health, but there are many islands with problems Funding for operations; involvement of local authorities Funding vaccine centrally reduces costs

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): National government needs support of local government to fund immunization operational costs. They tried a task force that moved and engaged local governments. There was buy-in.

Central government funds logistics while local governments fund operations 3. Outline of variables reported from 3 peers evaluating Indonesia’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

29.

30.

31.

function

level

govern~t

mechan~m

began

how_adva~d

budget budget advocacy

national regional national

MoH MoH MoH

missing top-down top-down

1-2 yrs 3+ yrs 1-2 yrs

tried fully inst tried

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Involving local government in operational costs of immunization is key to SIF and reaching hard to reach LGs, and by understanding local dynamics The local government must be closely monitored

5) Preliminary peer assessment report: Kenya Eight peer reviewers analyzed Kenya’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: DRC (5), Liberia (2), and an unidentified reviewer. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Increase immunization financing Proper coordination to address problem, lack of coordination among stakeholders Financing of immunization programs, earmarked immunization budget line Health for all pronounced but doesn't come; communication, sensitization of the public visĂ -vis immunization needs reinforcement Replace funds from certain stakeholders; maintain advocacy to combat rumors; budgetary transparency

Information about children, civil society, and the population All partners working together and immunization depends on development of partners 2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Initial meeting to start advocacy to bring stakeholders The top-bottom approach is used and the MoH serves as the leading government agency, especially line items of vaccines Success with immunization depends in part on communication 3. Outline of variables reported by the 8 peers evaluating Kenya’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

32.

33.

34.

35.

36.

fin+budget finance other budget fin+legis

nat+subnat nat+subnat nat+subnat national national

MoH MoH+MoF MoH+MoF+elect MoH+MoF+elect elected

outside group missing bottom-up top-down top-down

37.

38.

39.

budget budget fin+budget

subnational nat+subnat nat+subnat

MoH+MoF MoH+MoF MoH+MoF+elect

missing top-down top-down

began 1-2 1-2 3+ 3+ 1-2

how_advanced

yrs yrs yrs yrs yrs

becoming inst fully inst tried becoming inst becoming inst

1-2 yrs 1-2 yrs 1-2 yrs

tried fully inst fully inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Support expanding advocacy; sensitize churches, chiefs; support private sector vaccination Increase sensitivity through the churches; involve private sector in vaccine financing Itemize immunization in budget The prospects are good to shift paradigm Pursue advocacy for immunization

6) Preliminary Peer Assessment Report: Liberia Twelve peer reviewers analyzed Liberia’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Sierra Leone (3), Cameroon (2), Madagascar (2), Sri Lanka (2), Nigeria (2), and Kenya. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Parliament has to advocate for budget increase MPs advocating for budget increase Sustainable financing for immunization Insufficient allocations for immunization Low coverage, low funding Parliamentary forum and advocacy for immunization Importance of vaccination and lacking of sufficient funding Draft legislation, increase budgetary support, lack of public awareness Vaccination budget provisional

Strong advocacy by MPs Legislation, finance, advocacy

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Parliamentarians are the champions Created a budget line for immunization, increase budget since 2010 using advocacy techniques Lobby in parliament Mass scale awareness campaigns, advocacy at legislature National legislation for vaccines and sustainable immunization financing Health insurance bill introduced, line item in local budgets to support immunization Few, insufficient resources for vaccination; reforms initiated by the government; reforms for vaccination program weak MPs champions Lobby, parliament for an increase budget Drafted national immunization law and estimated a performance form of support 3. Outline of variables reported from 12 peers evaluating Liberia’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

began

how_advanced

40.

41.

42.

43.

44.

fin+bud fin+bud+leg+adv budget fin+bud+leg+adv budget

national national national subnational national

MoH+MoF MoH+MoF+elect MoH+MoF+elect MoH+MoF MoH+MoF+elect

top-down outside group top-down top-down top-down

1-2 1-2 1-2 1-2 1-2

yrs yrs yrs yrs yrs

tried becoming inst becoming inst tried becoming inst

45.

46.

47.

48.

49.

budget fin+budget fin+bud+legis finance fin+budget

subnational national national national national

MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect

bottom-up top-down top-down top-down top-down

1-2 1-2 1-2 3+ 1-2

yrs yrs yrs yrs yrs

becoming becoming fully becoming becoming

50.

51.

fin+adv budget

national nat+subnat

MoH+MoF+elect MoH+MoF+elect

bottom-up top-down

1-2 yrs 1-2 yrs

inst inst inst inst inst

becoming inst missing

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Take ownership Take ownership and more peer exchange Continue, persist working Be sure to move the innovation through all layers of government and parliament They are working hard, yet there is a long way to go. Need to stimulate them constantly Lift cultural and financial barriers for immunization; assure uniform procedures Taking ownership by respective countries of the immunization program Lobby to parliament, work together with parliament, ministry of health and finance Major challenge: insufficient budgetary support; Ministry of Finance should create an immunization budgetary line item

7) Preliminary Peer Assessment Report: Madagascar Six peer reviewers analyzed Madagascar’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Nepal (3), Indonesia, Liberia, and Mali. Their responses are summarized below.

1. In the presenters’ words, what problem or opportunity does the innovation address?

Establish fund, adoption of law by parliament Adopt the law on immunization in parliament Budget EPI Government unstable due to election; role of district Development of regulation, draft law How to secure the needed funds?; How to manage them?; What are sustainable funding sources?; The transitional sociocultural situation

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Follows the Addis Ababa action points Finance, justice, health Finance; national assembly and senate Semester meetings with districts Stop external partner financing; state contribution too small 3. Outline of variables reported from 6 peers evaluating Madagascar’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

52.

53.

54.

55.

56.

other fin+bud+legis fin+bud+legis fin+budget fin+bud+legis

national national regional national national

MoH+MoF+elect MoH+MoF MoH+elected MoH MoH+MoF+elect

top-down top-down top-down top-down top-down

57.

advocacy

national

MoH+MoF

bottom-up

began 1-2 1-2 1-2 1-2 1-2

yrs yrs yrs yrs yrs

this yr

how_advanced becoming fully becoming fully

inst inst inst inst tried tried

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Continue strong advocacy with the government and non-government actors together Develop the draft regulations for the national fund To approve the law Advocacy to implicate private sector in vaccine financing; validate the regulations concerning funds for epidemic and pandemic control

8) Preliminary Peer Assessment Report: Mali Three peer reviewers analyzed Mali’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Nigeria (2) and Senegal. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

High level advocacy Draft legislation that could easily become law The crisis; creation of a high-pressure network; government leadership 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Parliamentary forum for immunization this year, immunization trust fund By the MPs who are the champions

3. Outline of variables reported by the 3 peers evaluating Mali’s innovations

58.

59.

60.

function

level

government

mechan~m

began

how_advanced

budget other fin+adv

national nat+subnat national

MoH+MoF+elect MoH+MoF+elect missing

top-down top-down top-down

this yr missing 1-2 yrs

becoming inst missing fully inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Ensure there is a good public information campaign for citizens to learn about the purpose of the fund; gather critical feedback Continue efforts to involve civil forum

9) Preliminary Peer Assessment Report: Mongolia Nine peer reviewers analyzed Mongolia’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Nigeria (3), Sierra Leone (2), Kenya (2), Cameroon, and an unidentified reviewer. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Addresses ignorance and unites government stakeholders Show how taxes were used to finance immunization Difficulties financing local health worker salaries, transport; weak local resources Not clear what has happened in 2012-13 but between 2003-2010 legislation process led to a law on immunization; problem: indirect cost of immunization was not addressed Increase funding, provision of legal framework and further strengthening with two reviews Legislation laws to support the financing of immunization Amending laws, increasing funding

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Government and MPs in briefing All taxes proportionately used Legislations is within the innovation as well as buying in by tax authorities Initiated in 2000 and reviewed twice in 2003 and 2010, championed by Parliament and Ministry of Health Law was passed and supported Start dialogue among and with concerned stakeholders 3. Outline of variables reported by the 9 peers evaluating Mongolia’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

began

how_advanced

61.

62.

63.

64.

65.

fin+bud+legis other fin+adv budget other

national national national national national

MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF

top-down top-down outside group top-down top-down

3+ yrs 1-2 yrs missing 3+ yrs 3+ yrs

fully inst talking about missing fully inst becoming inst

66.

67.

68.

69.

budget budget fin+adv budget

nat+subnat national nat+subnat national

MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect

top-down top-down top-down top-down

3+ 3+ 3+ 3+

yrs yrs yrs yrs

missing fully inst missing fully inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Important - all stakeholders can synchronize towards the same goals Continue to request more funding from taxes Need a joint budget platform for ministries of health, finance There are inconsistencies; if activity plans for 2012-13 and amendment of law of immunization 2003-10. What happened in 2010-13?

Open the fund to the public for private sector contributions; continue sensitizing, raising awareness about the fund; monitor expenditures Early stage of SIF intervention in Mongolia; implementation of the 2012 transition plan should be priority

10)

Preliminary Peer Assessment Report: Nepal

Five peer reviewers analyzed Nepal’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Mongolia (2), Kenya, DRC, and an unidentified reviewer. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Getting other players to ensure sustainable financing removes pressure from government Secure immunization financing Low local immunization funding 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Financing Drafting the immunization law and using village development committees as a resource, champions, legislators There is an independent chapter, guarantee timely vaccinations More towards ownership, institutionalize immunization law

3. Outline of variables reported by the 5 peers evaluating Nepal’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

70.

71.

72.

73.

74.

function

level

government

mechan~m

fin+bud+legis other fin+bud+legis finance budget

national nat+subnat national national national

MoH+MoF+elect MoH+MoF MoH+MoF+elect MoH+MoF+elect MoH

top-down top-down top-down top-down top-down

began 3+ 3+ 1-2 1-2 3+

yrs yrs yrs yrs yrs

how_advanced becoming inst talking about tried becoming inst becoming inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Synergy among institutions; peer exchange with other countries; give management of funds to an autonomous representative Don't replace government's role and responsibility with the establishment of a national immunization fund

11)

Preliminary Peer Assessment Report: Nigeria

Four peer reviewers analyzed Nigeria’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: DRC (3) and Indonesia. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Since 2012, the approved vaccination budget is directly allocated for vaccination (managed by EPI) Deviation of national oil revenues; polio eradication; political transition; global vaccine shortage; security challenges The budget allocated needs to go directly to EPI Budgets allocated to immunization must be immediately disbursed 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Maternal and neonatal and child health days (2/year);

national vaccine summit 2012 Avoid vaccine stock-outs The EPI budget goes directly to the program and not to the Ministry of Health 3. Outline of variables reported by the 4 peers evaluating Nigeria’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

75.

76.

77.

78.

function

level

government

mechan~m

began

how_advanced

finance finance advocacy finance

national national national national

MoH+MoF+elect MoF MoH+MoF MoH+MoF+elect

top-down top-down top-down top-down

1-2 yrs 1-2 yrs missing 1-2 yrs

fully inst tried becoming inst tried

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Ministry of Health follows, manages allocations; in the north, strong social communication strategies to overcome resistance; mobilize partners but insist on transparency via civil society Try to find similarities, exchange experiences Effectively implemented; concerned institutions must regularly follow up and evaluate; the innovation must be routine

12)

Preliminary Peer Assessment Report: Republic of Congo

Seven peer reviewers analyzed the Republic of Congo’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Nepal (2), Liberia (2), Mongolia, Mali, and Uganda. Their responses are summarized below.

1. In the presenters’ words, what problem or opportunity does the innovation address?

To pass immunization law Plan after graduating GAVI Immunization law, financing Long term financing, dependence on donors; involvement of many stakeholders like NGOs executives and communities Budget support Weak staff training, lack of law Underdeveloped administrative capacity; advocacy with concerned parties

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Ministry of Health and Ministry of Finance Pass the law on immunization, improve budget Draft law on immunization; additional funding 3. Outline of variables reported by the 7 peers evaluating the Republic of Congo’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

began

how_advanced

79.

80.

81.

82.

83.

fin+budget fin+bud other fin+bud+legis fin+adv

national subnational national regional nat+subnat

MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect MoH+MoF+elect

top-down bottom-up top-down top-down top-down

this yr 1-2 yrs 1-2 yrs 1-2 yrs 1-2 yrs

becoming inst becoming inst tried tried becoming inst

84.

85.

fin+bud+legis budget

national national

MoH+MoF MoH+MoF+elect

top-down bottom-up

3+ yrs 1-2 yrs

tried talking about

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Continue effort to pass immunization law Pass the law on immunization Monitoring mechanism for implementing the law is important A robust strategy to galvanize support

13)

Preliminary Peer Assessment Report: Senegal

Four peer reviewers analyzed Senegal’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Nepal (2), Uganda, and DRC. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Budget increase Sustainable financing and increased ownership by increasing the budget for immunization Financing, earmark Involve private sector in immunization financing 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Draft law elaborated established TAC advocacy on SIF Legislation and advocacy to ensure buy in Draft law, technical advisory committee

3. Outline of variables reported by the 4 peers evaluating Senegal’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

86.

87.

88.

89.

function

level

government

mechan~m

began

how_advanced

legislation 12 advocacy budget

national national national national

MoH MoH+MoF MoF MoH+MoF+elect

top-down top-down top-down top-down

1-2 yrs missing 1-2 yrs 1-2 yrs

becoming inst becoming inst tried tried

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Bill, finance, and regionalization More advocacy Pass the bill; budgeting Keep up the fight, create a strong network

14)

Preliminary Peer Assessment Report: Sierra Leone

Four peer reviewers analyzed Sierra Leone’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: DRC (3) and Uganda. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Parliament defeated on health budget issues Immunization financing is donor oriented; government should be part of funding opportunities; more stakeholders like NGOs; support from parliament/executive Advocacy; increase immunization budget; create a vaccine line of credit 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Want to separate the EPI budget from health budget

Initiated by cabinet/ministry of health 3. Outline of variables reported by the 4 peers evaluating Sierra Leone’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

90.

91.

92.

93.

function

level

government

mechan~m

fin+adv fin+bud+legis budget fin+budget

national national national national

MoH+MoF+elect MoH+MoF MoH+MoF+elect MoH+MoF+elect

top-down top-down top-down top-down

began 1-2 1-2 1-2 1-2

yrs yrs yrs yrs

how_advanced talking about tried tried becoming inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

The innovation should be effective in a reasonable period; an evaluation system is needed; implicate all in the EPI budget process to make it sustainable Ownership and sustainability, advocacy is a key, more partnership to drive the innovations Implement an effective vaccine law; evaluate; make the budget perennial

15)

Preliminary Peer Assessment Report: Sri Lanka

Five peer reviewers analyzed Sri Lanka’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: DRC (3), Liberia and Uganda. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Financing of the new vaccines No major problem; new vaccines require that the government spends more Amending the immunization act; financing of new vaccines due to cost Lacks an immunization policy Co-financing for introducing new vaccines Advocacy; increase immunization budget; create a vaccine line of credit

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Financing introduced in 1978; Policy is aimed at entrenching funding for the new vaccines Immunization legislation A policy will help pass the vaccination law To create and operationalize a national vaccine policy following the Addis colloquium 3. Outline of variables reported by the 5 peers evaluating Sri Lanka’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

94.

95.

96.

97.

98.

function

level

government

mechan~m

fin+budget fin+adv legislation fin+bud+legis legislation

national national national national national

MoH MoH MoH+MoF MoH+MoF+elect MoH+MoF+elect

top-down missing top-down top-down top-down

began 1-2 3+ 1-2 1-2 1-2

yrs yrs yrs yrs yrs

how_advanced becoming becoming becoming becoming becoming

inst inst inst inst inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Strengthen the policy framework; address the state challenges Make strong investment case for new vaccines Progress depends on commitment to work Keep up efforts to pass vaccination law Pursue innovations until a law is passed supporting vaccination; it is a strong health system

16)

Preliminary Peer Assessment Report: Uganda

Five peer reviewers analyzed Uganda’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Sri Lanka (3), Kenya, and DRC. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Tracking expenditures, private sector promising support Private sector needs to be tapped; not done yet, but needs successful advocacy for parliament to track expenditures on immunization at local level, which is quite difficult Buy in by legislators was key, "refusal and pass 2012/13 budget" The innovation is the law, with partner support Advocacy for financing; increase immunization financing; immunization act

2. In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): Draft law, successful advocacy Engagement of key people to ultimately amplify advocacy Involvement of new players 3. Outline of variables reported by the 5 peers evaluating Uganda’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable)

99.

100.

101.

102.

103.

function

level

govern~t

mechanism

fin+adv fin+budget budget fin+budget fin+bud+legis

national national national national missing

MoH elected MoH+MoF elected elected

top-down bottom-up top-down bottom-up top-down

began 3+ 1-2 3+ 3+ 1-2

yrs yrs yrs yrs yrs

how_advanced becoming becoming becoming becoming becoming

inst inst inst inst inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Continue creating popular awareness Congratulate and encourage the delegates to meet their Kenyan counterparts, develop common strategies Appropriation of the law is a possibility for the government to have a political midpoint Improve data quality; track actual spending; translate immunization act into real budget increases and implementation rate; improve transparency

17)

Preliminary Peer Assessment Report: Vietnam

Seven peer reviewers analyzed Vietnam’s institutional innovation(s) during the poster session. The poster reviewers were peers from the following countries: Mongolia (2), Nepal (2), Liberia, Uganda, and DRC. Their responses are summarized below.

1.

In the presenters’ words, what problem or opportunity does the innovation address?

Getting more funding for immunization Budget gap of 40%; problem of operating funds and co-financing; presence of the law Lack of political will Local vaccination financing Government budget for EPI is increasing, government budget still meets 60% of the heads for EPI 2.

In your own words, describe the innovation (what happened, where was it initiated and implemented, why was it necessary, how did it proceed, who are the champions): MoH/EPI initiated Financing, law

It was initiated by Ministry of Finance and the Ministry of Planning and Investment Targets 40% of the population National EPI submit budget to MoF, MoH, and MoPI 3. Outline of variables reported by the 7 peers evaluating Vietnam’s innovations.

(Refer to Table-1 at the beginning of this appendix for the description of each listed variable) function

level

government

mechanism

104.

105.

106.

107.

108.

fin+adv advocacy other budget finance

national national nat+subnat national national

MoH+MoF MoH+MoF MoH+MoF MoH+elected MoH+MoF

top-down bottom-up top-down top-down top-down

109.

110.

advocacy finance

national regional

MoH+MoF+elect MoH

bottom-up bottom-up

began 3+ 3+ 3+ 1-2 3+

yrs yrs yrs yrs yrs

3+ yrs 3+ yrs

how_advanced fully fully becoming becoming becoming

inst inst inst inst inst

fully inst becoming inst

4. What feedback and recommendations do you wish to convey to these delegates about this particular innovation?

Advocacy can work to get more funding Social mobilization is important; health insurance for EPI Social mobilization

Annex E: Thematic group reports

Table E.1 Thematic group reports (verbatim): Budget/finance Problem

Solution

Group 1 Problems related to the budgeting process (preparation) - Lack of involvement from the Ministry of Finance, Ministry of Budget and other stakeholders in the process of budgeting for vaccination

- Ensure that planning is inclusive of all the stakeholders

- Low capacity of the EPI Program to effectively budget for all the program requirements

- Strengthen the budgeting capacity of EPI teams - Establish a system of internal arbitration at the Ministry of Health for a pre-allocation of resources among priority

- Difficult to estimate the cost per fully immunized child

needs - Standardize the allocated budget for vaccination, securing it and making it one of budget categories that have to be spent mandatorily every year in accordance

- Low involvement of the private sector

with how they are budgeted - Insert into the law on immunization financing a

- Difference between the cMYP and the immunization

compulsory threshold that will need to be allocated to

budget actually passed by parliament

immunization in the national budget

- Failure to comply with the priorities set in each

- Put in place a system of budget monitoring

programming area Problems with resource mobilization for immunization - Difficulty involving the private sector - Strong dependence on external financing - Lack of strategies for sustainability of national immunization financing - No involvement of the Ministry of Finance in finding solutions for sustainable national funding Problem with the management of immunization resources - Failure to meet deadlines in expenditure commitments - The immunization budget is not ring-fenced, not tied to the immunization expenditures Problems related to monitoring and control - Lack of a system to monitor immunization budget execution - Non-compliance with immunization financing regulations Group 2 Funding gaps for vaccines and immunization programs

Funding gap

- High cost of new vaccines

- Advocacy – Legislation

- Dwindling of national resources

- Ensure budget line for vaccines

- No budget for new vaccines

- Innovative financing mechanisms, i.e. PPP, taxes

- Low budgetary support for immunization programs - Resistance to financial risk sharing

Weak communication of financial data among stakeholders

Weak communication

- Weak coordination of stakeholders

- Capacity building for staff of institutions

- Lack of transparency and sharing of financial data

- Expand membership of ICC to include other national

among institutions

institutions, i.e. Parliamentarians, MoF, etc.

- Deploy modern technologies, i.e. mobile technologies in tracking and reporting expenditures

Difficulty with release of funds

Release of Funds

- National and subnational expenditure tracking

- Create buffer funding

- Lack of transparency and sharing of financial data

- Expand membership of ICC to include other national

among institutions

institutions, i.e. Parliamentarians, MoF, etc.

Group 3 Limited National Resources

Increase resource base (sources of funding) * Private sector * Ear mark taxes * Sin taxes * Needs MoH & MoF dialog * Economic / fiscal analysis * Legislation * Increase Revenues * Improve tax collection * Alliance of use of immunization to improve public perception on taxes * Local taxes revenues to allocate for immunization (not vaccines) * Potential Use of Health Insurances Improve efficient use of resources

* Prioritize program or activities * Analyze direct/indirect cost drivers * Procurement practices (pool procurement) * Introduce new technologies Alignment of immunization to national planning and budgeting processes, MTEF Inability to track funds spent on immunization (accountability/transparency)

Timely performance report from immunization * Expenditures * Performance (# children vaccinated, wastage, equity, etc.) * Immunization report to MoF, Parliament Improve Information System (HMIS, BMIS) * Use of surveys, coverage surveys, etc. * Internal or external audits * Production of evaluations

Lack of accurate / timely information for planning / budgeting

Use of performance reports Include use of sub-national information * Budget * Performance Conducting economic analysis * Cost benefit * Cost effectiveness * Cost saving Analysis of global vaccine market Table E.2 Thematic group reports (verbatim): Legislation

Problem

Solution

Group 1 Strengthening the capacity of parliamentarians to make them understand the law on vaccination, as well as how administrative delays

to implement and monitor its implementation

plethora of stakeholders

Advocacy with the government counterparts

government's reluctance to face innovations for financing

The organization of information days between

for immunization

parliamentarians and policy makers

the government's tendency to consider vaccination as a

Sharing of experiences by countries that already have a

priority that is financed by partners

legislative framework (legislation on vaccination)

Heaviness, length, uncertainties, complexity of the legislative process

Increasing public awareness on immunization issues The creation of a network at each national parliament to support vaccination, more precisely a forum involving all parliamentary networks that work on immunization

political instability

issues The organization of periodic peer exchanges between parliaments, government, and civil society on the

lack of information, lack of resources

importance of immunization

the socio-political and economic context, the political transition

The strengthening of monitoring and evaluation

the lack of a multi-sectoral framework for cooperation between the government and the parliament

Develop an advocacy document

Heaviness in the process leading to the adoption of the

Involvement of all the levels (regional, national,

law

provincial and local)

The deficit of information on vaccination among the

The use of approaches that are better adapted (project

parliamentarians

or bill on immunization, public health law vs law on

immunization) to the context of each country Multiply the forms and information missions for capacity building of the elected officials Group 2 First: Law on Immunization (steeped in operational Prioritization and Commitment

realities, defined budget line) Second: Oversight with M&E Framework, quarterly reporting (technical and financial), timeliness of

Implementation and Accountability

releasing finances Third: Vaccine and immunization fund, CSR (domestic

Sustainability

private partners), training and retention of HRH Fourth: Independent Operational Research, economic/security importance of immunization, disaster

Demand on System

preparedness and control Fifth: Gradual withdrawal with help in emergencies, peer

Externalization

support and peer capacity building

Group 3 Tracking of vaccines and immunization expenditures @ the country level (Lack of/No guidance on budget

Evidence based advocacy: Generate data to inform

tracking and accountability)

advocacy :

No law/legislation on Immunization financing to

Building investment case(s) for vaccines/Immunizations

safeguard funds for immunization

-@the country level

Regional perspective: Poor Data/ acquisition to inform legislative processes /Evidence for legislations

Developing budget line for immunizations

The need for Immunization laws to be more specific visĂ -vis being generic

Ring fencing immunizations financing

Convincing policy and law makers on legislating for

M&E: Strengthen multi-sectoral mechanism for

Immunizations /Linking mortality to legislation

monitoring and evaluation of Immunization budget flows

(Messaging & communication)

and performance

No laws/provisions on immunization budget line @ the country level, leading low Political commitments on immunization financing Competing governments priorities and limited resources; in the absence of legislation on immunization.

Rights to protect every child from Vaccine preventable diseases is not guaranteed Observation: Majority of countries have draft laws on immunizations: Drafts, drafts, drafts‌..

Most important: Losing the right to protect every child Sustainability of financing due to lack of political commitments Framework of tracking expenditures and accountability Definition/clarity of roles of different stakeholders Group 3 Tracking of vaccines and immunization expenditures @ the country level (Lack of/No guidance on budget

Evidence based advocacy: Generate data to inform

tracking and accountability)

advocacy :

No law/legislation on Immunization financing to

Building investment case(s) for vaccines/Immunizations

safeguard funds for immunization

-@the country level

Regional perspective: Poor Data/ acquisition to inform legislative processes /Evidence for legislations

Developing budget line for immunizations

Annex F: Country Action Points Cambodia's Action Points Delegates: Mr. Uy Visal*, Dr. Chheng Morn*, H.E Mr. Ouk Damry, Ms. Kan Bola Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Increase budget for immunization program

Collaborate with development partners to fulfill the gap of the immunization program fund Resource tracking (Consultation with stakeholders, technical workshop in Nov. 2013, and a quarterly followup)

Financial Management

Institutional & Operational Changes

Immunization Legislation

Ministry of health will initiate to discuss with related sector, agency, to draft the immunization

Drafting Immunization Law through a series of workshops and submit it to the National Assembly

Law

Advocacy Activities & Partnerships

(expected due date July 2014) Initiate discussion with related sector agency to create tri�fund that includes private sector and NGOs

Continue to monitor and promote immunization activity at the provincial level through local Authority

Advocacy on SIF and draft law (Through a series of meetings)

Global Vaccine Action Plan (GVAP) Cameroon's Action Points Delegates: Hon. Amougou Mezang*, Mr. Maina Djoule, Mr. Ngwen Ngangue, Mrs. Marie Yvonne Facksseu Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Financial Management

Institutional & Operational Changes

To ensure that the Fund to Support Health is operational by 2014

Immunization Legislation

Advocacy Activities & Partnerships

Prepare a draft law to create a national immunization fund

Organize a day of advocacy for political commitment at the highest level

Pass a law establishing an Immunization Section in the Directorate for effective management of immunization Prepare the technical arguments for the establishment of the Immunization Section in the Directorate

Complete the legislative process of the law on vaccination by June 2014

Develop a national action plan for implementation of the global plan of action for vaccines (GVAP) (before March 2014)

Global Vaccine Action Plan (GVAP) Kenya's Action Points

Delegates: Hon. Dr. David Eseli*, Dr. Dominic Mutie, Dr. David Githanga, Ms. Sharon Wanyeki, Mr. Jack Ndegwa, Dr. Gene Bartley Dakar, Senegal -

Addis Ababa, Ethiopia - 2011 Themes

Accomplished

2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Donors who are involved in financing activities within immunization framework are obliged to report to the relevant ministry

Financial Management

Immunization budget formulation, execution and oversight shall be undertaken by the relevant department to ensure that they give cash flow projections. (a.)

Budget should be completed and released on time to the ministry of finance. (b.)A common monitoring and evaluation framework for immunization financing should be followed with quarterly reports made to the relevant parliamentary committee

Institutional & Operational Changes Immunization Legislation

Draft legislation for immunization financing which is pegged on the projected base cohort so that it is predictable

- Consolidate/Build consensus on drafts immunization bills & factor in

and efficient. (a.)

Legislation should be for free, compulsory routine vaccination

- Engage parliamentarians, starting with the committees on health, with advocacy - Engage civil societies in advocacy

Advocacy Activities & Partnerships

Ensure that there is an obligatory media dissemination of key government messages on health/immunization

devolution issue in Kenya - Parliament continues to ensure line item, adequate & appropriate funding until the immunization law is in place; Ensure itemized budget tracking & monitoring Flexibility in use of funds; Focus on establishing an Immunization Fund - Sensitize Members of Parliamentary Health Committee on Internal National Assembly process 2013 2015 (2 years) - Dissemination of ACSM strategic plan / sensitize MPS, CSOs, development partners et.al; Implementation of the plan - Continuous engagement among MOH/MOF/ MOD&P/ Parliament

Dev. partners/CSOs Global Vaccine Action Plan (GVAP) Liberia's Action Points Delegates: Rev. John B. Sumo*, Hon. William V.Dakel, Hon. Johnson T. Chea Addis Ababa, Ethiopia - 2011 Themes

Financing for Immunization

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by

Create a line item to be included in the fiscal year budget to support immunization

2015 Increased budgetary support for immunization program (new vaccines, immunization services)

Financial Management

Institutional & Operational Changes

Immunization Legislation

- Develop legislation for sustainable immunization financing - Complete introduction of health insurance

- Finalize legislation for sustainable immunization financing - Review and finalize TOR for Legislative Forum - Finalize health

bill that will support immunization

insurance bill Scale up advocacy and awareness to include County and district levels (tradition leaders, women, students, and civil society organizations)

Conduct advocacy and awareness at the executive, legislative, country and district levels for sustainable immunization financing

Advocacy Activities & Partnerships Global Vaccine Action Plan (GVAP)

Madagascar's Action Points Delegates: Dr. Louis Marius Rakatomanga*, Hon. Aro Tafohasina Rajoelina* Dakar, Senegal -

Addis Ababa, Ethiopia - 2011 Themes

Accomplished

2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing Immunization

Financial Management

for

Recommendation/declaration Addis Ababa on the financing of the National immunization fund

Update the funding needs for immunization

Establish a mechanism for monitoring and evaluation of

immunization financing involving different entities Institutional & Operational Changes

Elaboration of a draft law on the creation of a National immunization fund Immunization Legislation

Advocacy Activities & Partnerships

Global Vaccine Action Plan (GVAP)

Advocacy to mobilize local resources (in the regions, districts, communes)

- Consolidating the amendments to the bill on the vaccination by the Ministry of Health and the Ministry of Finance and Budget - Finalize the document bill by lawyers - Submit to the vaccination bill to the government - Report the achievements of the second Colloquium in Dakar - Advocate for funding from various public and private sector decision makers Develop a new National Action Plan for immunization from the Global Action (GVAP)

Mali's Action Points Delegates: Hon. Fanta Mantjini Diarra*, Dr. Nouhoum Kone*, Dr. Aguissa Maiga, Mr. Mahamadou Sidibe Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Financial Management

Institutional & Operational

Introduction of new

Changes

Immunization Legislation

- Prepare a draft law to create a national fund for immunization - Prepare the technical arguments for the establishment of the Immunization Section in the Directorate

Pass a law establishing an Immunization Section in the Directorate for effective management of immunization

- Official submission of the draft immunization law to the National Assembly - Adoption and enactment of immunization laws - Changing the immunization section into the directorate of immunization within the MOH

Advocacy Activities & Partnerships

Advocating for the inclusion of immunization in development plans of decentralized authorities - Dissemination of the GVAP to all the key players - Update the CMYP to make sure it is consistent with the GVAP

Organize a day of advocacy for political commitment at the highest level

Global Vaccine Action Plan (GVAP) Nepal's Action Points

Delegates: Mr. Kedar Prasad Paneru, Mr. Komal Prasad Acharya, Mr. Giri Raj Subedi Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Financial Management

Increase international resource; increase the vaccination resource for NIP

Establish the Immunization fund

- Forward the Immunization Fund Regulation to the Council of Ministers - Resource Tracking:

Estimation, source identification; Budget requested

by NIP; Budget approval, disbursement and expenditure Institutional & Operational Changes

Develop detailed modality of function of operations by December 2011

Immunization Legislation

Advocacy Activities

The final draft bill to be resolved by cabinet by March 2012; the bill submitted to the parliament by April 2012

Forward the draft bill to the Parliament once the Parliament exist

Advocated communications

Advocacy at various level (National and Subnational) to generate fund for National Immunization Fund

& Partnerships Global Vaccine

Country plan addressing GVAP

Action Plan (GVAP) Nigeria's Action Points

Delegates: Dr. Lekan Olubajo*, Sen. Adegbenga S. Kaka, Dr. Ade Abanida, Dr. Doyin Odubanjo, Mr. Muhammed Muhammed Themes

Addis Ababa, Ethiopia - 2011 Accomplished

Partially

Not

Dakar, Senegal 2013 To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Expand the scope of Accountability Framework for RI in Nigeria (AFRIN) to include indicators and tracking of funding for immunization

Financial Management

Institutional & Operational Changes Immunization Legislation

Advocacy Activities & Partnerships

- Advocate for the implementation of the national strategic health development plan - Advocate for the passage of the health bill - Solicit continuous support of the debt relief grants that support

- Advocate for and secure funding for implementation of the National RI Strategic Plan - Continued advocacy for passage of the Health Bill

immunization Global Vaccine Action Plan (GVAP) Democratic Republic of Congo's Action Points Delegates: Hon. Grégoire Lusenge*, Hon. Célestin Bondomiso, Hon. Grégoire Kiro, Dr. Audry Mulumba, Mr. Jules Baganda*, Mr. Benjamin Feruzi, Mr. Raphael Nunga, Dr. Abderrahmane Ba (UNICEF), Mrs. Yolande Masembe (WHO) Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Financing for Immunization

Engaging the EPI to present the cMYP and evaluating its budgetary estimates, paying particular attention to : the global cost of vaccination; the cost per completely vaccinated child

Financial Management

Formulation, Execution and Supervision of the

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015 - Take into account the cMYP budget in the budget estimates for immunization - Allocate adequate preliminary funds to immunization in the overall allocation for health (internal arbitration); enter the immunization budget lines as part of the mandatory spending in the country.

budget for vaccination Institutional & Operational Changes

Immunization Legislation

Advocacy Activities & Partnerships

Legislation for the National immunization fund (NIF): review of the proposals for the draft law on the NIF; filing and passing of the draft law in parliament; dissemination of information on the NIF law

- Monitor the different stages of the Legislative process - Extend the network of parliamentarians to the Provincial Assemblies.

Restitution and advocacy with institutional authorities for sustainable financing of immunization

- Giving feedback on the results of the Colloquium to the institutions and decision-makers; Organize an information session on immunization for the MPs who are members of the Socio-cultural Commission and the Commission on Economy and Finance - Advocate with MPs on the immunization law

prior to the National Assembly debate Global Vaccine Action Plan (GVAP) Senegal's Action Points Delegates: Dr. Elhadji Mamadou Ndiaye*, Dr. Oumy Seck, Dr. Amy Lo Ndiaye, Ms. Ndeye MayĂŠ Diouf*, Dr. Farba Lamine Sall Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Financial Management

Institutional & Operational Changes

Involvement in the implementation: - Participation in the budget process - Participation in supervision - Participation in the annual review

and revision of the CMYP

Prepare a draft law to create a national fund for immunization

Immunization Legislation

Organize a day of advocacy for political commitment at the highest level

Advocacy Activities & Partnerships

Global Vaccine

- Prepare the technical arguments for the establishment of the Immunization Section in the Directorate - Pass a law establishing an Immunization Section in the Directorate for effective management of immunization

Development and adoption of draft immunization law by 2015

Advocacy activities with: - Health Commission of the Parliament, - Economic and Social Council, - Other Ministries( Women, Education and Interior ) - Governors and prefects - Local communities, - Civil society - Private sector( philanthropists, PPP) Translation of the Global Vaccine

Action Plan (GVAP) into the National Action Plan

Action Plan (GVAP)

Sierra Leone's Action Points Delegates: Hon. Veronica Sesay, Mr. Sam M. Aruna, Dr. Sartie M. Kenneh Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Financial Management

Institutional & Operational Changes

Immunization Legislation

Formulate a concept paper on sustainable immunization financing addressing three key issues (advocacy, legislation, budgeting/financing)

Prepare a cabinet paper to seek approval on recommendations to address advocacy, legislation and financing

Set�up an ad�hoc tripartite committee comprised of the ministry of finance, ministry of

- Finalization of the Cabinet Paper to seek approval to address, legislation on sustainable immunization financing - Set up an ad-hoc

health, and parliament to implement the conclusions of cabinet position

tripartite committee comprised of the Ministry of Finance, Ministry of Health, and Parliament to implement the conclusion of the Cabinet Paper - Creation of Parliamentary Forum on Immunization

Present the concept paper to the minister of health and sanitation for adoption, ownership and leadership

Advocacy Activities & Partnerships Global Vaccine Action Plan (GVAP)

Sri Lanka's Action Points Delegates: Hon. Dr. Ramesh Pathirana, Dr. Paba Palihawadana Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

Ministry of health requests additional funding for new vaccine introduction. This process will be

Increase budgetary allocation of immunization by 25% for 2014

transparent and constructive and involve all relevant stakeholders including representatives of the ministry of finance To estimate Direct/Indirect Cost incurred by the NIP-cross sectional study

Financial Management

Institutional & Operational Changes Committee will be appointed to study existing legal provisions to see whether additional provisions are needed to ensure sustainable immunization financing, and services included in the NIP

Immunization Legislation

Advocacy Activities & Partnerships

Sri Lanka will continue to follow good practices and regularly update parliamentary committees on the National Immunization Programme (NIP)

Immunization act to be amended by 2014

- Advocacy sessions for cabinet of ministers, parliamentarians, provincial members, higher level officers at national & provincial/district level

- Peer to peer exchange programmes Global Vaccine Action Plan (GVAP) Uganda's Action Points Delegates: Mr. Ishmael Magona*, Hon. Huda Oleru, Dr. Mayanja Robert, Mr. Chriastian Acemah Addis Ababa, Ethiopia - 2011 Themes

Accomplished

Dakar, Senegal 2013

Partially

Not

To be

Accomplished

Accomplished

accomplished by 2015

Financing for Immunization

- Evidence: Trend analysis (coverage, budget), MP information, costbenefit analysis - Encourage MPs to monitor Immunization

Financial Management

Institutional & Operational Changes

Review how routine immunization can be strengthened and develop a strategy for action

if necessary

Immunization Legislation

Advocacy Activities & Partnerships Global Vaccine

Engage parliament and build a case to advocate for increased immunization financing: Following development of the support case, respective heads of ministries and institutions will be debriefed (ministry of health, ministry of finance, speaker of parliament) - Convene a meeting, with support from Sabin, to present a report that was developed following the conclusion of the colloquium - Advocate to parliament and cabinet to increase primary healthcare funding, in particular increase funds for immunization - Develop information, education and communication strategies targeting leaders in the country (religious and cultural leaders, and civil society organizations)

Convene a meeting, in collaboration with colleagues from Kenya, comprised of members of the two national assemblies to develop common strategies to increase sustainable immunization financing in the region

- Corporate Social Responsibility: Communication involving private sector, media etc.

- Advocacy: MPs, Local Govt., CSOs

Action Plan (GVAP) Mongolia’s Action Points Delegates: Munkhbat Delger, Bayanselenge Tsagaan Zangad, Enkhbold Amjaa Themes

Financing for Immunization

Dakar, Senegal - 2013 To be accomplished by 2015 - To discuss at the Parliament the portion of the Health fund go to the Immunization fund. Currently, 2% of the income from excise tax is goes to Health Fund - To insure sustainable financing when GAVI co-financing stops -To decrease the price of the vaccines and use the limited government fund efficiently

Financial Management Institutional & Operational Changes Immunization Legislation

Advocacy Activities & Partnerships

To provide trainings for vaccine officers to insure all standards are meet Within the framework of the drafting the proposal for the health program, the sustainable Immunization financing issues will be discussed at the Parliament.

- To establish the group for women parliament members to advocate for sustainable financing - To improve the link between the Government and the Community - To increase public awareness, and educate citizens for family planning and have healthy child

Global Vaccine Action Plan (GVAP) Vietnam's Action Points Delegates: Mr. Nguyen Van Quyet, Dr. Duong Thi Hong Themes

Dakar, Senegal - 2013

To be accomplished by 2015

Financing for Immunization

Vaccination should be paid by health insurance as treatments diseases for children under 6 (free of charge) following the strategy/itinerary health insurance for all Vietnamese people

Financial Management Institutional & Operational Changes

Improving domestic vaccine products, new technology as vaccines were approved as national products by the Government

Immunization Legislation

Advocacy Activities & Partnerships

Global Vaccine Action Plan (GVAP)

Advocate and strongly involve local authorities and communities (particularly parents) for immunization. Citizens in the rich provinces are willing to pay for the vaccination (new vaccines), the government financial resources spent for the poorer populations defined by the Ministry of Labor (they receive immunization free of charge) The plan of using vaccine in EPI period 2015 – 2020 with updating GVAP approved by MOH, considered by Ministry of Planning and Investment (MPI), MOF and submit to the Prime Minister. (including the financial resources for vaccines, logistic, especially new vaccines... meet requirements of the target of population and objectives, strategy in EPI) Republic of Congo's Action Points Delegates: Hon. Leyinda Alain Pascal

Themes

Dakar, Senegal - 2013 To be accomplished by 2015

Financing for Immunization

Advocate for increased funds allocated to immunization in the budget law 2014 to the Director General of Health in accordance with the revised 2013-17 CMYP; Monitor the various stages of the budget process.

Financial Management Institutional & Operational Changes

Immunization Legislation

Advocacy Activities & Partnerships

Popularize the immunization bill among EPI stakeholders to gather their opinions and/or amendments; Finalize the draft law for its submission to the government; Advocate with MPs and senators to adopt the law on vaccination; Monitor the various stages of the legislative process To brief the Parliament, Ministry of Health & Population, Ministry of Finance, and civil society on the Colloquium's results; organize an immunization information session for the Committee on Health, Social Affairs, Family and Gender and the Commission on Economics and Finance and Parliament

Global Vaccine Action Plan (GVAP)

Indonesia's Action Points Delegates: Hon. Nova Iriyanti Yusuf, Hon. Supriyatno Sardjono Askani Dr. Tini Suryanti Suhandi, Dr. Teresia Sandra Diah Ratih Mr. Pungkas Bahjuri Ali, Mrs. Asmaniar Saleh (WHO) Themes

Dakar, Senegal - 2013 To be accomplished by 2015

Financing for Immunization Financial Management

Institutional & Operational Changes

- Identify weak links of immunization delivery across actors under decentralization, as an input to the formulation of the medium term plan as a part achieving national target and addressing inequity - Data management (target beneficiaries) - Mapping financial & human resources (including at Local level) - Mapping all the Regulation on immunization and evaluate the implementation and effectiveness in ministerial Regulation on immunization. Recommendation on the Regulation/legislation

Immunization Legislation

Advocacy Activities & Partnerships Global Vaccine Action Plan (GVAP)

Advocacy to local (district) parliamentarian to ensure proper funding on the immunization program especially for operational cost, including establishing a multistakeholder expert team - Including socialization of existing regulations

Annex G: