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Page | 1 Asia Peer Review Workshop on Sustainable Immunization Financing Practices Phnom Penh, Cambodia July 21-23, 2014 Report Prepared by the Sabin Vaccine Institute
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Asia Peer Review Workshop on Sustainable Immunization Financing Practices
Phnom Penh, Cambodia
July 21-23, 2014
Report Prepared by the Sabin Vaccine Institute
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Contents
Introduction ................................................................................................................................................ 3
Workshop Goals .......................................................................................................................................... 3
Methods ...................................................................................................................................................... 3
Proceedings ................................................................................................................................................. 3
Day One .................................................................................................................................................... 3
Opening remarks ........................................................................................................................ 3
Theme I: Budgeting and Resource Tracking ............................................................................... 5
Theme II: Immunization Legislation ........................................................................................... 8
Day Two .................................................................................................................................................... 9
Theme II: Immunization Legislation, continued ........................................................................ 9
Peer Review Exercise ............................................................................................................... 13
Day Three ................................................................................................................................................ 15
Theme III: Advocacy in Practice ............................................................................................... 15
Workshop Evaluation ............................................................................................................... 15
Closing Remarks ....................................................................................................................... 16
Annex A ..................................................................................................................................................... 17
Annex B ..................................................................................................................................................... 19
Annex C ..................................................................................................................................................... 23
Annex D ..................................................................................................................................................... 25
Annex E ..................................................................................................................................................... 29
Annex F...................................................................................................................................................... 31
Annex G ..................................................................................................................................................... 34
Annex H ..................................................................................................................................................... 35
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Introduction
Since 2008, the Sabin Vaccine Institute has been working with fifteen lower and lower middle income (LLMICs) in Africa and Asia through its Sustainable Immunization Financing (SIF) Program. The focus of the Program has been on nurturing innovations- new ways of working- by national counterparts within the key public institutions concerned with health financing. In August 2013, peers from the SIF countries reviewed their innovations in a Sabin-organized SIF Colloquium in Dakar, Senegal. Since then, the six Asian SIF countries have made further progress toward the sustainable immunization financing objective. To assess this progress, Sabin and the Government and Parliament of Cambodia organized the “Asia Peer Review Workshop on Sustainable Immunization Financing”, which took place on 21-23 July, 2014 in Phnom Penh, Cambodia. Representing the Parliament of Cambodia were Senators, Representatives and staff members from the Senate and National Assembly. Representing the Cambodian Government were officials from the Ministry of Health (MoH), Ministry of Economy and Finance (MoEF) and the National Development and Planning Agency (NDPA). Joining them were parliamentary counterparts from Mongolia, Nepal and Sri Lanka and ministerial counterparts from Indonesia, Mongolia, Nepal, Sri Lanka and Vietnam. The workshop was facilitated by counterparts from WHO (Cambodia and Indonesia), UNICEF (Cambodia, Nepal and Indonesia) and two Sabin Senior Program Officers. The list of participants is shown in Annex A.
Workshop Goals
The goals of the workshop were to: a) Identify and share best financing, budgeting, resource tracking and advocacy practices; b) Assess proposed immunization-related legislation c) Document institutional innovations to achieve sustainable immunization financing in the
six countries
Methods
The workshop employed a peer-to-peer learning approach (Annex B). Delegates worked in small groups and interacted collectively in plenary discussions. External partner agency counterparts facilitated the small groups and documented the proceedings. A formal peer review exercise was carried out in which each delegate was asked to assess work in three other countries. A standard checklist was used. Upon completion of the workshop, delegates presented their results to parliamentarians in the Cambodian National Assembly.
Proceedings Day One Opening remarks
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Mr. Hok Khiev, Director of the Department of Legislation, Ministry of Health of Cambodia, welcomed the participants and presented the workshop objectives. He then described recent developments regarding Cambodia’s draft immunization law. Dr. Devendra Gnawali, Senior Program Officer, Sabin Vaccine Institute, summarized the
evolution of SIF Program advocacy work with the Asian countries, highlighting the periodic peer
exchanges through which peers from the countries learned from one another. The
parliamentarians engaged in these exchanges generated a series of influential parliamentary
declarations which testify to the countries’ commitment to achieving the sustainable
immunization financing objective. In the Dakar Colloquium, recalled Gnawali, the innovative
work undertaken by the Asian peers was plain for all to see. The SIF Program has since grown to
twenty-two countries with the Asian countries setting the pace so far.
In his remarks, Dr. Shafiqul Hossain, representing WHO/Cambodia, emphasized the importance
of sustainable immunization financing to health systems. This is an area where WHO is
committed to supporting ministries of health, he added. WHO works as well with UNICEF, Sabin
and many other development partners, at national, regional and global levels to accomplish this
goal.
Dr. Chheng Morn, Deputy Manager of Cambodia’s National Immunization Program (NIP),
provided an overview of national immunization financing. The Program budget has steadily
increased in recent years, he stated, indicating the government’s growing financial commitment
to the Program. Complementing Dr. Morn’s presentation, Mr. Kim Phalla, Deputy Director
General, Department of Public Finance Policy in the MoEF, explained the policy basis for the
government’s increasing support to immunization. The country’s national health and
development plans squarely recognize the important contributions immunization that makes to
the nation’s health and prosperity.
H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of the
Cambodian Association of Parliamentarians on Population and Development (CAPPD), noted
the important complementary role external partners and civil society organizations have played
in the development of the NIP. Their efforts have helped the Royal Government of Cambodia
to build the program. He then described how the Cambodian Parliament has also emerged as a
key NIP supporter in recent years, reflecting the leadership of Prime Minister Hun Sen who has
revitalized the country’s health sector through the Government’s Rectangular Strategy for
Growth, Employment, Equity, and Efficiency.
Following these opening remarks, the workshop took up three technical themes, the results of
which are summarized towards the end of this report.
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Theme I: Budgeting and Resource Tracking
Plenary session (Chair: H.E. Mr. Ouk Damry)
Dr. Shafiqul Hossain, WHO/Cambodia, summarized the Global Vaccine Action Plan (GVAP). He
said that WHO/WPR has developed a Regional Framework for Implementing the Global Vaccine
Action Plan which translates the strategies and activities recommended by the GVAP into the
Western Pacific Regional context. Dr. Hossain stated that GVAP charts a path for necessary
changes in the immunization field. Particularly significant, he added, is the GVAP Monitoring
and Evaluation/Accountability Framework, through which WHO Member Countries are annually
reporting their progress toward the six GVAP strategic objectives.
To fix ideas for this first technical theme, Dr. Devendra Gnawali shared a presentation entitled
“Budgeting and Resource Tracking for Immunization: Concepts and Applications”. In the
presentation, Dr. Gnawali summarized how LLMIC immunization programs are currently being
financed. The poorer countries are still largely dependent on external funding. Estimating
progress toward sustainable immunization financing is difficult due to the poor quality of the
available immunization expenditure data. Governments report their routine immunization
expenditures annually through the WHO/UNICEF Joint Reporting Form (JRF). Sabin analyses
have revealed that the JRF expenditure data are widely under-reported and misreported. These
reporting problems need to be fixed. JRF Indicator 6500 (government expenditures on routine
immunization) is a key indicator in the GVAP Monitoring & Evaluation/Accountability
Framework; it is the best direct measure of country ownership and financial sustainability, Dr.
Gnawali stressed. It is up to immunization program managers to find ways to improve, and to
themselves utilize, those expenditure data. Proper expenditure reporting will help managers
make their immunization programs more efficient. They can use the data to compare actual vs.
expected expenditures. Secondly, they can use current expenditures to formulate the coming
year’s budget. Each delegation then presented its innovative work in this area.
Cambodia
Ms. Bola Kan, Deputy Chief Officer of the Budget Department, MoEF, addressed the theme
“Budgeting and Resource Tracking Practices in Cambodia”. Her focus was on public financial
management structures and current budget practices, including Cambodia’s budget cycle,
budgeting, and resource tracking processes. One innovation her Department is discussing is
performance-based budgeting. In this approach, managers cross-analyze program and financial
information to make programs more efficient and budgets more realistic. Human resources and
procurement are two areas where the MoEF and MoH could cross-analyze expenditure data
with program data to the benefit of Cambodia’s immunization program. The main problem is
that current information systems are not quite up to the task. The MoEF is working to institute
timely, comprehensive expenditure tracking procedures whereby line ministries will submit
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more punctual and detailed performance reports to MoEF, which would then do the needed
analyses and produce the feedback to each ministry. The immunization program is a good place
to start this kind of innovation, concluded Ms. Kan. Dr. Chheng Morn, EPI Manager of the
Cambodian Ministry of Health spoke next, sharing his views on these budgeting and resource
tracking concepts. The need to innovate is growing, he said, as government immunization
spending continues to increase. The MoH has committed to strengthening routine
immunization, including financial management of the program. The Ministry continues to meet
its (Gavi) grant co-payments for pentavalent and pneumococcal vaccines, and is prepared to
absorb the additional co-financing costs associated with the introduction of the Japanese
Encephalitis vaccine.
Mongolia
Dr. Ganchimeg Ulziibayar from the National Center of Public Health, Ministry of Health,
described current immunization financing and resource tracking practices in Mongolia. The
Mongolian EPI program was 100% dependent upon external development partner support until
2000. Since then, the government share for immunization financing increased from 7% in 2003
to 89% in 2011. A National Immunization Foundation was established in 2001 under
Government Order N67. Its associated trust fund serves as the main resource tracking
mechanism for the national immunization program.
Dr. Ulziibayar offered three recommendations to countries considering the establishment of
such a fund.
1. Stakeholders should first map out resource tracking gaps, compile all relevant legal and regulatory documents, and then harmonize them to devise a bridled strategy.
2. The immunization program team should conduct an immunization cost analysis at subnational levels.
3. The immunization program team should develop the best corresponding expenditure tracking system and link it to the disease surveillance system.
Sri Lanka
Mr. Sameera Wickramasinghe, Director of the Budget Department, Sri Lankan Ministry of
Finance and Planning, presented Sri Lanka’s budgeting and resource tracking practices. The
government accounts for 90% of the immunization budget, reported Mr. Wickramasinghe. The
remainder is funded by international partners. Because the immunization budget is comingled
with that of other health programs, immunization expenditures are not readily identifiable.
With Sabin support, the Department of Epidemiology of the Ministry of Health recently carried
out a routine immunization costing study in one district. Results were extrapolated to estimate
national routine immunization costs. The study revealed that the estimated per capita cost to
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immunize a child under five years is ~USD13.00 (excluding vaccine costs). The Epidemiology
Unit plans to repeat the study in four other districts.
Indonesia
Mr. Entos Zainal, Head of Health Promotion and Nutrition Community Sub-Directorate of the
National Development Planning Agency, outlined Indonesia’s health expenditure data and
tracking mechanisms for routine immunization and other programs. The expectation is that a
new government-wide e-Monev resource tracking mechanism, established in 2013, will capture
immunization expenditures as well. The e-Monev system operates at national and subnational
levels. However, the Federal Ministry of Finance alone has the authority to trace expenditures
and this information is not yet available to the immunization program, precluding expenditure
tracking. Taking another approach, the Ministry of Finance recently partnered with UNICEF to
conduct a four-district resource tracking study in East Java. In order to institutionalize quality
resource tracking, however, Indonesian stakeholders must advocate for new or amended
legislation, whether a law or a Presidential decree.
Nepal
Mr. Shambhu Prasad Jnawali, incoming national immunization manager, Ministry of Health and
Population (MoHP), described how his program does resource tracking and financial reporting.
Expenditures are tracked for cold chain maintenance and equipment, human resources and
monitoring & supervision functions. Mr. Jnawali explained that Nepal’s JRF under-reporting is
due to the omission of shared system expenditures for immunization. This problem aside, the
government expenditure reporting and monitoring system is robust. Mr. Jnawali described how
it works:
1. Regional and district level health officers submit their monthly expenditure and programmatic reports to the District Treasury Controller’s Offices (DTCOs) before the 7th of every month. They send analogous quarterly reports to the Finance Section in the MoH Department of Health Services.
2. Each DTCO submits its combined financial report to the Office of the Auditor General Control. The latter audits and verifies the reports before entering them into the National Compilation Form, which is relayed to the Auditor General.
3. The Auditor General enters the information from the National Compilation Form into the annual financial report and conveys it to the President of Nepal.
As far as formal financial control is concerned, the system is effective, stated Mr. Jnawali.
Thinking of the immunization program’s needs, he suggested one innovation: that regional and
district level authorities submit their information to the DTCOs online. The digitized, pre-
audited information could then be more easily made available to immunization and other
managers.
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Mr. Jnawali next outlined the immunization program budget cycle:
1. The MoHP immunization program submits its budget request to the Department of Health Services (DoHS)
2. Upon approval, the DoHS Finance Section distributes the funds to each DTCO 3. The DTCOs allocate the funds to their respective Regional and District Health Authorities
In summary, stressed Mr. Jnawali, the current government disbursement and transfer systems
are adequate but are not granular enough to track program resources and expenditures. The
Program Division of MoHP is currently developing guidelines for resource tracking which will be
piloted in three districts.
Vietnam
Dr. Nguyen Van Cuong, Deputy National Immunization Program Manager, National Institute of
Hygiene and Epidemiology, next presented his Program’s recent advances in budget allocation
and resource tracking. Over the period 2006-2014, the government Program budget rose to
US$14.2m-a 250% increase. Engaging provincial immunization managers in resource tracking
has been an effective innovation. Expenditure reporting has risen from around half to nearly all
of the 63 provinces. The improved reporting helped the program avert a planned budget cut
last year.
Theme I: Small Groups
After the plenary session, delegates were assigned to work in small groups. External partner
counterparts facilitated the group work using the nominal group technique. The theme for the
group work was resource tracking experiences for immunization. The small group findings were
reported out in plenary by a six-person panel consisting of one spokesperson for each country
delegation. The presentations were followed by a question and answer session. Small group
results are shown in Annex C.
Theme II: Immunization Legislation
Plenary session (Chair: H.E.Mr. Ouk Damry)
As an introduction to this theme, Dr. Khongorzul Dari, Senior Program Officer, Sabin Vaccine
Institute, presented the provisions of a model immunization law and outlined the steps through
which such a law is created. The model law, outlined below, is based on research in Latin
America.
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Declarative Criteria
Free Vaccination Free and universal provision of vaccines by the government for all citizens; vaccination as a free
public good, guaranteed by the state.
Compulsory Vaccination Mandatory vaccination of all citizens
Financial Criteria
Budget Line Required line item in national budget for vaccine purchase and immunization program
Tax Exemptions Guaranteed tax exemptions for the importation of vaccines, vaccine-related supplies, and cold
chain materials
Supply Mechanism Identification of specific procurements mechanism (e.g. Revolving Fund) to guarantee a safe,
efficient and reliable supply of vaccines and vaccine-related supplies
Operational Criteria
Regulatory Oversight Established regulations on vaccination program to ensure safe, efficacious vaccines are
administered
Immunization Schedule Required definition of a national immunization schedule
Enforceability Established sanctions for failing to comply with provisions of law (fines, restrictions on school
entry, etc.)
Existence of NITAG Legally chartered National Immunization Technical Advisory Group
(Source: Trumbo et al 2012)
Among its provisions, a model vaccine law ensures free, universal access to immunization.
Public financing sources are defined as are vaccine procurement procedures. Any law is
designed to give general direction and orientation. Actual implementation of the law is through
more detailed regulations, executive decrees and other executive instruments.
The presentation was followed by an open discussion. With this, Day One came to a close.
Day Two
Theme II: Immunization Legislation, continued
Dr. Dari opened Day Two with a summary of the proceedings of Day One. Delegations then
presented their legislative projects. The status of the six projects is summarized in the figure
below. As can be seen, the three newest SIF countries, Indonesia, Mongolia and Vietnam,
already had vaccine laws in place before joining the Program. Of the remaining three countries,
Nepal moved two stages forward since the August 2013 Dakar Colloquium.
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Phase I Phase II Phase III Phase IV Phase V Phase VI
Background
Legislative
Research
Legislative
Strategy
Selected
Drafting of
Bill/
Amendments
Stakeholder
Consultation
Bill
Submitted
to
Parliament
Passage of
Bill
Cambodia
Indonesia†
Mongolia†
Nepal*
Sri Lanka
Vietnam†
* Moved one or more phases since August 2013.
Phase V
Phase II
† Laws passed prior to joining the Sabin-SIF Program.
Legislative projects, SIF Asian Countries (May 2014)
SIF-pilot Countries
Phase III
Following this introduction, each delegation presented its immunization law or legislative work
in progress.
Cambodia:
Dr. Koam Sinoun, Deputy Director of Department of Legislation, Ministry of Health, outlined
the key provisions of Cambodia’s draft immunization law.
Mandatory, Universal Vaccine Uptake: The draft law stipulates that all citizens must uptake all
vaccines introduced by the National Immunization Program.
Country Ownership: The draft law ensures that the Royal Government of Cambodia shall
provide sufficient funds for implementing the national immunization program. The government
will cover the cost of vaccines, vaccine and cold-chain equipment, and distribution and logistics
at the national level.
Immunization Fund: The draft law envisions the establishment of a Vaccination Fund and
National Immunization Council to oversee the Fund. The Health Minister will chair the Council
with participation from relevant ministries and institutions. The composition, organizational
structure and operation of the council will be determined by a sub-decree.
Tax Exemptions: The law will exempt vaccines and vaccination equipment from import taxes.
Penalties: The provision of penalties for parents of unvaccinated children was widely discussed.
Participants, especially those from Cambodia, suggested this provision be revised.
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Nepal:
Mr. Komal Acharya, Under Secretary (Legal) of the Ministry of Health and Population,
presented the declarative, financial and operational provisions included in Nepal’s draft
immunization law.
Free, Universal Vaccine Uptake: The law provides that everyone has the right to be vaccinated
and that the government will provide free vaccines via the National Immunization Programme.
It is strictly prohibited for an institution, individual, or group of people to impede vaccine
delivery.
Country Ownership: The draft law clearly stipulates that the government alone will adequately
finance the national immunization program. The government will further maintain a quality
cold chain system, the storage and distribution of vaccines following given standards, and the
efficient and reliable supply of vaccine-related supplies.
Immunization Fund: The draft law will establish a public-private immunization fund to do so.
Mr. Acharya reported that the National Immunization Fund Regulation was published in the
Nepal Gazette in January 14, 2014 and the Ministry of Health and Population established the
National Immunization Fund on July 8, 2014. The sources of funding will be the Nepalese
private sector (financial institutions, corporate houses, philanthropists, and other institutions),
foreign governments, external development partners and others. Proceeds from fund
investments will be allocated to the immunization program. The provisions of the draft
immunization law correspond closely to the national immunization fund regulations.
Tax Exemptions: Mr. Acharya also emphasized that tax exemptions afforded to importers of
vaccines, vaccine-related supplies, and cold chain materials are already guaranteed by other
laws.
Sri Lanka:
Dr. Paba Palihawadana, Chief of Epidemiology Unit, Ministry of Health, described Sri Lanka’s
draft immunization law.
Free, Universal Vaccine Uptake: The Government of Sri Lanka will continue to provide quality,
free, and universal immunization services to the population in a sustainable and equitable
manner. The draft law further includes a regulatory oversight mechanism to ensure the
vaccination program continues to promptly administer only safe and effective vaccines.
Country Ownership: The Ministry of Health has already developed a National Immunization
Policy that emphasizes financial sustainability. The national budget will dedicate a stand-alone
budget line for the National Immunization Program. The draft law currently stipulates that each
provincial authority will ensure the timely availability of adequate funds and other resources.
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The next step, Dr. Palihawadana concluded, will be the introduction of necessary legal
provisions to achieve key policy objectives.
Tax Exemptions: There is a tax exemption mechanism in place for the importation of vaccines,
vaccine-related supplies, and cold chain materials.
NITAG: The National Advisory Committee on Communicable Diseases (NACCD) of the Ministry
of Health acts as the National Immunization Technical Advisory Group (NITAG). The NACCD is
chaired by a variety of immunization experts from different backgrounds.
Mongolia:
Next, Mrs. Otgontuya Majaa, Senior Officer of Standing on Social Policy, Education, Culture and
Science of the State Great Hural (Parliament), presented Mongolia’s immunization law.
Parliament passed the law on 20 July, 2000. It has since been amended three times (first in
2003, second in 2006, and in 2010).
Free Vaccine Uptake: According to the law, vaccination is mandatory and vaccines are provided
free of charge.
Country Ownership: The government is entrusted to finance the immunization program and
mobilize the necessary resources for its operation.
Immunization Fund: A Government Resolution in 1993 established the National Immunization
Program, and the immunization law established the Immunization Fund. The Immunization
Fund is chaired by the Vice Minister of Health, with support from the Ministry of Finance and
the National Center for the Study of Infectious Diseases. The National Immunization Fund is
financed by state and local governments, external development partners, and the Mongolian
private sector.
Indonesia:
Indonesian delegates stated that eighteen pieces of health-related legislation exist which are
relevant to immunization. The Decree for Immunization was passed in 2013 by the Minister of
Health and is still a part of the national health law. Still, the NIP/MOH sees the need to update
this and plans to pass a free-standing immunization law.
Free, Universal, Mandatory Vaccine Uptake: The decree guarantees free and universal
vaccinations provided by the state. Vaccination is mandatory for under-5 and elementary
school children, and women of reproductive age.
Country Ownership: The decree further includes a stand-alone budget line for vaccine
procurement.
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NITAG: The National Immunization Technical Advisory Group was established by a piece of
legislation in 2006.
A plenary discussion followed the country presentations. Delegates then broke into small
groups to further analyze their projects.
Theme II: Small Groups
In their small groups, participants compared legislation and legislative advances, drawing on the
introductory themes. Results reported by the small groups are captured in Annex D.
Countries were also invited to document their legislative projects in a follow-on round of small groups. Two countries, Indonesia and Nepal, produced legislative narratives (Annex E).This exercise completed Day Two.
Peer Review Exercise
The final activity of the workshop entailed a peer assessment of each other’s institutional innovations using a standard peer review guide (Annex F). The guide included several open-ended and multiple choice questions and a list of ten items scored on a Likert scale (1=doubtful, 2=unlikely, 3=uncertain, 4=likely, and 5=almost certain). Each peer reviewer was asked to evaluate three countries. The peer review activity was divided into two consecutive 30-minute sessions. In the first session, reviewers interviewed their peers from Cambodia, Nepal, and Sri Lanka. In the second round, peers from those countries interviewed their peers from Mongolia, Indonesia, and Vietnam. Completed forms were collected at the end of each session. Scores were tabulated by Sabin staff. At the end of the workshop, delegates were asked to complete a standard workshop evaluation form. Results The exercise generated thirteen assessments (response rate= 23%). All were in the areas of resource tracking and legislation with one country (Nepal) contributing innovations in both categories. Eight peers (44%) from three countries (Indonesia, Nepal, Sri Lanka) served as raters. At least one assessment was received for each innovation. Multiple assessments were received for two (Indonesia, resource tracking; Nepal, legislation). Median responses are reported for these cases. Results are shown in Annex G. Summarizing the Likert items, raters determined that one of the innovations (Cambodia, legislation) had begun within the past year, four had begun 1-2 years earlier and one (Mongolia, legislation) was launched more than three years earlier.
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In all but two cases, reviewers unanimously agreed, the innovations had been launched in “top down fashion”, i.e., they were developed at the national level and progressed downward. The exceptions were Indonesia and Nepal, which each received one “bottom up” assessment. Reviewers enumerated as many as seven institutions involved in the innovative practices. All cases involved one or more government ministries with non-governmental organizations participating in 5/6 countries (83%). Considering how advanced the innovations were, reviewers rated one resource tracking innovation (Nepal) and two legislative innovations (Indonesia, Nepal) as fully institutionalized. Three were judged to be in earlier stages of implementation and two were still being theorized. Some resistance to the innovation was noted in 4/6 countries. Four of the 13 raters (30%) thought countries should have taken another approach to the problem. At least one rater per country thought the innovation would incur added costs. Only three raters did not foresee added costs (countries: Indonesia, Nepal). Considering whether the innovation would ultimately be institutionalized nationwide, one or more raters responded affirmatively for 5/6 countries. Only 3/12 (25%) raters responded negatively to this item. For all but one country, one or more raters felt the innovations would succeed or have already succeeded in accomplishing their objectives. Raters formulated a number of recommendations for their peers. Nepali peers were encouraged to keep pushing their legislative project until the bill becomes an Act of Parliament. One rater urged Sri Lankan peers to publish their proposed legislation online. Another congratulated Cambodian peers for their comprehensive legislative work but predicted that it would put new budgetary demands on the government. Mongolia was urged to start work on resource tracking. Two raters advised Indonesian peers to expand their pilot resource tracking innovation nationwide. Another added that Vietnam should study vaccine legislation in other countries. Discussion A formal peer review of institutional work for sustained immunization financing in six Asian countries was carried out by peers engaged in the Sabin SIF Program. Thirteen peers rated seven institutional innovations in the areas of resource tracking and legislation. Results show the peers generally understand the concept of institutional innovations. Most of the innovations they examined had been launched more than a year before. The innovations tended to materialize in top-down fashion and to involve multiple institutions. They often encountered resistance and were judged likely to add costs to national immunization programs.
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The innovators were not always seen as taking the best approach to increasing national financing. Yet the raters felt the innovations would ultimately succeed. These results are encouraging but must be interpreted with caution due to the low response rate. Only 44% of the peers participated in the exercise. Of these, only three scored two or more innovations. Inter-rater reliability (consistency) could therefore not be calculated. The peer review exercise took place at the end of a busy two days. Delegates may have been too fatigued to participate. Alternatively, they may have misunderstood the exercise, disliked evaluating or being evaluated, or were simply unmotivated to participate. Language barriers were also a likely cause of the low participation. Interpreters were not available and the workshop was conducted only in English.
Day Three
Theme III: Advocacy in Practice
Following a review of the proceedings from Day Two, Mr. Hok Khiev, Director of the Department of the Department of Legislation, Ministry of Health, Cambodia, presented the country’s draft immunization law and fielded participants’ suggestions for improvement. Suggestions addressed budgeting and resource tracking, penalties, and public education provisions. Next, Dr. Chheng Morn, EPI Manager, Ministry of Health, Cambodia, moderated a one-hour discussion on how to best advocate and persuade governments to take on the sustainable immunization financing challenge. Delegates from all six countries participated, often using homegrown examples to make their points. The delegates then identified their main conclusions from the workshop. Conclusions are found in Annex H.
Workshop Evaluation
Delegates were invited to evaluate the workshop using a standard evaluation form. Evaluations
were received from 21 participants, of whom 16 were delegates from the target national
institutions. Two-thirds of respondents were previously familiar with the work of the Sabin
Vaccine Institute. Nine respondents (43%) stated they had attended previous Sabin-organized
SIF events; 18/21 (86%) would recommend their peers participate in a future Sabin peer review
workshop.
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Respondents uniformly felt that the three thematic rounds in the workshop (resource tracking,
legislation, advocacy practices) were informative and that their small groups had been
productive.
Seven respondents (33%) felt two days were sufficient for the workshop. Seventy-seven
percent (15/21) felt they had sufficient time to complete the peer review.
Seventeen respondents (81%) indicated they had learned of an innovation which might work in
their countries. All respondents plan to continue working with the Sabin SIF Program.
Looking ahead, respondents were evenly divided on whether they thought their countries
would achieve sustainable immunization financing by 2020. Seven (33%) thought their
countries have already achieved it while 8 (38%) thought they have not.
Closing Remarks
H.E. Mr. Ouk Damry adjourned the workshop with closing remarks. Legislative work often faces difficult challenges, he noted, and it is a long process involving a plenitude of stakeholders and obstacles. However, he was hopeful that, as a result of the learning and sharing exhibited over the three-day period, all participating countries may develop strategies and policies conducive to securing greater government support for and promoting financial sustainability in immunization programs. H.E. Damry extended the Parliament’s invitation to all delegates to attend a Solidarity Dinner at 18:30 that evening.
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Annex A
List of Participants
Name Title/Institution Country
Dr. Otgontuya Dari Public Health Institute Mongolia
Mrs. Otgontuya Majaa Standing Committee on Social Policy, Education, Culture, and
Science; Parliament of Mongolia Mongolia
Dr. Ganchimeg Ulziibayar Ministry of Health Mongolia
Mr. Komal Prasad Acharya Under-Secretary, Legal Department,
Ministry of Health and Population Nepal
Mr. Shambhu Prasad Jnawali EPI Manager, Ministry of Health and Population Nepal
Mr. Birendra Bahadur Karki Secretary; Women, Children, Senior Citizen and Social Welfare
Committee; Parliament of Nepal Nepal
Dr. Nguyen Van Cuong Deputy Manager, National Institute of Hygiene and Epidemiology Vietnam
Mr. Do Cong Thanh Ministry of Finance Vietnam
Dr. Paba Palihadawana Chief Epidemiologist, Ministry of Health Sri Lanka
Ms. Nandini Ranawaka Appuhamillage Health Committee, Parliament of Sri Lanka Sri Lanka
Mr. W Arachchilage Don Dushantha Sameera Wickramasinghe
Director, Budget Department, Ministry of Finance and Planning Sri Lanka
Mr. Maliki Arif Budianto Head of Planning and State Budget Subsection,
Bureau of Planning & Budgeting, Ministry of Health Indonesia
Dr. Diany Litasari Immunization Sub-Directorate, Ministry of Health Indonesia
Mr. Entos Zainal Head of Health Promotion and Nutrition Community Sub-Directorate, National Development and Planning Agency
Indonesia
H.E. Ouk Damry Senior Advisor to the National Assembly,
General Secretary of CAPPD Cambodia
H.E. Uy Visal Director, International Relations Department,
National Assembly of Cambodia Cambodia
Prof. Sann Chan Soeung Advisor, National Immunization Program, Ministry of Health Cambodia
Dr. Chheng Morn Deputy NIP Manager, Ministry of Health Cambodia
Mr. Hok Khiev Director, Department of Legislation, Ministry of Health Cambodia
Mr. Kim Phalla Deputy Director General, Department of Finance and Public Policy,
Ministry of Economy and Finance Cambodia
Mr. Sok Khorn Department of Public Finance and Policy, Ministry of
Economy and Finance Cambodia
Ms. Bola Kan Health Economist, Budget Department, Ministry of Economy and
Finance Cambodia
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Hon. Mr. Uk Bun Chhoeun Chairman of Commission 8, Senator Cambodia
Hon. Mr. Yan Sen Chairman of Commission 1, Senator Cambodia
Hon. Mr. Chhit Kim Yeat Vice-Chairman of Commission 8, National Assembly Cambodia
Hon. Mrs. Pov Savoeun Secretary of Commission 8, National Assembly Cambodia
Hon. Mrs. Krouch Sam An Secretary, National Assembly Cambodia
H.E. Kob Maryas National Assembly Cambodia
H.E. Khim Hi Advisor to the National Assembly Cambodia
H.E. Mr. Kin Ratha Advisor to the National Assembly Cambodia
Mr. Kal Ketnin Advisor to the National Assembly Cambodia
Mr. Sur Sovanpheach Advisor to the National Assembly Cambodia
Mr. Son Kakson Advisor to the National Assembly Cambodia
Dr. Koam Sinoun Deputy Director, Department of Legislation, MOH Cambodia
Dr. Enheng Morn Ministry of Health Cambodia
Mr. Thiep Chanthan Senior Program Officer, Ministry of Health Cambodia
Chhat C. Valthanak Cambodia
Mr. Phar Cambodia
Development Partners
Dr. Md. Shafiqul Hossain Technical Officer, WHO Country Office Cambodia
Dr. Chham Samnang Technical Officer, WHO Country Office Cambodia
Mr. Hong Rathmony Health Specialist, UNICEF Country Office Cambodia
Mr. Chum Aun Health Officer, UNICEF Country Office Cambodia
Dr. Ashish KC Child Health Specialist, UNICEF Country Office Nepal
Dr. Kenny Peetosutan UNICEF Country Office Indonesia
Dr. Asmaniar Saleh WHO Country Office Indonesia
Dr. Devendra Prasad Gnawali Senior Program Officer, Sabin Vaccine Institute Nepal
Dr. Khongorzul Dari Senior Program Officer, Sabin Vaccine Institute Mongolia
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Annex B
Workshop Agenda
Day One: Cambodiana Hotel
Time Presentation Presenters Places/Notes
8:00-8:30 Registration
Plenary
8:30-8:40 Welcoming remarks, objectives of the meeting
Mr. Hok Khiev, Director of the Department of Legislation, Ministry of Health, Cambodia
8:40-9:30
Remarks by Sabin Vaccine Institute Dr. Devendra Prasad Gnawali, Senior Program
Officer, Sabin Vaccine Institute
Remarks by WHO Cambodia Dr. Md. Shafiqul Hossain, Medical Officer,
WHO Cambodia
Remarks by UNICEF Cambodia TBC
Keynote address by Ministry of Health Dr. Chheng Morn, Deputy Manager of the
National Immunization Program (NIP), Ministry of Health
Keynote address by Ministry of Economy and Finance
Mr. Kim Phalla, Deputy Director of the General Department of Public Finance Policy,
Ministry of Economy and Finance
Opening address H.E. Mr. Ouk Damry, Senior Advisor to the
National Assembly and General Secretary of CAPPD
9:30-10:00 Coffee Break
Theme I: Budgeting and resource tracking Chair: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD
10:00-10:20 An overview of the Global Vaccine Action Plan 2011-2020
Dr. Shafiqul Hossain, WHO Cambodia
Plenary
10:20-10:40 Budgeting and resource tracking for immunization: Concepts and applications
Dr. Devendra Gnawali, Sabin
10:40-10:50 Discussion
10:50-11:00 Cambodia: Budgeting and resource tracking practices in Health
Ms. Bola Kan, Department of Budget, Ministry of Economy and Finance
11:00-11:10 Cambodia: Budgeting and resource tracking practices in Immunization
Dr. Chheng Morn, Deputy NIP Manager, Ministry of Health
11:10-11:20 Mongolia: Budgeting and resource tracking practices
Dr. Ganchimeg Ulziibayar, National Center of Public Health, Ministry of Health
11:20-11:30 Sri Lanka: Budgeting and resource tracking practices
Mr. Sameera Wickramasinghe, Ministry of Finance and Planning
11:30-11:40 Indonesia: Budgeting and resource tracking practices
Indonesian delegation
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Day Two: Cambodiana Hotel
11:40-11:50 Nepal: Budgeting and resource tracking practices
Mr. Shambhu Jnawali, EPI Manager, Ministry of Health and Population
11:50-12:00 Vietnam: Budgeting and resource tracking practices
Dr. Nguyen Van Cuong, National Institute of Hygiene and Epidemiology, Ministry of Health
12:00 – 12:20 Discussion
12:20 – 12:30 Summary and instructions for Group Work (Round One)
Dr. Devendra Gnawali, Sabin
12:30-13:30 Lunch Break
13:30-14:30
Group Work (Round One): Processes and experiences completing and using SIF Budget Flow analyses for management and advocacy; documenting best resource tracking practices (1) Nepal and Cambodia; (2) Sri Lanka and Vietnam; (3) Mongolia and Indonesia
Group Work Breakout Rooms
14:30-15:30 Panel presentation: Best budgeting and resource tracking practices (20 min allocated to each group)
Country Delegates Plenary
15:30-15:45 Coffee Break
15:45 – 16:30 Discussion and Summary of Theme I Sabin Plenary
Theme II: Immunization legislation Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD
16:30-16:45 Overview of model immunization laws and legislative processes
Dr. Khongorzul Dari, Sabin
Plenary 16:45 – 17:00 Discussion Country Delegates/Sabin
17:00 End of Day One
Time Presentation Presenters Places/Notes
Theme II: Immunization legislation, continued Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD
8:30-8:40 Summary of Day One Sabin Plenary
8:40-8:50 Cambodia: Update on immunization legislation
Dr. Koam Sinoun, Deputy Director of Legislation Department, Ministry of Health
Plenary
8:50-9:00 Nepal: Update on immunization legislation Mr. Komal Acharya, Under Secretary (Legal),
Ministry of Health and Population
9:00-9:10 Sri Lanka: Update on immunization legislation
Dr. Paba Palihawadana, Chief Epidemiologist, Ministry of Health
9:10-9:20 Mongolia: History and role of immunization legislation
Otgontuya Majaa, Senior Officer, Standing Committee on Social Policy, Education,
Culture and Science of Great Hural State (Parliament)
9:20-9:30 Indonesia: History and role of immunization legislation
Indonesian delegation
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9:30-9:40 Vietnam: History and role of immunization legislation
Dr. Nguyen Van Cuong, National Institute of Hygiene and Epidemiology, Ministry of Health
9:40-10:10 Discussion
Sabin
10:10-10:15 Instructions for Group Work (Round Two)
10:15-10:30 Coffee Break
10:30-11:30
Group Work (Round Two): Comparative review of vaccine-related legislation and regulatory documents (1) Nepal and Cambodia; (2) Sri Lanka and Vietnam; (3) Mongolia and Indonesia
Group Work Breakout rooms
11:30-12:30
Panel presentation: Legislative review findings and recommendations (10 mins per group, 30 mins open discussion)
Plenary
12:30-12:45 Discussion
12:45-13:45 Lunch Break
13:45-14:30 Group Work (Round Three): Documenting country legislative case studies (delegates work by country)
Group Work Breakout Rooms
14:30-15:30 Panel presentation: Country case studies (5 mins per country, 30 mins open discussion)
Group Work -Mr. Hok Khiev, Director of the Department of Legislation, Ministry of Health (Cambodia) 5 mins -Nepal 5 mins -Vietnam 5 mins -Mongolia 5 mins -Sri Lanka 5 mins -Indonesia 5 mins
Plenary
15:30-15:45 Coffee Break
15:45-16:15 Discussion & Summary of Theme II Country Delegates/Sabin Plenary
Theme III: Advocacy in practice Moderator: H.E. Mr. Ouk Damry, Senior Advisor to the National Assembly and General Secretary of CAPPD
16:15-16:30 Advocacy for sustainable immunization financing: Concepts and applications
Sabin Plenary
16:30-17:30
Group Work (Round Four): Documenting advocacy case studies (delegates work by country; each country 5 mins, 30 mins open discussion)
Group Work -Dr. Chheng Morn (NIP Cambodia), 5 mins -Nepal 5 mins -Vietnam 5 mins -Mongolia 5 mins -Sri Lanka 5 mins -Indonesia 5 mins
Breakout rooms
17:30 End of Day Two
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Day Three: Cambodiana Hotel
Time Presentation Presenters Places/Notes
***Peer Review Exercise: Innovations in sustainable immunization financing*** Moderator: H.E. Ouk Damry, Sr. Advisor to the National Assembly and General Secretary of CAPPD
9:00-10:00 Presentation on Cambodia’s draft law and discussion
Mr. Hok Khiev, Ministry of Health (Cambodia)
Plenary
10:00-11:00 Delegates prepare “Conclusions” of the workshop
Delegates
11:00-11:30
Peer review, Part One: Delegates from
Mongolia, Indonesia, Vietnam interview
delegations from Cambodia, Nepal, Sri Lanka Country Delegates
11:30-12:00
Peer review, Part Two: Delegates from Cambodia, Nepal, Sri Lanka interview delegations from Mongolia, Indonesia, Vietnam
Country Delegates
12:00-12:30
Recap of workshop proceedings and evaluation
Sabin
12:30-13:00 Closing remarks H.E. Mr. Ouk Damry
13:00-14:00 Lunch Break
18:30 Solidarity Dinner Hosted by H.E. Ouk Damry
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Annex C
Theme I: Budgeting and Resource Tracking Purpose:
Exchange processes and experiences in using the SIF budget flow analysis tool for management and advocacy purposes
Document best budgeting and resource tracking practices
Group One Facilitator: Kenny Peetosutan (UNICEF/Indonesia) Spokesperson: Shambhu Jnawali (Ministry of Health and Population, Nepal) Members: Nepal: Birendra Bahadur Karki (Parliament), Komal Acharya (MOHP) Cambodia: Dr. Enheng Morn, Dr. Chheng Morn, Thiep Chanthan (MoH); H.E. Kob Maryas (Parliament); Bola Kan, Sok Khorn (MEF); Loeng Vuthy, Mr. Phar, Chheang Thary
Problems Facilitating Factors
• Funding for resource tracking is insufficient or non-existent because policy-makers have yet to be persuaded to prioritize immunization
• Health Management Information System (HMIS) doesn’t provide for reporting NIP expenditures
• HR isn’t equipped for resource tracking
• Government prioritizes and adequately funds NIP
• Adequate support and coordination among stakeholders across institutions, including MOH and MOF
Problems Proposed Solutions
• 1. Funding for resource tracking is insufficient or non-existent because policy-makers have yet to be persuaded to prioritize immunization
• 2. HMIS doesn’t provide for reporting NIP expenditures
• 3. HR isn’t equipped for resource tracking
• 1. Advocacy to policy-makers and high-level officials
• 2. HMIS needs to incorporate immunization-related expenditures
• 3. Improve competency of health workers (HWs) in resource tracking procedures
• Formulate comprehensive immunization law
• Establish a trust fund • Improve coordination between MOH
and MOF
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Group Two Facilitator: Dr. Ashish KC (UNICEF/Nepal) Spokesperson: Members: Sri Lanka: W.A.D.D.S Wickramasinghe (Ministry of Finance and Planning), Nandini Ranawaka Appuhamillage (Parliament) Indonesia: Dr. Asmaniar Saleh (WHO) Vietnam: Dr. Nguyen Van Cuong (Ministry of Health), Do Cong Thanh (Ministry of Finance) Cambodia: Dr. Koam Sinoun (Ministry of Health)
Problems Proposed Solutions
• Data collection at national and subnational levels
• Misreporting of data (delayed reporting & under-reporting)
• Inconsistencies in reporting
• Establish data collection system at national and subnational levels
• Centrally-controlled funding mechanism
• Train and raise the awareness of health workers and managers in resource tracking
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Annex D
Theme II: Immunization Legislation
Purpose: Review vaccine-related legislation and regulatory documents Group One Facilitator: Kenny Peetosutan (UNICEF/Indonesia) Spokesperson: Komal Acharya (Ministry of Health and Planning, Nepal) Members: Nepal: Birendra Bahadur Karki (Parliament); Komal Acharya, Shambhu Jnawali (MOHP), Cambodia: Dr. Shafiqul Hossain (WHO), Dr. Chheng Morn, Dr. Chhat C. Valthanak, Dr. Koam Sinoun (MOH)
Problems Facilitating Factors
• Coordination and cross-consultation among stakeholders is lacking or inadequate
• Poor institutional memory • Long process
• Nepalese govt. has prioritized immunization act
• Both countries (Nepal & Cambodia) have signed Phnom Penh, Kathmandu, Kampong, etc. declarations
• Previous peer review meeting is ongoing
• Draft of immunization law is in hand
Problems Proposed Solutions
• Coordination and cross-consultation among stakeholders is lacking or inadequate
• Poor institutional memory • Long process
• Establish an in-country coordination mechanism, i.e working group
• Such a task force should be organized and should facilitate a series of consultative meetings
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Group Two Facilitator: Spokesperson: Dr. Ashish KC (UNICEF/Nepal) Members: Sri Lanka: W.A.D.D.S Wickramasinghe (MOFP), Nandini Ranawaka (Parliament) Indonesia: Dr. Asmaniar Saleh (WHO) Vietnam: Dr. Nguyen Van Cuong (MOH), Do Cong Thanh (MOF) Cambodia: Dr. Koam Sinoun (MOH) Overview of Vietnam’s Immunization Legislation Landscape
• The Law on the Prevention of Communicable Disease covers immunization financing • If the legislative process permits, an immunization fund provision will be inserted as well • If the legislative process proceeds, NEPI and the MOH Planning Department will provide
input to the law from the immunization program • The immunization program is approved by the MOH • For the introduction of new vaccines, recommendations from ICC, NITAG, MoH, and
MoF will be required for funding and approval from the government Overview of Sri Lanka’s Immunization Legislation Landscape
• There is an existing law on prevention & control of communicable diseases • Free vaccination is compulsory • There is a separate EPI budget for vaccine procurement • Tax revenues are guaranteed to subsidize vaccines and cold chain • There is a procurement mechanism for vaccines under special consideration (fast track
vaccines) • The National Immunization Policy enhances access to and sustainability of the
vaccination program • The National Advisory Committee for Immunization assesses the disease burden and
decides on new vaccine introduction. • Vaccine financing is somewhat sustainable
Group Three Facilitator: Dr. Khongorzul Dari (Sabin) Spokesperson: Ms. Otgontuya Majaa (Parliament, Mongolia), Members: Mongolia: Dr. Ganchimeg Ulziibayar, Dr. Otgontuya Dari (MOH, Mongolia) Indonesia: Dr. Maliki Arif Budianto, Dr. Diany Litasari (MOH); Entos Zainal, (NDPA)
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Problems Facilitating Factors
1. The law is too general; a more specific immunization decree is needed
2. Regulations are satisfactory for national programs but not subnational ones
3. Weak community participation
1. Government is capable of supporting the law’s implementation and raising solid public awareness.
2. National mid-term planning session sets a budget and an achievable target
3. Health law contains articles pertaining to immunization
Group Four
Facilitator:
Spokesperson:
Members:
Cambodia: H.E. Chhun Sirun, H.E. Nuon Sarin, Nuom Sophorn, Khim Chhun I (Parliament);
Chum Aun (UNICEF), Mao Phirun (MOJ), So Chhorvy Roth (MOEY), Kim Phalla (MoEF), Seng
Phal Davin (MOWA), Theab Chanthorn (MOH); Am San Ath, Khat Sok, Sar Sokha, Leong Vuthy
Suggestions on draft immunization law by Cambodian MPs and officials:
• Each article should be organized by title • Chapter 10: “Penalties” should be changed to “administrative fines” to avoid
criminalizing language; the fine should be reduced • Violators under Article 36, 39 should receive proper warning or education before
incurring such a fine • The government should provide additional education to those unfamiliar with the
necessity of immunization injections; an article should provide that violators receive proper education upon being fined
• The law should establish an evaluation committee in case unanticipated issues are encountered, such as an adverse event following immunization (AEFI), at both national and sub-national levels.
• Should an AEFI occur, a procedure should be established to protect personnel • H.E. Chhun Sirun, Member of 8th and 9th Committee of the National Assembly,
announced his full endorsement of the immunization law. He raised two issues in reference to Article 31:
• It stipulates that products may be destroyed in line with the existing procedure. H.E. Sirun asked whether such a procedure indeed exists, and if not, which ministry should develop one.
P a g e | 28
• Regarding the fact that it is the vaccine owner’s responsibility to incur the cost of destroying a vaccine in such a case, H.E. Sirun inquired as to what the government should do if the vaccine owner doesn’t comply.
• A concern was raised pertaining to the utilization of the Khmer words for “son” and “daughter” in Article 10.
• Article 35: The Ministry of Economy and Ministry of Health alone should administer the provision of incentives to officers, instead of the “Royal Government” more generally.
• Chapter 6: The MPs requested the addition of one more article stipulating that the MOH should cooperate with related ministries, especially with local authorities, so that immunization percolates to the community level.
• Chapter 4: Article 14 should include a provision for the inclusion of vaccinations administered by the private sector to be captured in an annual report to the National Immunization Program (NIP) • Article 13: Provincial and municipal health departments are responsible for safe
storage and distribution of vaccines at the provincial level. • The district and khan (city) immunization program managers are responsible at the
district level, and the health center managers are responsible at the health center level.
• Chapter 1, Article 1: General Regulation • First Revision: Requested to replace “this law has the purpose of managing
immunization in the Kingdom of Cambodia” with “The National Immunization Program is a national priority”.
• Second Revision: Requested replace “this law has the purpose of managing immunization in the Kingdom of Cambodia” with “Law on Providing Immunization”
• Chapter 9, Article 26: The non-compliance fine should be moved to Chapter 10 • Chapter 2 should be administered by relevant management institutions, including the
National Immunization Council (NIC), National Immunization Program (NIP), and the immunization working group.
• The NIC should be responsible for the annual budget and fund; the NIP, for processing and vaccine issues (such as vaccine type)
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Annex E
Documenting Country Legislative Case Studies
Country: Nepal Spokesperson: Komal Acharya, MOHP Delegates: Birendra Bahadur Karki (Parliament), Shambhu Jnawali (MOHP), Dr. Ashish KC (UNICEF) NOTE: Different actors are involved at each legislative phase
Government Stakeholders Development Partners
• Ministry of Health and Population • Ministry of Finance • Ministry of Education • Ministry of Law & Justice • Council of Ministers • Parliament • Ministry of Women, Children and
Social Welfare • Ministry of Federal Affairs and Local
Development
Agencies • UNICEF • WHO
INGOs • Sabin
Philanthropic • Rotary International • Lions Club
Business Community • FNCCI • Chamber of Commerce
Advocacy techniques used to generate draft legislation 1. Drafting of concept note 2. Sharing and discussion of concept note 3. Consultative meetings with line agencies and stakeholders 4. Consensus of the Ministry of Law and Justice in formulating a separate immunization
law 5. Briefing to relevant Cabinet committee to secure high-level approval 6. Referencing a case study from another country 7. Peer review with other SIF program countries
Challenges encountered at each legislative phase and solutions proposed
Challenges Solutions
• Stakeholder under-appreciation of the necessity of an immunization law
• Delay in law-drafting process due to changes in the government
• Series of consultation meetings • Frequent briefings to Ministers and
policy-makers
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Lessons learnt: • Developing a health-specific law requires a combination of technical knowledge,
administrative skill and legal expertise
• Developing the capacity of different institutions is instrumental in promulgating the law
at large.
• The proposed milestone is the formulation of a law vis-à-vis an orientation targeting
non-health sector stakeholders on the importance of health and immunization
especially.
Country: Indonesia
Spokesperson:
Delegates: Entos Zainal (NDPA); Dr. Maliki Arif Budianto, Dr. Diany Litasari (MOH)
Approach Challenges
• Review eighteen existing pieces of immunization-related legislation
• Initiated by MoH, with support from the Ministry of Internal Affairs (MOIA), NDPA, universities, Indonesian Technical Group for Immunization (ITAGI), NAEFI, the Pediatrician Association, and other stakeholders
• MoH (inter program), MoIA, Bappenas, University, ITAGI, NAEFI, Pediatrician Association, Stakeholders
• Not strong enough for compliance from sub-national level because of decentralization
• A presidential decree would be more successful
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Annex F
SABIN SUSTAINABLE IMMUNIZATION FINANCING INNOVATION PEER REVIEW GUIDE
******************************************************************************
Reviewer’s country: _______________________________________________
Reviewer’s home institution (check one):
___Min health ___Min finance ___parliament ___other (specify: ___________________)
___Partner agency counterpart
Country studied: ___________________________________________
******************************************************************************
***
Classify the innovation by functional area (check one or more):
___ financing ___ budget, resource tracking ___ legislation ___advocacy activity
___other (specify: ________________________________________________________)
In the presenters’ words, what problem or opportunity does the innovation address?
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):
When- how long ago- did the innovation begin (check one)?
___three or more years ago ___past 1-2 years ___this year
How did the innovation begin (check one)?
___ Top -> down ___ Bottom -> up ___ Outside third party introduced it
On which level of governance did the innovation originate (check one)?
_____ regional or sub-regional multiple countries)
___ national ___sub-national ___ both levels together
Which institutions are or were involved in developing the innovation (check one or more)?
Government
___ ministry of health ___ ministry of finance ___ elected body
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___ other government ministry or agency (identify: ___________________________________)
Non-government
___ community service organization (identify: ____________________________________)
___ domestic business sector (identify: ______________________________________)
___ other (identify: ______________________________________)
At this point, how advanced is the innovation (check one)?
___ people are just talking about it
___ the new practice(s) is (are) now being tried
___the new practice(s) is (are) becoming institutionalized
___the new practice(s) is (are) fully institutionalized
___ the innovation is being blocked
What feedback and recommendations do you wish to convey to these delegates about this
particular innovation? (continue writing on back of page if needed)
On a scale of one to five, with 1 being no chance and 5 being almost certain, please answer the
following questions. Circle one response per item.
Item
1 2 3 4 5
No chance Not likely Unsure Likely Almost certain
The innovation is well conceptualized. The proposed solution matches the problem or
opportunity it addresses.
1 2 3 4 5
Another approach would have been more suitable for solving the problem/improving the
sustainability of the immunization program.
1 2 3 4 5
The right mix of institutions is or was involved in developing the innovation.
1 2 3 4 5
There is or was a lot of resistance to this innovation.
1 2 3 4 5
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This innovation is or was carried out without incurring significant new costs.
1 2 3 4 5
The innovation will help the country reach sustainable immunization financing sooner.
1 2 3 4 5
The innovation will ultimately be institutionalized nationwide.
1 2 3 4 5
If successful, the innovation will increase country ownership of the immunization program.
1 2 3 4 5
Considering all the factors, how likely is the innovation to succeed, to become institutionalized?
1 2 3 4 5
This innovation would likely succeed in your own country.
1 2 3 4 5
List below and briefly describe any other innovations you observed in this country.
THANK YOU FOR YOUR CONTRIBUTIONS! THE SABIN SIF TEAM WILL ANALYZE AND DISTRIBUTE
THESE RESULTS TO ALL PARTICIPANTS.
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Annex G
Peer Review Results
Innovations in Resource Tracking
Country (No. raters)
Indonesia (n=4)
Nepal (n=1)
Cambodia (n=1)
Status of innovation Implemented Institutionalized Implemented
Institutions involved MOH, MOF, Natl Dev &
Planning Agency, Parliament
MOH, MOF, Sabin, UNICEF, WHO
MOH, MOF, ADB, WB, IMF, UNICEF,
WHO
Right institutions are involved almost certain almost certain Likely
Solution to problem almost certain almost certain Likely
Better solution exists likely uncertain Likely
High resistance to innovation unlikely doubtful Likely
Low new costs from innovation uncertain uncertain Likely
Innovation catalyzes SIF progress likely/almost certain likely almost certain
Likelihood of institutionalization likely uncertain Likely
Innovations in Legislation
Country (No. raters) Indonesia (n=1) Nepal (n=2) Sri Lanka (n=1) Vietnam (n=1) Mongolia (n=1)
Status of innovation Institutionalized Implemented/
Institutionalized Implemented Theorized Theorized
Institutions involved
MOH, MOF, Natl Dev & Planning Agency, Cabinet
Secretary
MOH, MOF, MOLJ, UNICEF, WHO,
Sabin
MOH, MOF, MOE, MOJ, WHO,
UNICEF, SABIN
MOH, MOF, Elected Body
MOH
Right institutions are involved
likely likely/almost
certain almost certain likely Unlikely
Solution to problem likely likely/almost
certain almost certain likely Unlikely
Better solution exists likely unlikely/unsure Likely likely almost certain
High resistance to innovation
uncertain Unlikely Doubtful uncertain almost certain
Low new costs from innovation
unlikely uncertain/likely Likely likely almost certain
Innovation catalyzes SIF progress
almost certain almost certain almost certain almost certain Doubtful
Likelihood of institutionalization
likely likely/almost
certain almost certain almost certain Uncertain
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Annex H
Asian Peer Review Workshop on Sustainable Immunization Financing Phnom Penh, Cambodia
21-23 July, 2014
Conclusions The Decade of Vaccines (2011-2020) envisions a world where all individuals and communities are free from vaccine-preventable diseases. To achieve this ambitious goal, the 65th World Health Assembly endorsed the “Global Vaccine Action Plan (GVAP)”. One of the GVAP objectives is for national immunization programs to be adequately and sustainably funded to ensure that every child is immunized for vaccine-preventable diseases. This is achieved through improved financial management and efficient allocation of resources directed at this preventative health intervention. Expenditures must be linked to outputs and impacts, and demonstrate a clear investment case for immunization. Maximum political and administrative support at both national and subnational levels is essential for the formal endorsement of sustainable, country-owned legislation and national policies. Following the “Phnom Penh Declaration 2010” made by the Parliamentarians and inspired by the GVAP’s guiding principles, we, the delegates from Indonesia, Nepal, Sri Lanka, Cambodia, Mongolia and Vietnam, support and recommend the following:
1. Track resources (based on WHO/UNICEF JRF) for the efficient use of available resources
and collect financial data that demonstrates a sound investment case for routine
immunization. This information will equip government officials to advocate for
increased national financial commitments and immunization-related legislation.
2. Promote the use of cost-benefit analysis to secure funds, support policy, and motivate
decision making-all in pursuance of sustainable immunization financing.
3. Ensure that legislation or a legal framework for long-term sustainable funding and
vaccine provisions promotes the National Immunization Program and are not preventing
any child from being fully immunized.
4. Continue advocacy to increase and sustain a high-performing immunization program,
and further, to synergize sustainable immunization methods with health system
strengthening.
July 23, 2014 Phnom Penh, Cambodia
