GOVERNMENT OF KENYA _____________________________
MINISTRY OF HEALTH KENYA EXPANDED PROGRAMME ON IMMUNIZATION
Financial Sustainability Plan
Submitted to GAVI November 2002.
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Signatures of the Government
Minister Of Public Health
Planning
Minister Of Finance and
______________________________ ______________________________ Hon. Prof. Sam K Ongeri EGH, MP ……………………………………,2002
Hon. Mr Chris Obure EGH, MP …………………….……………………….,2002
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_______________________________________________________________________ Table of Contents ACKNOWLEDGEMENTS .......................................................................................................................... IV EXECUTIVE SUMMARY .............................................................................................................................V ABBREVIATIONS AND ACRONYMS .................................................................................................... VIII 1.0 COUNTRY AND HEALTH SYSTEM CONTEXT....................................................................................1 INTRODUCTION ...................................................................................................................................................1 1.2 ECONOMY .....................................................................................................................................................1 1.3 DEMOGRAPHIC AND HEALTH INDICATORS ....................................................................................................2 1.4 POVERTY.......................................................................................................................................................3 1.5 PUBLIC SECTOR REFORMS .............................................................................................................................3 1.6 ROLE OF THE PRIVATE SECTOR .....................................................................................................................6 2. BUDGETING FINANCIAL MANAGEMENT AND PROCUREMENT................................................... 7 2.2 FINANCIAL MANAGEMENT ............................................................................................................................7 2.2 BUDGETING...................................................................................................................................................7 2.3 PROCUREMENT..............................................................................................................................................8 3 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES ................................................. 9 3.1 QUALITATIVE AND QUANTITATIVE INFORMATION ABOUT PROGRAM PERFORMANCE AND TARGETS .............9 3.2 POSSIBLE CHANGES IN PROGRAM OBJECTIVES IN THE LIGHT OF FINANCIAL CONSTRAINTS ..........................12 3.3 GOVERNANCE AND MANAGEMENT OF THE IMMUNIZATION PROGRAMME ....................................................13 3.4 ROLES AND RESPONSIBILITIES OF PARTNERS IN IMMUNIZATION FINANCING AND SERVICES DELIVERY .......13 4 BASELINE AND CURRENT PROGRAM COSTS AND FINANCING ..................................................15 4.1 PRE-VACCINE FUND (BASELINE) PROGRAM COSTS AND FINANCING PATTERNS...........................................15 4.2 CURRENT EXPENDITURES AND FINANCING PATTERNS .................................................................................16 5 FUTURE RESOURCE REQUIREMENTS AND PROGRAMME FINANCING ....................................20 5.1 COSTING SCENARIOS ...................................................................................................................................20 5.1.1: SCENARIO A – TARGETING 90% COVERAGE – IMPLEMENTING THE KEPI STRATEGIC PLAN 2001-2005: ..........................................................................................................................................................................20 5.1.2: SCENARIO B - THE 80% COVERAGE TARGET ..........................................................................................27 5.2. SUMMARY ..................................................................................................................................................31 6. SUSTAINABLE FINANCING STRATEGIC PLAN AND INDICATORS .............................................. 32 SUSTAINABLE FINANCING STRATEGIC PLAN.................................................................................... 34 7 STAKEHOLDERS ENDORSEMENT ...................................................................................................... 38 8: PREPARATION AND REVIEW TEAMS:.............................................................................................. 39
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_______________________________________________________________________ ACKNOWLEDGEMENTS The Ministry of Health would like to express gratitude to all the individuals and the various development partners particularly WHO, DFID, UNICEF and GAVI for valuable technical support in the development of this Financial Sustainability Plan (FSP) and also members of the ICC and Task Force for their review and input in the finalization of the plan. The participation and efforts of the KEPI Central Management Unit officers and the MOH core-working group is highly appreciated. The contribution made by two consultants hired for the assignment and funded by the DFID is acknowledged. Also appreciated is the contribution made by two officers from the Ministry of Finance and Planning towards the compilation of this FSP. This plan will support the efforts of the MOH in implementing its policy to provide quality immunization services for the protection of all children under 5 years of age and all women of child bearing age from vaccine preventable diseases. Special thanks go to our development partners who have contributed in one way or another towards the provision of the health care services in the country. Similarly, a request is put forward to willing bilateral and multilateral partners and individuals within and outside Kenya to come up and support this plan in any capacity or with any resources at their disposal at whatever level.
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_______________________________________________________________________ EXECUTIVE SUMMARY This Financial Sustainability Plan for the Kenya Expanded Programme on Immunization covers three distinct periods: the pre GAVI (2000-2001), the GAVI the funding period (2002-2006) and the post GAVI period (2007-2009). The Global Alliance for Vaccines and Immunization (GAVI) requires all countries seeking its support to prepare a financial sustainability plan (FSP) after the first two years of support. This Plan examines the base year (i.e. pre-GAVI) estimates of national costs of the immunization program, the projected future costs of running the programme and the various options available to improve the financing and sustainability of the programme. Apart from the support being received through GAVI, there is a wide spectrum of immunization services development needs such as improvement of cold chain, capacity building and social mobilization, that Kenya will need to address on its own funds and, in part, with assistance from development partners. The Plan links domestic and international funds. It envisages that by the end of the Plan period, the Government of Kenya will, to some extent, put immunization services financing on a sustainable basis. Scope of the Plan The FSP assesses the cost and funding of the Kenya Expanded Programme on Immunization and the projected program’s resource needs. The Plan report comprises six main parts: Country and health system context (Chapter 1) Financial, Budgeting and Procurement (Chapter 2); Programme characteristics, objectives and strategies (Chapter 3); Baseline and current programme costs and financing (Chapter 4); Future resource requirements and programme financing (Chapter 5); Sustainable financing strategic plan and indicators (Chapter 6) and The baseline year is 2000. Projections cover the period 2002-2009. The distinction is maintained between secure funding (how much funding has a very high chance of being made available); probable funding (how much funding is likely to be available, but not guaranteed in any way) and possible funding (how much funding may be available, but not particularly likely). Program objectives for expansion and improvement Kenya targets to immunize 90% of its children aged less than one year against the eight vaccine preventable diseases. These include the traditional six antigens namely: measles, polio, diphtheria, whooping cough (Pertusis), tetanus and tuberculosis. Through the GAVI support, Hepatitis B and Haemophillus Influenza type B vaccinations have been introduced into the Programme (with effect from December 2001).
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_______________________________________________________________________ In order to raise coverage, the programme will endeavour to improve community awareness through intensive social mobilization, motivation of health workers through training and intensified supervision, allocation of funds to enable districts carry out outreach services and distribute supplies and do minor repairs on their available transport. The programme will also look into ways in which locally available support can be mobilized with a view of strengthening it. Autodisable syringes were introduced to the KEPI together with the pentavalent vaccines. There are plans to fully introduce Autodisable syringes for all injectable vaccines within the programme starting from 2003. The programme will ensure improvement in timeliness and completeness of routine reporting from the districts to 90% with view to identifying weak areas in routine immunization, vaccine management, detection and response to outbreaks vaccine preventable diseases. The issue of wastage will be addressed with the aim of reducing the rate significantly. Current programme costs and sources of financing The estimated cost of KEPI was US$ 17.75 million for the year 2000 with vaccines costing $ 3.3 million or 18% of the total programme costs. Personnel emoluments cost $9.1 million (49.2% of the total). Overall, the funds for the immunization programme were mainly from the Government, which contributed 55.7% of the total. Japanese Government, the primary donor, contributed 15.0 % of total cost in 2000. Routine services increased to $19.2 million in 2001 from $13.4 in 2000 largely on account of introduction of new vaccines, which accounted for 15% of the total costs in 2001. Polio NIDs costs reduced almost by half ($2.2 million) in 2001 compared to $ 4.1 million in 2000 as not all districts were covered in 2001 (focus was on border districts and large urban districts). Overall, total costs in 2001 increased by 17% from the previous year. On the whole, the government made a substantial contribution to the national immunization program through purchase of BCG vaccine, yellow fever vaccine, part of the routine polio and measles vaccines and meeting personnel emoluments among others. Donors, on their part, played a very important role in providing support to KEPI including financing vaccines and cold chain equipment, vehicles, training and social mobilization/communications. Projected gap in resources during and after the remainder of vaccine fund support The projection covers the time period 2002-2009 and uses 2000-2001 as the base line years. Projected numbers rely on the assumed expansion and the structural change in the EPI. Specifically, to make these assumptions as explicit as possible, and to allow for a range of possibilities, two cost scenarios have been considered. These are: Scenario A assuming 90% coverage target; Scenario B assuming 80% coverage target; For scenario A, the expenditure on EPI is expected to total $184 million during the vi
_______________________________________________________________________ 2002-2006 period. Vaccines (traditional 6 antigens - 3.2% of total, new and underused- 39.8%) account for 43% of the total cost. In 2003, the cost of supplemental immunisation activities will decrease as a result of reduced activities. Under scenario B, the routine EPI vaccines are projected to cost $ 12.3 million in 2002 increasing to $16.8 by 2006 for a total cost of $146 million for the 2002-2006 period. About 87% of the funds are secured. The gap increases from $ 1.3 million in 2002 to $ 24 million by 2009 for a total of $78 million. As in scenario A, the large gap will exist due to lack of committed financing for purchase of vaccines beyond 2006. Strategic priorities for financing sustainability Among the many actions Kenya government will take to move towards higher and more stable levels of funding for immunization services, the following stand out as the ones with the highest potential impact: Mobilize adequate resources
Increase domestic resources to health through advocacy at inter-ministerial level, local authorities, local corporate and individuals; Expand the ICC membership in an effort to solicit their support for the EPI; Engage development partners in discussion of resource requirements and seek commitments to cover major funding gaps; Create enabling environment so as to attract foreign funding; Considering the importance of EPI in the prevention of diseases, the Ministry of Health will review it’s priority ranking. Currently, EPI is ranked 5th in the essential health package.
Increase reliability of resources
Donor commitments assured Establishment of an enabling political and economic environment
Increase efficient use of resources
Create an environment to allow flexible operation of donor funds Establish a system of accountability and transparency Develop and impliment programs to reduce wastage Establish proper reporting and feedback Management of resources
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_______________________________________________________________________ Abbreviations and acronyms AFP Acute Flaccid Paralysis AIDS Acquired Immune Deficiency Syndrome AIE Authority to Incur expenditure BCG Bacille-Calmette-Guerin vaccine for Tuberculosis CBS Central Bureau of Statistics CIDA Canadian International Development Agency DANIDA Danish International Development Agency DFID Department for International Development DPT Diphtheria, Pertussis, Tetanus Vaccine EPI Expanded Program on Immunization FIC Fully Immunized Child FSP Financial Sustainability Plan GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GNP Gross National Product GoK Government of Kenya Hep B Hepatitis B Vaccine Hib Haemophilus Influenzae Type B Vaccine HIV/ AIDS Human Immunodeficiency Virus / Auto-Immune Deficiency Syndrome ICC Inter-Agency Coordinating Committee IEC JICA KDHS KEPI MoFP MoH MTEF NCPD NGOs NHSSP NID’s NIP OPV
Information, Education, Communications Japanese International Cooperation Agency Kenya Demographic Health Surveys Kenya Expanded Programme On Immunization Ministry of Finance and Planning Ministry of Health Medium Term Expenditure framework National Council for Population and Development Non-governmental organizations National Health Sector Strategic Plan National Immunization Days National Immunization Programme Oral Polio Vaccine
SIA SNID’s SWAP TB TT UNICEF USAID VVM
Supplementary Immunization Activities Sub National Immunization Days Sector-Wide Approach Tuberculosis Tetanus Toxoid United Nations Children’s’ Fund United States Agency for International Development Vaccine Vial Monitor
WHO
World Health Organization
PRSP
Poverty Reduction Strategy Paper
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_______________________________________________________________________ 1.0 COUNTRY AND HEALTH SYSTEM CONTEXT Introduction National governments in the recent years, have become increasingly concerned with the issues of financing immunization activities. In Kenya, despite the tremendous gains achieved in immunization coverage in the early 1990s following the establishment of the Kenya expanded Programme on Immunization in 1980, immunization coverage rates in the late 1990s showed some decline. This decline may have resulted from a number of factors including reduced donor funding for the immunization programme, declining national health budgets due to deteriorating economic conditions and focusing on other national health priorities. GAVI requires all countries seeking its support to prepare a financial sustainability plan (FSP) after the first two years of support. This Plan examines the base year (i.e. pre-GAVI) estimates of national costs of the immunization program, the projected future costs of running the programme (under various scenarios); and the various options available to improve the financing and sustainability of the programme. These options include: increasing central government allocations to KEPI, ensuring efficient use of the available resources, increasing the role of the private sector in immunization service delivery, and mobilizing resources from other potential players in health service provision. The first section of the Plan describes the country and health system context, while the second chapter presents the financial management. The third and fourth chapters present programme characteristics, objectives and strategies and information on expenditures and costs of the programme as well as sources of financing respectively. The fifth chapter describes the future financing requirements, sources, mechanisms of financing, and risk assessment while the sixth chapter focuses on sustainable financial strategic plan and indicators. 1.2 Economy During 1996, a growth rate of 4.6% was recorded but declined substantially to 2.4% in 1997 closing with a negative growth rate of 0.2 per cent in the year 2000. The growth, however, recovered to record a modest rate of 1.2 % in 2001. The deceleration was occasioned by a decline in almost all the key sectors of the economy and was largely attributed to the prolonged drought of 1999-2000, inadequate power supply, and deterioration of infrastructure and low aggregate demand. Table 1.1 provides the details. Table 1.1: Selected Macroeconomic Indicators for Kenya Indicator Gross Domestic Product Growth Rate (%)
1997 2.4 1
1998 1999 2000 2001 1.8 1.4 -0.2 1.2
_______________________________________________________________________ GDP at market prices (US$ billion) 9.9 11.2 10.2 10.2 11.4 GDP per capita (US$) current 304.5 332.8 298.0 301 320.9 GDP per capita (US$) Constant prices 57.0 57.3 48.2 43.9 43.5 GNP (US$ Billion) 9.7 11.0 10.0 10.1 11.3 Inflation Rate (%) 11.2 6.6 3.5 6.2 0.8 Debt service charge as % of GDP 4.3 4.2 4.2 4.3 1.8 Estimated population (million) 28.1 28.8 29.5 30.2 30.8 Exchange Rate: 1 US Dollar for Kenya shillings 62.7 61.9 72.9 78.0 78.2 Source: Ministry of Finance and Planning- Central Bureau of Statistics: Economic Survey, 2002.
The year 2002 is an election year. Inflation is projected to rise to 2 percent and the economy is expected to register a real GDP growth of 2 percent in 2002. Kenya is not among the countries likely to benefit from debt relief (HIPC) in the foreseeable future. The relief would have, no doubt, resulted in increased revenue flows. The current debt burden accounts for about 4% of GDP. This means that given the low current funding of health services, non-debt relief would negatively affect EPI future funding, as well as constrain the available resources. The projected growth targets for Kenya are shown in Table 1.2. The growth of Kenya economy is expected to average 4% during the Plan period. This may increase funding flow to the health sector, but not sufficient enough to address the underfunding problem. Table 1.2: Projected Growth targets (2000-2008)
Year 2002 2003 2004 2005 2006 2007 2008
GDP per Real GDP at capita (US$) Population 1982 prices Current (million) (US$ million) prices 1,390 303 31 1,439 306 32 1,490 311 32 1,549 316 33 1,615 323 33 1,688 331 34 1,771 341 35
Source: National Development Plan 2002-2008
1.3 Demographic and Health Indicators Good health is a pre-requisite for socio economic development of the country. The total fertility rate, the average number of children per woman, went down from 7.6 in 1969 to 4.7 in 1998 while infant mortality rate reduced from 119 per 1,000 in 1969 to 74 per 1,000 in 1998. Problems in the health sector include increased emergence of diseases, inadequate funding and high cost of health care. Table 1.2 shows the key demographic indicators for Kenya.
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_______________________________________________________________________ Table 1.2: Key Demographic and health indicators for Kenya Year 1969a 1979 a 1989 a 1993 § 1998 § Crude birth rate* 50 52 48 35.8 34.6 Crude death rate * 17 14 10 na na Infant Mortality rate ** 119 104 66 62 74 Under 5 mortality 113 93 105 Total Fertility Rate 7.6 7.9 6.7 5.4 4.7 Contraceptive Use (%) 7(1977) 17(1984) 27 33 39 Note: * - per 1,000 population, na- not available a Kenya Population Census, § - Kenya Demographic and Health Survey; ** per 1,000 live births. 1.4 Poverty Poverty is a profound problem in Kenya and the major obstacle to development. There has been a substantial increase since 1992 in the number of poor people (45%), and by 2001 social demographic indicators showed that 56% of the population live below the poverty line. Poverty has been worsened by an increased lack of employment due to, among other factors, economic restructuring and the privatisation of public enterprises. The Government, through a participatory process, has drawn a Poverty Reduction Strategic Paper (PRSP) as part of its effort to address this problem. However, the high poverty levels are a hindrance to the utilization of immunization services as mothers/guardians lack resources to maximize use of the services (especially time and transport costs). 1.5 Public Sector reforms The year 2000 saw major reforms in the public service. This resulted in reduction in the number of staff in the public sector as part of a “right sizing” initiative. The resulting implication for the Ministry of Health was that health services including immunization services were affected. Fewer health workers have had to deal with increased workload. Recently, the situation has been recognized as an impediment to the provision of quality health care and although a general Government embargo on recruitment has been in place, the Ministry of Health, as a key sector, has been authorized to employ nurses among other key health cadres, albeit, on small scale. Another step to improve the performance of the National Immunization Programme (NIP) is the implementation of the performance improvement initiative. In this initiative, staff will be trained on how to improve performance on health care service delivery including immunization services. Following the reduction in the number of staff in year 2000, the government improved the remuneration of staff including housing and other allowances to ensure the staff are adequately motivated.
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_______________________________________________________________________ 1.5.1 Health financing In the public health sector, health finance is derived from three sources: direct allocations from the Treasury, the National Health Insurance Fund and revenue generated by health facilities through user fees. The National Health Sector Strategic Plan (1999-2004), however, highlights a range of health care financing strategies including increased cost recovery and social insurance scheme. The Ministry of Health is, therefore, in the process of developing a social health insurance strategy with a view to providing cover for minimum health essential package to all Kenyans including immunization services. However, this process is likely to take a while to be fully operational and hence the need for external assistance. There are also a number of firms providing private medical insurance. Unfortunately, these do not cover preventive services. The Government is, therefore, in the process of formulating a regulatory framework to control the services of these private providers. It is envisaged that when the framework is ready, they will be compelled to cover preventive services including immunization. 1.5.2 Decentralisation The day-to-day management of health services was delinked from the national control to district level control in 1995 through the formation of District Health Management Boards, Hospital Management Boards, Health Centre and Dispensary Management Committees. As such health services in all 77-health districts in Kenya are presided over by these bodies. The only aspect of health services provision that is yet to be decentralised is personnel management (recruitment and termination of services) that is still governed nationally by the Directorate of Personnel Management. However, management of human resources is a major component in a decentralized system. For health personnel to achieve high performance in a decentralised systemtraining on performance management and target setting at all levels is being given priority. Both the Boards and Committees are custodians of the locally generated revenues, and have to approve proposed budgets of the District/Hospital/Facility Health Management Teams, before any expenditure can be made. Plans of activities (and budgets) are drawn up by the various health management teams and are based on health service priorities and needs. These include curative and preventative services. Although EPI services always feature in the plans of action, the allocations they receive varies with the current competing priorities and availability of funds.
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_______________________________________________________________________ Local authorities are authorized to raise their own revenue. In the major urban areas of Nairobi, Mombasa and Kisumu, these local authorities provide support for immunization costs, mostly to cover personnel, transport and injection supplies – all vital to high coverage and delivery of safe vaccination services. Due to low revenue collection base, these local authorities have limited capacity to absorb further costs to support immunization programme activities; and to demand increased contributions would be unreasonable. The Ministry of Health provides some support, including the provision of transport and vaccine supplies to these local authorities. Indeed, rather than expecting to mobilize increased resources from these local authorities, the Central Government will need to continue to provide supplementary support. The Medium Term Expenditure framework (MTEF), a new budget approach, is also addressing improvement in the provision of immunization services (immunization is one of the six essential packages). The MTEF is geared towards poverty reduction and thus immunization is expected to receive reasonable support as part of Poverty Reduction Strategic Paper (PRSP) initiative. A notable development beginning the financial year 2002/03 is the government introduction of budget lines for vaccines and other immunization activities. 1.5.3 National Health Sector Strategic Plan 1999-2004 A five year National Health Sector Strategic Plan (NHSSP) has been developed by the Ministry of Health for the period of 1999–2004. One of the main objectives of the NHSSP is to enhance equity, quality, accessibility and affordability of health care through better targeting of resources to the poor. National Health resources are currently heavily allocated to curative services compared to preventive/promotive services (70% vs. 30%) the will to shift from this disparity remains so as to provide maximum benefits to the majority of the vulnerable groups who form a larger proportion of our society. In the context of EPI services, the NHSSP recommends decentralization of all aspects of EPI program planning, monitoring and evaluation. While the national level will continue to be responsible for development of policies and standards, donor coordination, vaccine procurement, technical assistance to lower levels, operational research, monitoring and evaluation, responsibilities will be devolved to the provinces, districts and health facilities for efficient management of immunization services. It is expected that the decentralization will have the net effect of improved immunization coverage. Immunization has proven to be one of the most effective public health measures in preventing deaths and illnesses from vaccine preventable diseases. Immunization coverage is, therefore, a major development indicator within the current health system. The Ministry of Health, however, also recognizes the important role played by other health programmes in the reduction of morbidity and mortality. The Kenya EPI works in collaboration with other preventive health programmes such as the Reproductive Health Programme to reduce the risk of maternal and neo-natal tetanus infection through quality birthing practices and vaccination. KEPI is
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_______________________________________________________________________ currently working on a proposal with the Malaria Control Programme to integrate immunize services with promotion of insecticide treated bed nets. Finally KEPI participates in all training activities for the introduction and implementation of the Integrated Management of Childhood Illnesses Programme.
1.6 Role of the Private Sector In Kenya, the private sector can be divided into non-profit providers and profit providers. The non-profit providers are non-governmental organizations (NGOs) and are important providers of health services both in rural and urban areas and hence key players in immunization services. The profit private sector provides mainly curative care services, but also provides services such as family planning and immunizations, with major providers being located mainly in urban areas. The scarcity of government resources means that an increasing share of curative/preventive services is delivered by the NGO/Private sector. Although contracting out to the private health sector is not envisaged in the short term, the government will wish to see the sector playing a more prominent role in the delivery of health services including expansion of immunization services. The Ministry of Health continues in a limited way to support the private sector in the provision of vaccines, and cold chain equipment. The Government indeed recognizes the participation of, particularly the mission non-governmental organizations (NGOs), who provide health services in remote areas which are generally neglected by the for profit providers. However, with low funding situation facing the Ministry of Health, there are insufficient resources to adequately support all logistics for EPI. Nevertheless, the private sector will continue offering health care services to those who can afford to pay. It is expected that the cumulative effort of the private /NGO sector and the public sector will translate into improvement in immunization coverage.
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_______________________________________________________________________ 2. BUDGETING FINANCIAL MANAGEMENT AND PROCUREMENT 2.2 Financial management Logistical support for the Kenya EPI has largely been through external donor funding. These funds have been used to purchase vaccines, support cold chain system and transport. The high dependence on donor funds has created a situation where the Ministry of Health does not demand for a vigorous costing and budgeting for this program. However, with diminishing donor funds, the Government contributions to the program have been enhanced and are likely to improve in future. 2.2 Budgeting The Government has introduced a new budgetary system commonly known as Medium Term Expenditure Framework (MTEF). Under the new budgetary framework, the health sector receives funding from three areas. These are public administration (for salaries and related items), human resource development (for program funds including immunization) and physical infrastructure (for funds to develop infrastructure network). The health sector continues to enjoy high priority in line with the Poverty Reduction Strategy Paper, where the public ranked health third in order of priority (after agriculture and education). In the last few years, health is the only Government Ministry, which has received increased allocations. These increases have now been translated into increased resource flow to the immunization program. The budgeting for the health sector is incremental and additional resources are distributed proportionately to all the programmes across the board. This is partly because no data is available on financial requirements to fully operationalise the program. Efforts are being made to calculate the cost of delivering the six essential packages, which includes immunization. When this costing exercise is complete it will be possible to use cost of service delivery inputs for programme budgeting. During the development of this proposal, the cost of inputs to the EPI programme have been estimated and this will form the basis for budgeting and advocating for additional resource flow to this area. One of the constraints to the budgeting of the EPI services is lack of accurate information on shared costs. These costs, which are not known are met by respective institutions providing immunisation and are very difficult to isolate. Funds for the support of EPI activities are channelled to the program managers based at the district level. The GAVI support is a supplement to a routine government allocation issued directly to districts for the running of general health services. The government allocation for EPI is however issued twice yearly, and is restricted to transport operating expenses and the procurement of liquid petroleum gas for gas operated refrigerators. The GAVI support to the districts started in 2001 and allows for more flexibility of use.
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_______________________________________________________________________ The program managers are responsible for planning on how to utilize these funds based on needs. To some extent this has enhanced efficiency in utilization of EPI funds, since decisions are made at the point of delivery. The release of GAVI funds to the districts is done in trenches and expenditure returns are required at the national level. This ensures easier access of funds at lower level for accelerated immunisation activities. This could have contributed to increase in immunisation coverage witnessed over the last one year. The flow of Government funds from the National Level to the Provincial and District levels is often not timely. National funds are released to other levels through an instrument/document known as an “Authority to Incur Expenditure” commonly referred to as an A.I.E. An AIE is a an accounting document which allows the implementors to incur expenditure when funds are available This delays implementation of planned activities and occasionally at the end of the financial year not all of EPI funds may be utilized. 2.3 Procurement The procurement of vaccines for KEPI is largely procured by UNICEF from reliable manufacturers of vaccines recommended by WHO and periodically through other development partners. It is assumed that this process gives us the best value for our money. However, procurement of cold chain equipment has been irregular because of reliance on donor goodwill. Although the quality of equipment purchased to date has been good, it has not been possible to ascertain whether they were bought at a bargain price. Again since the government does not depreciate equipment in use it is difficult to plan for new ones. This irregular supply and maintenance of cold chain and other supplies is probably the biggest constraint facing immunization program.
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_______________________________________________________________________ 3 PROGRAM CHARACTERISTICS, OBJECTIVES AND STRATEGIES 3.1 Qualitative and quantitative information about program performance and targets Ministry of Health through KEPI designs planning, monitoring and evaluation tools for all the aspects of quantitative and qualitative performance. The data is analysed by the districts to identify weaknesses in the specific areas of routine immunization, vaccine management, detection and response to outbreaks of vaccine preventable diseases. The expected improvements during the Plan period include: •
Increased demand for immunization to be created by effective advocacy and social mobilization at all levels; • Improved districts’ capacity to manage vaccines and reduce wastage, through the use of new guidelines; • Improved district coordination of EPI activities through logistical integration with other health activities. • Health workers clear on the use of operational manuals and performancemonitoring tools through training; Strengthening the collaboration and coordination of stakeholders’ support for EPI activities at national, district and community levels. 3.1.1Performance Targets • Increase coverage for all antigens to at least 90% in all districts by 2005; • Improved timeliness and completeness of routine reports from the district to 90%; • Reduce drop out rates; • Coverage for fully immunized children (FIC) 90% Kenya intends to immunize 90% of its children aged less than one year against the eight vaccine preventable diseases. These include the traditional six antigens namely: measles, polio, diphtheria, whooping cough (Pertusis), tetanus and tuberculosis. Through GAVI support, Hepatitis B and Haemophillus Influenza type B vaccinations were introduced into the Programme in December 2001. Autodisable (AD) syringes were introduced to KEPI together with the pentavalent vaccines and are currently in use. Plans are at an advanced stage to fully introduce Autodisable syringes for all injectable vaccines within the programme starting from 2003. Through the immunization schedule, the government has continued to record an improvement in child health indicators, especially a reduced infant mortality rate. The current immunization policy allows immunizations to be given daily, though in practice most vaccinations are administered only five days per week. The current immunization schedule for the administration of the vaccines is shown in Table 3.1. Table 3.1: Immunization Schedule, Kenya Age At birth
ANTIGEN BCG and Birth OPV 9
_______________________________________________________________________ 6 weeks DPT/HepB/Hib 1 and OPV 1 10 weeks DPT/HepB/Hib2 and OPV2 14 weeks DPT/HepB/Hib 3 and OPV 3 9 months Measles 9 months Yellow Fever (in the four endemic districts of Baringo, Koibatek, Keiyo and Marakwet). The GAVI funds that the programme has received have been utilised to accelerate routine immunization coverage. The coverage had showed some decline after 1994. The central government is increasing its funding to the programme mostly in purchase of vaccines and cold chain preventive maintenance while development partners are giving aid and support in many forms. It is envisaged that the coverage is going to improve substantially in the Plan period. In order to improve the coverage, the programme is planning to improve community awareness through intensive social mobilization, motivate health workers through trainings and intensified supervision, allocate funds to enable districts carry out outreach services and distribute supplies and do minor repairs on their available transport. The programme is also looking into ways in which the locally available support can be mobilized with a view of strengthening it. The programme mission is to offer immunization services through four guiding principles of making immunization services accessible, affordable, available and attractive to all children of Kenya with the ultimate goal of reducing or eliminating childhood immunizable diseases to a level they will no longer be a public health problem. This is a big challenge that requires careful planning and substantial amount of resources to attain the set goals and objectives. One of the main milestones toward the diseases reduction and elimination is to raise the immunization coverage levels of all antigens to a level that the diseases causative agent will be totally disrupted or its transmission cycle destroyed or the environmental condition made completely unfavourable for the diseases transmission continuity. Table 3.2 shows the immunization coverage targets based on the past performance of the programme (it has not been possible to reach 90% coverage levels for all antigens except for BCG).
Table 3.2: Immunization coverage targets No 1 2 3 4 5
Antigen BCG DPTHepB+Hib Measles TT Polio
2002 95%
2003 95%
2004 95%
2005 95%
2006 95%
2007 95%
2008 95%
2009 95%
75%
80%
85%
90%
95%
95%
95%
95%
75% 60% 75%
80% 70% 80%
85% 80% 85%
90% 90% 90%
95% 95% 95%
95% 95% 95%
95% 95%
95% 95%
95%
95%
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_______________________________________________________________________ The latest Kenya demographic Health Survey (1998) indicated negative trend on national immunization coverage from 79% for fully immunized children in 1994 to 65% in 1998. This has been a worrying situation and a lot of effort has been put to reverse the trend through the material and financial support received from GAVI and other Partners to accelerate the immunization activities by carrying out outreach and mobile services to the disadvantaged and hard to reach population. Data completeness and timeliness has been one of the obstacles in assessing the actual coverage through the administrative methods. However, the reporting rate has improved from 51% to 78% by the end of August 2002. With the current 82% reporting response, it is estimated that the current level of fully immunized children stands at about 75%. All the districts will continue to carry out their daily immunization services supplemented with at least one outreach or mobile per month. The most crucial thing is to reach the set targets and maintaining them within the set period of time. This will require more resources and participation of all. Monitoring of the activities coupled with the regular programme review to give the direction of the programme will be undertaken. Appropriate action will be taken as necessary. Community surveys carried out in the past have been more reliable in presenting accurate situation of immunization coverage. Table 3.3 shows the estimated immunisation coverage assessment based on routinely reported (administrative) data. The low coverage is mainly due to low reporting rates, which range between 30% and 75%. Table 3.3: Estimated immunization coverage (%) assessment based on routinely reported (administrative) data YEAR 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
BCG Coverage 47 55 57 49 46 50 63 53 55 52 50 64 50 71
OPV – 3 Coverage 25 35 46 44 40 43 53 39 43 43 43 55 49 58
DPT – 3 Coverage 31 42 43 41 40 42 51 47 46 43 45 55 51 68
Measles Coverage 29 37 42 37 36 38 48 41 39 46 38 45 45 52
Fully Immunized 29 37 42 37 36 38 48 41 39 46 38 45 45 42
(Source, KEPI Health Information System, Administrative Data)
3.1.2 Vaccine wastage The programme has now developed guidelines to monitor vaccine wastage including the necessary tools. This has become necessary due to the high cost of vaccines as well as the need to monitor programme efficiency.
11
_______________________________________________________________________ 3.2 Possible changes in program objectives in the light of financial constraints Since the introduction of the new DPT-HepB-Hib vaccine, the Kenya EPI is heavily dependant on the GAVI and other partners for the support of purchase of vaccines and necessary logistics. However, the Kenya Government through the Ministry of Health, currently supports the following: • • • • • • • • • •
Purchase of BCG vaccine; Purchase of yellow fever vaccine for routine services; Purchase of part of the routine OPV vaccine; Purchase of part of the routine TT vaccine; Purchase of part of the disposable needles & syringes for routine services; Purchase of liquid petroleum gas for cold-chain refrigerators; Maintenance of cold-chain equipment and preventive maintenance; Transport operating expenses for government vehicles involved in EPI service provision General operating costs of the KEPI Management Unit. Payment of salaries for all government health workers
In the event of constraint in the availability of finances for EPI services the greatest impact would be on: • Availability of vaccines and other related supplies; • General operational expenses; • Programme operational strategies; • Cold chain maintenance and sustainability. The program objectives most likely to be affected by any constraint of finances are; • The increase and sustaining of national immunization coverage of 90; • The increase of access to immunization services nationally to 90 and above. 3.2.2 Vaccine Stock-outs The effect of vaccine stock out, as experienced in 2001 with BCG, would result in: • • • •
A decline in coverage most probably due to increased missed opportunities, Institutionalisation of cost-sharing for immunization services, Increased dropout rates probably due to financial barrier leading to reduced access and lack of motivation or knowledge among the parents to finish the immunization schedule. Reduced wastage of vaccines as health facilities resort to reducing the number of immunizing days per week so as to maximize use of the limited stocks of vaccines and support supplies
3.2.3 General operations • •
Reduced Ministry of Health allocations to districts for EPI operational expenses; Reduced KEPI supervision support to provinces and districts;
3.2.4 Changes of strategy
12
_______________________________________________________________________ Again from past experience in the operations of the EPI services in Kenya, financial constraints affect the strategies used for service delivery in the following ways: • • • • •
Outreach/mobile services → usually stopped altogether, Supermarket approach at static immunizing sites → vaccination restricted to specific days of the week, “Open-vial” policy → vaccinators wait until there is a “quorum” for each vaccine, Quality supervisory visits to immunizing facilities → revert to unpredictable visits during distribution of vaccines/supplies/drugs, Regular update training of vaccinating staff → suspended or minimized.
3.3 Governance and management of the immunization programme There are no major governance or management changes planned for KEPI in the immediate future. KEPI is a division within the Ministry of Health, with well-defined roles and responsibilities. There are no immediate or long term plans to delink it from the governance of the Ministry of Health. The organisational structure of KEPI is line with WHO recommendations, with a Manager as the head, assisted by a deputy manager, a logistician, social mobilization officer, data management officer, training officer and surveillance officers among others. It is however felt that the KEPI Management Unit has outgrown its current physical facilities for administrative and storage services. Any changes of location, however, would most likely be supported through external assistance. Subsequently, the running costs would still be borne by the Ministry of Health and are not expected to be significantly different from current costs. 3.4 Roles and responsibilities of partners in Immunization financing and services delivery Immunization services delivery is the basic responsibility of the Government and supplemented by individuals, donors, NGOs, Bilateral Agencies, and close Partners and to less extent private sectors. The EPI in Kenya is now about twenty years since it was officially started in this country. During the first three phases (pilot, implementation and consolidation), of the programme about 90% both the capital and recurrent costs (excluding personnel salaries) were borne by the donors especially DANIDA and UNICEF. WHO continued to give mainly technical support until early 1995 when the Polio Initiative was started in this country and WHO started fully financing all the surveillance and all activities related to the polio eradication initiative? These activities have either been funded by DFID, JICA and CIDA through WHO or UNICEF. UNICEF is committed to EPI services delivery in the country through: •
Survival, protection and development of children as universal development imperatives that are integral to human progress; 13
_______________________________________________________________________ • Mobilization of political will and materials resources to help ensure a first call of children and to build capacity to form appropriate policies and deliver services for children and their families. Since DANIDA withdrew national support to the programme, UNICEF, DFID, JICA and recently GAVI are providing financial support particularly for vaccines procurement, strengthening of cold chain and acceleration of the immunization activities in the Districts. The Government of Kenya has also taken keen interest in financing the EPI activities as part of the poverty reduction effort by ensuring that the children of Kenya continue enjoying the immunization services. Through this effort, the Government has continuously enhanced its annual funding of both the recurrent and development allocation to KEPI by almost 10 and introduced some more budget lines in recurrent vote. This is the right direction towards the programme sustainability and Government commitment in financing its own programme. Several discussions held between the Government of Kenya and various donor agencies have indicated the difficulties in pledging their tangible commitments for the coming years because of their different planning cycles. However, they have indicated their commitment in supporting KEPI as long as there will be, good and realistic and strategic annual work plans, which can be discussed and agreed upon in the monthly ICC meetings. Despite the government wish to finance the immunization services in the country, it may not be operationally possible due to other national social and economic obligations and the current economic situation. This means, therefore, donor agencies, private sectors and individuals will be called upon to give the necessary support toward the immunization services delivery in this country.
14
_______________________________________________________________________ 4 BASELINE AND CURRENT PROGRAM COSTS AND FINANCING This section provides a picture of financing levels and patterns before the Vaccine Fund (baseline year 2000), and how these have changed with the addition of Vaccine Fund support during the current year 2001. This section, therefore, provides the basis for the assessment of how resource requirements are likely to grow in the future as examined in Chapter 5, which covers the Vaccine Fund and Post-Vaccine Fund periods. 4.1 Pre-Vaccine Fund (baseline) program costs and financing patterns. Table 4.1 presents the immunisation specific costs for 2000 as the base year. The information includes both the program-specific inputs as well as costs of shared inputs. The estimated cost of the programme was US$ 18 million for which vaccines accounted for $ 3.3 million or 18% while personnel emoluments cost $9.1 million (49.7% of the total). Table 4.1: Immunization Specific Costs -Base year 2000. (FSP Table 1.1.1) TOTAL IMMUNIZATION SPECIFIC COST. BASE YEAR 2000 Item Component Routine Services Polio NIDs-SNIDs Other SIA* Total No. [A] Operational Cost US$ US$ US$ US$ Required Information Vaccines 1 1.1 Vaccines (traditional 6 1,400,758 1,144,600 800,025 antigens) 1.2 Vaccines (new and underused vaccines) 2 Injection supplies 530,730 3 Personnel 120,118 1,215,448 4 Transportation 76,923 648,660 5 Maintenance and 145,312 overhead 6 Short-term training 358,763 7 IEC/social mobilization 440,610 8 Monitoring and 293,568 68,428 surveillance 9 Others/ Audit 98,500 Optional information 10 Shared Personnel 10.1 -Salaries 5,256,893 10.2 -Incentives/per diems 2,539,019 11 Others - including shared 624,543 overheads Subtotal Operational 10,987,864 3,975,009 800,025 [B] Capital Cost Required Information 13 Vehicles 146,844 14 Cold Chain Equipment 285,564 142,502 Optional information 15 Building 1,269,044 16 Other Equipment 119,896 17 Long-term training 25,641 Subtotal Capital 1,846,990 142,502 GRAND TOTAL 12,834,853 4,117,511 800,025
3,345,383
530,730 1,335,566 725,583 145,312 358,763 440,610 361,996 98,500
5,256,893 2,539,019 624,543 15,762,898
146,844 428,066 1,269,044 119,896 25,641 1,989,492 17,752,389
Table 4.2 shows the immunisation costs by source of funding. Overall, the funds for the immunization programme came mainly from the Government (mostly personnel 15
_______________________________________________________________________ and infrastructure), which contributed 53.2% of the total. Japanese Government, the primary donor, contributed 19.5% of total cost in 2000. Table 4.2: Immunization Specific Costs- Base year 2000 by Source (FSP Table 1.1.2) TOTAL FINANCING BY SOURCES FOR NATIONAL IMMUNIZATION PROGRAMME Item Component Nat'l Gov Private UNICEF DANIDA DFID JAPAN WHO Total No. Sector [A] Operational US$ US$ US$ US$ US$ US$ US$ Cost Required Information Vaccines 1 1.1 Vaccines (traditional 6 154,098 276,700 458,960 511,000 1,944,625 3,345,383 antigens) 1.2 Vaccines (new and underused vaccines) 2 Injection supplies 27,000 503,730 530,730 3 Personnel 120,118 1,215,448 1,335,566 4 Transportation 76,923 648,660 725,583 5 Maintenance and overhead 103,108 42,204 145,312 6 Short-term training 358,763 358,763 7 IEC/social mobilization 1,333 286,667 152,610 440,610 8 Monitoring and surveillance 68,428 293,568 361,996 9 Others/ Audit 98,500 98,500 Optional information 10 Shared Personnel 10.1 -Salaries 5,256,893 5,256,893 10.2 -Incentives/per 2,539,019 diems 2,539,019 11 Others - incl. 624,543 shared o/heads 624,543 Subtotal 8,874,702 Operational 1,333 590,367 458,960 3,053,409 2,448,355 335,772 15,762,898 [B] Capital Cost Required Information 13 Vehicles 146,844 146,844 14 Cold Chain 25,500 Equipment 223,344 36,720 142,502 428,066 Optional information 15 Building 1,269,044 1,269,044 16 Other Equipment 119,896 119,896 17 Long-term training 25,641 25,641 Subtotal Capital 1,414,440 - 223,344 36,720 314,987 1,989,492 GRAND TOTAL 10,289,142 1,333 813,711 458,960 3,090,129 2,763,342 335,772 17,752,389
4.2 Current expenditures and financing patterns
16
_______________________________________________________________________ Table 4.3 shows the current expenditures and financing patterns, including the Vaccine Fund resources. Routine services increased to $19.2 million in 2001 from $13.4 in 2000 largely on account of introduction of new vaccines, which accounted for 15% of the total costs in 2001. Polio NIDs costs reduced almost by half ($2.2 million) in 2001 compared to $ 4.2 million in 2000 as in latter year not all districts were covered. Overall, total costs in 2001 increased by 17% from the previous year. Table 4.3: Immunization Specific Costs- Current year 2001 (FSP Table 1.2.1) CURRENT YEAR 2001 Component
Item No. [A] Operational Cost Required Information Vaccines 1 1.1 traditional 6 antigens 1.2 2
TOTAL IMMUNIZATION SPECIFIC COST Routine Services US$
Polio SNIDs US$
NIDs- Other SIA*
Total
US$
US$
84,100
new and underused vaccines Injection supplies
1,743,333 3,248,684
2,181,483
354,050 3,248,684 394,004
394,004 3 4 5 6 7 8 9
Personnel
1,014,016 166,026
847,990
152,564
605,174
Transportation Maintenance overhead Short-term training
757,738 and
25,848 25,848 295,643 98,090
197,553
55,776
110,605
612,989
41,656
IEC/social mobilization Monitoring surveillance Audit
166,381 and
654,645 76,923 76,923
10
Accelerated Immun. Activities Optional information Shared Personnel 10 10.1 -Salaries 10.2 -Incentives/per diems 11 Other (incl. shared o/heads) Subtotal Operational
1,164,588 1,164,588 5,256,893 3,695,674 717,205
5,256,893 3,695,674 717,205 84,100 17,331,674
19,649,725
2,233,951
[B] Capital Cost Required Information 13 Vehicles
248,188 248,188
14
Cold Chain Equipment
420,295 420,295
Optional information 15 Building
1,229,877 1,229,877
Subtotal Capital
1,898,360
-
17
1,898,360
_______________________________________________________________________ GRAND TOTAL
84,100 19,230,034
21,548,085
2,233,951
Table 4.4 presents the costs by source of financing for 2001. The sources of funds for the immunisation programme in Kenya can be divided into two broad typesgovernment sources and external sources. The external sources comprise all the donor agencies providing funds for the programme. The government made a substantial contribution (60%) to the national immunization program both through its recurrent and development budgets. From the revenue budget, it purchased BCG vaccine, yellow fever vaccine, and part of the requirements of OPV vaccine and part of the requirements of measles vaccine among others. Donors, on their part, have played a very important role in providing support to KEPI including financing vaccines and cold chain equipment, vehicles, training and social mobilization/communications. Table 4.4: Immunization Specific Costs- Current year 2001 by Source (FSP Table 1.2.2) TOTAL FINANCING BY SOURCES FOR NATIONAL IMMUNIZATION PROGRAMME Nat'l Gov GAVI / UNICEF DANIDA DFID JAPAN WHO Total Vaccine Fund [A] Operational Cost US$ US$ US$ US$ US$ US$ US$ US$ Required Information Vaccines 1 1.1 traditional 6 antigens 1,327,092 323,027 98,600 160,000 272,764 2,181,483 1.2 new and underused vaccines 3,248,684 3,248,684 2 Injection supplies 161,758 198,576 33,670 394,004 3 Personnel 166,026 847,990 1,014,016 4 Transportation 152,564 605,174 757,738 5 Maintenance and overhead 25,848 25,848 6 Short-term training 98,090 197,553 295,643 7 IEC/social mobilization 55,776 110,605 166,381 8 Monitoring and surveillance - 117,952 41,656 495,037 654,645 9 Audit 76,923 76,923 10 Accelerated Immun. Activities 516,885 647,703 1,164,588 Optional information Shared Personnel 10 10.1 -Salaries 5,256,893 5,256,903 10.2 -Incentives/per diems 3,695,674 3,695,684 11 Other (incl. shared o/heads) 717,205 717,205 CURRENT YEAR 2001 Item Component No.
18
_______________________________________________________________________ Subtotal Operational [B] Capital Cost Required Information 13 Vehicles 248,188 Cold.Chain Equipment Optional information 15 Building
248,188
14
411,707
8,588
1,229,877
420,295
1,229,877
Subtotal Capital GRAND TOTAL 12,982,886 4,199,145 331,615
19
98,600 2,039,901 471,340 1,424,598 21,548,085
_______________________________________________________________________ 5 FUTURE RESOURCE REQUIREMENTS AND PROGRAMME FINANCING 5.1 Costing scenarios In developing the financial sustainability plan costs and sources of finance identified in chapter 4 were projected specifically for the two-time periods; Vaccine Fund (VF) period 2002 - 2006 and Post VF period 2007 – 2009. In order to achieve this, a number of assumptions require to be made about the manner in which KEPI will function over the projection period. The assumptions are based on: • Existing policies and practices; • Population growth – which increases the annual cohort of newborns; • Adoption of new and underused vaccines; • Adoption of injection safety and safe disposal measures; • Modifications to the immunization schedule, and • Inflation, which is assumed away by use of constant 2002 prices (on all items) and fixed exchange rate of Ksh.78.5: 1US $ Two scenarios have been considered. • •
Scenario A: 90% coverage target Scenario B: 80% coverage target
The assumptions underlying each of these scenarios are detailed in the following subsections. 5.1.1: Scenario A – Targeting 90% coverage – Implementing the KEPI strategic plan 2001-2005: This scenario takes as its starting point the target of achieving a 90% fully immunisation coverage by one year of age by 2006 and sets out to cost the inputs to the activities which would make attainment of this target feasible. It is inevitable that unit costs (cost per fully immunised child) will rise rapidly in this scenario, largely because the gap between current coverage and target coverage consists mostly of the “hard to reach” infants, located mostly in remote areas and urban slums. It also assumes that a combination of outreach efforts, programme accessibility and social mobilisation efforts will be essential to reach the demanding coverage target and each element of this package is potentially very expensive when compared with existing practice. For example, if static clinics, in the “hard-to-reach” areas, are to provide immunisation services daily, it is inevitable that vaccine wastage rates (and hence costs) will be higher than if immunisation is offered only on selected days. Although the assumption is that unit costs will rise sharply, in all areas of programme implementation, there is no empirical information available on what inputs are actually required to achieve any given coverage targets in different ecological zones in Kenya.
20
_______________________________________________________________________ Table 5.1 shows the projected costs of maintaining the EPI over the vaccine fund period (2002-2006). The cost of the programme is estimated at about $184 million over the five years. Vaccines (traditional 6 antigens - 3.2% of total, new and underused- 39.8%) account for 43% of the total cost. Secured funds account for 82% of the total. TABLE 5.1: TOTAL IMMUNIZATION SPECIFIC COST Projections - VF period 2002-2006 SCENARIO A (FSP Table 2.1.1) Item Component No.
[A] Operational Cost Required Information 1 Vaccines 1.1 Vaccines(traditional 6 antigens) 1.2 Vaccines(new & underused) 2 Injection supplies 3 Personnel 4 5 6
Suppl. Immu. Activities All other operatioal costs Outreach
Projected Total Secured Total Probable Total Requirements for Financing Financing Possible VF-Period (Sum of all 2s) Funding (Sum of all 1s) (Sum of all 3s) US$ US$ US$ US$
5,307,729
4,803,859
73,213,872
63,528,199
5,363,922 55,452,459
4,354,349 55,452,459
14,853,840
7,777,989
4,745,610
2,330,241
23,364,886
13,713,708
3,795,403
5,855,775
1,297,884
1,297,885
503,871 9,685,673 1,009,573
-
Subtotal Operational [B] Capital Cost Required Information 7 Vehicles 8
Cold Chain Equipment Subtotal Capital Total Cost
178,854,592
150,928,448
8,186,016 19,740,130
2,227,375
107,000
2,120,375
2,213,750
398,750
300,000
4,441,125
505,750
300,000
3,276,625
183,295,717
151,434,198
20,040,130
11,462,641
21
1,156,250
_______________________________________________________________________ Table 5.2: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections VF period: 2002-2006-SCENARIO A (FSP Table 2.1.2) Item Component No.
[A] Operational Cost Required Information 1 Vaccines 1.1 Vaccines(traditional 6 antigens) 1.2 Vaccines(new & underused) 2 Injection supplies
Risk Risk Government (Type Government (Type 1, 2 1, 2 or 3) or 3) US$ US$
Personnel
4
Suppl. Immu. Activities All other operatioal costs Outreach
US$
/ Risk DONORS (Type 1, 2 or 3) US$
1
Risk DONORS Risk DONORS Risk UNFUNDED (Type (Type (Type 1, 2 1, 2 or 1, 2 or 3) 3) or 3) US$ US$ US$
1
2,574,700
2,229,159
2
3
503,871
-
Risk Total (Type 1, 2 or 3) US$
3 (1)
1
5,307,729 2
63,528,199
9,685,673 1
3
GAVI Vaccine Fund
73,213,872 2
4,354,349
1,009,573
5,363,922
1 55,452,459
5 6
55,452,459 1
1
400,400
7,377,589 1
1,959,754
2 1,845,403
9,529,954
3
2
3
4,790,948 1
2,224,000
2,284,903
1,950,000
14,853,840 3
5,855,775
23,364,886
60,387,313
1,297,885 1,845,403
78,710,387
1,297,885 11,830,748
[B] Capital Cost Required Information 7 Vehicles
7,244,819
1
-
2
107,000 8
3
1 -
Subtotal Operational
1
2
Cold Chain Equipment Subtotal Capital
18,835,923
3 1,050,000
1
2
178,854,593
3 1,070,375
3
2,227,375 3
398,750
450,000
350,000
1,015,000
2,213,750
-
-
-
505,750
450,000
1,400,000
2,085,375
4,441,125
60,387,313
1,845,403
78,710,387
12,336,498
7,694,819
1,400,000
20,921,298
183,295,718
Total Cost
24
_______________________________________________________________________ Table 5.3: TOTAL IMMUNIZATION SPECIFIC COST Projections Post VF period: 2007-2009 SCENARIO A (FSP Table 2.2.1) Item No.
TOTAL IMMUNIZATION SPECIFIC COST Component Projected Requirements for VF-Period
[A] Operational Cost Required Information 1 Vaccines 1.1 traditional 6 antigens 1.2 2 3 4 5 6
US$
Total Secured Total Probable Total..Possible Financing Financing Funding (Sum of all 1s) (Sum of all 2s) (Sum of all 3s) US$
US$
US$
920,646 2,296,446
1,375,800
-
56,579,667
-
-
4,450,443
-
-
44,689,723
44,689,723
-
5,607,776
-
-
18,296,001
180,000
5,442,805
1,418,587
-
-
133,338,642
46,245,523
5,442,805
576,250
-
150,000
1,113,750
-
150,000
1,690,000
-
300,000
135,028,642
46,245,523
5,742,805
new & underused
56,579,667
Injection supplies
4,450,443
Personnel
-
Suppl. Immu. Activities
5,607,776
All other operational costs
12,673,196
Outreach
1,418,587
Subtotal Operational
81,650,315
[B] Capital Cost Required Information 7 Vehicles 8
426,250
Cold Chain Equipment
963,750
Subtotal Capital
Total Cost
1,390,000
25
83,040,315
_______________________________________________________________________ Table 5.4: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections Post VF period: 2007-2009SCENARIO A (FSP Table 2.2.2) Item Component No.
Government
[A] 1 1.1
US$
1.2 2 3
Operational Cost Vaccines traditional 6 antigens
Risk (Type 1, 2 or 3)
GAVI Vaccine Fund US$
/ Risk DONORS (Type 1, 2 or 3) US$
Risk DONORS (Type 1, 2 or 3) US$
Risk UNFUNDED (Type 1, 2 or 3) US$
1 1,375,800
920,646
-
56,579,667
-
4,450,443
new & underused Injection supplies
3
56,579,667
3
4,450,443 44,689,723
1
Suppl. Immu. Activities
3 2
1
1,501,040
3
180,000
12,673,196
18,296,001
1,418,587
1,418,587 133,338,642
Outreach Subtotal Operational 50,007,287
[B] 7
1,501,040
180,000
81,650,315
Capital Cost Vehicles
2 150,000
8
5,607,776
5,607,776 2
All other operatioal costs 3,941,765
6
2,296,446
-
5
3
1
Personnel 44,689,723
4
Risk Total (Type 1, 2 or 3) US$
3
2
Cold Chain Equipment
576,250
426,250 3
150,000
963,750
1,113,750 1,690,000
Subtotal Capital -
-
-
300,000
1,390,000
50,007,287
1,501,040
180,000
300,000
83,040,315
Total Cost
135,028,642
26
_______________________________________________________________________ The cost projections indicate a total immunization programme cost of US$ 321 million for the period 2002 up to 2009 against an estimated secure and probable financing (risks 1 & 2) of US$224 million, which indicates a financing gap of US$ 97 million as illustrated in Figure 5.1. Vaccine purchases will account for 43.7% of total costs. The secured funds clearly decline from 92% in 2002 to only 36% by 2009 Figure 5.1 Projected Financing Scenario A 50
45
40
Projected Costs ($ ,000,000)
35
30
25
20
15
10
5
0 2002
Govt secure
03
Gavi secure
04
Donors secure
05
06
Govt probable
07
Donors probable
08
09
FINANCING GAP
5.1.2: Scenario B - The 80% coverage target This scenario assumes a target of 80% of the birth cohort attaining fully immunised child status by 2006. It makes the same assumptions about the productivity of incremental resources as Scenario A. Under this scenario, the programme is projected to cost $12.3 million in 2002 increasing to $16.8 million in 2006 to a total cost of $146 million for the period of which 87% of the funds are secured.
27
_______________________________________________________________________ TABLE 5.5: TOTAL IMMUNIZATION SPECIFIC COST Projections - VF period 2002-2006 SCENARIO B (FSP Table 2.1.1) Item No.
Component
[A] Operational Cost Required Information 1 Vaccines 1.1 traditional 6 antigens 1.2
new & underused
2
Injection supplies
3
Personnel
4
Suppl. Immu. Activities
5
All other operatioal costs
Projected Requirements for VF-Period
Total Secured Total Total Financing Probable Possible Funding (Sum of all 1s) Financing (Sum of all 2s) (Sum of all 3s) US$ US$ US$
US$
5,062,218
4,564,980
497,239
0
66,460,824
63,518,399
2,942,426
5,058,299
5,058,299
-
32,578,191
32,578,190
-
14,853,840
7,777,989
4,745,610
2,330,241
17,839,254
12,746,940
3,795,403
1,296,911
141,852,627
126,244,797
11,980,678
3,627,153
1,711,375
107,000
1,593,750
368,750
450,000
760,000
3,305,125
475,750
450,000
2,364,375
126,720,547
12,430,678
5,991,528
6 Subtotal Operational
[B] Capital Cost Required Information 7 Vehicles 8
1,604,375
Cold Chain Equipment Subtotal Capital
Total Cost 145,157,752
28
_______________________________________________________________________ Table 5.6: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections VF period: 2002-2006- SCENARIO B (FSP Table 2.1.2) Item No.
Component
[A] Operational Cost Required Information 1 Vaccines 1.1 traditional 6 antigens 1.2 new & underused
Government Risk Government Risk GAVI / Risk Type Type Vaccine Type 1, 2 1, 2 Fund 1, 2 or 3 or 3 or 3 US$ US$ US$
DONORS Risk Risk Risk Risk Type DONORS Type DONORS Type UNFUNDED Type 1, 2 1, 2 1, 2 1, 2 or 3 or 3 or 3 or 3 US$ US$ US$ US$
1
1
2,529,038
2,035,942
2
Injection supplies
3
Personnel
0
1
5,062,219 2
2,942,426
66,460,825
1 5,058,299
5,058,299
1 32,578,190
Suppl. Immu. Activities 5 All other operatioal costs Subtotal Operational [B] Capital Cost Required Information 7 Vehicles
32,578,190 1
4
8
US$
3
497,239
63,518,399 2
Total
1
400,400
7,377,589 1
2
1
2
3
4,745,610 1
1,959,754
1,845,403
8,563,186
2,224,000
1,950,000
37,467,382
1,845,403
77,139,884
11,637,531
7,192,849
107,000
1
368,750
1
2,330,241 2
14,853,840 3
-
1,296,911
17,839,254
6,569,579
141,852,628
2
886,375
3
718,000
3
1,711,375
2
237,500
3
522,500
3
1,578,750
Cold Chain Equipment 450,000
Subtotal Capital -
-
-
475,750
450,000
1,123,875
1,240,500
3,290,125
37,467,382
1,845,403
77,139,884
12,113,281
7,642,849
1,123,875
7,810,079
145,142,753
Total Cost
29
_______________________________________________________________________ Table 5.7 shows the cost projections for the post vaccine fund period (2007-2009). Overall, the cost reduced to $34.2 million in 2009 from $ 36.5 million in 2002 mainly on account of reduced supplemental immunization activities. Table 5.7: TOTAL IMMUNIZATION SPECIFIC COST Projections Post VF period: 2007-2009- SCENARIO B (FSP Table 2.2.1) Item Component No.
Projected Requirements VF-Period
[A] Operational Cost Required Information Vaccines 1 1.1 traditional 6 antigens 1.2 new & underused 2 Injection supplies
US$
Total Secured Total Probable Total Possible for Financing Financing Funding (Sum of all 1s) (Sum of all 2s) (Sum of all 3s) US$
US$
2,302,836 52,942,637 4,294,607
1,375,800
Personnel Suppl. Immu. Activities All other operational costs
20,339,255 5,607,776 14,272,523
20,339,255
Subtotal Operational
99,759,634
25,417,281
US$
927,036 52,942,637
1,965,230 778,861
3 4 5
[B] Capital Cost Required Information 7 Vehicles
1,550,516 5,607,776 8,593,762
1,736,996 3,941,765 4,720,626
69,621,728
576,250
426,250 150,000
8
Cold Chain Equipment
668,750
Subtotal Capital
1,245,000
150,000 300,000
518,750 945,000
5,020,626
70,566,728
Total Cost
101,004,634
25,417,281
The attainment of 80% coverage assumes a lower capital outlay of $72 million to that of scenario A and allows for the available funds, especially those committed by GAVI, to be spread beyond the 5 year VF support period. This has the effect of reducing the financing gap by a considerable margin. Table 5.8: TOTAL IMMUNIZATION SPECIFIC COST Financing Projections Post VF period: 2007-2009 SCENARIO B (FSP Table 2.2.2) Item Component Risk GAVI / Risk GAVI / Risk Risk Risk Total No. Government Type Vaccine Type Vaccine Type DONORS Type UNFUNDED Type 1,2 Fund 1, 2 Fund 1, 2 1, 2 1, 2 or 3 or 3 or 3 or 3 or 3 [A]
Operational US$ Cost Required Information 1 Vaccines 1.1 traditional 1,375,800 6 antigens 1.2 new & underused 2 Injection supplies 3 Personnel 20,339,255 4 Suppl..Immu. Activities
US$
US$
US$
1
US$
927,036
1,229,681
1 1,514,410
2
3
2,302,836
52,942,637 1,550,516
3 52,942,637 3 4,294,607
5,607,776
20,339,255 5,607,776
1
30
US$
_______________________________________________________________________ 5
All other operatioal costs Subtotal Operational
3,941,765
2 1,556,996
25,656,820
2,786,677
[B] Capital Cost Required Information 7 Vehicles 8 Cold Chain Equipment Subtotal Capital Total Cost
1
180,000
1,514,410
1
180,000
150,000 150,000
8,593,762
3 14,272,523
69,621,728
99,759,634
2 2
426,250 518,750
3 3
576,250 668,750
-
-
-
300,000
945,000
1,245,000
25,656,820
2,786,677
1,514,410
480,000
70,566,728
101,004,634
Figure 5.2 illustrates the projected financing sources and gaps for scenario B over the 2002 to 2009 period. The gap increases from $ 1.3 million in 2002 to $ 24 million by 2009 for a total of $78 million. As in scenario A, the large gap will exist due to lack of committed financing for purchase of vaccines beyond 2006. Figure 5.2
Projected Financing Scenario 'B' 40
35
Projected Costs ($ ,000,000)
30
25
20
15
10
5
0 2002
Govt secure
03
Gavi secure
04
Donors secure
05
06
Govt probable
5.2. Summary
31
07
Donors probable
08
09
FINANCING GAP
_______________________________________________________________________ In the two scenarios above, there are certain common cost drivers. The first of these is population growth, which is increasing the annual cohort of newborns by just fewer than three per cent per annum. The second is the decision to adopt the more expensive pentavalent vaccine (DPT + HepB + Hib) in place of DPT. The new vaccine was introduced from December 2001, and therefore the higher level of costs is only marginally reflected in baseline period expenditures. The third factor is the adoption of injection safety measures, including auto-disable syringes and safe disposal measures. A fourth factor is inflation. Although all monetary values are expressed in current US dollars, with conversion from Kenya shillings at the current (2002) exchange rate - Ksh.78.5: 1US $, this does not completely remove the impact of inflation. While no projection is made of future inflation, the large increase in total KEPI programme costs in 2001 over 2000 is largely explained by a huge increase in nominal and real staffing costs associated with adjustments to housing allowances. Few of these cost drivers are considered reversible. Population growth rates are determined extraneously. Vaccine choice and injection safety measures are policy decisions. Modifications to the immunisation schedule are prompted by efficacy or safety considerations, but are usually cost enhancing. Inflation is assumed away by the recommended use of constant prices. Figure 5.3 depicts the comparative cost of the base and current years and the projected costs for scenarios A and B. Figure 5.3 Alternative Programme Costs 50 45
costs ($ ,000,000)
40 35 30 25 20 15 10 5 0 2000
,01
,02
,03
,04
,05
,06
,07
,08
years Scenario A
Scenario B
Base & Current Years
6. SUSTAINABLE FINANCING STRATEGIC PLAN AND INDICATORS
32
,09
_______________________________________________________________________ In order to strengthen the immunization program over the Plan period, funding gaps will primarily affect the purchase of basic EPI vaccines, cold chain, transport capacity, laboratory capacity, injection safety and coverage. The introduction of new vaccines presents significant financial challenges, not least of which is finding a balance between expanding the program with limited funds, and consolidating and strengthening it. Thus, the Government will implement policy decisions to improve financial sustainability, accountability, and equitable access to immunization service. This section presents assessments with a view to strengthening sustainability of the immunization programme financing. The section discusses policy issues, resource allocation and management mechanisms that would enable higher and more predictable funding of NIP needs. Among the many actions Kenya government will take to move toward higher and more stable levels of funding for immunization services, the following stand out as the ones with the highest potential impact: 6.1 Mobilise adequate resources
Increase domestic resources to health through advocacy at inter-ministerial level, local authorities, local corporate and individuals; Expand the ICC membership in an effort to solicit their support for the EPI; Engage development partners in discussion of resource requirements and seek commitments to cover major funding gaps; Create enabling environment so as to attract foreign funding; Considering the importance of EPI in the prevention of diseases, the Ministry of Health will review priority ranking. Currently, EPI is ranked 5th in the essential health package. Allocation criteria of resources on the basis of poverty out patient cases among others factors have been developed. This will ensure districts get adequate resources and this will translate in immunization services benefiting.
6.2 Strategies and actions to increase the reliability of resources
The government will endeavour to meet the agreed donor conditions; Ensuring political and economic stability and good governance;
6.3 Strategies to increase efficient use of resources
In order to implement programme activities with ease, special accounts of donor funds will be maintained in commercial banks with flexible operation;
Improved accountability and transparency will be enhanced, as the spending level against the EPI budget line (introduced during the financial year 2002/2003 for the procurement of EPI vaccines and supplies and other operational costs as part of its long-term commitment to EPI activities) will take responsibility for correct use of the funds. Specific EPI activity budget lines will reduce the risk of funds being diverted to other expenditure areas;
33
_______________________________________________________________________ Wastage rates are a useful financial management tool as good wastage management facilitates accurate forecasting resulting in reduction in procurement and distribution costs. Although wastage rates appear acceptable at the national level at the moment, an in-depth analysis at district level will highlight regional discrepancies.
The existing system of regular monitoring, reporting, and feedback will be strengthened;
Management of equipment: The immunization programme has substantial resources, which will be managed well to reduce costs. These include the cold chain, laboratory equipment and vehicles. All these have been put in the inventory. However, in the Plan period their functional status, performance, and maintenance schedule will be strictly monitored for optimal efficiency and longevity. Reports on breakdown in the cold chain will be addressed promptly. A national inventory and monitoring system will facilitate needsbased planning and make resource mobilization more efficient;
Establish performance targets for all the districts.
Sustainable Financing Strategic Plan Objectives
Indicators
Actions
Increase mobilization of resources
34
Means of verification
_______________________________________________________________________ Objectives
Increase Government financial contribution s to the NIP
Indicators
Mobilize external resources to fill financing gap
Mobilize local private and community participation
National operating expenditure on immunization as of GDP Government expenditure on NIP as of the health budget Donor contribution as of financing
Actions
FSP incorporated in to the national health plan;
Disseminate and advocate the FSP;
Hold regular ICC meetings.
Means of verification
Partners participating in NIP planning; Submission of proposals seeking additional/New financial support
Private enterprises and NGO’s encouraged to participate in NIP
Private enterprises and Locally based NGO’s included in the ICC
Community participation strengthened
Communities representation in local health boards and committees
Integration of the FSP into MOH plan; Number of copies of FSP disseminated; Number of ICC meetings held; Line allocation to NIP introduced. Number of partners participating in NIP planning Number of proposals submitted Number participating in ICC;
Activities supported;
Number participating in boards and committees. Existence of long-term financing plan Existence of disbursement regulations Time needed to transfer funds Number of days of delay in fund disbursement
Increase reliability of funds
Reduce financing fluctuations on program performance
Mean number of years of Government and Donor commitments Disbursement mechanisms established
Develop long-term capital financing plan
Build-up financial information and monitoring systems
Conditions met
Improve programme efficiency
Program costs reduced
Critical
35
Conduct costeffective /costbenefit analysis; Inventory of program inputs;
Number of studies conducted;
Number of updates;
_______________________________________________________________________ Objectives
Indicators Programmatic issues addressed
Actions
Means of verification
Procurement mechanisms standardized; Demand creation for services; Implement WHO guidelines on vaccine utilization; Data quality improved; Regulate fund appropriation process; Implement staff training protocols; Use of appropriate technology.
Purchases from approved manufacturers;
Increased coverage recorded;
Vaccine wastage reduced Number complete, accurate and timely reports;
Number of accounts audited;
Number of staff trained; Number equipment/vehic les meeting local conditions.
Indicators of Financial Sustainability Dimension of Financial Sustain-ability Mobilization and Use of Adequate Resources
Indicator
Unit
Explanatory Notes
Creation of Budget Line Item
Yes
Efficient Use Resources
Purchase of quality vaccines with use of international procurement mechanism
Yes
The EPI budget line introduced during the financial year 2002/03. It is expected to increase during the Plan period All the vaccine have been procured through UNICEF
of
36
_______________________________________________________________________ Dimension of Financial Sustain-ability Efficient Use of Resources
Indicator
Unit
Explanatory Notes
Existence of an accounting system for the immunization program where expenditures can be disaggregated by activity
Yes
Efficient Use Resources
of
Trends in wastage rates over time
Efficient Use Resources
of
Trends of vaccine stock-outs by region
The introduced EPI budget lines show specific activities, which will ensure the risk of funds being diverted to other expenditure areas is, reduce. The wastage rates will be monitored as this will result in cost savings. The vaccine stock outs will be monitored.
Reliability Resources
of
Reliability Resources
of
Share of actual domestic expenditures on recurrent costs of immunization program over recurrent amount budgeted/allocated Share of actual domestic expenditures on capital costs of immunization program over the amount budgeted for capital costs. Share of caretakers (mothers, fathers and guardian) knowledgeable about at least one benefit of immunization services Plan of Action on Communication for Demand creation implemented
Self-sufficiency
Self-sufficiency
Number,
The share will be monitored to reveal any serious variances.
The share will be monitored to reveal any serious variances.
Knowledge, attitude and practice studies will be undertaken
Yes
37
(KAP)
In order to increase demand for immunization (and hence improved coverage) communication strategies have been implemented and will be evaluated to assess their effectiveness.
_______________________________________________________________________ 7 STAKEHOLDERS ENDORSEMENT We, the undersigned members of the Inter-Agency Coordinating Committee endorse this Financial Sustainability Plan. Signatures of endorsement of this document do not imply any financial (or legal) commitment on the part of the partner agency or individual. Agency/ Organization Chairman, ICC
Name/Title
Date
Dr Richard O. Muga
British DFID
Ms Trisha Bebbington
WHO- Kenya
Dr Peter Eriki
UNICEF- Kenya
Dr Nicholas Alipui
CIDA- Kenya
Ms Eleanor Rose
JICA
Mr Masaaki Otuska
PATH
Ms Michelle Folsom
UNFPA
Dr Sidiki Coulibaly
CHAK
Dr Samuel Mwenda
USAID
Mr Victor Masbayi
Commentaries:
38
Signature
_______________________________________________________________________ 8: Preparation and Review Teams: (A)
National Technical Team:
1. Ms. A. G. W. Njiru 2. Mr. S. N. Muchiri 3. Mr. S. J. M. Kalama 4. Dr. K. C. Koskei 5. Dr. T. Gakuru 6. Dr. M. A. Hassan 7. Ms. B. W. Gathirwa 8. Mr. J. G. Kibera 9. Eng. M. Owino 10. Mr. J. M. N. Ole Kiu 11. Mr. A. K. Langat 12. Mrs. G. N. Kandie 13. Mrs. A. Koori 14. Mr. A. Runyago 15. Mrs. G. C. Masese 16. Mr. Ng’ang’a 17. Dr. S. Sonoiya 18. Dr. T. Kamau (B)
- Chief Finance Officer (Chairperson) MOH - Deputy Chief Economist “ - Chief Health Administrative Officer “ - Chief Pharmacist “ - Head, Health Sector Reform Secretariat “ - Head, Preventive and Promotive Health Care “ - Principal Accounts Controller “ -Ag. Director, Kenya Medical Supplies Agency “ - Head, Dept. of Bio-Medical Engineering “ - Chief Clinical Officer “ - Chief Public Health Officer “ - Chief Nursing Officer “ - Deputy Chief Economist MOF&P - Senior Economist “ MOLG “ - KEPI Manger (Secretary) MOH - Deputy KEPI Manager “
Core Working Group:
1. Mr. G. M. Gachuhi 2. Mr. G. Kimani 3. Mr. D. Murigi 4. Mr.M. Wheeler 5. Mr. A. Kimunya 6. Mr. S. M. Kamau 7. Mr. A. Chewya 8. Mr. A. Noor 9. Dr. J. Songa 10. Dr. A. Munyiri
Senior Health Administrative Officer (Team Leader) MOH Economist, Planning Dept. “ - Accounts Dept. “ - DFID Consultant……… - DFID Consultant - National Logistician, KEPI Management Unit “ - i/c Central Vaccine Stores “ “ - Health Administrative Officer “ “ - WHO Kepi officer - UNICEF Programme Officer
39
