Kenya cMYP 2011-2015 - WHO

Kenya DVI Comprehensive Multi-Year Plan 2011-2015 1

REPUBLIC OF KENYA

MINISTRY OF PUBLIC

HEALTH & SANITATION

DIVISION OF VACCINES AND IMMUNIZATION (DVI)

MULTI YEAR PLAN

2011-2015


Contents

LIST OF TABLES.........................................................................................................................................................3 LIST OF ACRONYMS .................................................................................................................................................4 Forward..........................................................................................................................................................................8 1.1. Geography and Demography .........................................................................................................................11 1.2. Health situation in Kenya ...............................................................................................................................11 1.3. Child health interventions in Kenya ...............................................................................................................13 1.4. Health Sector Priorities..................................................................................................................................16 2. HEALTH CARE DELIVERY SYSTEM IN KENYA .......................................................................................18 2.1. External Policy Environment..........................................................................................................................18 2.2. Sector strategic framework, and documents ...................................................................................................19 2.2.1. Policy level documents ..............................................................................................................................19 2.2.2. Strategic level documents ..........................................................................................................................20 2.2.3. Investment level documents .......................................................................................................................20 2.2.4. Operational level documents......................................................................................................................21 2.3. Sector targets and indicators...........................................................................................................................21 2.3.1. Recap of sector strategic priorities .............................................................................................................21 2.3.1.1. Recap of Vision 2030.................................................................................................................................21 2.3.1.2. Recap of the First Medium-Term Plan, 2008–2012...................................................................................21 2.3.1.3. Recap of NHSSP II 2005–2012 .................................................................................................................22 3. IMMUNIZATION PROGRAMME IN KENYA ...............................................................................................23 3.1. Organogram of Division of Vaccines and immunization ...............................................................................23 3.2. Goal of routine Immunization ........................................................................................................................24 3.3. Immunization Schedule for Kenya .................................................................................................................24 4. IMMUNIZATION SYSTEM COMPONENTS .................................................................................................26 4.1. Service Delivery .............................................................................................................................................26 4.2. Vaccine Supply, Quality and Logistics ..........................................................................................................26 4.3. Disease Surveillance.......................................................................................................................................27 4.4. Advocacy, social Mobilization and Communication......................................................................................27 5. SITUATION ANALYSIS ..................................................................................................................................29 5.1. Routine Immunization Performance, Gaps and Challenges ...........................................................................29 5.2. Polio eradication.............................................................................................................................................33 5.3. Accelerated disease control ............................................................................................................................33 6. PRIORITIES, OBJECTIVES AND MILESTONES FOR EPI...........................................................................35 7. IMPLEMENTATION PLAN .............................................................................................................................43 8. COSTING, FINANCING AND FINANCIAL SUSTAINABILITY..................................................................50 8.1. Costing and financing methodology...............................................................................................................50 8.2. Macroeconomic Information ..........................................................................................................................51 8.3. Cost projections 2011-2015 for immunization programme............................................................................52 8.4. Cost profile .....................................................................................................................................................54 8.5. Baseline Financing .........................................................................................................................................55 8.6. Cost by immunization strategy .......................................................................................................................56 8.7. Projected future resource requirements for immunization from all sources from 2011-2015. .......................57 8.8. Projected future financing: Secured, probable and gaps for immunization from 2011-2015. ........................58 Annex 1: Activity timeline 2011-2015 ........................................................................................................................61 Annex 2: Annual operational plan 6 (AOP 6) Family Health Department ..................................................................63 Annex 3: Annual work plan 2011/2012, Division of vaccines and immunization ......................................................65 Annex 4: Using GIVS framework as a checklist .........................................................................................................75


LIST OF TABLES

Table 1:Leading cause of death and DALYs in Kenya Page: 12

Table 2: Health Sector strategic documents Page: 20

Table 3: Current Routine Vaccination Schedule for Children under 1 year Page: 25

Table 4. Situational analysis of routine EPI by system components based on previous years' data (2007-2009)

Page: 32

Table 5: Situational analysis by accelerated disease control initiatives, Based on previous years' data (2007-2009)

Page: 35

Table 6: National objectives and milestones, AFR regional and global goals Page: 36

Table 7: Service delivery and Programme Management Page: 45

Table 8: Advocacy and Communications Page: 50

Table 9: Surveillance Page: 50

Table 10: Vaccine supply, quality and logistics Page: 51

Table 11: Inputs to different EPI systems components Page: 53

Table 12: Macro Economic Trends in Kenya, 2010 – 2015 Page: 55

Table 13: Programme costs and Future Resources Requirements Page: 55

LIST OF FIGURES

Figure 1: Top causes of outpatient morbidity in Kenya Page: 11

Figure 2: Trends in Health Impact indicators during the period of the policy review (1994-2000)

Page: 13

Figure 3: Trends of DTP 3 in Kenya, 1980-2008 Page: 14

Figure 4: Proportion of districts with at least 80% DTP3 coverage among children 12-23 months.

Page: 15

Figure 5: DTP3 coverage trends by residence and by mother's level of education Page: 15

Figure 6: DTP3 coverage among children 12-23 months by province Page: 16

Figure 7: Pillars of Kenya’s development framework – Vision 2030 Page: 17

FIGURE 8: ORGANOGRAM OF THE DIVISION OF VACCINES & IMMUNIZATION

Page: 24

Figure 9: Trends of immunization performance for selected indicators, 1992-2009, Kenya

Page: 39

Figure 10: Routine Immunization Programme Expenditure Breakdown Page: 56

Figure 11: Baseline Financing Profile Page: 57

Figure 12: Costs by Strategy Page: 59

Figure 13: Projection of future resource requirements 2011-2015 Page: 59

Figure 14: Projection of future financing gap. Page: 60


LIST OF ANNEXES

i. ANNEX 1: Action plan & timeline for 2011-2015

ii. ANNEX 2: AOP 6

iii. ANNEX 3: First year annual plan 2011

iv. ANNEX 4: GIVS checklist

v. ANNEX 5: Logistics forecasting tool [Soft copy]

vi. ANNEX 6: Costing tool [Soft copy]

LIST OF ACRONYMS

AD - Auto Destruct (syringes)

AEFI - Adverse Events Following immunization

AFP - Acute Flaccid Paralysis

AIDS - Acquired Immune Deficiency Syndrome

AIE - Authority to Incur Expenditure

AOP - Annual Operation Plan

BCC - Behaviour Change and Communication

BCG - Bacille Calmette-Guerin (Vaccine)

CAG - Cash Assistance to Government

CBAW - Child Bearing Age Women

CBHC - Community Based Health Care

CBO - Community Based Organization

CBS - Central Bureau of Statistics

CDC - Communicable Disease Control

CFC - Chloro Flouro Carbon

cMYP - Comprehensive Multi Year Plan

CORPS - Community Own Resource Persons

DALYs - Disability Adjusted Life Years

DANIDA - Danish Aid National Development Agency


DARE - Decentralized Aids and Reproductive

DDSC - District Disease Surveillance Coordinator

DIFD - Department for International Development

DFH - Divison of Family Health

DHE - Division of Health Education

DHEO - District Health Education Officer

DHMT - District Health Management Team

DHP - District Health Programme

DoHP - Department of Health promotion

DMOH - District Medical Officer of Health

DMS - Director of Medical Services

DPT/ (DTP) - Diphtheria Pertusis and Tetanus

DQA - Data Quality Audit

DRCO - District Registered Clinical Officer

DVI - Division of Vaccines and Immunization

EPI - Expanded Programme on Immunization

FBO - Faith Based Organization

FIC - Fully Immunized Children

GAVI - Global Alliance for Vaccines and Immunization

GDP - Gross Domestic Product

GIVS - Global Immunization Vision and Strategy

GOK - Government of Kenya

HepB - Hepatitis B

Hib - Haemophilus influenza type b

HIS - Health Information Systems

HIV - Human Immunodeficiency Virus

NHSSP - National Health Sector Support Programme

ICC - Inter Agency Coordination Committee

IDS - Integrated Disease Surveillance

IDSR - Integrated Disease Surveillance & Response


IEC - Information Education and Communication

IMCI - Integrated Management of Childhood Illnesses

JICA - Japan International Agency

JPWF - Joint Program of Work and Funding

KBC - Kenya Broadcasting Corporation

KDHS - Kenya Demographic and Health Survey

KEMRI - Kenya Medical Research Institute

KEMSA - Kenya Management and Supplies Agency

KEPH - Kenya Essential Packages for Health

KEPI - Kenya Expanded Programme on Immunization

KHPF - Kenya Health Policy Framework

KMTC - Kenya Medical Training College

MCH - Maternal Child Health

MDGs - Millennium Development Goals

MDVP - Multi Dose Vial Policy

MLM - Mid Level Management

MNT - Maternal Neonatal Tetanus

MoH - Ministry of Health

MTEF - Mid Term Expenditure Framework

MTP - Medium Term Plan

MTRH - Moi Teaching and Referral Hospital

MYP - Multi Year Plan

NCPD - National Council Population Development

NGO - Government of Kenya

NID - National Immunization Days

NPCC - National Polio Certification Committee

NPEV - Non-Polio Enteroviruses

NPHL - National Public Health Laboratories

NPEC - National Polio Expert Committee

NNT - Neonatal Tetanus


OJT - On the Job Training

OPV - Oral Polio Vaccine

PDSC - Provincial Disease Surveillance Committee

PHC - Primary Health Care

PHEO - Provincial Health Education Officer

PHI&RO - Provincial Health Information and Records Officer

PHMT - Provincial Health Management Team

PHO - Public Health Officer

PHT - Public Health Technician

PRSP - Poverty Reduction Strategy Paper

PS - Permanent Secretary

RED - Reaching Every District

SIA - Supplemental Immunization Activities

SDP - Service Delivery Point

SNID - Supplemental National Immunization Days


Forward

The Ministry of Public Health & Sanitation through the Division of Vaccines and Immunization

aims to increase access to immunization services nationwide in order to reduce morbidity and

mortality due to vaccine preventable diseases. This is in acknowledgement of the proven benefits

of immunization in the prevention, control and even eradication of life threatening diseases over

the years. Of particular importance is the reduction of infant and child morbidity and mortality in

line with the United Nations Millennium Development Goals (MDG) by the end of this Multi

Year Plan. The other major consideration is to implement the WHO/UNICEF Global

Immunization Vision & Strategy (GIVS) which challenges national governments to immunize

more people, from infants to seniors, with a greater range of vaccines.

EPI vaccination service delivery forms the bulk of the workload of the Division of Vaccines &

Immunization, while non-EPI vaccination services is also expected to grow and be standardised

over the duration of this multi year plan. Currently the portfolio of infant vaccines covers ten

diseases (viz. Tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus

influenza type b, yellow fever and measles). The introduction of a pneumococcal conjugate

vaccine into the infant immunization schedule in January 2011 will improve life expectancy for

children in Kenya and also contribute to achieving MDG 4 target. Kenya plans to introduce rota

virus vaccine in the routine schedule, hepatitis B vaccine for health workers and meningococcal

vaccine for travellers proceeding for Hajj during the period of this MYP.

The non-EPI vaccines include typhoid vaccine for food handlers and other special populations at

high risk, anti rabies vaccine, anti snake venom and yellow fever vaccine for travellers.

This multi year plan 2011-2015 will serve as a reference point in the implementation of

immunization activities and the preparation of annual action plans, in addition to the National

Health Sector Strategic Plan III – due to be developed from 2012. Some aspects may have to be

adjusted subsequently to align the cMYP to the NHSSP-III


The MYP highlights the national goals, objectives & strategies for the improvement of the health

of Kenyans in reference to specific vaccine preventable diseases. The Government of Kenya

recognises vaccination as a high impact intervention of national importance and has projected to

continue supporting the costs of expansion of immunization services. It is anticipated that the

development partners and agencies that have assisted the Government of Kenya so far in the

immunization arena will continue with us for the duration of the cMYP. The success of the

immunization programme depends significantly on adequate and timely financing of all

proposed activities. Other contributory factors include committed coordination through the Child

Health Inter-agency Coordinating Committee (ICC) and other bodies such as the National

Immunization Technical Advisory Group (NITAG) that is in the process of formation.

The main areas of focus are improving and sustaining the disease control gains achieved through

improved routine and supplemental immunization coverage and increasing the range of vaccine

preventable diseases covered –for infants and the general population. The latest two Kenya

Demographic & Health Surveys (2005-06 & 2008-09) show progressive improvement in the

proportion of children fully immunized. The cMYP has detailed how these gains are to be

sustained and improved.

There will however be risks in achieving the goals outlined in the cMYP due the transitional

challenges that the country will invariably experience as it implements a radical new constitution

which will, among other things, devolve governance of health service delivery from the current

national level coordination to 47 new county governments. The new constitution should be fully

implemented by 2012 and therefore rapid restructuring of national and regional levels of

administration are expected in all government departments by then, including the Ministries of

Health. This is a grey period and the Division of Vaccines & Immunization intends to mitigate

any regression of gains achieved so far through close consultation with immunization

stakeholders and dialogue with the health departments of County governments.

Kenya is committed to implement the cMYP 2011-15 through the dedication of health workers,

community participation and support from partners in health to achieve the MDGs 4 & 5 targets.



Background

1.1. Geography and Demography

Kenya is situated in East Africa; it borders Tanzania to the South, Uganda to the West, Ethiopia and Sudan to the North, Somalia to the Northeast, and the Indian Ocean to the Southeast. It has a surface area of 582, 646 square kilometres and approximately 80 % is either arid or semi-arid while only 20% is arable. Following the promulgation of the new Constitution of Kenya in August 2010 the country is now administratively divided into 47 counties. Kenya’s population according to the August 2009 national population and housing Census is 38,610,097.

1.2. Health situation in Kenya

Good health is a pre-requisite for socio-economic development of the country. Kenya had recorded positive health indicators after independence due to the progress that was made in the provision of health care services. However, the indicators began deteriorating in mid 1990s. Current trends in health indicators are optimistic. Infant mortality has declined from 77 per 1,000 in 2003 to 52 in 2008/09 while in the same period under five mortality rate declined from 115 per 1,000 to 74. The overall HIV prevalence rate among adults 15–49 years has decreased from 6.7% in 2003 to 6.3% in 2007. Kenya has had relative success in scaling up access to anti-retroviral treatment. Currently there are more than 360,000 patients on ARV treatment.

A high disease burden is a barrier to economic growth - Most of sicknesses are caused by preventable conditions. Top five causes (malaria, Disease of the Respiratory System, Disease of the Skin, diarrhoea, and accidents) of outpatient morbidity account for about 70% of total causes with malaria contributing about a third of total morbidity.

Figure1: Top causes of outpatient morbidity in Kenya


Malaria

31%

Disease of the

Respiratory System-

e.g.Bronchitis, Tonsolitis

, running nose/cough

25%

Disease. of the Skin

(Incl. Ulcers)

7%Diarrheal Diseases

5% Pneumonia

3%Accidents (incl.. fractures, burns

etc)

2%

Rheumatism, Joint pains etc

2% Eye Infection

2%Urinary Tract Infections

1%

Intestinal Worms

1%

All Other Diseases e.g

Cancer and diabetes

21%

Other

28%

Top five causes of outpatient morbidity account for about 70% of total causes.

5

The health sector will play its part in the attainment of the Vision goals. In this regard, the need for a robust health infrastructure; a financing mechanism that allows Kenyans, especially the poor to access affordable and quality services; an increased focus on preventive and promotional healthcare and the delinking of the Ministries of Health from service provision are identified as some of the key interventions that need to be implemented in the medium to long term period

The Leading causes of deaths and DALY’s in Kenya are summarized in the table below:

Table 1:Leading cause of death and DALYs in Kenya

Causes of death Causes of DALY’s

Rank Disease or injury

%

total

deaths

Rank Disease or injury

% total

DALYs

1 HIV/AIDS 29.3 1 HIV/AIDS 24.2

2 Conditions arising during the perinatal period 9.0

2

Conditions arising during the perinatal period 10.7

3 Lower respiratory infections 8.1 3 Malaria 7.2

4 Tuberculosis 6.3

4 Lower respiratory infections 7.1

5 Diarrheal diseases 6.0 5 Diarrheal diseases 6.0 6 Malaria 5.8 6 Tuberculosis 4.8 7 Cerebro vascular disease 3.3 7 Road traffic accidents 2.0 8 Ischemic heart disease 2.8 8 Congenital anomalies 1.7 9 Road traffic accidents 1.9 9 Violence 1.6

10 Violence 1.6

10 Unipolar depressive disorders 1.5


Impact indicators are a good measure of trends in overall health of the population. The most commonly used impact indicators relate to the mortality indicators – Adult Mortality Rate (AMR), Maternal Mortality rate (MMR), Under-5 Mortality Rate (UMR), Infant Mortality Rate (IMR), Neonatal Mortality Rate (NMR) and other similar measures. Improvements in the mortality indicators suggest impact of interventions meant to improve the health of the population.

The trends in mortality impact indicators during the period of the policy are shown in the figure below

Figure 2: Trends in Health Impact indicators during the period of the policy review (1994-

2000)

0

100

200

300

400

500

600

700

0

20

40

60

80

100

120

140

1993 1998 2003 2008

U5M

R, IM

R, N

MR

/ 1,

000

U5MR IMR NMR MMR Linear (MMR)

Source: Respective Demographic and Health Surveys

The general trend in impact indicators suggests a stagnation of the health situation during the period of the policy framework that is only appearing to improve during its last few years. Infant, and Under 5, and Mortality are starting to show improvements, while maternal and neonatal mortality have stagnated.

Data from the 2009 Demographic and Health Survey is also suggestive of improvements in Adult Mortality towards the end of the policy. A comparison of the rates from the 2008-09 KDHS and the 2003 KDHS indicates a decline in adult mortality for both women and men, but the patterns differ slightly.

Female adult mortality rates from the 2008-09 data are lower for all ages, except from age 35 upward, where the rates are nearly the same as those from the 2003 survey. Male adult mortality is lower for most of the age groups, except age groups 15-19 and 45-49.

1.3. Child health interventions in Kenya

Kenya's child health strategy includes a range of interventions in early childhood, neonatal health care, school health services and adolescent health. Integrated management of childhood illness (IMCI) for children less than five years of age was introduced in selected districts in the late nineties and expanded during the following decade.


NHSSP-II 2005-2010 specified the Kenya essential health package (KEPH). It is based on the life cycle approach. The key indicators for phase 1 (pregnancy, delivery and the newborn child) include BCG vaccination. Phase 2, early childhood, includes nine indicators on service access, notably IMCI, and coverage such as bed nets, breastfeeding, immunization coverage, vitamin A supplementation. Phase 3 concerns late childhood with community interventions focused on de-worming of children and school health programmes and phase is about adolescence and the access to youth friendly services.

Coverage trends for Immunization

Long term annual trends in immunization coverage are derived from facility reports and regular household surveys. The best estimate of DTP3 coverage during 1980-2009 is shown in Figure 3 below. DTP3 coverage reached a peak of over 90% in 1995, gradually declined to a low of just over 70% during 2002-2004 and climbed in recent years to 85% in 2008. The other vaccines - BCG and measles - show a similar pattern. DTP dropout rates, the proportion of children who receive the first dose but not the third, was well below 10% in 1993, but increased to 17% in 1998 and 19% in 2003. The KDHS 2008 however showed that the DPT 1-3 dropout rate had reduced to 10%.

Figure 3: Trends of DTP 3 in Kenya, 1980-2008

The health facility reports show that the proportion of districts that have reached at least 80% coverage of DTP3 increased during 2003-06 to a high of 64%, but that in 2007 and 2008 a large decline was observed. The decline during this period should be interpreted with a background of the socio-political instability that resulted to disruption of health services, dislocation of populations and withholding of donor support.

Figure 4: Proportion of districts with at least 80% DTP3 coverage among children 12-23

months.


37

45

50

64

58

44

0

10

20

30

40

50

60

70

2003 2004 2005 2006 2007 2008

Perc

en

t o

f d

istr

icts

wit

h a

t le

ast

80%

DP

T3 c

overa

ge

The household surveys can provide further insight into what population groups are affected most by the changes in coverage over time. It is notable that KEPI has succeeded in reaching rural populations just as well as urban children and that this has remained unchanged since 1998. Both urban and rural children were equally affected by the declining trend until 2003 and the subsequent upturn 2003-2008. The situation by mother's level of education is different. There were large differences in DTP3 coverage by level of mother's education and especially children of mothers with no education has lower coverage and were affected more severely during the weaker performance period of the immunization programme. The 2008 KDHS however indicates that immunization coverage among children of mothers with no education increased more than for other children, reducing the gap.

Figure 5: DTP3 coverage trends by residence and by mother's level of education,

50

55

60

65

70

75

80

85

90

95

100

1988 1993 1998 2003 2008

Urban

Rural

50

55

60

65

70

75

80

85

90

95

100

1988 1993 1998 2003 2008

No educ

Prim inc

Prim com

Sec+

Source: KDHS 1998-2008.

The provincial differences are shown based on data from the 1993 and 2008 KDHS. Overall, DTP3 coverage was the same in both years (86%). North Eastern Province was for the first time included in 2003. It is notable however that, even though DTP3 coverage is lower than in other provinces, there was a dramatic increase from 25% in 2003 to 57% in 2008. Four out of eight provinces had DPT3 coverage of over 85% both in1993 and 2008. Nairobi province has shown a


declining trend of the same, while Nyanza and Western province hardly achieved coverage beyond 80%. The data from North eastern province is limited to ascertain coverage and trends.

Figure 6: DTP3 coverage among children 12-23 months by province

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

Nairobi Central Coast Eastern Nyanza Rift

Valley

Western N

Eastern

1993 KDHS

2008 KDHS

The proportion of pregnant women who received one or two doses of tetanus toxoid was very close to antenatal care coverage and was 85% in 2003. In the KDHS 2008 it was computed that 72% of mothers had their last live birth protected from neonatal tetanus1

The KDHS shows that most of the pregnant women receive Tetanus toxoid vaccine during their first ANC visit as demonstrated by the comparable coverage for both interventions.

1.4. Health Sector Priorities

The Government of Kenya (GOK) is determined to improve both access and equity of essential

health care services, and to ensure that the health sector plays its essential role in the realization

of the Vision 2030 and the Medium Term Plan (MTP) 2008-2012. As a signatory of the

Millennium Declaration with its internationally defined Millennium Development Goals

(MDGs), Kenya has expressed its commitment to reach these targets by 2015. Kenya has

incorporated these and other international goals into its national targets. These are further being

translated into regional and district level targets as part of the MoH’s annual operational plan to

inform and guide local priority setting and resource allocation. Specific outcomes to be achieved

1 Includes mothers with two injections during the pregnancy of the last live birth, or two or more injections (the last within 3 years of the last

live birth), or three or more injections (the last within 5 years of the last live birth), or four or more injections (the last within ten years of the

last live birth), or five or more injections prior to the last live birth


in the Vision 2030 represent the achievements of the targets by MOH, through the

implementation of the annual operational plans.

Figure 7: Pillars of Kenya’s development framework – Vision 2030

Source: Kenya National Economic and Social Council.

At national level, the Vision 2030 and the First Medium Term Plan 2008-2012, whose three

pillars are economic, social and political aims at achieving a globally competitive and prosperous

nation with a high quality of life. The above will be achieved through strengthening the

institutions of governance; rehabilitating and expanding physical infrastructure; and investing in

the poor. A key component of the Vision 2030 is the introduction of the Social Health Insurance

in a phased approach to eventually achieve universal coverage of free health care to the Kenya

Population.


2. HEALTH CARE DELIVERY SYSTEM IN KENYA

Kenya’s Ministries of Health (Ministry of Medical Services and Ministry of Public Health and

Sanitation) offer health services through their public sector health facilities that account for 46%

of the 6,761 health facilities in Kenya. FBO/NGO and the private for-profit sector ‘own’ the

remaining 54%. However, all EPI services in 4100 Public/FBO/NGO/Private facilities are

supported by the Division of Vaccines and Immunization (DVI). The major NGO/FBO health

care providers include: AMREF, CHAK/NCCK (Christian Health Association of Kenya), KCS

(Kenya Catholic Secretariat), and the Kenyan Aga Khan Foundation.

FBOs/NGOs and Private for Profit health providers are key actors in contributing to the

achievement of the current National Health Sector Strategic Plan (NHSSP II). The NHSSP II

recognizes that ‘reversing the trends’ cannot be achieved by the government health sector alone.

2.1. External Policy Environment

The Kenya national health system is operating within the context of other international health

initiatives. In this regard, achievement of the MDGs targets is of primary importance, especially

MDG 4 for DVI. Other policy documents are the Global Immunization Vision and Strategies

(GIVS) and the African Region EPI Strategic Plan for 2006-2009.

The National Health Sector Strategic Plans (NHSSPs) are translated into annual activities that

are aligned to the available resource envelope for a particular fiscal year. An AOP, therefore,

defines the year’s priorities, targets, activities and resources, on the basis of the ideals, strategies

and targets spelt out in a particular NHSSP as well as on the lessons learnt from the

implementation of preceding AOP. This annual operational plan is the sixth in the series. The

Second National Health Sector Strategic Plan (NHSSP II)2, whose end date has been extended

from 2010 to 2012 for the following reasons, forms the basis for this AOP:

• To align health sector strategic planning cycle to the Government of Kenya’s strategic planning cycle

2 Ministry of Health, Reversing the Trends-The second National Health Sector Strategic Plan for Kenya: NHSSP 11, 2005-2010, September 2005.


• The NHSSP II strategic priorities are in line with the Kenya Vision 2030 and the First Medium- Term Plan (MTP) for 2008-2012

• The economic down turn, the post election events and the associated reorganisation of the Government health services had a negative impact on the implementation of the Roadmap for Acceleration of Implementation of Interventions to Achieve the Objectives

of the NHSSP II,3 and as such the extension will provide an opportunity to ensure the

implement the roadmap hence achieving the NHSSP II objectives.

2.2. Sector strategic framework, and documents

The sector has a comprehensive set of strategic documents guiding its actions. These are either primary guidance documents, or secondary guidance documents that represent a re-arrangement of information in the primary documents, based on expectations of different constituents. These different documents, and their relations, are highlighted below.

Table 2: Health Sector strategic documents

Area of

guidance

Primary documents Secondary documents

Policy level Kenya Health Policy Framework

Program – specific policy guidelines

Strategic level National Health Sector Strategic Plan

Investment level Joint Program of Work and Funding

National Health Strategic Plan Ministry strategic plans Department investment / strategic plans Program – specific investment / strategic plans System – specific investment / strategic plans

Operational level

Annual Operational Plans - Departmental AOP 6

plans - Provincial AOP 6 plans - Parastatal AOP 6 plans

AOP 6 consolidated plan

The sector results chain is defined around the primary documents. The secondary documents re-package the information in the primary documents, depending on the constituent needs.

2.2.1. Policy level documents

These define the long term direction the country is taking in health. The Kenya Health Policy

Framework is the primary policy document for health in Kenya. This is being updated during this AOP 6, to cover the period 2011 – 2030, to provide the key policy directions for the health 3 Ministry of Health, Roadmap for Acceleration of Implementation of Interventions to Achieve the Objectives of the NHSSP II

, December 2007.


sector leading to attainment of the Vision 2030. Specific policy guidelines are developed, for key areas in the sector, but which are all linked to attainment of the policy imperatives of the KHPF.

2.2.2. Strategic level documents

These outline the Medium Term strategic direction for the health sector in the country. It is captured in the five strategic objectives of the National Health Sector Strategic Plan II. Originally intended to guide the sector up to 2010, its timeframe has been extended to 2012 (see proceeding section).

2.2.3. Investment level documents

These outline the investment priorities during the period of the sector strategic plan. The overall sector investment plan is the Joint Program of Work and Funding (JPWF), 2005 – 2010, around which all investments in the sector are aligned. It forms the basis for the sector partnership process, which is designed to align and coordinate efforts of the sector in attaining the respective priority investments. Most current sector documents are a re-packaging of the investment priorities in this JPWF

- The roadmap for acceleration of NHSSP II objectives: This is the way forward, arising from the Mid Term Review of the NHSSP II. It highlights the investment priorities the sector needs to focus on, to accelerate movement towards the NHSSP II objectives.

- The Ministry Strategic Plans: These re-package the JPWF investment priorities, around the respective mandates of each Ministry, and provide more detail on implementation priorities

- The Health Strategic Plan: This brings together the investment priorities from the strategic plans of both Ministries into one document

- The departmental / division strategic plans: These re-package the JPWF investment priorities around the mandate of a given department, and provide more detail on the deliverables.

- The program investment plans (e.g. EPI MYP, Malaria strategy): These re-package the JPWF investment priorities around the mandate of a given program area, and provide more detail on the deliverables.

- The system investment plans (e.g. HRH strategic plan): These re-package the JPWF investment priorities around the mandate of a given system area, and provide more detail on the deliverables.


2.2.4. Operational level documents

These represent the guide for the activity priorities for different sector constituents. Each health facility or management unit in the sector has an annual operational plan (AOP). These are consolidated at each level, up to the single sector wide Annual Operational Plan 6 document.

The above results chain is comprehensive in structure, covering all the sector planning and monitoring needs. The only gap is in the timeline of the NHSSP II, which ends in 2010.

2.3. Sector targets and indicators

These remain the same as in the NHSSP II document. Overall impact sought is outlined in Annex 6.

2.3.1. Recap of sector strategic priorities

2.3.1.1. Recap of Vision 2030

Kenya Vision 2030 articulates the national development agenda for the country. The Vision specifies strategies for achieving the following economic, social and governance targets that are expected to transform Kenya from low income to a rapidly industrializing middle-income nation by the year 2030:

� Sustainable economic growth of 10% per year over the next 25 years.

� A just and cohesive society enjoying equitable social development in a clean and secure environment.

� An issue-based, people-centred, result-oriented and accountable democratic political system.

Kenya’s Vision 2030 for health is to provide equitable and affordable health care at the highest affordable standard to all citizens, involving (among other things) the restructuring of the health care delivery systems in order to shift the emphasis from curative to preventive and promotive health care. Improved access, equity, quality, capacity and institutional framework are the main focus areas that will be achieved through a devolution approach that will allocate funds and responsibility for delivery of health care to hospitals, health centres, dispensaries and communities

2.3.1.2. Recap of the First Medium-Term Plan, 2008–2012

The first MTP sets out the policies, reform agenda, projects and programmes that Kenya’s Grand Coalition Government is committed to implement during the period 2008–2012 in line with Vision 2030. The MTP health sector objectives are to:


1. Reduce under-five mortality from 120 to 33 per 1,000 live births;

2. Reduce the maternal mortality ratio (MMR) from 410 to 147 per 100,000 live births;

3. Increase the proportion of deliveries by skilled personnel from the current 42% to 90%;

4. Increase the proportion of immunized children below one year from 71% to 95%;

5. Reduce the number of cases of TB from 888 to 444 per 100,000 persons;

6. Reduce the proportion of in-patient malaria fatality to 3%; and

7. Reduce the national adult HIV prevalence rate to less than 2%.

The MTP flagship projects for health are rehabilitating health facilities, strengthening the Kenya Medical Supply Agency (KEMSA), fully implementing the Community Strategy, de-linking the health ministry’s from service delivery, building the human resource capacity and developing equitable financing mechanisms.

2.3.1.3. Recap of NHSSP II 2005–2012

NHSSP II outlines the health sector strategies aimed at achieving the national development priorities and the Millennium Development Goals (MDGs). NHSSP II has as its overall goal is to reduce inequalities in health care services and reverse the downward trend in health-related outcome indicators. Five strategic objectives were set for the realization of this goal:

� Equitable access to health services increased.

� The quality and responsiveness of services in the sector improved.

� The efficiency and effectiveness of service delivery improved.

� The fostering of partnerships enhanced.

� The financing of the health sector improved.

The main innovations of NHSSP II in terms of service delivery are the definition of the Kenya Essential Package for Health (KEPH)4 and the re-definition of service delivery levels – most particularly the inclusion of level 1 (community level) services as part of the service delivery units. In order to deliver the essential health services effectively, core support systems to be strengthened are also articulated.

4 Ministry of Health, Reversing the Trends: The Second National Health Sector Strategic Plan of Kenya – The Kenya Essential Package for Health, July 2007.


3. IMMUNIZATION PROGRAMME IN KENYA

The immunization programme in Kenya is currently managed by the division of vaccines and

immunization (DVI). The division has been in existence since 1980 when it was established as

Kenya Expanded Programme on Immunization (KEPI) under the department of the Department

of Preventive and Promotive Health Services of the then Ministry of Health. It was renamed as

the Division of Vaccine and Immunisation (DVI) in 2008 in order to focus on handling of

vaccines and immunization services in Kenya.

3.1. Organogram of Division of Vaccines and immunization

FIGURE 8: ORGANOGRAM OF THE DIVISION OF VACCINES & IMMUNIZATION

DIRECTOR OF PUBLIC HEALTH & SANITATION

HEAD, DEPARTMENT OF

FAMILY HEALTH

HEAD, DIVISION OF VACCINES &

IMMUNIZATION

1

POLICY DIRECTION,

ADVOCACY, TRAINING &

PERFORMANCE MONITORING

0 (1)

COMMODITY SECURITY & QUALITY ASSURANCE 1 (0)

GENERAL ADMINISTRATION 0 (1)

Advocacy

Officers

� Clerical Officers – (1) o Registry

� Secretaries – 1 (0) � Drivers – 3 (1)

� Support staff – 1 (0) LOGISTICIAN – 1 (0)

� Central Vaccine Store Staff – 3 (0)

� Dry Stores Staff – 2 (0)

� Cold-chain maintenance staff – 4 (-1)

Training Officers

1 (1)

Data Officers

5 (0)

Total staff = 24 (3) (Technical- 17 (1) & General – 3 (2)


3.2. Goal of routine Immunization

The goal of the Division of Vaccine and Immunization is to reduce morbidity, mortality and

disability due to life threatening infections due to vaccine preventable diseases.

The Government of Kenya provides vaccines for the vaccine preventable diseases free of charge

through DVI. During the period of this plan, the following diseases have been targeted:

Tuberculosis, poliomyelitis, diphtheria, pertusis, tetanus, hepatitis B, Haemophilus influenza

type b, measles, yellow fever and pneumococcal disease. Rota virus vaccine is planned for

introduction in 2013 subject to availability of GAVI support as the Government has already

expressed intent of introducing this vaccine to GAVI.

3.3. Immunization Schedule for Kenya

Kenya has been expanding its package of immunization in line with advances in technology in

development of vaccines. The table below is a summary of Kenya’s immunization schedule:

Table 3: Current Routine Vaccination Schedule for Children under 1 year

Indicate by an

“x” if given in:

Vaccine

Ages of administration of routine

immunization services Entire

country

Only in

part of

the

country

Comments

BCG At birth X

OPV At birth, 6wk, 10wk and 14wk X SIAs planned for 2011

DPT-HepB-Hib

6wk, 10wk and 14wk X

Pneumococcal vaccine (PCV 10)

6wk, 10wk and 14wk X To be introduced in January 2011

Measles 9 months X Measles SIA planned for 9 to 59 months old in 2012 and 2015

Yellow Fever 9 months X Given in four districts ( Baringo, Keiyo, Koibatek and Marakwet) at high risk of yellow fever


disease. Follow up SIAs planned for 2012

TT Pregnant women, WCBA and School aged children 7to14years

X Given in pregnancy under the 5TT schedule.

SIAs in high risk districts targeting WCBA in 2011

Vitamin A 6m,12m,18m,24m,30m,36m,42m,48m,54m and 60m. Less 6 weeks Postpartum mothers.

X To be integrated with measles/OPV SIAs

Unlike other antigens, Yellow fever vaccine is not administered throughout the country, but in

only four districts that are high risk of yellow fever, whereas additional strategies are used for TT

also in high risk districts. The additional strategies for TT include SIAs for women of child

bearing age (WCBA) districts and School-Based TT immunization activities.


4. IMMUNIZATION SYSTEM COMPONENTS

The immunization system components include service delivery, vaccine supply, quality, logistics, disease surveillance and advocacy, communication and social mobilization.

4.1. Service Delivery

In the next five years, the programme will endeavour to sustain and improve on the gains made

over the years by providing quality immunization services. In Kenya, primarily most of

immunizations take place in fixed posts and the programme will endeavour to re-energise the

outreach strategy within the RED strategy framework and sustain it. In addition SIAs will be

implemented periodically. .

4.2. Vaccine Supply, Quality and Logistics

The EPI programme will ensure that adequate vaccines bundled with injection materials are

procured through WHO/UNICEF approved mechanisms. The Child Health ICC will advocate for

the adequate and timely release of funds, procurement of vaccines and other logistics to be

prioritised to avoid disruption of services. The current storage capacities for both vaccines and

dry store materials at central and regional vaccine stores will be expanded in tandem with the

growing population and range of vaccines.

DVI internal quality assurance mechanisms will in-turn ascertain vaccine quality is maintained to

the point of utilization. AEFI surveillance will be improved through production of guidelines,

adequate tools and specific AEFI training.

Introduction of a computerised stock management system is planned for the regional vaccine

store rooms so as to improve management of vaccines and injection materials. This will require

procurement of computers and accessories. Ongoing projects, such as the construction of the

new DVI headquarters, additional national and regional stores are expected to be completed in

the duration of this cMYP through the support of JICA.

At district and health centre levels, trainings will be conducted to improve stock keeping.

Adherence to vaccine management guidelines and target settings will be monitored during the

period. Transport availability for distribution of the programmes critical logistics will be


improved at all levels through procurement of appropriate types of transport during the plan

period. This will be accompanied with resources for maintenance and other operational costs of

the vehicles. In addition a number of cold-chain equipments will be procured to expand our total

cold-chain capacity. The programme will therefore advocate for adequate resources to achieve

this obligation and also explore other cost effective options for logistics management.

Injection safety and waste management will be strengthened through ensuring continued use of

AD syringes in both routine and supplemental immunization services and proper disposal of

injection materials. National Health Care Waste Management Policy will guide the managements

of Immunization waste. Health workers will from time to time receive training on safe injection

and waste management practices. Since health care waste management has to be tackled in a

broader perspective, the EPI will compliment efforts made by the MOPHS and other

stakeholders by providing support for the construction of incinerators to cover the remaining

District Hospitals to achieve 100% coverage during the planned period.

4.3. Disease Surveillance

The division of disease surveillance and response (DDSR) is responsible for disease

surveillance and response activities, but DVI will liaise closely with DDSR for all vaccine

preventable diseases.

Vaccine preventable disease surveillance data (Polio, measles, PBM and MNT) will be

monitored so as to address gaps in immunization coverage in a timely manner as appropriate.

PBM, Rota virus surveillance will be used to inform the introduction of rota virus vaccine and

meningococcal vaccine.

In this multiyear plan, we hope to maintain or improve the tempo of detection and notification of

AFP, measles, and NNT at current levels efficiently.

4.4. Advocacy, social Mobilization and Communication

Advocacy, social mobilization and communication are very crucial in EPI services. Through the

Child Health ICC and the health SWAp, the programme will lobby for more resources for

effective implementation of the planned activities. Of priority, will be the development and


dissemination of the EPI communication plan informed by the KAP survey. The advocacy plan

will be aligned to the National Health Promotion Policy. As part of the dissemination, health

workers will be trained on the new guidelines. Advocacy meetings will be conducted with

District Health Management Teams (DHMTs) and District Health Stakeholders for more EPI

specific resource mobilization. Key EPI messages will be developed and disseminated through

print media and electronic media both nationally and at local levels where this capacity is

available. Other channels such as drama and community meetings will be encouraged and

strengthened, spearheaded by the CORPs in conjunction with their respective CHEWs. The

quarterly DVI newsletter will continue to be published and distributed to all health facilities and

pre-service health institutions.


5. SITUATION ANALYSIS

This chapter presents the performance of the immunization system components focusing on the status, gaps and challenges over the last five to ten years.

5.1. Routine Immunization Performance, Gaps and Challenges

The figure below shows the trends of immunization showing the trends of coverage of selected

antigens since 1992 to 2009.

Figure 9: Trends of immunization performance for selected indicators, 1992-2009, Kenya

In the 1994 to 1999 the immunization coverage declined significantly. This was as a result of

some key donors pulling out from supporting immunization programme. Kenya has been

showing positive progress from the year 2000 to 2006. However, from the year 2006 to 2009,

there has been downward trend in immunization coverage.


The performance of routine immunization services has been on the downward trend for the last

three years for most of the indicators. The uptake of tetanus toxoid, Pentavalent, measles and

BCG vaccine has been low. The poor performance is attributable to challenges arising within the

immunization program, the health system and beyond the health sector. Such reasons include the

following:

1. Inaccessibility of immunization services because of distant health facilities especially

among the nomadic communities, poor health seeking behaviour of caregivers due to

socio-cultural issues and poor road network.

2. Inadequate finances for purchase of vaccines and immunization operations.

3. Cash flow problems of the allocated funds from treasury to Ministry of Health resulting

to untimely flow of funds despite the timely plans of financial requirements resulting to

delayed implementation of activities.

4. Vaccine stock outs at the service delivery points

5. Limited community participation in planning of health services

6. Shortage of human resource to man the health facilities due to absolute shortage and

mal-distribution of existing health workers in addition to lack of requisite skills,

knowledge and low morale.

7. Lack of quality support supervision by management at all levels compounded by lack of

adequate transport to facilitate movement. Support supervision has been infrequent,

poorly coordinated, unplanned and not evidence-driven

8. Missed opportunities due to limited knowledge and capacity of health care workers on

immunization compounded by negative attitude of health workers. Moreover, the health

workers have not proactive to look for missed opportunities.

9. Increase in the number of districts resulting to inadequate finances and resources for

programmatic management including purchase and maintenance of cold chain equipment.

10. Lack of communication strategy and plan to create demand for immunization services

due to lack of necessary expertise and social profiling.

11. Inadequate human resources at service delivery points to provide immunization services.

The table below summarizes the situation analysis of EPI progress of each system component.


Table 4. Situational analysis of routine EPI by system components based on previous

years' data (2007-2009)

National∗∗∗∗ System

components

Suggested indicators

2007 2008 2009

National coverage of fully immunized child (FIC)

77 71 69

National DPT3/Hib/HepB(Penta3)

coverage

81 72 75

% of districts with > 80% coverage 57 56 58

National DPT1-DPT3 dropout rate 9 14.2 6.3

Routine Coverage

Percentage of districts with dropout rate

DTP1-DTP3>10%

34.6 28.3 34

New vaccines National HepB3 coverage NA NA NA

% of surveillance reports received at

national level from districts compared to

number of reports expected

No data

No data No data Routine Surveillance

Quality of surveillance data sufficient?

(Y/N)

Y Y Y

Cold chain/Logistics

Percentage of districts with adequate

number of functional cold chain

equipment

65 70 72

Percentage of districts supplied with

adequate (equal or more) number of AD

syringes for all routine immunizations

100 100 100

Percentage of districts supplied with

safety boxes

100 100 100

Immunization safety and Waste Management

Percentage of districts with proper sharps

waste management systems

No Data-survey

No Data-survey

No Data-survey

Was there a stock-out at national level

during last year? (Y/N)

Y Y Y

If yes, specify duration in months 3 1/1 3*/1/1

If yes, specify which antigen(s). BCG BCG/OPV

BCG, OPV, Measles

Vaccine supply

Vaccine wastage monitoring at national N N N

∗ It is useful to include the data source for each data set.


level for all vaccines? (Y/N)

Availability of a plan? (Y/N) N N N

Percentage of districts which have

developed EPI communication plans

No data

No data No data

Communication

Percentage of caretakers of children < 1yr

understanding the importance of routine

immunization.

Financial sustainability

What percentage of total routine vaccine

spending was financed using Government

funds?(including loans and excluding

external public financing)

100 100 100

Are a series of district indicators collected

regularly at national level?(Y/N)

N N N Management planning

Percentage of all districts with micro

plans.

No data

No data No data

Research/studies

Number of vaccine related studies

conducted/being conducted

1-PCV 7 trial

1-PCV 7

1-Rotateq

NRA Number of functions conducted-

registration of vaccines to determine

efficacy

0 0 0 7

National ICC Number of meetings held last year-withy

EPI agenda discussed

4 4 4

Percentage of sanctioned posts of

vaccinators filled-no vaccinator cadres in

Kenya

N/A N/A N/A

Percentage of health facilities with at least

1 health worker

60

Percentage of health workers time

available for routine EPI

40 40 40

Human Resources availability

Number of health workers / 10.000

population

11

Transport / Mobility

Percentage of districts with a sufficient

number of supervisory/EPI field activity

vehicles/motorbikes/bicycles in working

condition

100 80 70

Availability of a waste management plan Y Y Y Waste Management

Linking to other Health Interventions

Were immunization services systematically

linked with delivery of other interventions

(Malaria, Nutrition, Child health etc)?

Y Y Y

Programme Timeliness of disbursement of funds to N N N


Efficiency district and service delivery level

Age Antigens provided Coverage 2007

Coverage 2008

Coverage 2009

\

School

Immunization

Activities 7-15 YRS TT, Abendazole 90 %**

**school based TT campaign in Coast Province in 2006/2007

5.2. Polio eradication

After 22 years of being polio free, Kenya unfortunately confirmed wild polio outbreak in Garissa

district in North Eastern province bordering Somalia in October 2006. This was quickly

contained. Another wild polio outbreak was confirmed in Turkana districts, Rift Valley in

January 2009 following importation of wild polio virus from Southern Sudan. A total of 19 cases

were reported. This followed a previous outbreak of wild polio in North Eastern province in

2006 imported from Somalia. Kenya followed the recommendations of the Advisory committee

on Polio Eradication and responded to the outbreaks that were contained at both times.

Kenya has attained the national AFP surveillance indicators although sub-optimal performances

have been reported in some regions. The immunity of the population has been low due to low

immunization coverage of OPV3 which has been declining in the last three years (2007-2009) as

shown in the table below hence putting Kenya at risk of wild polio importation from the

neighbouring countries. This poor performance has resulted from challenges facing the

immunization programme as discussed under routine immunization.

5.3. Accelerated disease control

The immunization coverage of measles and maternal and neonatal tetanus has been declining for

the last 3 years (2007-2009) as shown in table 5. Measles outbreaks have been reported in

various parts of Kenya and 1218 cases were reported in 2009. See table 5 below. So far the about

94 cases of measles (29 lab confirmed, 57 epi-linked and 8 compatible) have been reported from

Jan to Jun 2010, however more than 90% of the cases are above 15years of age (outside the EPI

target group). The reasons for the downward trend in the immunization coverage are discussed in

detail under routine immunization.


Table 5: Situational analysis by accelerated disease control initiatives, Based on previous

years' data (2007-2009)

National∗∗∗∗ System

components

Suggested indicators

2007 2008 2009

OPV3 coverage 76 74 72

Non polio AFP rate per 100,000

children under 15 yrs. of age

2.56 2.23 3.2

Polio

Extent: NID/SNID

No. of rounds

Coverage range

SNID

2

92

SNID

8

TT2+ coverage 78 71 60

Number of districts reporting >

1case per 1,000 live births

NONE NONE NONE

MNT

Was there an SIA? (Y/N) N Y N

Measles coverage 80 76 74

No. of outbreaks reported 262 1280 1218

Measles

Extent: NID/SNID

Age group

Coverage

NID

9-59 mths

83

∗ It is useful to include the data source for each data set.


6. PRIORITIES, OBJECTIVES AND MILESTONES FOR EPI

Based on the situational analysis, the priority activities for immunization programme for the

planned period are the following:

i) Polio eradication

ii) Accelerated disease control

iii) Improving performance of routine Immunization

iv) Supplemental Immunization

v) Improving financial flows

vi) Creating demand of immunization services through evidence-driven advocacy

vii) Improving the capacity of health workers

The table below gives in detail the priority areas, objectives and the milestones. Table 6: National objectives and milestones, AFR regional and global goals

National

priorities

NIP Objectives NIP Milestones

AFRO

Regional goals

Order

of

Priority

To attain immunization coverage (Penta 3) of 90% nationally with at least 80% coverage in every district by 2015

2011: 80 2012: 83 2013: 85 2014:88 2015:90

By 2010 all countries will have routine immunization coverage of 90% nationally with at least 80% coverage in every district.

1 Routine

Coverage

To attain fully immunized child national coverage of 90% by 2015

2011: 70 2012: 75 2013: 80 2014: 85 2015: 90

1

Polio To attain immunization coverage (OPV3) of 90% nationally with at least 80% coverage in every district by 2015

2011: 80 2012: 83 2013: 85 2014: 88 2015: 90

. 1


National

priorities


AFRO

Regional goals

Order

of

Priority

Measles To attain measles immunization coverage of 90% nationally with at least 80% coverage in every district by 2015

2011: 80 2012: 83 2013: 85 2014:88 2015:90

1

TT2 + To attain TT2+ immunization coverage of 80% nationally with at least 80% coverage in every district by 2015

2011: 70 2012: 73 2013:75 2014:77 2015:80

3

Hepatitis B REFER TO DPT 3

2011: 2012: 2013: 2014: 2015:

Hib REFER TO DPT 3

2011: 2012: 2013: 2014: 2015:

Yellow Fever To attain 90% coverage in the high risk districts by 2015

2011: 80 2012: 83 2013: 85 2014:88 2015:90:

5

Rubella To conduct a congenital rubella syndrome baseline survey by 2013

2011: 2012: 2013: 2014: 2015:

9

Vitamin A

Supplementation

To attain 80% coverage (2 doses )of Vitamin A by 2015

2011:45 2012: 50 2013:55 2014:60 2015:80

20

Pneumococcal To attain immunization

2011: 80 2012: 83

1


National

priorities


AFRO

Regional goals

Order

of

Priority

coverage (PCV-10) of 90% nationally with at least 80% coverage in every district by 2015

2013: 85 2014:88 2015:90

Rota To introduce rotavirus vaccine by 2013

2011: 2012: 2013: Introduction of Rotavirus vaccine 2014: 2015:

8

HPV To be advised by RH division

2011: 2012: 2013: 2014: 2015:

Immunization

Safety

To sustain 100% supply of safe injection supplies and practices by 2015

2011: 100% of all districts supplied with safe injection supplies 2012:100% of all districts supplied with safe injection supplies 2013:100% of all districts supplied with safe injection supplies 2014:100% of all districts supplied with safe injection supplies 2015:100% of all districts supplied with safe injection supplies

20

Waste

Management

To provide 100% of the districts with waste disposal mechanism by 2015

2011: 60% of districts with incinerators 2012: 70% of districts with incinerators 2013:80% of districts with incinerators 2014:90% of districts with incinerators 2015:100% of districts

6


National

priorities


AFRO

Regional goals

Order

of

Priority

with incinerators

Surveillance To sustain core indicators for AFP and Measles by 2015 To attain NNT elimination by 2012 and PBM, and Rotavirus indicators by 2015 To prevent outbreaks of vaccine preventable diseases targeted for eradication, elimination and control by 2015

2011: Core AFP, measles indicators achieved by 2011 and sustained: NP: AFP rate: 2.5, Non measles febrile illness: 3.3 NNT incidence: <1/1000 live births? PBM: ?? 2012: Elimination of NNT 2013: to get an appropriate RVS indicator 2014: 2015:

4

Vaccine Supply To attain 100% of districts with no stock outs of vaccines at the district stores by 2012

2011: 80% of districts with no stock outs 2012: 100% of districts with no stock outs 2013: 100% of districts with no stock outs 2014: 100% of districts with no stock outs 2015: 100% of districts with no stock outs

1

Cold Chain /

Logistics

To increase the number of districts with functional cold chain at the district stores from 72% to 95% by 2015 (To be reviewed when the results of cold chain inventory are available by

2011: 75 2012: 80 2013: 85 2014: 90 2015: 95

3


National

priorities


AFRO

Regional goals

Order

of

Priority

October 2010)

Advocacy and

Communications

To develop and implement a communication strategy and plan for immunization in all districts by 2012

2011: Communication strategy and plan developed and disseminated 2012: Implementation of the communication strategy in all districts 2013: Review of the status of implementation 2014: Updated advocacy and communication plan 2015: End term review

7

Management

and Planning

To increase the proportion of districts with immunization specific micro-plans to 100% by 2012

2011: 100% of all districts with immunization micro-plans 2012: 80% of districts will carry out regular quarterly planning, coordination and performance review meetings 2013: 100% of districts will conduct regular quarterly planning, coordination and performance review meetings 2014: 2015:

A 4

Programme

Efficiency

To increase timelines of disbursement of funds from 0% to 100% by 2015

2011: Timeliness of disbursement at 100% 2012: Timeliness of disbursement at 100% 2013: Timeliness of disbursement at 100% 2014: Timeliness of disbursement at 100% 2015: Timeliness of disbursement at 100%

2

Financial

Sustainability

To increase and ring fence financial

2011: Co-financing for pneumo factored in 2011/2012 budget and


National

priorities


AFRO

Regional goals

Order

of

Priority

allocation from 550million to 830million for immunisation activities by 2015

subsequent years 2011: Financial allocation for purchase of traditional vaccines and injection material increased from Kshs. 400million to Kshs.670million 2011: Financial allocation for operations at sub-national level increased from Kshs. 40million to Kshs. 160million 2012: Co-financing for rota virus factored in annual budget of 2012/2013 2013: Availability of sustainability plan for pentavalent, pneumococcal and rota vaccine beyond 2015 2014: Financial allocation for immunization increased in tandem with population growth 2015:

Human

Resources

Management

To increase proportion of health facilities with at least one nurse from 60% to 100% by 2015.

2011: Identify critical HR gaps for immunization and share the with HR department and all partners 2012: Recruitment/deployment of health workers 2013: Sustained human resource recruitment 2014: 2015:

10

Transport To improve service delivery of immunization services through

2011: Inventory of vehicles done 2012: 50% of constituencies with


National

priorities


AFRO

Regional goals

Order

of

Priority

provision of at least one vehicle per constituency

vehicle 2013: 100% of constituencies with EPI vehicle 2014: 2015:

Training and

Supervision

To improve capacity of health workers on immunization in 80% health facilities in every district by 2012 To regularize data driven quarterly EPI supervisory visits by national, provincial and district teams by 2011

2011: Training needs assessment conducted and training materials developed 2011: All newly recruited health workers and poor performing districts trained on immunization 2012: The curriculum of training colleges (KMTC and Medical schools) on immunization revised 2013: Health workers trained on rota virus 2011:Quarterly EPI data driven supervisory visits regularized 2012:

Research /

Studies

To establish the impact of vaccines on the burden of the targeted diseases and burden of disease due to congenital rubella syndrome by 2015

2012: Baseline data on burden of congenital Rubella syndrome 2013: Impact studies of the introduction of PCV10 2015: Impact studies of the introduction Rota virus vaccine.

National

Regulatory

Authority

To establish a mini lab for vaccine quality assurance

2011: Mini lab establishment-link up with NQCL

Linking to Other 2011: Availability of


National

priorities


AFRO

Regional goals

Order

of

Priority

Health

Interventions

To accelerate integrated implementation of high impact child survival interventions to reach all districts by 2015

integrated plans at district level Ensure that all districts prioritize high impact interventions in their annual operational plans. 2012: Joint plans and M&E 2013: 2014: 2015:


7. IMPLEMENTATION PLAN

The focus of the implementation plan is on the core areas that will improve the immunization coverage and control of vaccine preventable diseases. The plan focuses on the following areas:

• Service delivery and programme management

• Advocacy for immunization

• Surveillance

• Vaccine supply, quality and logistics Under service delivery the focus will be on the roll-out of all components of RED strategy and monitor its implementation. Other issues to be implemented are integration as best practices and data management. In order to create demand for immunization services, we will develop and implement an advocacy and communication plan at all levels. Surveillance will be strengthened through improvement of capacity of health workers, enhanced supervisory capacity, improving laboratory capacity in diagnosis and strengthening use of data for action. Vaccine supplies, quality and logistics will be improved through guaranteed availability of quality vaccines and injection materials, expansion of the cold capacity, improved efficiency of the supply chain and vaccine distribution, improved vaccine handling and storage and effective waste management. The tables 7, 8, 9 and 10 below provide detailed strategies and activities to achieve the objective.


Table 7: Service delivery and Programme Management

National Objective

Strategy Key Activities

Strengthen static health facilities and institutionalize outreach in priority areas

Conduct quarterly review meetings at national, provincial and district levels

Conduct monthly defaulter tracing

Hold quarterly community stakeholders meetings

Conduct monthly data analysis and dissemination meetings at each level

Roll out of RED /DQS in districts that contribute 80% of un-vaccinated children (Health workers quantity and quality, increasing cold chain equipment, dedicated vehicle to ensure availability of logistics) refer to tables 2 and 3

Conduct quarterly data verification, validation and written feedback

To attain immunization coverage (FIC, Penta 3, OPV3, Measles and PCV 10) of 90% nationally with 80% of the districts attain 90% by 2015

National child health days [Malezi bora]

Carry out periodic intensification of routine immunization


Implement SIAs for WCBA

To attain TT2+ immunization coverage of 80% nationally with at least 80% coverage in every district by 2015

Implement the 5 TT schedule targeting WCBA within and outside pregnancy using routine and high risk approach SIAs

TT validation






Integrating with routine immunization


To attain 80% coverage (at least 2 doses) of Vitamin A by 2015 in all <1

Using Malezi bora Carry out periodic intensification of routine immunization



To increase immunization coverage of yellow fever from 13% to 90% in the high risk districts by 2015

Roll out of RED/DQS





Training of health workers

Sensitize and supervise health workers on the administration of two vaccines together

Follow up immunization of

yellow fever

To conduct follow up immunization campaign of high risk population

Constitution and launch of the national steering committee, technical coordinating committee and sub-committees

Planning for pneumococcal introduction

Development of district micro plans

Develop a budget and mobilize resources for introduction of PCV-10

Lobbying for sustained annual financial increment for co-financing commitment for vaccine procurement

Resource mobilization

Source for technical and financial assistance from partners

Conduct cold chain inventory

Develop a cold chain replacement and expansion plan

Commodities, supplies and logistics

Distribution of vaccines and other supplies to all levels

Development of training materials Build human resource capacity Training of health workers

Develop, print and distribute communication materials

Conduct stakeholders sensitization meetings at all levels

Advocacy and communication

National, provincial an district launch

Revise, print and distribute all data collection tools

Pre, during and post introduction monitoring

Conduct catch up campaign in two districts (Bondo and Kilifi)

To introduce ten valent pneumococcal conjugate vaccine (PCV-10) by 2011

Monitoring and evaluation

Conduct AEFI study

Constitution and launch of the national steering committee, technical coordinating committee and sub-committees

To introduce rotavirus vaccine by 2013

Planning for Rota virus vaccine introduction

Development of district micro plans


Develop a budget and mobilize resources for introduction of rota virus vaccine

Resource mobilization

Lobbying for sustained annual financial increment for co-financing commitment for vaccine procurement

Source for technical and financial assistance from partners

Conduct cold chain inventory

Develop a cold chain replacement and expansion plan

Commodities, supplies and logistics

Distribution of vaccines and other supplies to all levels

Development of training materials Build human resource capacity

Training of health workers

Develop, print and distribute communication materials

Conduct stakeholders sensitization meetings at all levels

Advocacy and communication

National, provincial an district launch

Revise, print and distribute all data collection tools

Pre, during and post introduction monitoring

Conduct catch up campaign in identified sites

Monitoring and evaluation

Conduct AEFI study

Conduct measles follow up SIA

Conduct preventive polio SIAs in high risk districts

Supplemental immunization activities

Conduct TT SIAs in high risk districts

Conduct risk assessment for MNT

To prevent outbreaks of vaccine preventable diseases targeted for eradication, elimination and control by 2015

Determine burden of MNT and prioritize districts for intervention

Carry out MNT validation exercise

Seek approval from child ICC and endorsement from HSCC

Print and distribute the plan to all stakeholders

Dissemination of cMYP

Carry out stakeholders dissemination meeting

To increase the proportion of districts with immunization specific micro-plans to 100% by 2012 Resource

mobilization for Hold monthly immunization technical working group meeting

Develop annual operation plan from cMYP

Develop district micro-plans

Annual update of the cMYP

Monitoring & evaluation of implementation of cMYP

Annual, mid-term and end term evaluation

Prepare an economic evaluation brief on immunization

Develop a costing model for immunization activities

Prepare a resource mobilization information package

Conduct a meeting with high level stakeholders

Evidence driven high level advocacy

Sustainability plan for Penta/pneumo and other new vaccines

Broaden ICC membership to include Ministry of finance etc

Conduct joint planning and coordination meetings

Fostering partnership

Conduct joint review of performance

Mapping of immunization stakeholders and potential funding agencies.

To increase financial allocation for immunization from Kshs 550million to Kshs830million and ring fence financial allocation for immunisation activities by 2015

Resource mobilization at sub-national levels Lobby for increased resources for immunization

from local stakeholders

To increase timeliness of disbursement of funds from 0% to 100% by 2015

Advocacy

Conduct regular consultative meeting with finance and accounts

Conduct immunization HR gap assessment HR gap analysis

Disseminate the HR gap analysis report to all stakeholders

Lobby deployment of HR to critical areas of need

To increase proportion of health facilities with at least one nurse from 60% to 100% by 2015.

Advocacy

Lobby for recruitment of critical HR

Carry out training needs assessment

Revise immunization training materials

To improve capacity of health workers on immunization in 80% of all health

Training of health workers on immunization

Carry out phased training incorporating the


RED/DQS approach targeting all health workers involved in immunization, especially newly recruited staff

facilities in every district by 2013

Review pre-service training curriculum of middle level medical training colleges and medical schools

Conduct transport inventory

Undertake advocacy of district at national, district and constituency levels

To improve service delivery of immunization services through provision of at least one vehicle per constituency

Advocacy at all levels

Review progress of success

Planning of supervisory visits

Prepare immunization supervisory plan

Evidence generation Carry out monthly immunization data analysis

Undertake quarterly EPI focused support supervision

To regularize data driven quarterly EPI supervisory visits by national, provincial and district teams by 2011

Monitoring performance

Give feedback and feed-forward on the findings of the supervisory visit

Conduct a congenital rubella syndrome baseline survey

To carry out a seroprevalence survey of yellow fever and entomological study in high risk districts

To undertake impact study of pneumococcal vaccine introduction

To establish the impact of vaccines on the burden of the targeted diseases and burden of disease due to congenital rubella syndrome by 2015

Impact studies

To carry out impact of introduction of rota virus vaccine introduction

.To accelerate integrated implementation of high impact child survival interventions to reach all districts by 2015

Provide technical support on incorporation of immunization components of the HII

Undertake joint planning, implementation and M&E

Undertake on job training on data management

Conduct periodic DQS at all levels

Conduct monthly data analysis and feedback at all levels

To monitor and evaluate Kenya’s immunization program by 2015

Improve data management

Print and distribute data capture and reporting


Table 8: Advocacy and Communications

National Objective

Strategy

Key Activities

Do a KAP survey to identify barriers for effective communication

Development of advocacy and communication plan

Develop the advocacy and communication plan

Dissemination of the plan

Identify and train district level focal people in social mapping and use of data for communications

Social and resource mapping, including of underserved populations

Training package developed for IPC skill development of health workers

Media training and partnership development

Prepare communication messages for specific target audience

To develop and implement an advocacy and communication plan for immunization in all districts by 2012

Implementation of the advocacy and communication plan

Monitor the implementation of plan

Table 9: Surveillance

National Objective

Strategy

Key Activities

Carry out cross border surveillance

Undertake quarterly surveillance review meetings at all levels

Improve sensitivity of surveillance system

Carry out risk assessment/analysis

Carry out on job training during support supervision at all levels

Training of newly recruited health workers and the new DHMTs

Strengthen the capacity of health workers on surveillance

Scale up IDSR roll out

Production IEC

Stocking of polio and measles lab reagents and equipments

Supply of essential laboratory, data documentation and communication materials

Print and distribute data capture tools

Conduct monthly data harmonization meeting

tools

Validation of EPI performance

To undertake EPI coverage survey

Vaccine safety Carry out AEFI monitoring


data quality

Timely submission of surveillance data

Table 10: Vaccine supply, quality and logistics

National Objective

Strategy Key Activities

Conduct comprehensive cold chain assessment at all levels

Develop and implement a cold chain maintenance plan

Planning for cold chain equipments

Develop a cold chain replacement and expansion plan at national level

Increasing cold chain capacity

Procure cold chain equipments

To increase the number of districts with functional cold chain at the district stores from 72% to 95% by 2015 (To be reviewed when the results of cold chain inventory are available by October 2010)

Secure budget for the procurement of cold chain equipments

Lobby for funding from GOK and partners

Conduct accurate vaccine forecasting at national and district levels to ensure uninterrupted supply of vaccines

Develop a procurement plan

Develop a quarterly distribution plan in line with shipment plan

Planning for vaccines and other supplies

Provide adequate and well functioning transportation system to all districts

Lobby for adequate finances for vaccines and other supplies through high level advocacy

Secure funds for purchase of vaccines

Ring fencing funds for vaccines and other supplies

Procure vaccines on time

Fasten clearance of vaccines after arrival in the country

Install stock management tool at all level

Efficient vaccine management and distribution of vaccines at all levels

Decentralize vaccine distribution mechanism to improve vaccine availability at the lower level

Train logisticians and health workers on vaccine handling and storage at all levels

Improve vaccine handling and storage Improve bundling of vaccines and diluents

Monitor vaccine wastage at all levels

To attain 100% of districts with no stock outs of vaccines at the district stores by 2012

Reduce vaccine wastage to recommended levels

Develop communication system to improve reporting of wastage

Capacity Disseminate health care waste management


guideline to all levels strengthening of health care workers on health care waste management

Train newly recruited health care workers on health care waste disposal

Construct at least one incinerator in each district

To attain 100% of the districts with waste disposal mechanism by 2015

Provide safe methods of waste disposal Construct at least a waste disposal pit in each

health facility

Conduct accurate forecasting for AD syringes and safety boxes at all levels

Develop a procurement plan

Develop a quarterly distribution plan in line with shipment plan

Planning for AD syringes and safety boxes

Provide adequate and well functioning transportation system to all districts

Lobby for adequate finances through high level advocacy

Secure funds for purchase of injection and safety devices Ring fence funds

Procure AD syringes and safety boxes on time

Fasten clearance of vaccines after arrival in the country

Install stock management tool at all level

Efficient supply and distribution of AD syringes and safety boxes at all levels Decentralize distribution mechanism

Train logisticians and health workers at all levels

Implement AD bundling policy with every vaccine in every district

Improve district reporting on AD use

To sustain 100% supply of safe injection supplies and practices by 2015

Improve handling and storage

Train the providers on safe injection practices


8. COSTING, FINANCING AND FINANCIAL SUSTAINABILITY

8.1. Costing and financing methodology

The success of the programme largely depends on adequate financing for all proposed activities

to be undertaken during the planned period. It will be the responsibility of DVI through the

Ministry of Public Health and Sanitation to ensure that the programme gets adequate financial

and material support both locally and internationally. In this section, we review the cost

implications of the proposed programme activities, and relate these to the known available

finance for respective cost categories of the programme to derive information relating to

financial gaps. The cMYP includes a series of interventions, which have associated activities,

and inputs needed to actualise. These are illustrated in the Table 11 below.

Table 11: Inputs to different EPI systems components

System

Components

Inputs Activities

Service delivery Human resources/salaries, outreach per diems, fuel for transport, operation costs for campaigns

Training, workshops, outreaches, SIAs, Supervision, Monitoring and Evaluation

Advocacy and

communication

IEC materials, radio, print media advertisements etc.

Social mobilization, IEC, developing advocacy and communication plan

Surveillance Surveillance equipment, laboratory networking and reagents etc.

Surveillance meetings and activities (sentinel sites, outbreak investigation), case investigation and follow-up.

Vaccine, supply,

quality and

logistics

Vaccines, AD syringes, safety boxes, other injection supplies, cold chain equipment, vehicles, spare parts, incinerators etc.

Monitoring, vaccine stock management activities

Programme

Management

Procurement of land and construction of KEPI HQs, computers, office supplies.

Meetings, planning, research, data management, EPI reviews, cold chain assessment.


The above listed activities and inputs are what are costed. The costs for the programme are

derived in a variety of costing methodologies, depending on the interventions planned. These

include:

• The ingredient approach, based on the product of unit prices, and quantities needed each

year, adjusted for the proportion of time used for immunization. This is used for costing

inputs such as vaccines, personnel, vehicles, cold chain equipment, etc.

• Rules of thumb, which are based on immunization practice, such as a percentage of fuel

costs as representative of maintenance costs for vehicles. This is used for deriving costs

for injection supplies, and maintenance of equipment, and vehicles.

• Past spending, where lump sum past expenditure is used to estimate future expenditure.

For example, past cost per child for specific campaigns, training activities etc.

These different approaches are all brought together in a pre-designed cMYP excel costing tool

and derived costs based on the following components:

• Vaccines and injection supplies

• Personnel costs (EPI specific and shared)

• Vehicles and transport costs

• Cold chain equipment, maintenance and overheads

• Operational costs for campaigns

• Programme activities, other recurrent costs and surveillance

• Other equipment needs and capital costs

• Overhead costs.

8.2. Macroeconomic Information

For purposes of placing the costing and financing information into wider financing framework,

some macroeconomic information has been included. This information is detailed in the Table 12

below. The GDP per capita has been fixed at the 2010 levels though this may increase with time

but has been fixed for planning purposes. The Government health expenditure is expected to

increase in line with the government’s plans and agenda to improve health care service and

health care delivery in line with Kenya vision 2030 which recognises health as an important

pillar for development and industrialisation of Kenya.


Table 12: Macro Economic Trends in Kenya, 2010 – 2015

YEAR 2010 2011 2012 2013 2014 2015

GDP per capita $ 738 $ 738 $ 738 $ 738 $ 738 $ 738

Total health expenditures (THE) per capita $ 33 34.0 35.0 36.0 37.0 38.0

Government health expenditures (GHE) as a % of THE 35.0% 38.0% 42.0% 48.0% 50.0% 60.0%

National health accounts figures are available from the WHO NHA website

http://www.who.int/nha/country

8.3. Cost projections 2011-2015 for immunization programme

The projected cost of the programme in the planning period (2011-2015) is $378 million

dollars. The cost will increase from 2010 to 2015. The major cost drivers are routine

recurrent costs, new vaccines, personnel and traditional vaccines continue to dominate all

other costs of the immunization program in the years of the cMYP. The introduction of

pneumococcal vaccine in January 2011 and Rotavirus vaccine in January 2013 will lead to a

rapid increase cost of vaccines and therefore an increase in co financing requirement by the

government. The Government is cognisant of these requirements and will ensure funds are

available. To mitigate the increasing cost of vaccines the Government is also converting to a

10 dose liquid formulation of pentavalent vaccine from a 2 dose lyophilized formulation.

This vaccine formulation will reduce costs to the Government and GAVI and also reduce

pressure on our cold chain requirements.

More details on the cost categories are shown in table 13 below.

Table 13: Programme costs and Future Resources Requirements



8.4. Cost profile

Program expenditure in the baseline year was US$ 134.79 million, of which US$134.78 million

is attributable to the routine recurrent program, with just under US$ 12,230 to the supplemental

immunization campaign activities. The expenditure breakdown for the routine immunization

program is further illustrated in the Figure 10 below.

Figure 10: Routine Immunization Programme Expenditure Breakdown


The major cost drivers in the baseline year are new vaccines that contribute 50% of the baseline

cost while traditional vaccines account for 9% the total cost. Personnel account for 19% and

other recurrent costs account for 18% of the total cost. The use of new and under used vaccines

such as pentavalent vaccine and yellow fever vaccine contribute heavily to the cost of new

vaccines. Kenya plans to introduce a 10 dose vial liquid pentavalent vaccine in 2011 and this will

help reduce the cost and cold chain space requirement. This is in anticipation of introducing

pneumococcal vaccine in 2011 and rotavirus in 2013 which will increase the cold chain

requirement and total cost of vaccines.

8.5. Baseline Financing

In terms of baseline financing, Government of Kenya (GoK) contributed 37%. The GAVI

alliance contributed to 46% of the cost and this was due to the cost of new vaccines. Other

partners contributed 17% of the cost. The Government fully financed all the traditional vaccines

and personnel cost associated with giving immunization. GAVI finance was used in procurement

of new and under used vaccines and injection supplies. Other partner contributions were utilized

in the financing of supplementary immunization activities and surveillance and other activities.

A breakdown of the contributions is shown in Figure 11 below.

Figure 11: Baseline Financing Profile


8.6. Cost by immunization strategy

From Figure 12 below, dominant strategy of immunization in Kenya is fixed strategy. Outreach

strategy is the second; while the third strategy is the mobile. Fixed strategies are planned and

expected t increase in line with government plans to increase fixed facilities at all levels.

Outreach will be a strategy for hard to reach and pastoralist communities. Major SIAs are

scheduled to take place in 2012 and 2015.

Figure12: Costs by Strategy


8.7. Projected future resource requirements for immunization from all sources from 2011-2015.

From the figure below, the total costs for immunization programme will increase from about

$95million in 2011 to $120 million by 2015. The requirements will increase significantly from

2011 till 2013 and then plateau till 2015 with marginal increase. This is because Kenya plans to

introduce rota virus vaccine by 2013.

Figure 13: Projection of future resource requirements 2011-2015


8.8. Projected future financing: Secured, probable and gaps for immunization from 2011-2015.

The secured funding for the year 2011 is over $46million and it increases to 91 million by 2015.

The funding gap taking into account secured funds only is approximately 10% of the total needs

and when probable funding is taken into account the funding gap reduces to 8% in 2011 and by

2015 the funding gap is only 2% of the total needs.

The bulk of the funding (secured and probable) is from government of Kenya and GAVI while

WHO, UNICEF and JICA play a big role. Other partners offer programme support and they

include USAID/MCHIP, SABIN, AMP, GSK, Merck vaccine foundation and micronutrient

international make up probable funders. The funding projection s is line with their historical

support to the programme.

Figure 14 and 15 show the financing gaps.


Figure 14: Projection of future financing gap.

Figure 15: The funding gap and selected indicator



Annex 1: Activity timeline 2011-2015

Key activities 2011 2012 2013 2014 2015

Service delivery and Programme

Management

Conduct outreaches in identified priority areas x x x x x

Conduct quarterly reviews meetings at national, provincial and district levels

x x x x x

Conduct monthly defaulter tracing x x x x x

Hold quarterly community stakeholders meetings x x x x x


x x x x x


x x x X x

Carry out periodic intensification of routine immunization

x x x X x

Carry out Vitamin A supplementation in all ECD centers

x x x X x

Conduct regular audits of yellow fever vaccine x x x X x

Constitution and launch of the national Pneumococcal steering committee, technical coordinating committee and sub-committees

x

Development of district micro plans x

Develop a budget and mobilize resources for introduction of PCV-10

x

Source for technical assistance from partners x

Conduct cold chain inventory x

Distribution of vaccines and other supplies to all levels x

Development of training materials x

Training of health workers x

Develop, print and distribute communication materials x

Conduct stakeholders sensitization meetings at all levels x

National, provincial an district launch x

Revise, print and distribute all data collection tools x

Pre, during and post introduction monitoring x

Conduct catch up campaign in two districts (Bondo and Kilifi)

x

Conduct AEFI study x

Constitution and launch of the national Rotavirus vaccine steering committee, technical coordinating committee and sub-committees

x

Development of district micro plans x

Develop a budget and mobilize resources for introduction of rota virus vaccine

x

Source for technical assistance from partners x

Conduct cold chain inventory x

Distribution of vaccines and other supplies to all levels x

Development of training materials x

Training of health workers x

Develop, print and distribute communication materials x


Key activities 2011 2012 2013 2014 2015 Conduct stakeholders sensitization meetings at all levels x

National, provincial an district launch x

Revise, print and distribute all data collection tools x

Pre, during and post introduction monitoring x

Conduct catch up campaign in identified sites x

Conduct AEFI study x

Conduct measles follow up SIA x

Conduct preventive polio SIAs in high risk districts x x x X x

Conduct TT SIAs in high risk districts x

Conduct risk assessment for MNT

Carry out MNT validation exercise x

Seek approval from child ICC and endorsement from HSCC (cMYP)

Print and distribute the plan to all stakeholders x

Carry out stakeholders dissemination meeting x

Hold monthly immunization technical working group meeting

x x x x x

Develop annual operation plan from cMYP x x x x x

Annual update the cMYP x x x x x

Annual, mid-term and end term evaluation x x x x x

Prepare an economic evaluation brief on immunization x

Develop a costing model for immunization activities x

Prepare a resource mobilization information package x

Conduct a meeting with high level stakeholders x x x x x

Sustainability plan for Penta/pneumo and other new vaccines

x x x x

Mapping of immunization stakeholders and potential x

funding agencies Broaden ICC membership to include Ministry of finance etc

x x x x x

Conduct joint planning and coordination meetings x x x x x

. Conduct joint review of performance x x x x x

Lobby for increased resources for immunization from local stakeholders

x x x x x

Conduct regular consultative meeting with finance and accounts

x x x x x

Conduct immunization HR gap assessment x x x

Disseminate the HR gap analysis report to all stakeholders

x x x

Lobby deployment of HR to critical areas of need x x x x x

Lobby for recruitment of critical HR x x x x x

Carry out training needs assessment x x x

Revise immunization training materials x x x

Carry out training targeting newly recruited health workers and in prioritized districts

x x x x x

Review pre-service training curriculum of middle level medical training colleges and medical schools

x x x

Prepare immunization supervisory plan x x x x x

Carry out monthly immunization data analysis x x x x x

Undertake quarterly EPI focused support supervision x x x x x

Give feedback and feed-forward on the findings of the supervisory visit

x x x x x


Key activities 2011 2012 2013 2014 2015 Conduct a congenital rubella syndrome baseline survey x

To carry out a seroprevalence survey of yellow fever and entomological study in high risk districts

x

To undertake impact study of pneumococcal vaccine introduction

x

To carry out impact of introduction of rota virus vaccine introduction

x

Select high impact interventions HII at the districts x

Develop of operation of high impact intervention x

Undertake joint planning, implementation and M&E x x x x x

Undertake on job training on data management x x x x x

Conduct periodic DQS at all levels x x x x x

Conduct monthly data analysis and feedback at all levels

x x x x x

Print and distribute data capture and reporting tools x x x x x

To undertake EPI coverage survey x

Carry out AEFI monitoring X x x x x

Annex 2: Annual operational plan 6 (AOP 6) Family Health Department DIVISION OF VACCINES & IMMUNIZATION – AOP-6 2010/2011

Responsibl

e Person Timeframe Available

Unfund

ed

Result Area

Interventions/Activities

Q

1

Q

2

Q

3

Q

4

Estimated

cost

Amount Source

Vaccination policy printed and disseminated to stakeholders

Head- DVI X X X X 5,000,000 5,000,000

WHO/

GOK

1. Policy

Formulati

on and

Strategic

Planning

Guidelines on other vaccine preventable diseases produced and disseminated

Quality Control and Commodity Assurance X X X X 6,100,000 6,100,000 WHO 0

Forecasting of routine emergency and new vaccines and injection equipment completed Logistics X 5,000 5,000 GoK 0

Vaccines and injection equipment procured and distributed Logistics X 664,715,135 664,715,135 GoK

National Cold Chain Inventory conducted Logistics X X X X 30,000,000 30,000,000

UNICEF/GOK 0

Additional cold chain equipment installed Logistics x X X X 20,000,000 20,000,000 GoK 0

2.

Security

for Public

health

Commodi

ties

Cold chain equipment maintained Logistics X X X X 6,500,000 6,500,000 GoK 0


Responsibl

e Person Timeframe Available

Unfund

ed

Result Area

Interventions/Activities

Q

1

Q

2

Q

3

Q

4

Estimated

cost Amount Source

Routine immunization data by levels maintained. Data X X X X 50,000 50,000 G.O.K 0

Vaccines monitoring tools procured and distributed

Logistics and Procurement X 32,000,000 32,000,000 GoK 0

Vaccines monthly Physical stock taking Logistics 10,000 10,000 GoK 0 3.

Performa

nce

monitorin

g

National routine immunization module updated. Data X X X X 500,000 0

GOK GAVI WHO 500,000

Districts trained on Target setting , Vaccine forecasting and micro-planning for EPI improvements in 60 poor performing Districts

Data, Training, Logistics X X 11,000,000 11,000,000

UNICEF/GOK

0

Integrated tools for vaccines preventable illness developed.

Data and Logistics X X 200,000 200,000 GoK 0

Data quality self assessment to 154 districts conducted.

Data Training, X X 13,000,000 13,000,000

UNICEF 0

DVI Quarterly newsletter developed and disseminated Data X X X X 1,000,000 1,000,000 GoK 0

Health workers skills on demand creation enhanced. Advocacy X X 8,450,000 8,450,000 WHO 0

Transport, supplies and communication systems efficient

Administration and Procurement X X X X 2,861,667 2,861,667 GOK 0

DHMTs trained in MLM in Eastern and Central Provinces Training X X X X 5,000,000 5,000,000

MERCK

Vaccine

Network/GOK 0

4.

Capacity

strengthe

ning

Media clips prepared and transmitted Advocacy X X X X 1,700,000 1,700,000

GOK/UNICE

F 0

5.

Resource

Mobilizati

on

Annual Work plan and Budget and Preparation of MTEF prepared Head- DVI X 10,000 10,000 GoK 0

6.

Operation

al

research

Batch testing at all levels

Quality Assurance and Commodity Assurance X X X X

2,000,000 0

GOK/WHO

2,000,000

Total X X X X 779,881,802 777,381,802

2,500,00

0


Annex 3: Annual work plan 2011/2012, Division of vaccines and

immunization (Aligned to Government of Kenya planning cycle)

Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

Service delivery and

Programme Management

1. Conduct outreaches in identified priority areas

High risk district/Health facilities

X

X X X X X X X X X X X

2. Carry out Vitamin A supplementation in all ECD centers

X X X X X X X X X X X X

3. Conduct monthly defaulter tracing

Health facilities with defaulters/unvaccinated children


4. Conduct quarterly reviews meetings at national, provincial and district levels

All district

X X X X

5. Hold quarterly community stakeholders meetings

Health facility/ community


6. Conduct monthly data analysis and dissemination meetings at each level

All levels X X X X X X X X X X X X

7. Conduct quarterly data verification, validation and written feedback

National/district X X X X

8. Carry out periodic intensification of routine immunization (Malezi Bora)

All health facility catchment areas

X X

9. Conduct regular audits of yellow fever vaccine

4 high risk districts X X X X X X X X X X X X

10. Constitution and National level-


Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

launch of the national Pneumococcal steering committee, technical coordinating committee and sub-committees

August 2010

11. Development of district micro plans for pneumococcal vaccines

Districts-October 2010

12. Develop a budget and mobilize resources for introduction of PCV-10

National-October 2010

13. Source for technical assistance (Training, Communication and Cold Chain/Logistics) from partners

National-August 2010

14. Conduct cold chain inventory

All levels-October 2010

15. Distribution of vaccines and other supplies to all levels

All levels-Oct 2010

16. Develop PCV-10 training materials

National-August/Sept 2010

17. Train health workers PCV-10

All levels-Oct. 2010

18. Develop, print and distribute communication materials for roll out of PCV-10

All-Nov 2010

19. Conduct stakeholders sensitization meetings at all levels for introduction of PCV-10

All levels-Nov 2010

20. National, provincial and district launches for PCV-10

Nov 2010

21. Revise, print and distribute all data collection tools that include PCV-10

All levels Oct-Nov 2010


Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

22. Pre, process and post introduction monitoring and evaluation


23. Conduct catch up campaign in two districts (Bondo and Kilifi)

24. Conduct AEFI study 25. Conduct cold chain

inventory

26. Distribution of vaccines and other supplies to all levels


27. Conduct preventive polio SIAs in high risk districts

X

28. Conduct risk assessment for MNT

Sept. 2010

29. Conduct TT SIAs in high risk districts

High risk districts X

30. Seek approval from child Health ICC and endorsement from HSCC (cMYP)

National-August 2010

31. Print and distribute the cMYP plan to all stakeholders

All levels-October 2010

32. Carry out stakeholders dissemination meeting

November 2010

33. Hold monthly immunization technical working group meeting

National X X X X X X X X X X X X

34. Develop annual operation plan from cMYP

National-September 2010

35. Annual update the cMYP

National X

36. Annual, mid-term and end term evaluation

Annual X

37. Prepare an advocacy economic evaluation brief on immunization and present to policy and planning team,

National-September 2010


Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

38. Develop a costing model for immunization activities and use for advocacy

October 2010-March 2011

X X X

39. Prepare a resource mobilization information package and present to policy and planning team

National

X

40. Conduct a meeting with high level stakeholders

X

41. Conduct regular consultative meeting with finance and accounts

X X

X

X

42. Develop sustainability plan for Penta/Pneumo and other new vaccines

X X X X X X

43. Broaden ICC membership to include Ministry of finance etc


44. Conduct joint planning and coordination meetings


45. Conduct joint review of performance

National/Province/District

X

46. Map immunization stakeholders and potential funding agencies.

All levels-starting with National

X X X X

47. Lobby for increased resources for immunization from local stakeholders



48. Conduct immunization HR gap assessment

National level

49. Disseminate the HR gap analysis report to all stakeholders

National level

50. Lobby deployment of HR to critical areas of need

National level

51. Lobby for recruitment of critical HR

National level


Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

52. Carry out training needs assessment


X

X

X

X

53. Revise immunization training materials

National level

54. Carry out training targeting newly recruited health workers and in prioritized districts

55. Review pre-service training curriculum of middle level medical training colleges and medical schools

56. Prepare immunization supervisory plan

57. Carry out monthly immunization data analysis

58. Undertake quarterly EPI focused support supervision

59. Give feedback and feed-forward on the findings of the supervisory visit

60. Conduct a congenital rubella syndrome baseline survey

61. To carry out a sero-prevalence survey of yellow fever and entomological study in high risk districts

62. To undertake impact study of pneumococcal vaccine introduction

63. To carry out impact of introduction of rota virus vaccine introduction

64. Select high impact interventions HII at the districts

65. Develop of operation


Funds availabl

e

Act

ivit

ies

Consolidated and

Integrated

activities

Where

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Unit

resp

onsib

le

Cost$

Govern

men

t.

Part

ners

Short

fall

of high impact intervention

66. Undertake joint planning, implementation and M&E

67. Undertake on job training on data management

68. Conduct periodic DQS at all levels

69. Conduct monthly data analysis and feedback at all levels

70. Print and distribute data capture and reporting tools

71. To undertake EPI coverage survey

72. Carry out AEFI monitoring


Activities

Wh

ere J

uly

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Un

it r

esp

on

sib

le

Cost$

Advocacy

and

communicati

on

73. Do a KAP survey to identify barriers for effective communication

74. Develop the advocacy and communication plan

75. Dissemination of the plan

76. Prepare communication messages for specific target audience

77. Monitor the implementation of plan

Activities

Wh

ere

July

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Un

it

Cost$

Surveillance

78. Undertake quarterly surveillance review meetings at all levels

79. Carry out risk assessment/analysis

80. Carry out on job training during support supervision at all levels

81. Training of newly recruited health workers and the new DHMTs

82. Scale up IDSR roll out 83. Production IEC

84. Stocking of polio and measles lab reagents and equipments

85. Print and distribute data capture tools

86. Conduct monthly data


harmonization meeting

87. Timely submission of surveillance data

Activities

Wh

ere J

uly

Aug

ust

Septe

mber

Octo

ber

Novem

ber

Decem

ber

January

Febru

ary

Marc

h

Apri

l

May

June

Un

it r

esp

on

sib

le

Cost$

Vaccine

supply,

quality and

Logistics

88. Conduct comprehensive cold chain assessment at all levels

89. Develop and implement a cold chain maintenance plan

90. Develop a cold chain replacement plan at national level

91. Procure cold chain equipments

92. Lobby for funding from GOK and partners

93. Conduct accurate vaccine forecasting at national and district levels to ensure uninterrupted supply of vaccines

94. Develop a procurement plan

95. Develop a quarterly distribution plan in line with shipment plan

96. Provide adequate and well functioning transportation system to all districts

97. Lobby for adequate finances for vaccines and other supplies through high level advocacy

98. Ring fencing funds for vaccines and


other supplies

99. Procure vaccines on time

100. Fasten clearance of vaccines after arrival in the country

101. Install stock management tool at all level

102. Decentralize vaccine distribution mechanism to improve vaccine availability at the lower level

103. Train logisticians and health workers on vaccine handling and storage at all levels

104. Improve bundling of vaccines and diluents

105. Monitor vaccine wastage at all levels

106. Develop communication system to improve reporting of wastage

107. Disseminate health care waste management guideline to all levels

108. Train newly recruited health care workers on health care waste disposal

109. Construct at least one incinerator in each district

110. Construct at least a waste disposal pit in each health facility

111. Conduct accurate forecasting for AD syringes and safety boxes at all levels

112. Develop a procurement plan

113. Develop a quarterly distribution plan in line with shipment


plan

114. Provide adequate and well functioning transportation system to all districts

115. Lobby for adequate finances through high level advocacy

116. Ring fence funds

117. Procure AD syringes and safety boxes on time

118. Fasten clearance of vaccines after arrival in the country

119. Install stock management tool at all level

120. Decentralize distribution mechanism

121. Train logisticians and health workers at all levels

122. Implement AD bundling policy with every vaccine in every district

123. Improve district reporting on AD use

124. Train the providers on safe injection practices


Annex 4: Using GIVS framework as a checklist

GIVS

strategies

Key activities Activity included in

MYP

Strategic Area One: Protecting more people in a changing world

Y N Not

Applic

able

New

activity

needed

Strengthen human resources and financial planning

x

Protect persons outside the infant age group x

Improve data analysis and problem solving x

Sustain high vaccination coverage where it has been achieved

X

Strategy 1: Commit and plan to reach everyone

Include supplemental immunization activities x

Assess the existing communication gaps in reaching all communities

x

Engage community members and non-governmental organizations

x

Develop communication and social mobilization plan

x

Strategy 2: Stimulate community demand for immunization

Match the demand X

Micro-planning at the district or local level to reach the unreached

X

Reduce drop-outs X

Strengthen the managerial skills X

Strategy 3: Reinforce efforts to reach the unreached in every district

Timely funding, logistic support and supplies X

Procure vaccines from sources that meet internationally recognized quality standards

X

Ensure safe storage and transport of biological products under prescribed conditions

X

Introduce, sustain and monitor safe injection practices

X

Strategy 4: Enhance injection and immunization safety

Establish surveillance and response to adverse events following immunization

X

Conducting accurate demand forecasting activities

X Strategy 5: Strengthen and sustain cold chain and logistics

Building capacity for stock management X


GIVS

strategies

Key activities Activity included in

MYP

Strategic Area One: Protecting more people in a changing world

Y N Not

Applic

able

New

activity

needed

Effective planning and monitoring of cold chain storage capacity

X

Firm management system of transportation and communication equipment

x

Regular immunization programme reviews X

Operations research and evaluation X Strategy 6: Learn from

experience

Model disease and economic burden as well as the impact

X

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Kenya cMYP 2011-2015 - WHO

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