MINISTRY OF HEALTH MINISTRY OF HEALTH HEALTH · 1 PLPL p P May 2013 Republi c of Benin MINISTRY OF...

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PLPL

p

P

May 2013

R e p u b l i c o f B e n i n

M I N I S T R Y O F M I N I S T R Y O F M I N I S T R Y O F M I N I S T R Y O F H E A L T H H E A L T H H E A L T H H E A L T H

Na t i o n a l A g e n c y f o r I mmu n i z a t i o n a n d P r ima r y H e a l t h C a r e

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CONTENTS

................................................................................................................................................................................. 1

ACRONYMS AND ABBREVIATIONS

I – COUNTRY DATA AND THE IMPACT ON EPI .......................................................................................... 10

1.1 - GEOGRAPHY .............................................................................................................................................. 10

1.2 - DEMOGRAPHY ........................................................................................................................................... 10

1.3 - ECONOMY .................................................................................................................................................. 11

1.4 – EPIDEMIOLOGIC AND SOCIAL AND HEALTH DATA ..................................................................................... 14

1.5 – HEALTH CARE SYSTEM ORGANIZATION ................................................................................................... 15

II – ANALYSIS OF THE SITUATION ............................................................................................................... 18

REVIEW OF EPI 2008, EMI+HERMES 2012 AND THE ANALYSIS OF THE BASIC SITUATION OF EPI HAVE

ALLOWED FOR THE IDENTIFICATION OF SOME WEAKNESSES AND STRENGTHS PER COMPONENTS AS FOLLOWS :18

2.1 – ANALYSIS OF THE SITUATION OF THE OPERATIONAL COMPONENTS OF EPI : ............................................ 18

2.1.1 – Vaccine supply and management ..................................................................................................... 18

2.1.2 – Logistics and quality of vaccines ..................................................................................................... 21

2.1.3 – SERVICE DELIVERY : ........................................................................................................................... 24

2.1.4 - SURVEILLANCE ..................................................................................................................................... 27

2.1.5 - COMMUNICATION .................................................................................................................................. 29

2.2 – ANALYSIS OF THE EPI SUPPORT COMPONENTS ......................................................................................... 31

2.2.1 – Strengthening of capacities ............................................................................................................. 31

2.2.2 - Management ..................................................................................................................................... 33

2.2.3 - Financing .......................................................................................................................................... 37

2.3 - ANALYSIS OF THE IDENTIFIED PROBLEMS, CAUSES AND CORRECTIVE STRATEGIES

BY EPI COMPONENT ....................................................................................................................................... 39

2.3.1 – In comparison to EPI operational components . .............................................................................. 39

2.3.2 - Identified problems, potential causes and corrective strategies related to support components

..................................................................................................................................................................... 46

III - NATIONAL OBJECTIVES AND STAGES, SETTING PRIORITIES 49

................................................................................................................ ERROR! BOOKMARK NOT DEFINED.

3.1 - OBJECTIVES ............................................................................................................................................... 49

3.1.1 – General objective ............................................................................................................................. 49

3.1.2 – Specific objectives by areas ............................................................................................................. 49

Specific objective for the systematic EPI

Specific objective for the decrease in the abandonment rate ...................................................................... 51

Specific objectives for the additional immunization » ................................................................................ 51

"Specific objectives for the epidemiological surveillance activities for EPI target diseases

Specific objectives for injection safety ........................................................................................................ 53

3.2 – SHORT PRESENTATION OF PRIORITY ISSUES, OBJECTIVES AND NATIONAL STAGES .................................... 54

IV- STRATEGY PLANNING BY COMPONENT .............................................................................................. 63

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4.1 – BASIC STRATEGIES .................................................................................................................................... 63

4.1.1 – Strengthening of routine immunizations .......................................................................................... 63

4.1.2 - Organization of additional immunization sessions .......................................................................... 64

4.1.3 – Integrated disease surveillance and response (IDSR) ..................................................................... 64

4.1.4 – Strengthening of funding and community participation .................................................................. 64

4.2 – Support strategies .............................................................................................................................. 64

V - TIMETABLE OF ACTIVITIES AND FOLLOW-UP INDICATORS ..................................................... 66

................................................................................................................ ERROR! BOOKMARK NOT DEFINED.

VI – VACCINE TIMETABLE ............................................................................................................................. 77

6.1 – Immunization timetable and vaccine types.......................................................................................... 77

6.2 – Administration of new vaccines (MenAfriVac, Rota Virus et HPV) .................................................... 78

6.3 – Required quantities for MenAfriVac, Rota Virus et HPV de 2014-2018 ............................................ 79

VII – ANALYSIS OF COSTS AND FUNDING ................................................................................................. 81

7.1 - METHODOLOGY ......................................................................................................................................... 81

METHODOLOGY USED IS ESSENTIALLY BASED ON THE FOLLOWING DOCUMENTS

7.1.1 – Methodology for the calculation of past costs ................................................................................. 81

7.1.2 – Methodology for the calculation of past finances ............................................................................ 82

7.2 – QUANTITY DATA REGARDING COSTS AND FUNDING IN 2012 ..................................................................... 83

7.2.1 – EPI costs in 2012 ............................................................................................................................. 83

7.2.2 – Funding for routine EPI in 2012 ...................................................................................................... 86

7.3 – EPI COSTS AND FUNDING FOR 2014-2018 .......................................................................................... 88

7.3.1 - Methodology ..................................................................................................................................... 88

7.3.2 – NECESSARY RESOURCES FOR THE 2014 – 2018 PERIOD ................................................................. 89

7.4 – 2014-2018 FUNDING ANALYSIS ................................................................................................................. 94

7.4.1 – Analysis based on secure funding .................................................................................................... 94

7.4.2 – Analysis based on secure and potential funding .............................................................................. 96

VIII – STRATEGIES FOR THE IMPLEMENTATION OF CMYP ............................................................... 100

8.1 – ASSETS AND CONSTRAINTS OF BENIN REGARDING FINANCIAL SUSTAINABILITY OF EPI .......................... 100

8.1.1 - Assets .............................................................................................................................................. 100

8.1.2 - Constraints ..................................................................................................................................... 101

8.2 – STRATEGIES AND MEASURES WHICH ALLOW FOR THE MOBILIZATION OF ADDITIONAL RESOURCES ........ 101

.................................................................................................................... ERROR! BOOKMARK NOT DEFINED.

8.2.1 – Strategies for the mobilization of internal resources ..................................................................... 102

8.2.2 – Strategies for the mobilization of external resources .................................................................... 103

8.2.3 –Action plan for the mobilization of proper resources .................................................................... 104

8.2.4 – Strategies and actions for more reliability of resources ............................................................... 110

8.2.5 – Strategies and actions for increasing the effective use of resources .............................................. 112

CONCLUSION ................................................................................................................................................... 119

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ACRONYMS AND ABBREVIATIONS APM : Agency for Preventive Medicine

NAI-PHC : National Agency for Immunization and Primary Health Care

NRA : National Regulatory Authority

BCG : Bacillus Calmette - Guérin

WB : World Bank

CCTM : Cold Chain Technologies Manager

ICC : Inter Agency Coordination Committee

CDC : Centre for Disease Control

CC : Cold Chain

MTEF : Medium Term Expenditure Framework

DHC : Department Hospital Centre

CPED : Centre for Procurement of Essential Drugs

AC : Antenatal Care

SPC : Social Promotion Centre

HC : Health Centre

DHO : Department Health Office

NDEPI - PHC : National Directorate of the Expanded Program on Immunization and Primary Health

Care

DPF : Directorate for Programming and Forecast

PRS : Poverty Reduction Strategy

DFMR : Directorate for Financial and Material Resources

DTP : Diphtheria, Tetanus and Pertussis

DTP/HepB/Hib : Diphtheria Tetanus Pertussis /Hepatitis B/Haemophilus influenzae type b

DVD-MT : District Vaccine Data Management Tool

TEHA : Team for Establishment for Health Area

WCA : Women of Childbearing Age

CF : Community Funding

CDF : Community Development Funds

PW : Pregnant Women

HU : Health Unit

EMI : Effective Management of Immunization

GVSI : Global Vision and Strategy on Immunization

HERMES : Modelling Tool developed by the VMI of Pittsburg University

HPV : Human Papillomavirus

BI : Bamako Initiative

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IVI : Initiative on Vaccine Independence

NID : National Immunization Days

MDEF : Ministry of Development, Economy and Finance

MenAfriVac : Meningococcal Meningitis Vaccine group A

MH : Ministry of Health

WHO : World Health Organization

NGO : Non-Governmental Organizations

II GAP : 2nd Government Action Program

PSHAD : Project for Support of Health Area Development

SAP : Structural Adjustment Program

PIMCI : Program for Integrated Management of Childhood Diseases

EPI : Expanded Program on Immunization

PIP : Public Investment Program

NPHD : National Plan for Health Development

CMYP : Comprehensive Multi -Year Plan

PSHD : Policies and Strategies for Health Development

AFP : Acute flaccid paralysis

HIPC : Heavily Indebted Poor Countries

PHRD : Project for Human Resource Development

GCPH : General Census on Population and Housing

SHS : Strengthening of Healthcare System

SMT : Stock Management Tool

SNIGS : National Health Information and Management System

MNT : Maternal and Neonatal Tetanus

WAEMU : West African Economic and Monetary Union

UNICEF : United Nations Children’s Fund

USAID : United States Agency for International Development

YFV : Yellow Fever Vaccine

MV : Measles Vaccine

TV : Tetanus Vaccine

OPV : Oral Poliomyelitis Vaccine

HA : Health Area

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COMPREHENSIVE MULTI-YEAR PLAN TEAM 2014-2018

Ministry of Health:

� Mr SOSSOU A. Justin GSM/MH � Dr BASSABI ALLADJI N’deye Marie GD/NAI-PHC � Dr DJIDONOU K. Justin NAI-PHC � Dr TOKPLONOU Evariste NAI-PHC � Dr GANSE Célestin NAI-PHC � Dr BEDIE KOSSOU Sonia NAI-PHC � Dr AFFO SAKA Yolande NAI-PHC � Mme MAMA SAMBO CISSE Assia NAI-PHC � Mr SEGLA Faustin NAI-PHC � Mr GBADAMASSI Salami NAI-PHC � Mr KOUGBLA Crespin NAI-PHC � Mr AMAGBEGNON Joseph NAI-PHC � Mr DOSSOU Thierry NAI-PHC � Mme AGOSSOU Martine NAI-PHC � Dr GLELE KAKAÏ Clément NDPH � Mr ADE Adrien NDPH � Mr RADJI Suradjou DPF � Mr HOUSSOU Venance DPF � Mr KAKPOSSA Jules DFMR

Ministry of Economy and Finance:

� Mr VIYOU Georges DGB/MEF

Technical and Financial Partners:

� Dr SOSSOU Aristide Rock WHO/Benin � Mr SATOULOU Alexis IST WA Oouagadougou � Dr HASSAN Jacques UNICEF/Benin � Mr DICKO Hamadou Modibo APM

Civil Society:

� Dr OSSENI Raïmi Safiou EPI Foundation of Benin

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FOREWORD

Since 1987, Benin has implemented the strategies necessary for revitalizing the health system at the periphery, establishing in this way the broad outline of the Bamako initiative meant to meet the health needs of the population. The reorganization of the primary health care system, which had as a starting point the Expanded Program on Immunization, was strongly supported by the development partners – this being the goal of the Expanded Program on Immunization, integrated in the Primary Health Care (EPI – PHC). Faced with the new challenges of a world in continuous change, that has a better control of the dangers that threaten children, due to the discovery of new vaccines, the cost for the implementation of quality services is constantly growing. In order to grant the Benin children permanent access to these quality services and, accordingly, to their survival, in the context of proper reforms meant to reach this goal, the Health and Finance Ministers have developed, in a tight collaboration with the Development Partners, a new Comprehensive Multi-Year Plan for Immunization (CMYP) 2014 – 2018; the year 2013 being the last year of the implementation of the CMYP 2009 – 2013. In Benin, the EPI has always been considered a priority. Therefore, being aware of the urgent need for ensuring its sustainability, and given the new vaccines and the additional costs, the EPI partners, namely GAVI, continue to support the Government’s efforts to provide access, at an affordable price, to these vaccines. Indeed, the introduction of these new combined vaccines facilitates not only the management of the Program within the health institutions, but also the management of the doses that are to be given per family. The renewal of the Comprehensive Multi-Year Plan for Immunization is of utmost importance for the children’s survival. That is why the Government has taken great care in its preparation. This has been discussed within the Inter Agency Coordination Committee for the EPI (ICC – EPI). Similarly, it has been subject to a critical and constructive review by the technical staff of the bilateral and multilateral agencies. The Government would like to take the opportunity in the presentation of the Comprehensive Multi-Year Plan to express its gratitude towards GAVI as well as the Technical and Financial Partners, for the efforts undertaken, in order to ensure the provision of quality vaccines for Benin. The Health and Finance Ministers of Benin solemnly commit on behalf of the Government

to implementing the current multi-annual plan and their signature hereby attests it. Health Minister Finance Minister

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INTRODUCTION

The elaboration of the third CMYP for 2014-2018 has been a participative exercise,

conducted exactly like the first two CMYPs. That is why it is important to recall that, in order

to continue to implement the GVSI, Benin has participated in two regional workshops for the

training of the teams in the African francophone countries. The first workshop took place in

Ouidah, in November 2011, and focused on the use of the cost analysis tool for the

continuation of the funding for immunization. The second one focused on monitoring the

funding, the supply and the management of the vaccines, was meant for the financial, supply

and management staff in charge, and was held in June 2012 in Grand-Bassam (Ivory Coast).

The training, during these two workshops, focused on the comprehension, completion and

management of the CMYP Costing Tool. The work plan established at the end of these two

workshops served as a basis for the National Agency for Immunization and Primary Health

Care (NAI-PHC).This, together with the support of health development partners, conducted

the process of elaboration of the CMYP for Benin for the period 2014 - 2018.

The team in charge of elaborating the CMYP has reviewed the document, and that was

the review of the first draft. Two workshops have been organised afterwards for the staff, for

the NAI-PHC, for some of the technical management of the Ministry of Health, of the

Ministry of Finance and of the EPI Foundation of Benin.

The first workshop focused on the analysis of the situation and partly on the analysis

of the costs of financing. During the second workshop the first draft was reviewed and the

analysis of the costs of financing was finished.

The outcomes of the workshops were strengthened by the work done by the team in

charge of elaborating the CMYP, after some exchanges with the partners and with their

colleagues from other management offices in the Ministry. The relevant remarks made by

them were taken into account when the document was finalized.

According to the GVSI, the National Directorate of the Expanded Program on

Immunization of Benin was transformed in 2011 into the National Agency for Immunization

and Primary Health Care; on the one hand, this was done in order to have a bigger number of

persons benefitting from the vaccination, by expanding it to other age categories besides

infants, and, on the other hand, in order to provide financial autonomy to this structure.

Taking into account this development, and the need to continue introducing other new

vaccines, it was essential to elaborate the third CMYP for the period 2014 – 2018.

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The present document introduced to the signatory members of the Inter Agency

Coordination Committee for EPI (ICC – EPI) has eight chapters:

o Country data and the impact on EPI;

o Analysis of the EPI situation in Benin;

o National objectives and stages, setting priorities;

o Strategy planning by components;

o Plan of activities and monitoring indicators;

o Timetable of vaccines;

o Cost analysis and financing;

- Previous costs and financing of EPI in 2012;

- Costs and financing of the EPI in the period 2014 - 2018;

o Strategies for the implementation of CMYP.

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I – COUNTRY DATA AND THE IMPACT ON EPI

1.1 – Geography

Benin is a country in West Africa that stretches from Nigeria in the North, to the

Atlantic Ocean in the South. It is bordered by Burkina Faso to the North West, Togo to the

West, and Nigeria to the East. It has a physical area1 of 114,763 km².

It is characterized by flat lands and rocky hills in the Mediterranean part of the

country, whereas the hills get higher and higher all the way to the North, reaching an altitude

of 641 meters (the chain of Atacora). From the North to the South, there are three climate

areas, as follows:

- the dry tropical climate in the North, with a dry season and a rainy season. Epidemics

of meningitis and yellow fever are frequent there;

- the Guinean-Soudanian climate in the Centre, characterized by a tropical and semi-

humid climate;

- the tropical humid climate in the South, with two rainy seasons (from April to June

and from September to October) and two dry seasons (from July to August and from

November to March), with frequent floods in the Southern areas and the risk of outbreaks of

diarrhoeal diseases that come along.

1.2 – Demography

The population of Benin is estimated at 9,671,591 inhabitants2 in 2013 of which

50.87% are women. Children under 5 years of age are estimated at 1,714,148, which accounts

for 17.72% of the total population. About 54.2% of the population lives in the rural areas.

Benin has 12 departments (Atacora, Donga, Borgou, Alibori, Zou, Collines, Mono,

Couffo, Atlantique, Littoral, Ouémé, and Plateau), 77 communes, 546 districts and 3,557

villages or town districts.3A new law passed by the National Assembly on February 18th 2013

increases the numbers of villages to 5, 300.4

1 National Geographic Institute, estimation from 1998. 2 Population forecast on the basis of data from RGPH-3, INSAE, January 2013. 3 Law n° 97-028 from 15th January 1999 4 Law establishing the creation, organisation, responsibilities and functionning of the local and administrative departments of the Republic of Benin.

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Graph N° 1 : The Administrative Map of Benin

1.3 – Economy

According to the 2011 Classification of the Central Intelligence Agency or CIA (CIA

Word Factbook), Benin is ranking 198th, out of 225 countries, according to the GDP. Indeed,

the GDP per capita stood at 1,500 USD, that is 750,000 FCFA in 2011, whereas about one

third of the population of Benin lives under the threshold of poverty.

At the macro economic level, the economic growth rate5 went down from 5% in 2008

to 3.5% in 2012. In the field of health, the budget allocations in nominal value diminished in

5 http://www.statistiques-mondiales.com/taux_de_croissance.htm

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the past 5 years. They went down from 111.354 billion in 2009 to 71.757 billion in 2013

according to table II of the annex.

Moreover, the inflation rate has increased, going up from 2.3% in 2010 to 3.1% in

2012. The rate might reach 5% in 2013. The outstanding debt (in % of the GDP) is on a

descending trend as of 2003, in the wake of the debt relief operations following the HIPC

initiative. Consequently, the resources thus obtained are mainly used for financing the social

sectors (education, health)6.

Tax revenues are on a growing trend as shown in Table III of the annex.

The reform of public finances allowed the Government to strengthen its commitment

to EPI, by initiating, as of 1996, the Initiative on Vaccine Independence (IVI). Along this line,

worth mentioning is that Benin has been funding vaccination of traditional vaccines since

2000, as indicated in the table below:

Table 1a: Development of government contributions and payments as part of the Initiative for Vaccine Independence, Benin, 1995 – 2001 (costs in million)

YEARS 1995 1996 1997 1998 1999 2000 2001

Estimated amounts (in millions of FCFA)

30 30 187.3 299 337 837 837

Government contribution to the procurement of vaccines

0% 10% 50% 80% 90% 100% 100%

Paid amounts (in millions of FCFA)

30 30 187 210 337 837 837

Amount allocated by GAVI

Source: External review of EPI – 2001, MDG.

It is important to stress that Benin has maintained a high level of funding for its

vaccines, in spite of the considerable financial support of GAVI, as shown in the table below.

6 First report on the Millennium Development Goals (MDGs), July 2003.

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Table 1b : Development of government contributions and payments as part of the Initiative for Vaccine Independence of Benin 2002 – 2012 (costs in million)

YEAR 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Estimated amounts (in million FCFA)

878,850 900 900 950 900 950 900

950

821,564

500

500

Government contribution to the purchase of vaccines

67.13% 67.13% 81.47% 29.19% 25.83% 18.79% 23.51%

20.04%

31.14%

16.50%

14.22%

Paid amounts (in millions FCFA)

783,732 295,973 899,390 667 875,190 650 459, 28

792,096

821,564

564,653

429,083

Amount allocated by GAVI

528,500 204,500 1, 617, 750 2,512,250 2, 809,000 1, 493,775 3,159 1,816,477 2, 856, 127 2,588

Exchange rate for the dollar in

2002 – 2007 : 1 $ = 500 F CFA

2008 : 1 $ = 450 F CFA

2009-2012 : 1$ = 480 F CFA

Source: EPI Annual Self-evaluation Report

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1.4 – Epidemiologic and social and health data

The epidemiologic profile of Benin is characterized by the prevailing endemic-

epidemic diseases such as: malaria, diarrhoeal diseases, gastroenteritis, respiratory infections,

anaemia, and certain diseases that can be prevented by immunization. They are measles, the

maternal and neonatal tetanus, and the polio.

The table below presents data about the social and health indicators:

Table 2 : Social and health indicators

Indicators Value

Gross birth rate (GBR) 33.3‰7

Gross death rate (GDR) 8.79‰8

Infant mortality rate (IMR) 60.03‰

Child mortality rate 115‰

Maternal mortality ratio (MMR) 350 death per 100,000 live births

Life expectancy at birth 60.26 years9

Male life expectancy at birth 59 years

Female life expectancy at birth 61.59 years

Total fertility rate (TFR) 4.9 children per woman5

Growth rate 3.5%

The traditional missions of the Ministry of Health have developed, since they have

taken into account the struggle against poverty, and consequently have extended in order to

include ”the improvement of the social and health conditions of families, on the basis of a

system which includes the poor population”. With a view to reach the Millennium

Development Goals for 2015, the Ministry of Health has been trying to improve the

performance of the Expanded Program on Immunization, with the support of its main

Partners. To that purpose, the Government considers increasing the rate of DTP3 estimated by

the WHO and the UNICEF at 85% in 2011 and at 95% in 2018 and the rate of Measles

Vaccine from 72% in 2008 to 92% in 2018.

For the decade 2009 – 2018, Benin has drawn up a national health plan which focuses on

five priority domains as follows:

• Prevention and struggle against this disease and improvement of the quality of health care

• Best use of human resources

7 EDSB-IV 2011-2012 8 www.statistiques-mondiales.com/benin.htm 9 CIA Word Factbook, version of 11th March 2012

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• Strengthening of the partnership in the health sector and promotion of ethics and of

medical responsibility

• Improvement of the health financing mechanism

• Strengthening of health management

1.5 – Health care system organization

In order to achieve these pragmatic goals, the national healthcare system relies on a

pyramid three-tier organization as shown in the table below:

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Table 3 : National healthcare system in Benin in 2013

Levels Structures Hospital and social and health institutions

Central or National

Ministry of Health

- National University Hospital (NUH) - National Centre of Pneumo-Phthisiology - National Centre of Psychiatry - National Centre of Gerontology

Intermediate or Department

Health Department Directorate (HDD)

- Lagune Mother and Child Hospital (LMCH) - Departmental Hospital Centre (DHC) - Centre for Information, Forecast, Listening and Counselling (CIFLC) - Centre for Anti-Leprosy Treatment (CALT) - Centre for Ulcer of Buruli d’Allada and of Pobè - Centre of Pneumo-Phthisiology of Akron

Peripheral

Area Health Office

- Area Hospital (AH) - Health Center (HC) - Centre for Actions of Solidarity and Development of Health (CASDH) - Private health training - TB Detection Centres (TDC) - Village Health Unit (VHU)

Source: DPF/PHC

In addition to public structures, Benin has an important number of private structures and stakeholders of traditional medicine.

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The health area is the peripheral level and it includes the planning, management and

execution operational units of the healthcare system. Benin has 34 health areas and the

government budget resources are directly allocated to them. The health area is the operational

area of EPI.

As far as the Human Resources are concerned, the public health sector of Benin

includes four categories:

(1) Permanent Public Employees (PPE) ;

(2) Contract Staff (CS) who can become PPEs after a four year work period;

(3) Contract Staff employed in a special program called ”Social Action” (SA); and

(4) Contract Staff employed following the Community Financing Funds (CFF).

The last two categories of staff are the most numerous, and the least qualified and they

also lack a career development plan for a long period. This problem is being solved once they

become CSs (State Contract Staff). The main rates of the health care staff are indicated in

table I of the annex.

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II – ANALYSIS OF THE SITUATION

The review EPI 2008, EMI+HERMES 2012 and the analysis of the basic situation in the

10 communes with a poor EPI performance in the South of the country have allowed for the

identification of several weaknesses and strengths per component as follows:

2.1 – Analysis of the situation of the operational components of EPI:

2.1.1 – Vaccine supply and management

Since 1996, financing of vaccines and consumables is mainly provided from the State

budget. Every year, the State purchases traditional vaccines (OPV, MV, TV, BCG) and

contributes to the co-financing of underused vaccines (YFV, Penta) and new vaccines (PCV13),

via the budget line of vaccine procurement and co-financing.

The supply of vaccines is ensured, within the Initiative on Vaccine Independence (IVI) of

Africa, with the support of UNICEF. Thus, vaccines are ordered via UNICEF, with which the

Government of Benin has signed a technical support protocol for the purchase of vaccines and

consumables. However, it is recommended to improve the evaluation mechanisms for vaccines

and the vaccination equipment quality when imported.

At national and intermediate levels, the need for vaccines and vaccine equipment is

estimated by the WHO tools, the SMT « Stock Management Tool » and DVD-MT « District

Vaccine Data Management Tool ». The yearly estimated need for vaccines and vaccine

materials is available at a central level.

At an operational level, the estimated need for vaccines and vaccine materials is not

managed in 5% of the health centres, according to the external EPI review of 2008.

However, mention should be made that not all SMTs and the DVD-MTs are updated. It seems

that the heads of departments do not to have a very good control of these tools in order to carry

out an extensive analysis.

The analysis of the supply and management of vaccines is presented in the table below:

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Table 4 : Analysis of the supply and management of vaccines

Domains Strengths Weaknesses Threats Opportunities

Policy and Strategy

Vaccine Independence and co-financing for vaccine procurement

Existence of a technical support protocol with UNICEF for the purchase of vaccines and consumables

Institution Absence a National Regulatory Authority (NRA)

Organization Existence of exemptions from vaccination

Difficulties in customs procedures for the removal of vaccine consumables

Staff instability

Availability of the TAP to accompany the supply system

Existence of the supply mechanism for vaccines and consumables (FORECAST)

Lack of an emergency plan in case of a flight delay is not estimated

The vaccines arrive always in very good conditions

The papers accompanying the delivery of consumables are not descriptive enough (incomplete description of delivered articles: difficulties in reading the documents, quantity, etc)

The Reception Reports for Vaccines are very well filled out

Vaccine availability at all levels

Computerized vaccine management at national and local levels (SMT and DVD-MT)

Tool not used at its best (SMT and DVD-MT)

Lack of the vaccine management tool (DVD-MT) down to the last level of vaccine distribution (Commune)

Support for vaccine and consumables management

Stock of recorded data not available at health centre level

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(Stock records, A25 and A 26)

Lack of archiving for the management of vaccines and consumables at commune and health centre levels

Insufficient training/refresher courses for the staff involved in the management of vaccines at all levels

Insufficient control over the training for the staff in charge of immunization

Good estimation of the need for vaccines by most of the departments

Knowledge and implementation of the policy of open vials

Environment Existence of a PUSH strategy every 2 months from the national to the department level

Lack of a refrigeration truck (temporarily broken down)

Poor condition of the roads

Existence of a PULL strategy every month from the department level up to the commune level and then to the health centre

Poor storage capacity in certain departments

Social and cultural

A good perspective on the supply system for vaccines and consumables at the operational level

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Economics Existence of a secure national budget line for financing vaccines and consumables

Existence of GAVI funds for the purchase of vaccines

2.1.2 – Logistics and quality of vaccines

The present situation of EPI is characterized by the insufficient cold chain technologies

at the operational and intermediate level, in spite of the efforts currently done for the renewal of

the cold chain technologies. At the same time, there is also a lack of motor vehicles

(motorcycles, cars and motor boats). At a central level, there is a plan for the rehabilitation and

renewal of technologies and this plan is being implemented.

The analysis of logistics and quality of vaccines is presented in the table below:

Table 5 : Analysis of logistics and quality of vaccines


Policy and strategy

Existence of a biomedical waste management document

Institution

Environment Access to the warehouse is easy for loading and delivery of vaccines and consumables

Poor condition of the infrastructure at central level (Buildings, Refrigeration room, Power Generator, etc.)

Unreliable access to electricity

Availability of a RHS fund for the rehabilitation of the buildings of the cold chain and of the consumables

Curative maintenance on demand

Poor condition of the cold chain technologies at operational level (56% of the refrigerators are more than 10 years old)

No regular fuelling of the refrigerators

Availability of skills for the maintenance of the cold chain technologies at national level

Insufficient refrigerators and freezers at the operational level

Use and difficult and expensive maintenance of the

Possibility of using solar refrigerators

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absorption equipment

Insufficient storage space for consumables at the national and department levels, in the event of introducing new vaccines

Training opportunities for specialists in health logistics

Absence of security devices for the warehouses

The existence of a demonstration site for specialists in health logistics (HA Comé) of the LOGIVAC Project

Poor condition of facilities and technologies

Absence of a truck for delivery of consumables

Organization Delivery is every two months according to a very well established and shared schedule

Refrigeration units in the cold rooms not functioning (only one out of two is functioning)

All deliveries have been planned

Storage in the refrigeration truck is not done according to the storage principles

Not a single loss due to exposure to freezing

Lack of an emergency plan for the vaccine delivery team (drivers and nurses)

The staff is knowledgeable about the range of temperatures and about the vaccines sensitive to freezing

Lack of temperature monitoring and mapping

23


Permanent registration of temperature and proper alert system

Absence of control on the use of the automatic temperature metering by several stakeholders at the operational level

Enough storage capacity for negative vaccines

Insufficient storage capacity for vaccines at the level of three departments (Ouémé, Mono, Atacora)

General situation of immunizations in 2012

Lack of a written emergency plan in case of technology breakdown

Evaluation EMI+HERMES & CCEM and strategic guidelines of the Ministry of Health during the September 2012 workshop

Lack of spare parts for the cold chain technologies

Meeting on the rehabilitation of the cold chain

Insufficient surveillance vehicles at all levels

The motorcycles used in the advanced strategy are not in a good condition

Insufficient water vehicles for the lake areas

50% of health units do not have a functional De Monfort incinerator

Insufficient EPI technicians trained for the preventive maintenance of the EPI technologies

No monitoring of motor vehicles at all levels

The condition of the vials of BCG and YFV (20 and10 dose/vials) does not contribute to the loss rate reduction

Inventory of the EPI technologies is not updated

24


Absence of transformers and of power generators for the regional warehouses

Social and cultural

Economics Budget lines for the EPI technologies

Participation of TAP to financing of the EPI technologies

2.1.3 –Service delivery:

Two vaccination strategies are currently in use: the basic strategy and the advanced

strategy. However, some health centres that have poor immunization coverage use the remedial

vaccination campaign. As part of the private sector, the church is mainly responsible for the

basic strategy, whereas the private health units are only rarely involved in it. Similarly, in the

basic as well as in the advanced strategy, all the health centres of the public sector provide

immunization according to a schedule that is not always observed in 50% of the centres because

of the insufficient means of transportation, fuel and even breakdown of the cold chain.

In fact, the EPI deliveries are not provided on a daily basis in all of the health centres.

Similarly, all the EPI antigens are not systematically used with every immunization session, for

fear of increasing the loss rate.

The analysis of service delivery is presented in the table below:

Table 6: Analysis of the service deliveries

Domains Strengths Weaknesses Threats Opportunities Policy, Strategy, Institution

Existence of NPHD Poor knowledge of the policies and strategies at a decentralised level

The Existence of the Poverty Reduction Strategy (PRS)

Absence of policies and strategies at the operational level

Adoption of the Global Vision and Strategy on Immunization (GVSI)

Existence of the immunization decade document

25

Domains Strengths Weaknesses Threats Opportunities Existence of CMYP 2009-2013

Existence of functioning ICC, CNC, CNEP

Organization EPI transformed into an Agency

Lack of a structure under Agency at the intermediate and local levels

Population illiteracy (80%)

Existence of organized groups and NGOs able to help with the immunization

Good health infrastructure coverage delivering the immunization

Lack of a functional timetable at all levels of the health pyramid

Lack of a budget line at the level of local communities to support immunization

Japanese cooperation (reception of the trainees in the health units)

Availability of partners to support the Ministry of Health in implementing its strategy

Insufficient and poorly distributed human resources in the health sector

The extreme weather conditions do not allow access to the immunization targets in all seasons in several regions

Involvement of the private sector in immunization

Staff in the field show poor interest in immunization activities

Geographic challenges facing some localities

Existence of human resources trained for the EPI management

Poor involvement of the community and of the organized groups in the EPI routine activities

Organization of additional immunization activities (NID, Measles monitoring campaign)

Insufficient immunization and surveillance indicators monitoring meetings at a certain level

Poor use of data for decision making at the local level

Existence of the RED approach (SF, SA, Remedial Campaign)

Insufficient planning and implementation of the advanced strategies

26

Domains Strengths Weaknesses Threats Opportunities Existence of a link to the other directorates (NDHC, DPF, DIEM)

Poor support for storage of data on vaccination in health and community units

Organization of training courses on EPIVAC

Department level : SDSP

Existence of EPIVAC network

Peripheral level : person in charge of EPI at communal level

The actors directly involved in immunization are not taken into account by EPIVAC

100% finalization of EPI routine data

Irregular surveillance of proximity

Insufficient small-scale planning of EPI activities at operational level

Economics Existence of funds allocated for the implementation of activities

Irregularities in the use of resources assigned to the medical units

Existence of a financing formula for action plans (equipment and motivation) by the RBF approach

Availability of partners to accompany the RBF

Existence of MTEF Poor use of the financial resources assigned and provided by the peripheral level

Contribution of community financing to the immunization activities

Social and cultural

Community joins immunization activities

Disturbance of the life and habits of the population because of the numerous door-to-door visits as part of NID

Development of a negative perception about immunization

Proximity with the endemic reservoir of WPC

Existence of social technicians (Social anthropologists)

27

2.1.4 - Surveillance

Like many of the countries in the region, Benin has organized an integrated surveillance

of diseases and has responded in all its medical units. However, there are some difficulties in

reporting from the peripheral level up to the intermediate and central levels. The most frequent

difficulties are about the poor transportation, the poor functioning of the Internet connection

and of telephony. The recommendation is to improve the mechanisms for disease detection and

notification of the community, including about the Adverse Reactions to Immunization (case

definition, AFP survey/notification reports, MNT, integrated surveillance reporting for Measles

and yellow fever and tracking of reports).

The comparison with the surveillance of bacterial meningitis indicates that the

department laboratories now have the capacity to making the difference between serotypes A

and C of the germ. Health units have more often resorted to the notification of individual cases

by providing samples of CSF, however, the data in detail are not reported in real time to the

higher levels.

The analysis of surveillance is presented in the table below:

Table 7 : Analysis of surveillance


Policy, Strategy, Institutions

Existence of NSDP Poor knowledge of policies and strategies at the decentralised level

Existence of GSRP

Existence of GVSI

Existence of the document on the immunization decade

Existence of CMYP 2009-2013

Existence of functional ICC, CNC, CNEP

The SMIR, RSI strategy is adopted and updated in Benin

28


Organization Existence of a case-by-case surveillance system of the diseases avoidable by immunization at Agency level

Good mobility of the health staff

Existence of organized groups and NGOs able to help with the surveillance

Good health infrastructure coverage for the implementation of the surveillance

Absence of a functioning timetable at all the levels of the health pyramid

Availability of the partners to support the Ministry of Health with the strategy implementation

Qualified health human resources Insufficient and badly distributed

Existence of surveillance structures at all levels

Lack of interest in the surveillance activities by the staff on the field

Involvement and training of the private health staff in surveillance activities

Availability of a guide for the epidemiological surveillance data

Insufficient monitoring meetings for the surveillance indicators at each level

Existence of areas of interest at all levels

Poor analysis of surveillance data for decision making at the local level

Natural disasters (epidemic, floods)

Involvement of traditional healers in the DEP surveillance

Insufficient planning and implementation of research activities into DEP cases

Involvement of the private sector in surveillance activities

Absence of a job description

Availability of TFPs for technical support

Insufficient investigation of epidemic outbreaks

Absence of a budget line for research into DEP cases at the

29


operational level

Poor documentation on AEFI cases

Economics Existence of allocated funds for the implementation of activities at the operational level

Irregularities in the use of resources allocated to medical units

Persistent economic crisis

Existence of a financing formula of the action plans (equipment and motivation) by the RBF approach

Poor use of the allocated financial resources, including of the community at the peripheral level

Existence of MTEF

Social and cultural

The community joins the surveillance activities

Development of a negative perception about surveillance

Proximity with the endemic reservoir of WPV

2.1.5 - Communication

Communication activities for supporting the development of EPI are coordinated by the

Primary Healthcare Directorate of the NAI- PHC. The external review of 2008 indicated some

irregularities related to the vision and to the implementation of communication activities

benefitting EPI. They refer mainly to the absence of a communication plan for EPI

implementation, to the insufficient skills of the main communication players, and to the fact

that communication activities should not be held only during the immunization campaigns.

The communication strategies included in the comprehensive multi-year plan 2014 –

2018 are inspired from the national policy and strategy paper for health development and are

meant to better target the population by approaching topics that are related to EPI.

Moreover, in order to improve communication there is also need for strengthening

relations of partnership with all the EPI stakeholders, especially at the peripheral level (private

sector, media, community leaders, parents of children, NGOs, associations, etc).

The analysis of communication is presented in the table below:

30

Table 8 : Analysis of communication

Domains Strengths Weaknesses Threats Opportunities Policy, Strategy, Institution

Existence of NPHD

Poor knowledge of policy and strategy papers at the decentralised level

Existence de GSRP

Existence of GVSI

Existence of the document on the immunization decade

Existence of CMYP 2009-2013

Existence of functioning ICC, CNC, CNEP

Existence of a strategic communication plan for EPI

No updated communication plan for EPI

Organization Existence of a timetable for the localities reluctant to immunization

Good mobility of the health staff

Existence of organized groups and NGOs able to help with the communication

Good coverage in health infrastructure

Absence of a functional timetable at all levels of the health pyramid

Existence of proximity radio stations

Qualified human resources insufficient and badly distributed

Availability of partners to support the Ministry of Health in the implementation of the EPI strategy

Existence of communication structures at central level

EPI communication activity less developed by the staff in the field

Use of proximity radio stations in the mass campaigns

31

Domains Strengths Weaknesses Threats Opportunities Existence of major communication points at the central and departmental level

Insufficient training on communication for health and community staff

Absence of a network of leaders to support EPI communication activities

Irregularities in the use of allocated funds for health units

Absence of communication materials for EPI

Economics Existence of a financing formula of the action plans (equipment and motivation) by the RBF approach

Poor use of financial resources allocated and provided at the peripheral level

Persistent economic crisis

Existence of MTEF

Protest demonstrations by the civil society

Social and cultural

Disturbance of the life and habits of the population because of the numerous door-to-door visits as part of NID

Development of a negative perception about immunization

2.2 – Analysis of the EPI support components

2.2.1 – Strengthening of capacities

At the central level, the organization of courses for MLM and EPIVAC provides every

year the training for about ten commune, zone and department doctors on the management of

EPI. Moreover, the training on Health Logistics recently implemented at IRSP (LOGIVAC

Project) is for the staff involved in the logistics management of EPI. Efforts are also being

made for integrating EPI management in the curriculum of schools and health training

institutions.

At the peripheral level, with the help of UNICEF, 350 EPI stakeholders were trained by

NAI – PHC on program management in 2012. There are still many staff members in the field

that are yet to be trained, and this will diminish the motivation of the EPI stakeholders in the

field. Therefore, the program envisages several related activities meant to slightly improve

32

performance. In this context, almost all of the staff at the level of departments, health areas and

communes will benefit from training on all the domains of EPI such as: vaccine stock

management, vaccine handling, injections safety, adverse reactions to immunization (ARI),

waste management, cold chain management (CC), EPI data monitoring, information, education

and communication techniques (IECT) and disease surveillance.

The analysis of the strengthening of capacities is presented in the table below:

Table 9 : Analysis of the strengthening of capacities


Human resources

Availability of the qualified staff in several MUs

Insufficient qualified staff in order to animate all the technical directorates of the NAI – PHC

Availability of the qualified staff on the labour market

Lack of interest of the qualified staff in immunization

Training Organization of the training monitoring

Absence of a career management plan

Abandonment of the job without any notice in order to get training abroad

Existence of grants for training

Insufficient certified training for the paramedical staff

Availability of TFPs to support the training

Existence of training institutions (IRSP, UAC, UP, APM, Dauphine Paris University).

. Lack of training for the assistive personnel

Training « Health Logistics »

Existence of training courses for mid level managers (MLM)

Existence of courses on vaccination for doctors

33

2.2.2 - Management

The general management of the program is delivered at the central level by the team

NAI – PHC with the support of WHO, UNICEF; whereas at the intermediate and operational

levels the persons in charge of the departments and communes are involved. The program

monitoring is carried out in compliance with the surveillance and monitoring mechanism whose

frequency varies according to the hierarchical level.

The National Agency for Immunization and Primary Health Care (NAI – PHC) has all

the tools it needs for providing a better management of the Program. The EPI still remains one

of the PHC components that benefits from a more or less regular supervision from the central

level down to the intermediate level and from the latter down to the peripheral level. However,

there are still some threats, such as debriefing and the implementation of recommendations. The

same goes for monitoring/micro planning, that apparently is not very well controlled nowadays

by some staff members in the field.

The analysis of management is presented in the table below:

Table 10 : Analysis of management

Domains Strengths Weaknesses Threats Opportunities Policy/Strategy Existence of the

Strategic Framework for Poverty Reduction : NPHD 2009-2018 ; CMYP 2009-2013, CSRP 2011-2015,

No finalization of CMYP review for 2009-2013

Political will

Insufficient financial resources for the implementation of advanced strategies on immunization (3/10 communes)

Institution Functioning of entities (ICC, CNEEP, CNC, CDEEP, CODIR, HA Meetings Joint review of performance, COGECS)

Absence of regular eligible meetings

Willingness of the international NGOs and TFPs to support the system

Absence of meetings on the delivery of EPI results to the communities via COGECS

No delivery of the monitoring

34

Domains Strengths Weaknesses Threats Opportunities results to NAI - PHC

Organization Existence of EPI management structures at all levels of the health pyramid down to the community level

Agency not functioning as an autonomous structure (absence of a Management Board )

Some areas are not accessible during the wine production period

Central level: integration of NDEPI into NAI - PHC with a general directorate and 03 technical directorates that have an organization chart

Absence of a person in charge of EPI at HA level

EPI activities are not integrated in the CCDP

Existence of a link with the other directorates (DSME, DPF, DIEM, DNSP)

Delay in the transmission of statistical data to the DPF

Department level: SDSP

Insufficient resources assigned for the functioning of the Agency

Peripheral level : EPI staff member in charge of the commune

Poor involvement of communities

The general directorate has a budget

Poor involvement of private sector actors

Existence of a strategic EPI plan as component of the NPHD and of the SFPR

Inexistence of micro plans at all health unit levels

Interference to the detriment of EPI activities in the field

Absence of financing in order to renew the registers and other data support devices

Planning Existence of staff development plans at

Frequent moves (at the

35

Domains Strengths Weaknesses Threats Opportunities HA level central level)

of the staff members for the EPI activities

Introduction of new immunization registers

Dropout of EPI activities by the qualified staff. These activities are left to the nurses

Monitoring/Evaluation Existence of new monitoring and surveillance tools validated in 2010

Irregularities in the proximity surveillance

The risk of biased decision making process because of data quality/unavailability

Willingness of the private sector to cooperate

Existence of an intervention package of high impact (IPHI) on the infantile and maternal morbidity and mortality

Various motivation practices for the staff involved in the EPI

Under-evaluation of the system performance due to the poor partnership with the private sector

Implementation of TWG for the IPHI and implementation of monitoring/supervision

Existence of an important number of untrained actors

Several training sessions on the monitoring/supervision methodology for staff at the central, intermediate and operational levels

Poor responsibility for private sector data

Social and cultural Religious leaders and opinion leaders share EPI

Existence of NGOs within the framework of social mobilization for EPI

Insufficient financial resources for supporting the contracts with NGOs, local radio stations

36

Domains Strengths Weaknesses Threats Opportunities within the framework of social mobilization for EPI)

Existence of local radio stations and of public speakers

Insufficient educational support for EPI (labels, posters, brochures, guide books)

Availability of community networks to accompany EPI

Lack of motivation of the community networks

Environment Improvement of waste management system for the biomedical waste resulting from immunization (biomedical waste in collected, destroyed, building of incinerators)

Lack of incinerators in some medical units

Existence of staff members in charge of managing biomedical waste

Absence of a maintenance mechanism for the existing incinerators

Absence of storing spaces for the biomedical waste

Difficult access for EPI activities to lake areas (Aguégués, Ouinhi, Sô Ava, Avlo, Karimama and Athiémé)

37

Domains Strengths Weaknesses Threats Opportunities Economics Creation of a budget

line for EPI activities Insufficient budget assigned to the health sector according to the conventions of Abuja (15%) and of WHO (10%) of the GSB

Persistence of the economic and financial global crisis

Political stability

Excellent factor for the mitigating health expenses

Insufficient resources assigned to the EPI

Global economic crisis

Contribution of TPFs, NGOs, Associations, etc.

Severe reduction in the morbidity rate as a consequence of immunization

Inexistence of a specific budget line for immunization at operational level

Gradual annual reduction in the budget assigned to the health sector regarding GSB

Many financial partners

Economic benefits that can be converted into the consumption of taxable commodities in order to obtain economic growth

Extensive dependence on external resources

Budget lines of the local communities for the health system

2.2.3 – Financing

The program has substantial financial support from the State and the partners as

indicated in the tables N° 1a and 1b. The new administrative reforms focused on the health area

as an operational unit, whereas meanwhile the budgets have consequently been decentralised.

However, there is a problem with transparency, since the financial and accounting

documents are not available at all levels. Moreover, the share from the community financing

that has been for a long time been earmarked for EPI activities (fuel purchase, support for

advanced strategies) is presently directed towards other HT needs (refunding the staff for other

activities, various other expenses etc).

The analysis of the financial situation is presented in the table below:

38

Table 11 : Analysis of the financial situation

Domains Strengths Weaknesses Threats Opportunities Mechanisms Purchase of traditional

vaccines by the NB (initiative for vaccine independence)

The Telethon Project

Co-financing of new vaccines with the TFPs

Coverage of the operational costs of routine immunization (NB, TFP, community financing)

Free immunization for the targets

Political stability

Decentralisation of assigned funds

Implementation of TWG financing at the Ministry of Health for definition of national health financing strategies

Procedures Contribution of the TFPs to immunization financing

Mechanism for the management of PFMNN

Lack of sustainability of the HUs

TFPs support for immunization activities

Practices Decentralisation of assigned funds

Prolonged closure of the PFMNN

Gradual increase in the costs of Community Financing

Possibility for the City council to contribute to immunization activities

Delays in reimbursement

Poor financial support by the communes for immunization activities Existence of commune health centres together with the HA that do not have resources to finance the immunization activities for the advanced strategies (Sakété, Adjohoun, Lokossa)

39

2.3 - Analysis of identified problems, causes and corrective strategies by EPI

component

2.3.1 – In comparison to EPI operational components.

In order to implement a response adapted to the problems identified, the following

strategies and activities should be implemented by component.

2.3.1.1 – Vaccine supply and management

Identified problems Plausible causes Corrective strategies

Vaccine quality control is not done after reception

No National Regulatory Authority (NRA)

Advocate for the creation of the NRA

Inadequacy in notifying the arrival of vaccine consumables

Customs procedures for the receipt of vaccine consumables are difficult and cumbersome

Advocate with the Ministry of Finance (customs) for the facilitation of customs procedures

Failure to timely inform the logistics department about any flight modifications regarding the arrival of vaccines

Lack of an alert and signaling system for flight movements

Implementation of an information and debriefing operational mechanism regarding vaccine arrival by air

Insufficient verification and registration of consumables quantities and quality by level

Incomplete description of items to be received (documents and quantities are difficult to read, etc.)

Training of manufacturers of consumables in order to improve descriptive devices for early warning and delivery as well as for those accompanying the delivery of consumables

Insufficient management of vaccine and injection material stocks

Inadequate monitoring of vaccines and consumables

Consolidation of management capacities for stocks of vaccines and consumables Regular monitoring

Less than optimal usage of tools (HOM and DVD-MT)

Non computerized vaccine management (DVD-MT) at health area levels Stock sheet data at health center level are not available

Vaccine and consumables management data at community and health center level are not archived

Insufficient training of agents involved in vaccine management at every level

Insufficient training monitoring of agents in charge of immunization

Failure to observe department supply

Refrigeration truck in disrepair and broken down

Implementation of the renewal plan for equipment

40


frequency for vaccines and consumables at national level

Poor storage capacity in certain departments

and fleet Accelerate the capacity to improve process for cold chains

2.3.1.2 – Logistics and vaccine quality


Frequent technology breakdown (cold stores, refrigerators, freezers, diesel generators, air conditioners, etc.)

Deterioration of technology at central level (buildings, cold room, generator, etc.)

Rehabilitation of the national storage facilities

Deterioration of cold chain technologies at operational level (56% of freezers are over 10 years old.)

Replacement of absorption technology by solar technology, with or without batteries

No updating for EPI technology inventory

Lack of information regarding the current situation (quantities, functionality) of EPI technology

Implementation of a dynamic inventory management system (CCEM)

Insufficient storage space for consumables at national and departmental level, in order to introduce new vaccines

Consolidation of storage capacities

No personal protection and security equipment at the level of national and departmental storage units

Equipment initially not included in the plan

Ensure the sufficient supply of personal protection and security equipment, in sufficient quantity and quality

Lack of trucks for the distribution of consumables

Strengthening of EPI management capacities

Lack of a waste collection system for waste resulting from vaccine and consumables packaging at central level

Poor management of such waste at national level

Frequent and sometimes simultaneous breakdowns of two refrigeration units per cold room

Deterioration of refrigeration units Lack of backup engine

Rehabilitation of national warehouse equipment by supplying a reserve stock

Lack of monitoring studies regarding temperature and temperature mapping

Ignorance of techniques by operators

Training of agents in charge of EPI logistics regarding the use of metering devices Lack of skills regarding the

proper usage of automatic temperature recording by some of the operational staff

Insufficient monitoring after training courses on metering device usage

41


Poor vaccine storage capacities at the level of three departments (Ouémé, Mono, Atacora)

Lack of cold rooms

Installation of cold rooms in Atacora/Donga

Purchase of cold rooms for Mono and Ouémé.

Lack of transformers /controllers and power generators for the 7 warehouses

Purchase of transformers/controllers and power generators for the 7 warehouses

Lack of a written emergency plan in case of equipment breakdown

Drafting and implementation of emergency equipment repair plans

Frequent breakdown of technologies in the cold chain

Repair maintenance for the CC equipment not always performed Lack of spare parts for the cold chain technologies

Purchase of spare parts for cold chain technology Providing preventive maintenance of cold chain technologies

Irregular monitoring of officers and advanced strategies

Vehicles used for advanced strategies are in disrepair Insufficient surveillance vehicles at all levels Insufficient small boats and motor boats for lake areas

Strengthening of fleet capacities of the NAI-PHC Application of the renewal plan for vehicles, motorcycles, small and motor boats

50% of all medical units have no De Monfort incinerator in operation

Lack of a waste removal plan

Drafting and implementation of a waste removal plan

Irregular preventive maintenance of EPI technologies

Insufficient EPI agents trained in preventive maintenance

Training of EPI agents in the field of preventive maintenance

High loss rates The condition of BCG and YFV vials (20 and 10 doses/vial) is not favorable

Training of agents on the application of the open vial policy

42


for the reduction of loss rates

43

2.3.1.3 - Service provision


Hardly any knowledge regarding policy and strategy documents at decentralized level

Failure to adequately comprehend institutional policy and strategy documents at operational level

Production and distribution of existing institutional policy and strategy documents

Low vaccine coverage (Penta3=74%, VAR/YFV=70%) according to EDS4

Lack of interest in immunization activities by field operatives

Implementation of the RED approach, highlighting the consolidation of advanced strategies and active research of treatment defaulters with the efficient involvement of the community

Poor involvement of the community and organized groups in EPI activities Insufficient planning and implementation of advanced strategies

Poor use of decision making support at local level Lack of monitoring meetings regarding immunization and surveillance indicators Bad archiving practices for immunization data at the level of medical units and health records held by mothers

Irregular proximity surveillance

Insufficiently qualified and distributed human resources

Poor data quality regarding immunization

Incorrect transcription of data from one environment to another

Regular validation of coverage data at all levels

No command of the target population by field operatives

Inherent demotivation of immunization operators on the field

Failure to apply career management plans for agents Training and refresher

courses for all agents Irregular training on surveillance

Stagnation of immunization service usage rates

Disturbance of the life and habits of the population following the multiple door-to-door visits by NID agents

Raising population awareness

44

2.3.1.4 - Surveillance

Problems Causes Corrective strategies

17% of the villages failed to communicate at least 2 AFP cases for 100,000 children at least 15 years of age in 2012

Few agents trained in notification

Training of new agents under DEP supervision in villages High mobility of trained staff

Lack of decision-making surveillance data at local level

Lack of interest for surveillance activities by field operatives

Integrate surveillance in the monitoring guide

Lack of involvement by the community and organized groups in surveillance activities

Raising community and organized groups awareness

Lack of monitoring meetings regarding surveillance indicators by level

Regular indicator monitoring meetings

Insufficient active research into DEP cases (measles, yellow fever, AFP)

Lack of planning regarding active researches

Include DEP active research in the PTA Absence of a budget line for the

research of DEP cases at operational level

High positivity rate of measles cases (60%)

Failure to observe case definition guides

Ensure that training on surveillance becomes regular Insufficient investigation of

epidemic centers Negligent attitude of responsible agents

Poor notification rates of AEFI

Negligent attitude of responsible agents

Raising agent awareness regarding AEFI management

45

2.3.1.5 - Communication

Problems Causes Corrective strategies

Only a few number of mothers are familiar with the immunization calendar, DEP and AEFI

Insufficient EPI communication channels

Drafting and implementation of an integrated communication plan for child survival based on the EPI routine, campaign and surveillance

Poor involvement rates of organized communities

Absence of an EPI communication plan

More and more frequent reluctant attitudes regarding immunization in certain villages, especially in mass campaigns

Lack of knowledge regarding

the diseases for which children

receive immunization

Insufficient training on

communication for health staff

and community agents

Lack of a specific

communication plan at NAI-

PHC level

Insufficient forms of education

regarding routine immunization.

Poor involvement of community

groups, religious, faith-based

organizations, non-government

organizations in communication

regarding the EPI

Drafting and

implementation of a specific

EPI communication plan.

Marketing for the EPI

Collaboration with the other

sectors (education, rural

development) in order to

promote immunizations.

Campaigning for

immunization activities by

local elected representatives

and religious leaders

Insufficient budget for funding EPI communication activities

Lack of budget lines for EPI communication activities at local level

Include in the PTA a budget line for communication activities

Use of community funding reserved for EPI activities in general for other purposes

Re-direct community funding towards EPI activities

Insufficient dissemination of DEP case definitions throughout the community base

2.3.2 - Identified problems, potential causes and corrective strategies related to support components

2.3.2.1 –Strengthening of capacities

Problems

Potential causes

Corrective strategies

Immunization activities are carried out by non-qualified staff in several medical units (72% of the immunization activities are carried out by assistive personnel)

Insufficient qualified staff to animate immunization services

Re-distribution of qualified staff Training of new EPI management agents

Incorrect distribution of qualified staff

Most members of the staff prefer urban areas to the detriment of rural areas

Motivate the agents who activate in rural areas.

The assistive personnel do not benefit from sufficient training courses for their career development

Failure to implement the career management plan

Update the career management training plan

Insufficient preventive

maintenance for cold chain

technologies

50% of immunization agents have received no training regarding EPI management

Draft and implement an EPI management training plan which involves the private sector

Lack of motivation for the staff involved in immunization activities

Advocate for the extension of RBF to include all Health Areas

Lack of motivation of community support networks due to insufficient funds

Certain medical units fail to involve community support networks in immunization activities part of advanced strategies

Insert in the PTA for health areas a line for the involvement of support networks

47

2.3.2.2 - Management

Problems Potential causes Corrective strategies

Lack of functionality for NAI-PHC as an independent structure

Inexistence of a management board

Advocate with MEF in order to make it designate a representative in the management board

Delay by MEF in choosing its representative

Insufficient planning and

budgeting of EPI activities in

health areas

Insufficient management of

statistical immunization data

Poor partnership between the

public and the private sector

within the EPI

Lack of knowledge regarding

planning and budgeting tools

Insufficient coverage of EPI

activities in the PTA

Incorrect storage of EPI data

Insufficient quality of EPI data

Insufficient monitoring of EPI

activities

Lack of a conciliation

background and sharing of

responsibilities regarding EPI

management between the

private and the public sector

No rewarding for the best

agents

Monitoring of plan

implementation at the level

of health areas

Efficient use of newly

provided management data

Regular monitoring of EPI

data

Training on surveillance

Strengthening of the public

and private partnership

(supply of immunization

aides and cold chain

technology)

Implementation and

facilitation of a conciliation

mechanism between the

public and private sector

within the EPI

Integration of a

representative of the private

sector in the ICC

Advocate with the Health

48

Lack of motivation from

staff involved in

immunization activities

Ministry for the promotion

of the best agents involved

in the immunization

process

Insufficient quality of statistical data regarding EPI activities (new monitoring/surveillance tools)

No vaccine coverage investigation between two DHC

Advocate with the TFPs in order to fund the investigation

No EPI external audit (the latest audit was in 2008)

Plan an external audit every three years at national level

Delay in the transmission of statistical data to DPF

Define mandatory data reception delays

2.3.2.3 – Funding

Problems Potential causes Corrective strategies

Insufficient financial resources for the performance of immunization activities at various levels of the health pyramid

The budget allocated to the health sector is still below 10% of the national budget

Advocate for increasing the national budget share allocated to the health sector and EPI

NAI-PHC still fails to generate additional financial resources

Implementation of structures allowing the NAI-PHC to fully benefit from its autonomy

Lack of a specific immunization budget line at operational level

The assigned funds fail to specify a budget line for immunization activities

Introduction in the PTA of a budget line for immunization activities

51% of the public HUs are not financially viable for EPI

Gratuity for a number of health care operations

Transparent management of state subsidies

The depreciation accounts of the CF are no longer supplied with money

The share of community funding reserved for EPI activities is used for other purposes

Illegal selling of essential drugs Consolidate management control for essential drugs

49

III - NATIONAL OBJECTIVES AND STAGES, SETTING

PRIORITIES 3.1 - Objectives

3.1.1 – General objective

Decrease morbidity and infant/child mortality rates due to diseases targeted by the EPI.

3.1.2 – Specific objectives by areas

The proposed areas are the following: i) systematic EPI (vaccine coverage, loss rates),

ii) abandonment rates, iii) additional immunization, iv) surveillance of targeted diseases, v)

injection safety.

Specific objective for the systematic EPI

� Increase national immunization rates for infants from 0 to 11 months old from 48% to

85% by 2018

� Increase national immunization rates for children between 0 and11 months, children

from 15 to 23 months and pregnant women, at national level, to the rates specified in

the table below, by 2018

Lack of funding for renewing registers and other data support devices

No budgeting for the renewal of EPI management tools in the PTA

Introduce tool renewal in the PTA

Advocate with the local elected representatives, NGOs and economic operators for funding immunization activities

50

Table 12: Annual immunization coverage objectives by antigen for 2014 - 2018

(objectives are set based on the current Benin EPI performance levels according to the

objectives set in the previous CMYP and reached in 2012)

Antigens 2014 2015 2016 2017 2018

BCG 98% 98% 99% 99% 99%

OPV3 97% 97% 98% 98% 99%

DTP-HepB+Hib3 97% 97% 98% 98% 99%

MV1 90% 90% 92% 92% 94%

PCV 13_3 97% 97% 98% 98% 99%

HPV3 50% 70%

Rota virus 50%

MenAfriVac 50% 70% 80%

MV 2 (Infants between 15 to 23 months old) 50% 70% 80%

YFV 90% 90% 92% 92% 94%

TV2+ 72% 75% 80% 85% 86%

Vitamin A2 annual doses for infants (6-59

months old) 80% 85% 85% 90% 95%

Vitamin A for mothers (<8 weeks after birth) 70% 75% 80% 85% 90%

Table 13: Annual loss rate objectives (in percentage rates) for 2014 - 2018 Routine immunization

Antigens Desired loss rates 2014 2015 2016 2017 2018

BCG 40% 40% 40% 35% 35% MV 25% 25% 25% 20% 20% OPV 15% 15% 15% 13% 13% DTC-HepB+Hib 15% 15% 15% 13% 13% YFV 25% 25% 25% 20% 20% TV 15% 15% 15% 13% 13% PCV13 5% 5% 5% 5% 5% HPV 15% 15% Rotavirus 5% MenAfriVac 25% 20% 20%

Additional immunization (campaign)

Campaign against polio

10% 10% 10% 8% 8%

Campaign against measles

10% 10%

51

NB: It must be noted that these rates have been set on the basis of the results calculated from

data from the Demographic Health Survey 2011-2012 (EDSB IV), in order to perform a

coverage investigation every year, to allow for a good general view on the immunization

coverage.

Specific objective for the decrease in the abandonment rate

Decrease in the abandonment rate between Penta1 and Penta3 to 10% by 2018 in 90%

communes.

Specific objectives for the “additional immunizations”

Poliomyelitis:

Provide two drops of OPV to every child between 0 and 59 months of age

Ensure immunization for at least 95% of the targeted children during mass campaigns or

information campaigns from 2014 to 2018;

Organize immunization response campaigns against poliomyelitis in areas where wild

poliovirus cases have been detected.

Measles:

Ensure immunization against measles for at least 95% children from 9 to 59 months of age

throughout the entire territory, during monitoring campaigns from 2014 to 2017

Organize immunization response campaigns against measles in outbreak zones.

Maternal and Neonatal Tetanus

Maintain the currently acquired elimination rates for maternal and neonatal tetanus, i.e.

maintain the incidence of neonatal tetanus to less than 1/1000 of live births reporting an

incidence of maternal and neonatal tetanus by year and by commune by 2014;

Organize immunization response campaigns against tetanus around each MNT case found.

Yellow fever:

Increase in the number of communes which report the occurrence of yellow fever from 55%

to 80%

Ensure immunization against yellow fever for at 95% of the target population in high risk

communes by 2018;

Organize immunization response campaigns against yellow fever around any cases discovered

according to the risk analysis.

52

Specific objectives for the “epidemiological surveillance activities for EPI target diseases”

Surveillance objective for AFP: by 2018,

Ensure that 90% of the communes report at least two AFP cases for 100,000 children below

15 years of age in each department;

Reach 80% of AFP cases with two stool specimens during the 14 days, in 90% of the

communes;

Maintain a promptness rate of at least 90 % regarding the monthly reports of the communes.

Surveillance objective for measles, by 2018,

Increase in the percentage of communes that reported at least one case suspected of measles

from 52% to 80%;

Maintain performances for the sampling of cases suspected of measles to 95%;

Decrease in the positivity rate of cases suspected of measles and then confirmed by the

laboratory from 57% to 10%;

Investigate 100% of the detected measles epidemic centers.

Surveillance objective for maternal and neonatal tetanus (MNT)

Investigate 100% of MNT cases detected;

Organize community-based surveillance of MNT cases with the help of the community

support networks.

Surveillance objective for yellow fever, by 2018,

Increase in the percentage of communes reporting at least one case suspected of yellow fever

from 55% to 80%;

Sample at least 80% of the cases suspected of yellow fever

Surveillance objective for pneumococcal infections

Ensure immunization for at least 91% of the target population by 2018

Sample and analyze at least 80% of the LCR samples in each health area;

Surveillance objective for the rotavirus.

Ensure immunization for at least 50% of the target population by 2018;

Decrease morbidity and mortality rates due to rotavirus infections.

53

Surveillance objective for meningitis A:

Decrease in the high mortality rate (currently above 10%) due to meningitis A;

Supply the adequate testing reagents to 100% of the meningitis laboratories of the operational

level;

Fit all epidemiologic surveillance centers with a uniform mask (EPI INFO)

Specific objectives for injection safety

Provide 100% risk-free injections by 2018;

Decrease in the AEFI to less than 1/1,000,000 by 2018;

Report at least 80% of AEFI cases occurring in medical units;

Investigate and assume control over at least 90% of serious AEFI cases reported by medical

units;

Ensure the disposal of used vaccine equipment according to the applicable standards

(incineration) in all communes by 2018;

Maintain high availability of auto-disable syringes and safety boxes, in sufficient quantities,

in all medical units providing vaccination services by 2018.

54

3.2 – Short presentation of priority issues, objectives and national stages

Prioritization of issues at this level is accompanied by the characteristics of the identified issues, the EPI objectives at national level and regional /

world goals of the GVSI. The table below proposes a short presentation, by major EPI component, of the priority issues and objectives to be reached

by stage in order to reverse the current trend.

Table 14: National priorities, EPI objectives and stages, regional/world goals and priority orders

Component: Supply

Priority Issues EPI/IDSR Objectives EPI Stages / Benchmarks

GVSI Regional/World Goals (by 2015) Priority Order

The management of vaccines and inputs is not optimal at every level of the health pyramid

Increase the percentage of health centers showing a good management of vaccines and consumables from 65% to 100%

2014: 65% 2015: 74% 2016:83% 2017:92% 2018:100%

Guarantee access to immunization and their quality: Every individual who has the right to immunizations envisioned by the national programs should receive such immunization through guaranteed quality vaccines and in compliance with the national timetables in force. Training of all agents involved in EPI Surveillance (Strategies 8 and 9 of GVSI)

2

55

Component: Logistics



Insufficient storage

space at central,

intermediate and

peripheral levels

with a view to

introducing new

vaccines.

Increase the cold rooms storage capacity of the central warehouse from 60 m3 to 200 m3 by 2018 Increase the vaccine storage capacity in health centers from 66% to 100% by 2018.

2014: 80 m3 2015: 160 m3 2016: 200 m3 2014: 66% 2015: 76% 2016: 86% 2017: 93% 2018:100%

Guarantee access to immunization and their quality: Every individual who has the right to immunizations envisioned by the national programs should receive such immunization through guaranteed quality vaccines and in compliance with the national timetables in force. (Strategies 6, 7, 8 and 9 of GVSI)

2

56% of the

communes lack a

surveillance vehicle

in a good operating

condition

Increase the percentage of communes that own an operational surveillance vehicle from 44% to 74%

2014: 44% 2015: 51% 2016: 58% 2017: 65% 2018: 74%

Maintain vaccine coverage. Vaccine coverage rates reached in 2010 according to the set objective will be maintained

1

48% of the

motorbikes used for

advanced strategies

are not in a good

operating condition.

Increase the availability of motorbikes used for immunization in advanced strategies by health centers by 2018 from 52% to 100% (or purchase 707 motorbikes)

2014: 52% 2015: 64% 2016: 76% 2017: 88% 2018: 100%

Only 43% of the

medical units have a

functional Montfort

incinerator

Increase the percentage of medical units that own a functional Montfort incinerator from 43% to 80% by 2013

2014: 43% 2015: 50% 2016: 60% 2017: 70% 2018: 80%

All national immunization plans will be designed as a component of sector plans for human resource development, funding and logistics

3

56

Component: Provision of services



Low vaccine coverage (Penta3=74%, MV/YFV=70%) according to EDS4

Reach Penta3 vaccine coverage (DTP+HepB+Hib)>90% at national level and >80% in all communes and for other antigens after investigations, by 2018

2013: 74% 2014: 80% 2015: 85% 2016: 90% 2017: 95% 2018: 100%

Maintain coverage. Vaccine coverage achieved in 2010 according to the set objective will be maintained.

Implementation of the RED approach with a

focus on the consolidation of advanced

strategies and active research of treatment

defaulters with the efficient involvement of the

communities.

Reintegration of immunization in schools

Involvement of private individuals

1

Component: Surveillance



- High rate of measles - High positivity rate in measles cases (60%)

Decrease in the occurrence of measles cases from 30 to less than 5 cases for 1,000,000 individuals by 2018

2013: 30 cases 2014: 25 cases 2015: 20 cases 2011: 15 cases 2012: 10 cases 2018: 5 cases

No later than 2015, all countries will have had the necessary means of disease surveillance and prevention by vaccine, at all levels, based on the identification of cases with laboratory confirmation if necessary, in order to measure the CV exactly and to put to good use the data

2

57



Poor notification of

AEFI

Make sure that 50% of trainings report AEFI cases by 2018

2014: 10% 2015: 20 % 2011: 30% 2012: 40% 2018: 50%

thus obtained

No commune

submits detailed

meningitis data in

real time

Fit all epidemiologic surveillance centers with standardized EPI INFO input mask by 2018 Fit all epidemiologic surveillance centers with internet connections

-

58

Component: Communication

Priority Issues EPI Objectives EPI Stages / Benchmarks


A small percentage of mothers who are aware of the immunization timetable, DEP and AEFI

Increase in the percentage of parents of children from 0 to 5 years of age aware of target diseases and the EPI vaccine timetable from 68% to 80% by 2018

2013: 68% 2014: 72% 2015: 74% 2016: 76% 2017: 78% 2018: 80%

Drafting and implementation of a

communication plan specific for the EPI.

(strategy 22 GVSI: Better communication and

better dissemination of information)

1

More and more frequent reluctance to immunization in certain communes, especially during mass campaigns

Decrease by 2/3 (33) the reluctance areas

2013: 50 2014: 43 2015: 36 2016: 29 2017: 23 2018: 17

. At world scale, morbidity and mortality of infants due to diseases which can be prevented by vaccines will have diminished by two thirds at least in comparison to the similar rates in the year 2000.

59

Component: Funding



Insufficient financial resources for the implementation of immunization activities at various levels of the health pyramid

Increase in the EPI internal funding from 35 % to 40% by 2018

2013: 35% 2014: 36% 2015: 37% 2016: 38% 2017: 39% 2018: 40%

Ensure sustainability. All national immunization plans will be designed, will be awarded budgets and will be carried out while making sure that the human resources, funding and supplies are sufficient.

2

Lack of a specific immunization budget line at operational level

Advocate with the DFMR in order to obtain a budget line for immunization activities by 2018

2

51% of the public

HUs are not

financially viable for

EPI

Have 100% of the management teams monitoring the depreciation accounts

2014: 60% 2015: 100% 2016: 100% 2017: 100% 2018: 100%

60

Component: Management


GVSI Regional/World Goals (by 2015)

Priority Order

Insufficient planning and budgeting of EPI activities in the health areas

100% of the health areas plan for and make budgets regarding EPI activities at the level of the health areas

2014: 60% 2015: 70% 2016: 80% 2017: 90% 2018: 100%

Ensure sustainability. All national immunization plans will be designed, will be awarded budgets and will be carried out while making sure that the human resources, funding and supplies are sufficient.

1

Insufficient management of statistical immunization data

Make sure that 100% of the medical units provide good archiving for the EPI data

2014: 60% 2015: 70% 2016: 80% 2017: 90% 2018: 100%

Make sure that 100% of the communes provide good quality EPI data

2014: 60% 2015: 100% 2016: 100% 2017: 100% 2018: 100%

Make sure that 100% of the communes correctly monitor the EPI activities

2014: 60% 2015: 100% 2016: 100% 2017: 100% 2018: 100%

Involve 80% of the private structures in EPI activities

2014: 60% 2015: 65% 2016: 70% 2017: 75% 2018: 80%

Lack of motivation of the staff involved in

Make sure that 100% of the communes assume responsibility

2014: 60% 2015: 100%

Ensure sustainability. All national immunization plans will be designed,

61



Priority Order

immunization for the immunization agents in advanced strategies

2016: 100% 2017: 100% 2018: 100%

will be awarded budgets and will be carried out while making sure that the human resources, funding and supplies are sufficient. Make sure that 100% of the health

areas (with the help of NAI) can promote all EPI model agents

2014: 60% 2015: 100% 2016: 100% 2017: 100% 2018: 100%


statistical immunization

data

Publish a monthly magazine with EPI data in 100% of the health centers by 2018

2014: 100% 2015: 100% 2016: 100% 2017: 100% 2018: 100%

62

Component: Strengthening of capacity



Priority Order

Immunization activities are

carried out by non-qualified

staff in several medical

units (72% of immunization

activities are carried out by

assistive personnel)

Increase in the training level of assistive personnel involved in immunization activities from 15 to 100% by 2018

2014: 60% 2015: 70% 2016: 80% 2017: 90% 2018: 100%

Every individual who has the right to

immunizations envisioned by the

national programs should receive

such immunization through

guaranteed quality vaccines and in

compliance with the national

timetables in force.

Implementation of the training plan

(Strategy 2 GVSI: Increase

immunization demand within the

community) (Strategy 18 GVSI:

Consolidate the data management,

analysis, interpretation, use and

exchange at all levels)

1

Insufficient preventive

maintenance of the cold

chain technologies

Increase in the training level of agents involved in the maintenance of cold chain technologies from 50 to 90% by 2018

2014: 50% 2015: 60% 2016: 70% 2017: 80% 2018: 90%

2


immunization activities

Increase in the training level of agents involved in immunization in EPI management from 45% to 95% by 2018

2014: 55% 2015: 65% 2016: 75% 2017: 85% 2018: 95%

2

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IV- STRATEGY PLANNING BY COMPONENT

Regarding the identified issues, it is essential to perform the appropriate actions in order

to reverse the current trend. For this, the following are needed: implementation of the RED

approach while improving the advanced strategy in order to reach the remotest villages,

strengthening of the EPI management capacities, improve data monitoring and quality,

consolidation of communication activities; social mobilization for immunization and

community participation, strengthening of logistics, involvement of private medical units in

immunization, and collaboration with schools to cover up gaps in immunization.

The new approach relies on the identification of priorities and focusing on specific

objectives, and consists of drafting and implementing policies compliant with the Millennium

Development Goals (MDG)10. Benin MDG report went for mother and child health, and for

fighting against priority diseases. Consequently, the following objectives are set:

o Decrease in mortality rates for children under five years of age from 125/1000 in

2006 to 65/1000 in 2015;

o Improve mother health by decreasing mother mortality rates from 397 in 2006 to

125 in 100,000 live births in 2015.

o Fight HIV/AIDS, malaria and other diseases by diminishing the prevalence of

IST/HIV/AIDS, control of malaria and other important endemics so that the

current trends are reversed by 2015.

Two types of strategies are envisaged.

4.1 – Basic strategies

4.1.1 – Strengthening of routine immunizations

Every child must receive the required vaccine doses before their first year and the

second MV dose by 15 months of age, according to the timetable in force. Immunization

sessions are organized based on different strategies:

- Daily immunization in designated locations in all medical units;

- Immunization for every contact after the verification of the immunization situation of

the child, according to the PIMCI directives;

- Advanced strategy in every commune more than 5 km away from a medical unit,

according to a timetable established with the population of these communes;

- Active research for children not brought in by their parents, with the help of community

support networks;

10 Annual health sector magazine, PHM, June 2004.

64

- Activities of exploration (mass immunization sessions in low vaccine coverage areas or

in areas where the poliovirus, the measles virus or the tetanus bacillus can be detected).

4.1.2 – Organization of additional immunization sessions

The organization of additional immunization sessions as national or local

immunization days and of special campaigns is focused on high risk regions, towns and

populations as recommended by the World Health Organization (WHO). It is a complementary

strategic approach used to reach world objectives regarding the eradication, the control and the

elimination of priority diseases.

4.1.3 – Integrated Disease Surveillance and Response (IDSR)

It consists of:

Reporting cases and deaths due to diseases with epidemic potential (DEP);

Collecting and transporting samples;

Investigating reported cases;

Confirming suspected cases by a laboratory;

Organizing vaccine response

Training of surveillance agents and other players according to the IDSR modules.

4.1.4 – Strengthening of funding and community participation

This contributes, among others, to increasing the medical unit go-to rates and the

permanent availability of essential drugs. It also allows for the decrease in the number of

excluded individuals by progressively implementing mutual health and care systems for the

indigenous population.

4.2 – Support strategies

- Implementation of resources to ensure service availability. All possibilities must be

used especially by the state, the local communities, the partners, the community and the

families.

- Implementation of a consolidated logistics system for human and material resources.

The technologies used are accredited by WHO and UNICEF, according to the PIS (EPI material

and technology specification catalogue). Regular monitoring of the 9 vaccine management

indicators.

- Training, surveillance, monitoring, evaluation and operational research, organized in a

systematic and regular manner, are the basis for the implementation of EPI.

65

- Communication aimed at changing the mentality will allow the community to become

involved in all stages, from planning all the way to evaluation. Communication can thus make

best use of the media available to a community, including proximity radio stations.

- Collaboration within and between sectors, especially with other sector programs like

PIMCI, NMCP, NTP etc. This collaboration is strengthened by institutions such as the Inter

Agency Coordination Committee (ICC) for EPI at all levels.

- International cooperation is coordinated within ICC-EPI, which in this way becomes a

management board for national and international resources for immunization, including

resources from the World Fund for Vaccines against major childhood diseases as part of the

Global Alliance for Vaccines and Immunization (GAVI).

66

V - TIMETABLE OF ACTIVITIES AND FOLLOW-UP INDICATORS Vaccine supply and management

Main activities

Year Indicators

2014 2015 2016 2017 2018 Advocate with the Ministry of Health for the creation of the NRA

Existence of a functional NRA (Annual reporting)

Decision of the Minister for the creation of the NRA Fit the NRA with the financial, human and material resources required for its operation

Advocate with the Ministry of Finance for the liberalization of customs procedures

Number of complaints regarding the customs clearance of vaccines and consumables (Annual reporting)

Draft a law for the creation of an information system targeting the exemption from customs taxes for vaccine consumables

Implement an operational information and debriefing mechanism regarding the arrival of vaccines by air

Existence of an emergency plan (Annual reporting)

Draft an emergency plan for the management of flight delays

Training manufacturers of consumables, through partners (UNICEF), to improve descriptive pre-signaling and consumables delivery information

Existence of better information (Annual reporting)

Strengthen agent skills by means of training courses in the management of vaccine and consumables stocks

Percentage of trained agents (quarterly reporting)

67

Main activities

Year Indicators

2014 2015 2016 2017 2018 Ensure quarterly surveillance of the agents involved in EPI management

Percentage of surveillance actions regarding EPI management (Bi-annual reporting)

Purchase a new refrigeration truck

Number of equipment and vehicles supplied/specified (Bi-annual reporting)

Install cold rooms in Atacora/Donga

Purchase a positive cold room for Mono/Couffo and Ouémé/Plateau

Provide vehicles for the communes and health areas

Vaccine logistics and quality

Main activities

Year Indicators

2014 2015 2016 2017 2018 Draft a renewal plan for the CC equipment at central

and departmental levels

Existence of a CC renewal plan (Annual reporting)

Every year, carry out an inventory of the EPI equipment and consumables

Inventory number (Annual reporting)

Draft a renewal and purchase plan for the operational

level

Existence of a renewal plan (Annual reporting)

Implement the renewal plan for equipment and fleet

Percentage of health centers fitted with equipment and fleet (Annual reporting)

Study the results of the LOGIVAC project demonstration in Comé

Available study report (Annual reporting)

68

Main activities

Year Indicators

2014 2015 2016 2017 2018 Implement scenario no. 2 “health area acting as final distribution level for vaccine distribution directly to HC” at national level

Number of health areas ensuring vaccine distribution in health centers (Annual reporting)

Fit the national warehouse and the intermediary warehouses with the necessary storage infrastructure for vaccine consumables

Number of warehouses fitted with adequate storage infrastructure (Annual reporting)

Fit the warehouses with security equipment, namely: fire extinguishers and warm clothing

Number of warehouses fitted security equipment (Annual reporting)

Draft and implement a preventive maintenance plan for buildings and equipment

Number of buildings and equipment under preventive maintenance (Annual reporting)

Purchase a truck for the distribution of consumables

Existence of a truck for the distribution of consumables (Annual reporting)

Outsource waste management at national level to a private company

Waste management contract with an available private company (Annual reporting)

Repair the second refrigeration unit of each cold room.

Number of repaired refrigeration units (Bi-annual reporting)

Purchase pallets for the refrigerating truck

Existence of pallets (Annual reporting)

Draft and implement an emergency plan for the vaccine distribution team (drivers and nurses)

An emergency plan is available (Annual reporting)

Carry out follow-up studies regarding temperature and temperature mapping (twice a year)

Number of follow-up study reports (Annual reporting)

Develop appropriate media for automatic metering devices (temperature reading)

Number of media developed (Annual reporting)

Ensure training of individuals in charge of immunization at the level of communes and HC regarding the use of automatic metering devices

Percentage of trained individuals (quarterly reporting)

69

Main activities

Year Indicators

2014 2015 2016 2017 2018 Install the cold rooms in Atacora/Donga

Existence of cold rooms in Atacora/Donga, Mono and Ouémé (Annual reporting)

Purchase two positive cold rooms for the 2 warehouses in Mono and Ouémé Purchase a transformer /controller for each machine in the CC

Number of CCs fitted with transformers and controllers (quarterly reporting)

Draft the emergency plan in case of equipment breakdown

Existence of emergency plans (quarterly reporting)

Specify the spare parts to be purchased Existence of the specified spare parts (Annual

reporting) Purchase the spare parts from the national budget Purchase vehicles (vehicles, motorbikes, small and motor boats) according to the current needs at all levels

Number of medical units fitted with vehicles (Annual reporting)

Build a De Monfort incinerator in each health center

Number of health centers fitted with an incinerator (Annual reporting)

Ensure agent training on hygiene, EPI focus areas and good practices in waste management

Percentage of agents having received training in good practices for waste management (Annual reporting)

Draft a preventive maintenance plan for the EPI equipment

Existence of a maintenance plan (Annual reporting)

Ensure training for EPI agents regarding good practices in preventive maintenance

Percentage of agents having received training in good practices for preventive maintenance (Annual reporting)

Carry out an analysis of the current situation with the help of the TFP

Available analysis report (Annual reporting)

Ensure training for the CVA and motorbike users (nurses, ancillary nurses, midwives) regarding maintenance of the fleet

Percentage of agents having received formation (quarterly reporting)

70

Main activities

Year Indicators

2014 2015 2016 2017 2018 Ensure agent training regarding the application of the open vial policy

Percentage of agents having received training (quarterly reporting)

Service provision

Main activities

Year Indicators

2014 2015 2016 2017 2018

Draft RED micro-plans in each commune Percentage of communes having RED micro-plans (Bi-annual reporting)

Systematically organize immunization in advanced strategies in each medical unit

Number of advanced strategies devised by medical unit, compared to targeted numbers (Monthly reporting)

Ensure regular formative supervision at all levels

Percentage of supervision activities carried out (quarterly reporting)

Involve the community (structures and others) in the active research for targeted individuals defaulting treatment at the level of each medical unit

Percentage of medical units getting structures involved in active research (monthly reporting)

Motivate the agents involved in the EPI (formative supervision, management of the SA team, etc.)

Percentage of medical units taking charge of agents in SA (monthly reporting)

Ensure quarterly activity monitoring at all levels in order to improve program performance

Number of available monitoring reports (bi-annual reporting)

Plan and perform exploratory activities in low performance areas every 3 months

Number of HAs having organized quarterly such exploratory activities (quarterly reporting)

71

Main activities

Year Indicators

2014 2015 2016 2017 2018

Organize active research of targeted individuals defaulting treatment

Number of targeted individuals defaulting treatment discovered by medical units (monthly reporting)

Organize traininf on the location of assistive personnel involved in immunization

Percentage of assistive personnel trained by the HAs (bi-annual reporting)

Award parents whose children are fully vaccinated

Percentage of targeted children fully vaccinated whose parents have been awarded (MIILD) (quarterly reporting)

Award communes with the best vaccine coverage after investigation

Number of high-performing communes having received a reward (annual reporting)

Send letters of congratulations to deserving agents

Number of deserving agents having received letters of congratulations (annual reporting)

Award training grants scholarships in the public health domain to deserving agents

Number of deserving agents having received scholarships (annual reporting)

Advocate in favor of immunization with the local authorities in order to obtain their support.

Number of health areas where the local elected representatives take part in awareness-raising sessions (quarterly reporting)

Draft the introduction plan for various new antigens (MenAfriVac, HPV and Rotavirus)

Existence of a plan (annual reporting)

Draft and review the channels for the introduction of various new vaccines (MenAfriVac, HPV and Rotavirus)

Existence of reviewed channels (annual reporting)

Train health staff in MenAfriVac vaccine management and introduce it

Percentage of trained health agents (annual reporting)

72

Main activities

Year Indicators

2014 2015 2016 2017 2018

Train health staff in Rotavirus vaccine management and introduce it

Train health staff in HPV vaccine management and introduce it

Organize the evaluation of MenAfriVac

Available evaluation reports (annual reporting) Organize the evaluation of the Rotavirus

Organize the evaluation of HPV

Submit requests to GAVI

Requests submitted to GAVI in due time (annual reporting)

Train health staff in the management of the second MV dose and introduce it

Percentage of trained agents (annual reporting)

Organize the evaluation of the 2nd MV dose introduction

Available evaluation reports (annual reporting)

Organize evaluation sessions regarding surveillance and routine EPI indicators

Available session reports (bi-annual reporting)

Control EPI data quality (DQS/DQA)

Existence of audit reports (quarterly reporting)

Create a directory of hard-to-access areas Existence of zone mapping (annual reporting)

Ensure that health area managers prioritize EPI activities

Percentage of high-performance HA

73

Support components

Management

Main activities

Year Indicators 2014 2015 2016 2017 2018

Advocate at the Ministry of Finance headquarters for the designation of a representative in the management board

Existence of an operating management board

Install the Management Board of the NAI-PHC

Install divisions of the NAI-PHC at intermediate level.

Hold regular statutory meetings of coordination structures at all levels

Existence of eligible meeting reports (monitored depending on level)

Estimate operating costs for the immunization implementation by health area and by level of the health pyramid

Estimation of operating costs available (annual reporting)

Present the CMYP 2014-2018 summary document to players in the MoH during a CNEEP session, for the joint Government-PTF review of the performances of the health sector

Existence of various reports (annual reporting)

Create a formal conciliation background (fundamental texts) for the public and private sector within the EPI

Existence of an operating conciliation background (annual reporting)

Sign twelve contracts with NGOs, 25 with radios and 1 with the TV)

Number of contracts signed (annual reporting)

Obtain community funding from the local communities in view of immunization

Number of health areas where the local elected representatives grant financial support (quarterly reporting)

Spread the CMYP 2014-2018 document around to all players and structures involved

Percentage of players having received the CMYP (annual reporting)

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Main activities

Year Indicators 2014 2015 2016 2017 2018

Monitor the implementation CMYP 2014-2018 (collecting data, regular balance sheet...)

Existence of PTA (annual reporting)

Regularly evaluate the implementation of CMYP 2014-2018 (one evaluation half-way through in 2015, one final evaluation in 2017)

Review of evaluations (five-year reporting)

Organize a discussion around the results of the monitoring/supervision, each semester (July, January) at the level of the department

Feedback reports (bi-annual reporting)

Discuss the monitoring results for NAI-PHC every semester at all levels

Ensure that each health area organizes a coverage investigation every year

Number of HA having performed VC investigations (annual reporting)

Organize an external audit every three years at national level

Review reports (three-year reporting)

Train the EPI team, 34 EEZS and 500 service providers according to the new directives regarding monitoring/ supervision

Percentage of trained agents (annual reporting)

Train staff in charge of statistical data management

Fit staff in charge of statistical data management with computer equipment and motorbikes

Percentage of staff having received new equipment (annual reporting)

Organize data harmonization at department level each semester

Existence data validation reports (bi-annual reporting)

Organize harmonization actions with the DPP, DDS, MCZS in order to acquire the type of community data that must be input into the National Health Information and Management System

Meeting reports (annual reporting)

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Funding

Main activities Year Indicators 2014 2015 2016 2017 2018

Introduce a communication note regarding CMYP together with the related budget in the Council of Ministers (including the additional costs)

Communication note introduced in the Council of Ministers (quarterly reporting)

Organize a day of reflection regarding the situation of medical units lacking economic and financial viability

Existence of reports (annual reporting)

Organize conciliation activities with the Benin Communes and economic operators

Existence of reports (annual reporting)

Regularly feed depreciation accounts at the level of medical units.

Number of medical units having depreciation accounts to date (monthly reporting)

Insert in the PTA a budget line for immunization activities, including equipment renewal

Existence of a provisional budget line with the PTA (quarterly reporting)

Advocate for the application of Result-Based Funding in all health areas

Number of HA which apply the RBF system (annual reporting)

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Strengthening of capacities

Main activities Year Indicators

2014 2015 2016 2017 2018 Advocate with the Ministry of Economy and Finance and with the Ministry of Labor for the recruitment of qualified staff in sufficient numbers

Number of recruited qualified staff (annual reporting)

Define a motivating career plan for the staff members

Existence of career plans (five-year reporting)

Draft a staff formation plan regarding immunization activities

Existence of a formation plan (annual reporting)

Train employed staff in immunization services (12 in vaccination, 250 in MLM and 6 in LOGIVAC) every year

Percentage of trained staff (annual reporting)

Train 50 assistive personnel in EPI management by department, at the level of immunization services, every year

Percentage of assistive personnel trained, by department (annual reporting)

Advocate for the awarding of graduate training scholarships for paramedical staff, with the partners and the Ministry of Health / Ministry of Development

Number of staff having received scholarships (annual reporting)

Advocate for the introduction of EPI management modules in Health Formation Schools in Bénin

Percentage of formation schools with EPI management modules (annual reporting)

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VI – VACCINE TIMETABLE

6.1 - Immunization timetable and vaccine types

Currently EPI gives 10 vaccines for children before their first anniversary: BCG, OPV, DTP HepB + Hib, YFV, MV and PCV13.

Furthermore, the anti-tetanus vaccine is also given to pregnant women

The current EPI vaccine timetable is as follows:

Table 15: Routine EPI vaccine timetable

Age Vaccine type

Birth BCG, OPV

06 Weeks OPV1, DTP-HepB-Hib1, PCV13



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9 months MV, YFV

Pregnant women TV1 at first contact

TV2 one month after and 02 weeks after birth

Immunization will be introduced against meningitis A, rotavirus and HPV during the period of time covered by this CMYP.

This introduction will be progressively entered in the vaccine timetable.

The new vaccines to be introduced will be those recommended by WHO.

6.2 - Administration of new vaccines (MenAfriVac, Rotavirus and HPV)

It is specified that the MenAfriVac will be introduced in the vaccine timetable starting in 2016, and the vaccine against the Rotavirus in

2018. These vaccines will be administered to all targeted children between 0 and 11 months who appear at immunization units as soon as they are

officially opened throughout the national territory, considering that these vaccines are not combined with other vaccines.

The HPV vaccine will be administered to girls between 9 and 13 years of age, namely during their puberty. It is essential that the vaccine

is administered before they have their first sexual intercourse. It will be introduced in the vaccine timetable in 2017, and this introduction

deserves special preparations since the targeted individuals are not the usual individuals targeted by the EPI.

This method of administration, as well as the targeted numbers, will be specified at the right moment, according to the WHO directives.

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6.3 – Required quantities for the MenAfriVac, Rotavirus and HPV vaccines for 2014-2018

� Required quantities of the MV vaccine for menAfriVac

The required quantities below have been calculated with the logistics projection tool based on the following parameters: a target

percentage of 4 % compared to the total population, 1 vaccine dose, a 50% coverage objective for the first year of introduction (2016), a 70 %

coverage in 2017, growing to 80% in 2018; an estimated 25% loss rate in 2016, diminishing to 20% in 2017 and 2018.

Table 16: Required quantities for the MenAfriVac vaccine and consumables

2016 2017 2018

Targeted individuals 326,393 336,837 347,616

Vaccine doses 203,996 294,733 347,616

0.5 ml AB syringes 203,996 294,733 347,616

5ml dilution syringes 20,400 29,500 34,800

5l safety boxes 2,245 3245 3825

The MenAfriVac vaccine will be administered to targeted individuals from 0 to 11 months old during routine immunization throughout

the country.

The MenAfriVac vaccine will be administered in one single intramuscular injection under the left deltoid muscle. The standard dose for

MenAfriVac is 0.5 ml.

� Required quantities for the Rotavirus vaccine

The required quantities below have been calculated with the logistics projection tool based on the following parameters: a target

percentage of 4 % compared to the total population, 3 vaccine doses, a 50% coverage objective for 2018 and an estimated 5% loss rate.

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Table 17: Required quantities for the Rotavirus vaccine

Inputs 2018

Rotavirus (targeted individuals) 347,616

Rotavirus (doses) 547,495

The Rotavirus vaccine is an oral vaccine administered to children from 0 to 11 months of age, as part of routine immunization since its

introduction in 2018.

� Required quantities for the HPV vaccine

The required quantities below have been calculated through the logistics projection tool based on the following parameters: a target

percentage of 6.3 % compared to the total population, 3 vaccine doses, a 50% coverage objective for the first year of introduction (2017),

growing to 70 % in 2018, and an estimated 15% loss rate.

Table 18: Required quantities for the HPV vaccine

Inputs 2016 2017 2018

HPV (Targeted individuals)

13,000 684,099 705,991

HPV (doses) 42,608 1,180,071 1,704,967

0.5 ml AB syringes 42,608 1,180,071 1,704,967

5ml dilution syringes 4,260 118,007 170,496

Safety boxes 470 12,980 18,755

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The HPV vaccine will be administered to girls between 9 to 13 years of age. It will be introduced in routine EPI in 2017 but this requires a

demonstration in 2016 in a small town, of only 200,000 inhabitants, before being generalized across the country in 2017.

VII – ANALYSIS OF COSTS AND FUNDING

7.1 - Methodology

The methodology used is essentially based on the following documents:

- Guide for the drafting for complete multi-annual plans (CMYP);

- The Cost and Funding Analysis Tool for Multi-Annual Planning (Tool Version 2.6 – June 2012; this is the new guide for the development

of a Comprehensive Multi-Year Plan (CMYP) for immunization in order to strengthen, improve and harmonize the various planning

processes for immunization at national level. These directives are based on existing multi-year plan models, plus cost, funding and co-

funding elements developed based on the Financial Sustainability Plan for immunization (FSP).

The year 2012 is noted down as benchmark year for the calculation of EPI costs in the past (first full budget year before the current year).

The average annual exchange rate used for the year 2012 is 1USD for 450 CFA. This exchange rate was calculated at the Cotonou UNDP offices.

7.1.1 – Methodology for the calculation of past costs

� Shared costs for staff involved in immunization at all levels have been calculated depending on the average time dedicated to

immunization activities and advanced strategies according to the existing framework. The time dedicated by the staff to the various

activities of this program differ from 81.8% at national level, to 22.0% at department level, to 14.00% at health area level and to 24.5% at

health center level. In general, the average time dedicated to advanced strategy activities is estimated at 74.10% in 2012 compared to

74.08% in 2008 and 16.9% in 2005. This is proof of the continuous good performance of the players compared to 2005.

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� Based on the salary scale in force in Benin, the average salary index for each staff category has been calculated, allowing for an

evaluation of the annual financial impact taking into account the indemnities and contributions to the Benin National Pension Fund

(BNPF).

� The salaries of WHO and UNICEF staff who act as EPI focus point within these two institutions have not been declared by their

respective institutions.

� A fixed amount of 1000 CFA has been used as amount for the indemnities granted to immunization agents during immunization sessions

in advanced strategies in communes. However, it must be noted that this payment directly dependant on the available resources from

community funding. The lack of motivation steadiness for these player agents in advanced strategy can undermine the improvement of

performance indicators at this level. The transfer of some agents to community funding sources should decrease costs at the level of

medical units and free resources which should allow for the adoption and permanence of advanced strategy activities.

� As for the cold chain technologies and vehicles, the data used refers to information updated on the publication date of monitoring studies

and based on the management of cold chain technologies and vehicles.

� Regarding the calculation of the cost of capital (depreciation), the useful life cycle11 of the cold chain equipment is estimated to 5 ans.

� The building costs and general expenses have also been taken into account.

7.1.2 - Methodology for the calculation of past finances

The working group collected new data from the partners and technical directorates of the Ministries involved.

11 Useful life cycle: it is the useful period after which the equipment must be renewed

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As for the sources of funding, the data regarding the contributions of local communities are not always available. However, the

communities contribute through the proceeds of community funding. The bodies in charge of the management of these resources are called

management boards and are structured by level of the health pyramid. For the entire country, the amounts resulting from community funding are

in principle meant for the payment of:

- Indemnities related to advanced strategies;

- Costs related to the transport and delivery of vaccines;

- Costs related to transport for advanced strategies;

- Costs related to the maintenance of cold chain technology and motorbikes;

- Rewards for public and community support networks; and

- Shared transport costs.

Here, internal funding is considered to be the national budget, community funding and “HIPC funds”. External funding comes from funds

granted by GAVI/FMV and external partners (bilateral and multilateral bodies and NGOs/associations).

7.2 – Quantity data regarding costs and funding in 2012

7.2.1 - EPI costs in 2012

During the year 2012, the total cost of immunization activities, including vaccine supply and other investments, amounted to 19,101,578

USD.

Routine immunization, including shared costs, amounted to 10,500,249 USD, namely 55% of the total EPI cost for 2012. Immunization

campaigns cost 8,601,329 USD, namely 45% of the total EPI cost for 2012.

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The costs of vaccines and injection equipment amounted to 11,651,963 USD, namely 61% of the global costs of the program. This is due

to the organization of several immunization campaigns (3 national immunization campaigns against polio and one immunization campaign

against A meningococcal meningitis).

The pricing costs for a child fully vaccinated against DTP-HepB-Hib3 amounted to 36.2 USD in 2012. This includes the costs of vaccines,

injection equipment and other operating costs.

Table 19: EPI economic and financial indicators in 2012 Indicator for reference year 2012

Total immunization expenses 19,101,578 $

Immunization campaigns 8,601,329 $

Routine immunization 10,500,249 $

by inhabitant 1.1 $

by child DTP3 36.2 $ % vaccine and injection equipment 61.0%

% government funding 46.7%

% total health expenses 3.8%

% total health expenses by the government. 10.1%

% GDP 0.08%

Total shared costs 0 $

% of shared costs in total TOTAL 19,101,578 $

The specific costs for routine EPI in 2012 is the following:

� The first cost category is basic vaccines 45 %;

� The second cost category is the staff, namely 19%.

� Including vehicle costs %;

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� The third cost category is new vaccines 18%

� The forth cost category is under-used vaccines 12%

� Basic vaccines represent 2%

� Cost categories for evaluated cold chains, vehicles, transport and injection equipment each represent 1%

Figure n°2: Specific cost profiling for routine EPI

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7.2.2 – Funding for routine EPI in 2012

In 2012 in Benin, the share of internal funding in specific EPI costs represents 28%. GAVI funds over half of specific routine EPI costs

(65%) and the other partners (WHO, UNICEF, USAID, UE…) contribute up to 7%. Internal funding covers a part of the purchase costs for basic

vaccines, injection equipment, staff salaries, per-diem staff for advanced strategies and surveillance/monitoring, transport and maintenance costs

for the cold chain. GAVI essentially covers purchase costs for de under-used vaccines, new vaccines and injection equipment. GAVI share is

rather high for 2012 due to the preventive campaign against A meningococcal meningitis, with the MenAfriVac vaccine. The other partners

mainly fund short term training, disease control and surveillance and program management expenses. However, the consolidation of funding

from internal resources has become necessary in order to attain total vaccine independence.

Figure 3: Fund profiling for specific routine EPI costs

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7.3 – EPI COSTS AND FUNDING FOR 2014-2018

7.3.1 - Methodology

7.3.1.1 – General methodology

Data from the basic year 2012 as well as forecasts of future resource are presented on pages dealing with “Data input” and “Funding” in

the Excel chart, by applying the methodology specified in the manual for the calculation of CMYP costs.

7.3.1.2 – Cost forecast methodology

The CMYP activities have been reviewed when the Excel spreadsheet was filled in, in order to account for the budgetary limits and be

more efficient. The costs presented here are the result of this operation.

Social mobilization activities, training activities, surveillance and program management activities have been budgeted for depending on

the resources necessary for their performance, then were inserted into the Excel spreadsheet. As for the results obtained during the first NID in

2012, strengthening of social mobilization and community involvement activities is required.

7.3.1.3 – Funding forecast methodology

Risk awarding has been categorized as follows:

� Risk 1 is awarded when funding is ensured.

� Risk 2, when funding is probable.

Therefore, we have listed under risk 1:

- Internal funding (communities, debt relief funds – PPTE –, regular state budget);

- Funding according to an explicit agreement for the EPI (bi-annual funding from WHO, GAVI fund awarding letters, etc.).

and under risk 2:

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- Forecast of funding habits.

- Strategies allowing for the improvement of EPI financial sustainability (budget growth for various funders, awarding of GAVI funds for

ISS and RSS offices, ...etc.).

The awarding of funding has been agreed with the partners based on past funding and plans currently in force.

7.3.2 – Necessary resources for the 2014 - 2018 period

Table no. 20 and 21 and figures no. 4 and 5 present the necessary financial resources for the entire duration of CMYP.

In order to reach the objectives set for the 2014-2018 period, the total financial resources needed is estimated at 240,339,580 USD for the

entire period. This cost is distributed for each year as follows:

Table 20: Short presentation of necessary EPI resources for the 2014 – 2018 period Year 2012 2014 2015 2016 2017 2018 Total 2014-2018

Total costs (USD) $ 33,413,020

$47,674,058 $41,460,186 $43,601,047 $55,856,737 $58,752,983 $247,345,011

Specific costs $ 15,405,074 $ 29,220,873 $ 22,607,016 $ 24,341,894 $ 34,650,395 $ 37,031,568 $ 147,941,747

Shared costs

$ 3,696,503 $3,850,087 $3,958,010 $4,066,090 $5,657,924 $5,772,029 $23,304,140

Recurrent costs

$ 14,311,443 $14,603,098 $14,895,160 $15,193,063 $15,548,418 $15,859,386 $76,099,124

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Annual growth rate (%)

43% -14% 5% 28% 5%

In 2014, a 43% growth can be noticed, compared to the basic year 2012. The explanation is the future organization of a measles campaign

in 2014. Between 2014 and 2018, the total annual costs of EPI grow from 47,674,186 USD to 58,752,983 USD, namely by 23%. However, a

decrease can be seen for 2015 before the growth downswing in 2018. The significant growth of total costs from 2016 to 2018 is due to another

measles campaign and the introduction of new vaccines, MenAfriVac, HPV and Rotavirus.

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Figure N°4: Forecast of necessary resources

New vaccine

Vaccination campaign

Cold chain

Other recurring costs

Staff

Underused vaccines

Shared costs

Other costs in capital

Other vehicles

Transport

Injection materials

Basic vaccines

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Table 21: Macroeconomic indicators and financial sustainability

Macroeconomic indicators and financial sustainability 2012 2014 2015 2016 2017 2018

% of total health expenses

Necessary resources for immunization

Routine immunization campaign 6.7% 18.4% 6.3% 6.4% 9.5% 9.5%

Only routine 3.6% 14.0% 4.5% 4.6% 5.1% 5.3%

Financial gap

With secure funding 9.0% -0.6% 0.1% 0.3% 0.1%

With secure and potential funding 9.0% -0.6% 0.1% 0.3% 0.1%

� The amount of health expenses for routine EPI and campaigns containing shared costs will increase from 6.7 % in 2012 to 18. 4% in 2014 and will

decrease in 2015, before progressively increasing to 9.5% by 2018.

� If we only take into account routine immunization, the amount of health expenses for routine EPI, including shared costs, will increase from 3.6% in

2012 to 14.0 % in 2014; in 2015 it will decrease to 4.5% and will have an increasing evolution between 2016 and 2018, up to 5.3%.

� In 2014, for EPI sustainability, the total EPI expenses should represent 49.1% of the health expenses made by the government, amount

which will decrease to 16.7% in 2015. This percentage should reach 17.0% in 2016, 25.3% in 2017 and 25.4% in 2018. But, in reality,

the resources generally mobilized for EPI represent a small part of the resources assigned by the government to the health sector. Thus,

resource mobilization strategies at national level should be developed in order to effectively guarantee immunization independence.

� The estimated financial resources mobilization, starting from the contribution of each inhabitant for the financial sustainability of CMYP

shows that in 2014 the contribution of each inhabitant should be of 5.7USD. This amount will decrease to 2.01USD in 2015. (including

the routine immunization campaign).

� Figure N° 5: Analysis of financial sustainability

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In the event of introducing new vaccines, Benin should globally co-fund the total of 3, 661, 408 USD.

This amount is exclusively dedicated to vaccines purchase.

Per inhabitant

% of total health expenses made by the government

% of total health expenses

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Table 22: Summary of Benin co-funding from 2014 to 2018.

Vaccine Classification 2014 2015 2016 2017 2018 2014-2018 $ $ $ $ $ $

DTP-HEPB+Hib Underused 224 963 232 162 242 655 242 684 255 062 1 197 526

YFV Underused 78 853 81 376 86 295 82 418 88 026 416 968

PCV 13 New 218 101 206 126 217 112 223 512 233 583 1 098 434

MenAfriVac New 0 0 57 871 66 812 76 774 201 457

HPV New 0 0 0 301 809 375 691 677 500

Rotavirus vaccine New 0 0 0 0 69 523 69 523

TOTAL 521 917 519 664 603 933 917 235 1 098 659 3, 661, 408

7.4 – 2014-2018 Funding analysis

7.4.1 – Analysis based on secure funding

Considering the above figure, the external contribution to the secure funding for the routine immunization is of 46%, out of which 31%

for GAVI funding. The Government (including community funding and HIPC funds) provides up to 54% of the total funds. The amount of the

global financial deficit for the 2014 – 2018 time period is 29,289,604 USD, i.e. 17 % of the total costs if we only consider secure funding

(without shared costs). At this rate, with the new vaccines it would be impossible to conduct immunization activities without the resources

expected from GAVI. Taking into account the harmful effects of the disease in the inside the country and those related to negative

externalization, it is mandatory to really insure the availability of resources expected from GAVI and to consider the mobilization of resources

together with other players and potential stakeholders.

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Figure N°6: Forecast of secure funding and gaps

Financial Gap Rotary International World Bank (PRSC) Belgian Cooperation EU Financing European Union UNICEF GAVI National Government

USAID AMP HIPC Funds Swiss Cooperation Japanese Cooperation WHO Local Government

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7.4.2 – Analysis based on secure and potential funding

When integrating secure and potential funding, it also becomes visible that the share expected from external resources within the funding

program is also rather high.

However, if we take into account the secure and potential funding, the financial gap is totally covered throughout the entire CMYP period.

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Figure N°7: Forecast of secure and potential funding and of Gaps

Financial Gap Rotary International World Bank (PRSC) Belgian Cooperation Community Funding European Union UNICEF GAVI

USAID AMP HIPC Funds Swiss Cooperation Japanese Cooperation WHO Local Government

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From the figure above, it can be deducted that the gaps vary from one year to another. For 2014 and 2018 the gaps are mainly represented

by vaccines and injection materials.

Figure N°8: Composition of financial gaps

Well-being is an excellent production factor for the considerable improvement of growth, and it proves to be indispensable in reaching

objectives at GPRS level for the allocation of more resources to the health sector. Thus, the time and resources dedicated to disease and even

* Unique specific costs. Shared costs are not included.

Vaccines and injection materials

Staff

Transport

Activity and other recurring costs

Logistics (vehicles, cold chain..)

Immunization campaign

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death management can be redirected to revenue generating activities or investments, which are development factors. Therefore, the fight against

morbidity and mortality related to EPI diseases is a relevant variable in all development processes. In order to insure immunization independence

and to support investment in the human capital, it is suitable to envisage specific taxes in favour of increasing well-being rates, in all its

applicable areas.

The Benin EPI is strongly dependent on external funding; it is thus essential that the strategies recommended in this document for the

mobilization of more resources, both internal and external, are efficiently implemented in order to carry out the planned activities and to reach

the objectives set forth.

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VIII – STRATEGIES FOR THE IMPLEMENTATION OF CMYP

The strategic plan is the core of CMYP for the time period running from 2014 to 2018. This document presents the strategy which should

be followed in order to achieve financial sustainability, and in the long run to insure “financial autonomy of EPI”. It takes into account its main

assets as well as the limitations, opportunities and risks related to future funding (see chapter 7.3). It proposes short and medium term measures

to be taken by the Government and its partners. Thus, the strategy set forth is adapted both to the situation in Benin and to its possibilities.

Thus, it is to be expected to have the necessary funds in order to perform the EPI activities. They will improve vaccination coverage and,

by doing so, will decrease the mortality and morbidity rates related to those diseases which can be avoided by immunization.

This strategic plan focuses on:

� The mobilization of additional resources besides national and external sources (according to 7.3.2);

� A reliable source of resources (according to chapter 5.4.1);

� The improvement of the program’s efficiency in order to only require a minimum number of additional resources.

8.1 – Assets and constraints of Benin regarding financial sustainability of EPI

8.1.1 - Assets

� As part of IVI, since 1996 Benin has funded vaccines and injection materials from the State Budget (specific budget line for vaccine

purchase).

� Benin has benefited from “HIPC funds” since 2000. A share of these funds is since then used to finance the purchase of traditional

vaccines and injection materials (instead of being purchased from the national budget).

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� Within the Bamako Initiative (community funding and participation), Benin uses a share of the resources made available by the awarding

of essential drugs for EPI funding (funding preventive actions by healing). This funding level is relatively important in what the amounts

made available are concerned.

� The Benin EPI has benefited since 1996 from the existence of a foundation – named the “EPI Foundation of Benin” - which can collect

donations of State companies in order to finance EPI activities (mainly the NID).

� Benin has benefited since august 2002 of the support of GAVI/GMF for the introduction of new (Hep B) and underused (yellow fever

vaccine) vaccines. Furthermore, in June 2005, it has equally benefited from the support of GAVI / GMF for the introduction of the

pentavalent (DTP-HepB-Hib) and yellow fever vaccines until 2015 and for support for injection safety (until 2007).

� EPI has an active ICC-EPI since 1998, and benefits from the commitment of numerous partners in the support of EPI (financial and

technical).

8.1.2 - Constraints

� The perspectives for economic growth are decreasing, which can be due to the decrease in fiscal revenues and thus to contributions level of

different programs to the national budget.

� The GAVI/GMF support for injection safety ended in 2007. Likewise, the co-funding for the yellow fever and Pentavalent vaccines has

started in 2008 and is scheduled to end in 2015. Benin thus has to identify new strategies for funding vaccines and injection materials now

financed by GAVI /GMF, especially for new vaccines which have relatively high costs.

� Partners long term commitment cannot be determined for certain.

8.2 – Strategies and measures which allow for the mobilization of additional resources The strategies refer both to internal and to external resources.

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8.2.1 – Strategies for the mobilization of internal resources

8.2.1.1 – Measures regarding contributions to the national budget

The world economic crises and the current budgetary constraints of Benin diminish any possibility and opportunity to increase the

resources assigned to EPI. Nevertheless, with respect to the priority character of EPI, the part of the national budget contribution to EPI will be

increased at least with the inflation rate and the economic growth rate.

In general, in order to meet all needs in this sector, it is mandatory for the State to increase the share from the budget awarded to the health

sector, by moving progressively from 7% to 10%, as recommended by WHO. In this process, priority will be given to EPI. In order to reach it, it

is necessary to start the “Definition of specific taxes for health”.

8.2.1.2 – Measures regarding contributions to HIPC Funds

The HIPC Funds must continue to finance the purchase of traditional vaccines and injection materials for EPI. For that matter, the HIPC

funds have taken progressively the charge of the co-funding of yellow fever and pentavalent vaccines since 2008, and of the pneumonia vaccine

starting from 2011 (transfer of underused and new vaccines funding from GAVI/GMF to HIPC funds).

8.2.1.3 – Measures regarding local communities/ towns

Within administrative decentralization, actions concerning the development of local communities are included in the development plans of

towns. These decentralized structures play a decisive role in the social mobilization of population. But, their financial contribution to the EPI is

not determined. Thus, efforts for community funding need to be made in order to integrate the needs of EPI in the development plan of the town.

A study must be performed in order to determine the contribution level of local communities to EPI.

Community funding contributes to the renewal of equipment (through the depreciation accounts implemented in Benin within the

Bamako initiative) and to the funding of immunization activities in advanced and basic strategies (daily staff salaries, fuel, maintenance - repair).

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Within this frame, the share of community funding dedicated to the performance of EPI activities will be increased from 3 to 10%, especially in

order to widespread the payment of daily staff salaries within advances strategies, the contribution of centers to the renewal of equipment and to

the purchase of spare parts.

8.2.1.4 – Measures at the level of internal non-government sources

The EPI Benin Foundation will be asked to advocate the community funding to companies for the funding of routine and additional

immunization activities.

8.2.2 – Strategies for the mobilization of external resources

8.2.2.1 – Measures at the level of GAVI /GMF contribution

In the event of pentavalent funding ending by GAVI / GMF, the second phase of GAVI support establishes a mechanism of co-funding by

the country. The objectives of co-funding growth are:

� The support the public health impact of new vaccines;

� Pressure on reducing the price for vaccines ;

� Supporting the country along the way of reaching financial sustainability.

Co-funding for the pentavalent vaccine is effective for the time period starting from 2006 to 2015. A progressive increase in payment

until it reaches the target level of payment will be stipulated. This mechanism is based on the contract concluded between GAVI and the country.

GAVI will again be asked to fund the three new vaccines (MenAfriVac, HPV and Rotavirus) which will be introduced during this period.

8.2.2.2 – Measures regarding contributions by EPI partners

A plea will be held within the meetings of ICC-EPI, in order to:

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� Insure the contribution of partners to the funding of EPI activities, depending on the scheduled activities, mainly for the funding of

additional activities, the reinforcement of equipment and integrated monitoring of diseases;

� Inform regional offices and headquarters (UNICEF, WHO, USAID, EU) of the campaign schedule established by ICC for the period

covered by CMYP, in order to help our partners mobilize the necessary funds;

� Reallocate the resources funded by partners depending on the needs.

8.2.2.3 – Strengthening of intra- and inter-sector collaboration

The intra-sector collaboration will be strengthened in order to insure the provision of resources necessary for the performance of activities,

mainly in what the staff and equipment for additional immunization activities (AIA) are concerned.

Inter-sectorial collaboration will also be strengthened, mainly for the insurance of proper and in time allocation of resources and the

mobilization of population.

The ICC-EPI and the Partners’ Meetings will serve as a background for the coordination of interventions.

8.2.3 – Action plan for the mobilization of proper resources

The following tables present: the main strategy, the actions, the implementation manager, the estimated costs of implementation, the

progress indicator and the current value of the indicator.

105

Table 23 : Action plan for specific measures for mobilizing resources

Main strategy Actions Institution in charge

Start date Estimated implementati

on cost

Progress indicators

Present value of the indicator

Expected outcomes

Measures related to

the contribution of

the national budget: Advocate for increasing the share from the state budget earmarked EPI

Study the comprehensive multi-year plan (CMYP) of EPI for 2014-2018 together with the costs and gaps of the program

NAI – PHC

May 2013

0,00

% increase in the share from the state budget earmarked for EPI

Already done The contribution of the national budget to the EPI will be at least increased according to inflation and to the economic growth rate

Define communication on the presentation of the comprehensive multi-year plan within the Council of Ministers

NAI – PHC Ministry of Health

May 2013 0,00

106



on cost

Progress indicators


Expected outcomes

Present the comprehensive multi-year plan (CMYP) in the Council of Ministers

Ministry of Health

May 2013

1,000 USD

Present the comprehensive multi-year plan (CMYP) to the National Assembly

Ministry of Health

October 2013

Advocate for the introduction of specific taxes benefitting the health system12

12 The logic at this level is that the products such as tobacco, alcohol and other products harmful for the health have to be strongly levied and that about 20% of these taxes have to be directed towards the financing of the health system, and especially for the investment (all the inputs necessary for immunization) in the immunization in general.

107



on cost

Progress indicators


Expected outcomes

Measures regarding

the contribution of

HIPC funds:

advocate for

increasing the share

assigned to EPI

Drafting of the advocacy paper

NAI – PHC December 2013

500 USD Increasing the share of HIPC funds assigned to EPI

The contribution to the co-financing of new vaccines is effective as of 2016

Measures related to

local

communities/commu

nes: Advocate for increasing the contribution of local communities

Evaluation of the contribution of local communities to the EPI

NAI – PHC

January 2014

1,500 USD

% of the communes benefit from contribution from the local communities

ND 90% of the communes benefit from contribution to EPI

Presentation of the CMYP of EPI and the costs and gaps of the program to the persons in charge of the local communities (Mayors and Prefects)

GH/MPH April 2014

Measures related to

non governmental

sources: Advocate for increasing the contribution CF to the EPI

Present the CMYP of EPI together with the EPI costs and gaps to the DHO, to the members of the HA and to the COGECS

GH/MPH

June 2014 % of the contribution of CF to the EPI

On average 5% for the entire

country according to

estimates

Increase from 3% up to 10% in the share of CF in the EPI

108



on cost

Progress indicators


Expected outcomes

Measures related

the contribution of

GAVI/FMV/

EPI

Integrate the rescheduled GAVI/FMV contribution to the CMYP

NDEPI – PHC

November 2014

0,00

Integration performed

Support scheduled for 5 years

Notify in written form the GAVI secretariat about the request signed by the members of ICC – EPI

MPH March 2014 0,00

Measures related to

the EPI partners Continue the quarterly meeting with the ICC – EPI

NAI – PHC January 2014

1,000 USD

% meetings held

75%

100%

Extend the membership of ICC to other partners and the General Head Offices

Ministry of Health

November 2014

0,00

Identification of financial partners for Health Areas which do not have financial partners in order to finance EPI

Coordinator Doctors for HA

January 2014

0,00

% health areas able to finance EPI

75% (estimation)

100%

109



on cost

Progress indicators


Expected outcomes

Strengthening of the intra and inter sectorial collaboration

Organize at national level, quarterly meetings for monitoring – evaluation of EPI activities of the IDSR

NAI – PHC

January 2014

18,000 USD (4,500 USD x 4 meetings)

% quarterly meetings held

50%

90%

Organize at department levels quarterly meetings of the Department Committee for the management of EPI and IDSR activities

Prefects

January 2014

6,000 USD (250 USD x 4 meetings x 6 departments)


0 % (Structures

implemented in January

2013)

80%

Organize at commune level monthly meetings for monitoring EPI and IDSR activities

Mayors January 2014

30,800 USD (100 USD x 4 meetings x 77 communes)


80%

110

8.2.4 – Strategies and actions for more reliability of resources

8.2.4.1 – Strategies related to budgeting

This refers to observance of the newly implemented procedures in order to ensure

access to budget resources according to the deadlines required at peripheral levels, and to

facilitate use of these resources.

8.2.4.2 – Strategies related to the disbursement of funds and to treasury management

After the transformation of ND/EPI into an Agency, the national budget procedures

related to the disbursement of funds will have to be more and more simplified. However, the

creation of a Management Board (which is not yet accomplished) is a condition for the

Agency to have more financial autonomy. The budget and disbursement procedures are not

yet controlled by all the actors, which makes more difficult the access to the funds and to their

disbursement. In this context the following actions are recommended:

� Advocate among the partners for the organization of workshops of information for the

staff in financial and accounting offices, as well as for the program managers in the

Ministry of Health, regarding the accounting and financial procedures held by their

institutions.

� Organization of training and refresher courses and workshops by the DFMR related to

the national public expenditure procedures

Moreover, the current supply of vaccines is being done correctly in Benin, following a

protocol with UNICEF on this particular topic. The funds from GAVI and from the national

budget are allocated before the beginning of that particular year; thus, the purchase of

vaccines is not longer a problem. The recommendation is to maintain the same procedure for

vaccine supply.

111

Table 24 : Specific action plan for making the resources available more quickly


Start date Estimated implementat

ion cost

Progress indicators


Outcomes

Strategies related to the disbursement of funds and to the treasury management

Advocate among partners on the control of accounting and financial procedures Organize workshops of information for the staff in financial and accounting offices as well as for the program managers in the Ministry of Health regarding the accounting and financial procedures held by the partner institutions in the sector Organization of training workshops by the DFMR on the national public expenditure

NAI – PHC

DFMR

WHO

UNICEF

USAID

WORLD BANK

DFMR

February 2014 March 2014 February 2014

0,00

2.500 USD US 1,500 USD

% of staff is informed % trained staff

40% (per estimation) 75% (per estimation)

100%

100%

112

8.2.5 – Strategies and actions for increasing the effective use of resources

8.2.5.1 – Reduction of the loss rate

The national average of the loss rates in 2012 is acceptable, but behind this figure there

are disparities between health centres, especially for the lyophilised vaccines.

- OPV : 14%

- DTP-HepB+Hib : 10%

- PCV13 : 3%

- YFV : 24 %

- MV : 23%

- TV : 13%

- BCG : 40%

The loss rates are reviewed according to the current situation; thus, from now to 2018,

the objectives for the loss rates have already been established:

- OPV : 13%

- DTP-HepB+Hib : 13%

- YFV : 25 %

- MV : 25%

- TV : 13%

- BCG : 35%

- Pneumococcal : 5%

- Rotavirus vaccine : 5%

8.2.5.2 – Open vial policy

Control of the open vial policy by EPI actors contributes to the slight reduction in the

loss rates of vaccines. This will trigger a reduction in costs for the purchase of traditional

vaccines and will improve availability of vaccines.

Regular training and refresher courses will be organized as part of the strengthening

capacities for EPI actors, including modules from WHO for MLM, intended for the new staff

members in the centres. The training is focused on the EPI management and, more precisely,

on the open vial policies. In this way the program to be effective in point of loss rates of

vaccines.

113

8.2.5.3 – Maintenance of the cold chain

This refers to the training of immunizers used in the cold chain technologies.

The cold chain technologies represent an important and unavoidable part of the

program. The implementation of the maintenance plan for these technologies will contribute

to the better functioning of the technologies and improvement of storage conditions for

vaccines, and therefore, a good quality immunization.

Particular attention will be granted to the training of EPI actors on the use and

preventive maintenance of the CC technologies.

8.2.5.4 – Improvement of the quality of planning and management at all levels

This strategy stands for the strengthening of the capacity of the major actors to

elaborate strategic plans and operational action plans (PTD, Budget Programs and Micro

plans) at the level of health areas and communes. The participative approach of the

beneficiaries is valuable since it contributes to the ownership and effective implementation of

these plans.

8.2.5.5 – The mobilization of the population for a better participation in the

immunization activities, especially as far as the advanced strategy is concerned

A better involvement of the actors in the field, particularly the local representatives,

the COGECS, the community networks and the associative groups, will improve the

participation of mothers in the immunization sessions.

8.2.5.6 – Reduction of the dropout rate

In 2012, the dropout rate between the DTP HepHib 1 and 3 was of 12%. This rate will

go down to 10% in 2018 for 90% of the communes. In order to achieve this, the following

actions should be undertaken:

Step up the strategy of social mobilization

The strengthening of the strategy of social mobilization should contribute to increasing

the coverage rate by reducing the dropout rate. This strategy should be directed towards the

target communities, the administrative structures and their components.

The combination of the basic and advanced strategies In the basic as well as in the advanced strategy, identification of synergy actions

should help during the daily immunization activities for keeping contact with and look for the

persons that were missing.

114

The active search for the lost persons

The active search for the lost persons that went through the census of the population,

the setting up of a system of identification of these persons (registers, schedule of payments)

in all the health units providing immunization.

The members of COGECS, the associative structures, the Village Administrative

Representatives, the community networks can conduct such activities.

Reduction of missed opportunities

At this level, the strategy consists in the verification and update of the situation of

vaccination of every child and woman at childbearing age, who goes to a health unit, in spite

of the type of consultation received. The implementation of this strategy can trigger losses of

vaccines, especially for the lyophilised vaccines. However, as far as the liquid vaccines are

concerned, the open vial policy allows for the reduction in losses.

8.2.5.7 – Control of the vaccine stock management

Stock shortage

The stock shortage of vaccines and injection equipment should be avoided by the

diligent implementation of the supplying and distribution plans for vaccines and injection

equipment from the central level towards the peripheral health units. This plan should observe

the frequency required for each level. The refrigeration truck should give priority to supplying

the departments and the local units.

Adequacy of the cold chain

This refers to:

� The strengthening of the staff capacity at different levels to determine the

storage capacities in point of volume;

� The organization of periodical evaluations of the storage capacity of vaccines,

in point of volume occupied per level.

115

Table 25 : Action plan for increasing effectiveness in using the resources

Main strategy Actions Institutions in charge

Start date

Estimated cost of

implementation

Progress indicators


Expected outcomes

Reduction in the loss rate of Antigens

Training of the actors at intermediate and decentralised levels for the management of EPI, epidemic surveillance and cold chain maintenance - Regular supervision of immunization entities

NAI- PHC

NAI – PHC EEZS

July 2014 July 2014

147,842 USD 1,241,563 USD

Antigen loss rates

Antigen loss rate in 2005 : - OPV: 30% - DTP-HepBHib:12% - YFV: 50% - MV: 50% - TV: 25% - BCG: 50%

From the present up to 2015 NAI – PHC

The antigen loss rates are reduced to - OPV: 19% - DTP Hib-HepB : 10% - YFV: 35% - MV: 35% - TV: 18% - BCG: 35%

Control of the stock management of vaccines

Monthly validate the monitoring table for the management of the vaccine stocks and injection equipment with the technical sub-commission of the ICC - EPI

NAI – PHC

January 2014

0,00

Antigen shortage rates for a given period of time

-DTP-HepBHib: 0% - YFV : 0% - MV : 0% - TV : 0% - BCG : 0%

The EPI antigens are available at all the levels of the health pyramid

Monitoring of the computerized management of vaccines and of injection equipment at national, departmental and local levels

NAI – PHC

January 2014

1,000USD

% of the departments and local units using the computerized management tools

80%

100%

116


Start date

Estimated cost of

implementation

Progress indicators


Expected outcomes

Control of the stock management of vaccines (continuation)

Collect and analyse, on a monthly basis, the data related to the consumption of vaccines and injection equipment Supplying the departments and local units with vaccines and injection equipment according to the agreed timetable Adequacy of the CC equipment following the periodical evaluations of the storage capacities for vaccines in point of volume occupied at each level

NAI – PHC

NAI – PHC

NAI – PHC

January 2014 January 2014 January 2014

0,00USD

2,500USD

$US 0,00

Filling in the data rates by the HA % health units with stock shortage % HA able to do a volume evaluation

30% 0% 20% (per estimation)

100% 100% 100%

Communication Strengthen the routine EPI by social mobilization activities

NAI – PHC

January 2014

518,351 USD

% covered populations

10%

100%

117

Table 26 : Action plan for increasing effectiveness in using the resources (continued)


Start date

Estimated cost of

implementation

Progress indicators


Expected outcomes

Reduction of the dropout rate between the DTP-HepBHib 1 and the DTP-HepBHib 3

Activate the active search system for the lost persons Continue the monitoring of the EPI and CF activities every semester Strengthen the search for the lost persons by using the census records or any other data support

Chief Nurse Chief Nurses Chief Nurses

January 2014 January and July of every year January 2014

250,000 USD ( 1,000USD x

50 priority communes x 5

years)

510,000 USD (1,200USD x 85 communes x 5 years) 0,00 USD (Action coordinated with the “Activate the search system for the lost persons”)

Dropout rate between the DTP-HepBHib 1 and the DTP-HepBHib 3

Dropout rate between the DTP-HepBHib 1 and 3 = 12% in 2008

Dropout rates between the DTP-HepBHib 1 and the DTP-HepBHib < 10%

118


Start date

Estimated cost of

implementation

Progress indicators


Expected outcomes

Strengthen the three basic immunization strategies in order to ensure the immunization of the targets, while observing the programs carried out in collaboration with the populations (RED approach) in 50 priority communes

Chief Nurses

January 2014

0.00 USD (Action

coordinated with “Activate

the search system for the lost persons’’)

119

CONCLUSION

Immunization is one of the most effective actions for public health. It contributes to the

reduction of poverty, and is part of the Government priorities. When it is time for introducing

new vaccines, the immunization of children becomes a real challenge that goes through a

long-term planning, and requires, in particular, a wide mobilization of the necessary resources

for the planned actions to be implemented. Therefore, CMYP is an essential tool for EPI to

become a permanent program. The effectiveness of CMYP depends on the involvement of all

the stakeholders in order to mobilize the resources needed for implementing it, and in

particular to identify the persons responsible for monitoring its implementation. Therefore,

the coordinator of the working group responsible for drafting the CMYP of Benin has already

been identified in order to ensure its success.

To its benefit, Benin, as part of IVI, has been financing the vaccines and the injection

equipment from the State budget (specific budget line for the purchase of vaccines) ever since

1996. EPI has benefitted from « HIPC funds » since 2000. Since then, part of the funds is

used for financing the procurement of traditional vaccines and injection equipment. Since

August 2002, Benin has been receiving the support of GAVI/FMV for the new vaccines, the

under-used vaccines and the injection safety.

In order to improve the financial viability of EPI and to ensure its long-term autonomy,

the strategic plan mainly focuses on:

A. The mobilization of additional resources in addition to the national and external

sources;

B. Reliability regarding the contribution to resources;

C. The improvement of the program effectiveness in order to further need only a

minimum of additional resources.

Whereas the perspectives for economic growth and for tax revenues are diminishing,

the need for resources in the health sector is definitely increasing. The promotion of

immunization is a form of investment in the human capital. Therefore, it is important to pay

particular attention to it, in order to cut down, in due time, the huge expenditures in health

care which push the already vulnerable population into dire poverty. It is recommendable that

the State of Benin should make efforts to allocate 10% of the state budget to the health sector

and increase the allocation of resources to EPI. Similarly important is to take into account

120

specific taxes benefitting the health sector in order to avoid a reduction in the resources

envisaged in case of economic recession.

In order to avoid the negative externalization of diseases, the Technical and Financial Partners

are expected to give their strong support in the framework for financing the CMYP for the

period 2014 – 2018.

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