Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing Abuja, Nigeria | 19-21 April 2016 Prepared by Diana Mugenzi, Dana Silver, Clifford Kamara, Andrew Carlson, Mike McQuestion

Contents Executive Summary ............................................................................................. 2

Acknowledgements ............................................................................................. 2

Introduction ........................................................................................................ 2

Proceedings ......................................................................................................... 3

Day One ............................................................................................................. 3

Theme I: Domestic Financing Arrangements.................................................... 5

Day 2 ............................................................................................................... 12

Theme II: Legislative Provisions and Implementation ................................... 12

Theme III: Budgeting, Resource Tracking, and Domestic Advocacy............... 16

Day Three ........................................................................................................ 18

Peer Review Exercise ..................................................................................... 19

ANNEXES ........................................................................................................... 26

Annex A: Concept Note .................................................................................... 26

Annex B: Participant List ................................................................................. 30

Annex C: Agenda ............................................................................................. 35

Annex D: Small group results .......................................................................... 38

Annex E: Welcome Address, Dr. Ado Muhammad ............................................. 41

Annex F: Opening Remarks, Hon. Minister of Health ........................................ 43

Annex G: Keynote Address, Managing Director, Fidelity Bank .......................... 45

Annex H: Peer Review Raters’ Comments ........................................................ 52

Annex I: Country Action Points ........................................................................ 56

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Executive Summary

On 19-21 April 2016, 156 delegates, local participants, and partners convened in Abuja, Nigeria for the second Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing (SIF), hosted by Nigeria Immunization Financing Task Team

(NIFT) on behalf of the Nigerian Federal Ministry of Health and National Primary Health Care Development Agency and organized in partnership with the Sabin Vaccine Institute.

The delegates represented Ministries of finance, Ministries of health, and other government and subnational ministries in Sierra Leone, Liberia, Nigeria, Uganda and

Kenya. Delegates evaluated each other’s past, ongoing and current solutions promoting sustainable immunization financing for their countries. Joining them were counterparts from global immunization partner agencies including WHO, UNICEF, the GAVI Alliance, the

Bill & Melinda Gates Foundation, Clinton Health Access Initiative, IVAC, and the Sabin Vaccine Institute, among others. Participants spent two and a half days in small groups

and plenary sessions, examining their countries’ immunization budgets, legislation, and advocacy strategies. The workshop culminated in a poster session where delegates assessed each other’s immunization financing innovations. Each country delegation

drafted action points that will help them achieve sustainable immunization financing. Assessment of the peer review results and country action points show that all five

countries have made progress and since the previous Anglophone Africa Peer Review Workshop, which took place in Nairobi in October 2015. Uganda had the largest increase in innovativeness during this period, as rated by the other countries. A summary of

Colloquium proceedings and results follows.

Acknowledgements

This report was compiled with the valuable assistance of the following individuals: Dr. Shola Molemodile (IVAC), Dr. Obinna Ebirim (IVAC), Ms. Funmilayo Adewumi (IVAC), Dr. Obi Emelife (NPHCDA), Mrs. Fadal Girei (NPHCDA), Dr. Ekene Osakwe (NABDA), Mr.

Chimaobi Chukwu (NABDA), Mr. Aloysius Ugwu (HERFON), Mrs. Fumilayo Ojo (Federal Ministry of Health), Ms. Saira Zaidi (CHAI), Ms. Oluseyi Abejide (Save the Children), Mr.

Kenneth Oshiobugie (Vaccine Network), Ms. Ndidi Chukwu (CHR), Ms. Celestina Obiekea (SLNI), and Dr. Ben Anyene (HERFON/NIFT).

Introduction

The Nigerian Federal Ministry of Health and National Primary Health Care Development Agency (NPHCDA) with intersectoral collaboration from Federal Ministry of Science and Technology hosted the peer review workshop. Much of the NPHCDA planning and support

to the workshop came through its Nigeria Immunization Financing Task Team (NIFT). The NIFT Concept Note for the workshop is shown in Annex A.

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On 12 April, the NIFT organized a press conference to preview the workshop and share

information on Nigeria’s strategies for achieving sustainable immunization financing.

In addition to Sabin, thirteen collaborating organizations were represented in the workshop, including: Clinton Health Access Initiative (CHAI), Community Health and Research Initiative (CHR/Nigeria), Healthcare Federation of Nigeria (HFN),

GlaxoSmithKline, Health Reform Foundation of Nigeria (HERFON), International Vaccine Access Center (IVAC), May & Baker, Nigerian Medical Association (NMA), Paediatric

Association of Nigeria (PAN), Pfizer, Save the Children, UNICEF, Vaccine Network for Disease Control, Gavi, the Vaccine Alliance, and WHO.

The five participating countries were represented by 16 delegates. In addition, 140 local participants, partner agency counterparts and high officials attended. The list of

participants is shown in Annex B. The workshop agenda (Annex C) departed from those of previous workshops in that time

was evenly divided between the peer review itself and sessions managed by the host country counterparts. Sustainable immunization financing was the common theme.

Proceedings were transcribed and periodically posted to Facebook (#NIFTNIG) and twitter

(@niftnig) throughout the workshop. The workshop objectives were the following:

1. Assess implementation of the country-specific action points developed at the previous Sabin/SIF Anglophone Africa Peer Exchange Workshop (Nairobi, Kenya,

October 2015) 2. Identify, share, and cross-evaluate innovations and best practices in immunization

financing, resource tracking, and domestic advocacy

3. Analyze and review the laws and regulations on vaccines and immunization that exist or are under preparation in the participating countries, and document the

status of ongoing legislative projects in each country 4. Develop new country-specific, short-term action points for achieving sustainable

immunization financing

Proceedings

Day One

Professor Ben Anyene, Chairman, National immunization Task team (NIFT), called the workshop to order. Following a round of introductions, Sabin SIF Program Director Mike McQuestion reviewed the Sabin portion of the workshop agenda. Professor Anyene then

described the Nigerian inputs to the agenda and the workshop arrangements which had been meticulously prepared by the NIFT planning committee headed by Dr. Adamu

Nuhu. Among the participating Nigerian institutions were the Ministry of Health (and

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within it the NPHCDA), the Ministry of Finance, Ministry of Science and Technology and Commissioners for Health and Financing from six of Nigeria’s 37 states. Also attending

were six NPHCDA zonal coordinators.

Mike McQuestion set the stage for the technical sessions with an introductory PowerPoint presentation (Immunization as a public good). It described the four topical areas in which the SIF Program works (financing arrangements, budget and resource tracking, domestic

advocacy, legislation) and presented indicators for each area which the Program uses to measure a country’s progress toward the SIF objective. Additional topics he covered

included immunization as a collective or public good and institutional change processes which are seen as the unit of analysis for any health transition.

In the next session (Collective update), one delegate from each country summarized progress made toward sustainable immunization financing since the October, 2015 Nairobi

workshop. Liberia has concentrated mainly on advancing new immunization legislation,

reported Hon. Senator Dr. Peter Coleman. After the Nairobi meeting, Liberian

delegates agreed they needed to insert an explicit financing provision into their draft law. The revised bill is now under review by the Ministry of Finance. It will then go

back to the Senate Health committee, then on to the joint (Senate and House) Budget Committee.

Speaking for Kenya, Dr. Dominic Mutie, deputy director national immunization program, described ongoing advocacy work the federal immunization team is doing with the 47 counties, which now control all immunization financing for the country.

Another round of advocacy workshops is planned with support from Gavi, the Vaccine Alliance.

Mr. Ishmael Magona (Ministry of Finance, Planning and Economic Development) described Uganda’s December 2015 passage and March 2016 enactment of its new Immunization Law. The Ministries of Health and Finance are currently writing

detailed regulations to implement the law. Hon. ABD Sesay (National Assembly) provided an update on Sierra Leone’s vaccine

legislative project. Stakeholder meetings have taken place since Nairobi. The draft bill now sits with the National Assembly’s Law Department. He expects the bill to be passed by the end of CY2016.

Dr. Lekan Olubajo (NPHCDA) summarized Nigeria’s advances on several fronts. A new public-private partnership trust fund to finance vaccines is in the works. Past

JRF financial reports are being reviewed and corrected as needed. The National Health Act was recently gazetted, moving it closer to full implementation. There is a broad base of stakeholders coming together for sustainable immunization financing,

thanks to the efforts of the NIFT. Nigeria is intent on developing local vaccine production as part of its sustainable immunization financing solution. A consultant

has been engaged to write a policy document and a business investment case is being prepared.

Prof. Ben Anyene then described Nigeria’s new Primary Health Care Under One Roof (PHCUOR) strategy, which aims to improve accountability and reduce fragmentation in the

system’s governance- to bring all governance under one roof. It has been approved by the National Health Council. A scorecard with 9 pillar indicators has been developed to show

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the level of PHC program performance in each state. Elsewhere, committees continue to work on the implementation of the National Health Act. At the moment, the 2016 budget

has not yet been signed so financial flows to immunization services and external vaccine payments are in suspense.

Theme I: Domestic Financing Arrangements

Following coffee, Prof. Abdulsalam Nasidi, CEO of the National Center for Disease Control, assumed the chair and opened the first technical theme (Domestic financing arrangements). In his remarks, Prof. Nasidi noted that countries and partners are in

agreement that, in the long run, Africa needs to be self-sufficient in vaccine manufacturing and procurement.

Mike McQuestion then set the stage for the financing theme with a slide set presenting recent vaccine and immunization program delivery costs, a summary of reported (JRF)

government expenditures for the five participating countries and an outline of sources and mechanisms of domestic immunization financing. Various domestic financing

arrangements, existing and in preparation in other SIF countries, were described. The presentation prompted a series of questions.

Dr. Chizoba Wonodi (IVAC) asked for more details on how federal and state financing is

being managed in other SIF countries. She asked how shared health system (delivery) costs be distinguished from pure immunization costs. She also wanted to hear more about

how trust funds are organized. In response, McQuestion commented on the importance of co-financing by federal and subnational governments in larger countries. At operational levels, identifying just immunization expenditures is usually impossible because all health

system costs at that level are shared, as they must be. The share attributable to immunization can be estimated at best. But even such estimates can be used for

advocacy purposes. Among the SIF countries, financial information is rarely shared across the two levels. An exception is Vietnam. Vaccine procurement, however, must be centralized for a host of reasons. In one region, the Americas, countries jointly procure

their vaccines. A trust fund is a legal term for assets in a fund that are no longer controlled by the benefactor. It may be a passive fund (assets are regularly deposited and

used at approximately the same rate) or a working fund (assets are invested and only the proceeds are spent). The money in any trust fund must be used for a pre-determined purpose. A trust fund is controlled by trustees/board of directors who are personally liable

for its use.

Professor Alex Akpa, Director of Medical Biotechnology at the National Biotechnology Development Agency (NABDA), asked why routine immunization delivery costs varied so widely. Perhaps the main reason is the cost of health staff. In the most expensive

programs, vaccinations can only be administered by physicians, replied McQuestion.

The agenda then moved to Theme I (Domestic financing arrangements). Each delegation presented one or more new practices, under development or already implemented, which are helping their countries achieve sustainable immunization financing.

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Nigeria

Dr. Adamu Nuhu summarized the work of Nigeria’s NIFT. Itself an institutional innovation, the NIFT was created by the NPHCDA in 2015 to address the huge funding gap in the national immunization value chain. New vaccines, added cold chain needs, rising

infrastructure operational costs and growing birth cohort sizes and the imminent (2021) exit of Gavi, the Vaccine Alliance are all contributing to the gap. By the year 2020, Nigeria

will be facing an annual vaccine bill of around US$426.3m. There has been recent progress toward sustainable immunization financing. The 2016 National Health Act was an important milestone, however, it is not expected to be fully operational until 2018 and

even then will not provide all the funding needed. (The proportion set aside for vaccines is insufficient.)

The NIFT brings together multiple government and non-government agencies, community service organizations and the domestic private sector. Its present work focuses on

creating and financing a new national trust fund for immunization. The fund will receive both public and private funds and will be directed by a board of fifteen individuals. Social

media (eg, bulk SMS messages) will be used to generate individual donations. Beneficiaries will be all vaccine-eligible Nigerians.

Q&A

Dr. Nuhu’s presentation stimulated a series of questions and comments. Prof. Alex Akpa asked if Nigeria’s proposed trust fund will finance research and development of vaccines.

No, those funds will come from the Federal Ministry of Science and Technology, responded Prof. Anyene. The latter institution will be offered a seat on the board of trustees of the national immunization trust fund.

Dr. Daniel Iya, Commissioner for Health, Nasarawa State, Nigeria, commented that the

focus should be on legislation. Nigeria’s National Health Accounts show that the percentage given to provide a minimum health care package to Nigerians is far below the Abuja Declaration target of 15% budget to health. Advocacy to the national assembly is

needed in order to increase the percentage stipulated in the National Health Act. Prof. Anyene responded that the NHA was never designed to solve all the health problems of

the country. The fund examines expenditures; it does not affect government health appropriations. To get the needed increases, government can only create an enabling environment. It cannot drive the advocacy process or it dies. Countries need to think

outside the box to achieve sustainable financing. Solutions will not emanate from the Ministry of Finance or Ministry of Health. They will come from the immunization fund

board and from all sectors contributing to the fund. Dr.Lawal Bakare (NEPAD) asked if there will be just one fund with philanthropic

donations or will public revenues go into it? If so, under what kind of arrangements? Will federal and state revenues both be allocated to the fund? Related to this, what will

happen to existing basket funding arrangements? Will the trust fund be supported by a law or just an act? How will the Ministry of Finance participate in the fund? Will it be truly

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independently managed? How will it raise its funds? New legislation will be needed, responded Dr. Nuhu, to ensure public revenues also flow into the fund.

Dr.Halima Mukaddas, Commissioner for Health, Bauchi State, Nigeria, asked whether

the national immunization trust fund will be duplicated at the state level. If so, what will happen to the Basket Fund that is available in select states? The plan is to have a single national trust fund, responded Dr. Nuhu. Individuals from subnational jurisdictions will be

invited to serve on the board of trustees.

Representing Uganda, Hon. Huda Oleru asked whether the proposed board of trustees has been established by law. When raising funds, she continued, will it be managed independently? How will Nigeria source the funding? Is there a mandate to go outside the

country or will fundraising be limited to domestic sources? She then described how her country is setting up its trust fund so as to avoid potential conflicts of interest among its

board members. In response, Dr. Felicia Imohimi, NPHCDA, stated that the Private Trust Fund is independent of government, so there will be no conflict of interest. The proposed trust fund legislation incorporates a wider provision for contributions to come

from State, LGAs and organizations. While the will be represented on the board, it will not manage or control the fund. Some organizations would otherwise be reluctant to

contribute.

Speaking for Gavi, the Vaccine Alliance, Dr. Karan Sagan described how Indian corporations must allocate 2% of their profits, by law, to social projects like immunization. Such an arrangement might work in Nigeria, he added.

Responding further, Prof. Anyene explained how Nigeria’s trust fund would be supported

by a law providing for both public and private contributions. NIFT is actively fundraising. Government will have limited control over its operations. Specific fund regulations have not yet been written by the Ministry of Health. When the fund is operating, NIFT will

generally oversee its work. Fund reports will link immunization program outputs (eg, number of children fully immunized) to financial inputs, thereby monitoring value for

money. The trust fund, he added, needs to be operating before Gavi exits in 2021. Chairman Nasidi reassured the participants that mechanisms will be put in place to build

confidence in the trust fund and that it is a great idea. The board and executive arm of government will meet to develop the needed arrangements. In Nigeria, raising money is

not the problem, he added; it‘s governance.

Liberia

Representing the Liberian Congress House Committee for Health, Hon. William Dakel presented that country’s newest practices for immunization financing. A structured study was carried out by the Ministry of Health (Research Unit, Health Financing Unit, Office of

Financial Management Unit) and county health teams to assess ways to develop increased capacity to track health sector resource flows. USAID and WHO provided technical

support. Costing routine immunization services is another need. Finding alternative domestic financing sources is a third. A technical working group is carrying this work

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forward, co-chaired by Research and Health Financing Units. Members of the House of Representatives Health Committee are also participating.

Developing these new practices is hindered by the lack of information about actual

expenditures. Fragmented external partner support further complicates financial management for the immunization program. Another block is the ongoing reconstruction of the post-Ebola health system, which the MoH is undertaking. All of these factors work

against the development of a domestic investment case for routine immunization. Perhaps the most visible new practices since the October 2015 Nairobi workshop are the activation

of a parliamentary forum on immunization and regular meetings between the immunization team and the House Health Committee.

Dakel noted that the parliamentary forum succeeded in getting the government to increase its annual immunization spending from US$50k to $500k. Parliament also

prevailed on the government to catch up with its delayed Gavi co-financing payments, but much more will be needed. Potential private sector donors and new revenue sources must be identified for a proposed new “ring fenced” immunization fund.

Sierra Leone

Dr. Dennis Marke, National Immunization Program Manager, Ministry of Health and Sanitation (MoHS), described recent immunization financing developments in Sierra Leone. The most pressing need he sees is to establish an immunization budget line item

and his presentation focused on this proposed innovation. Currently, government immunization funds are comingled with funds for other child health programs so

immunization-specific costs are unknown. Budget disbursement is a problem and the country is chronically behind in its Gavi co-financing payments. The Director of Financial Resources in the MoHS and counterparts in the Ministry of Finance and Economic

Development are working together to ameliorate this cash hoarding problem.

Within its scope, the immunization program carefully proposes and manages its budget based on an annual plan of action (cMYP). Expenditures are reported quarterly. There has been increased attention to the annual JRF financial reports and this has raised awareness

of the financing challenges the country faces. If the budget line item can be created, these reporting needs can be better met. To make further progress, the budget line item would

be used to regularly track government immunization expenditures. This was one of Sierra Leone’s action points stemming from the last (May 2015) Sabin-organized peer exchange meeting in Freetown. Other institutions, particularly Parliament and local government,

must be brought into the process to provide oversight. In 2013-14, such an inter-institutional network did briefly materialize, however, it became inactive due to frequent

staff turnover, elections and the Ebola epidemic. If the network could be revived, Dr. Marke believes, the proposed new practices could be established and they would be sustained.

The second new practice, described in Theme II below, is to update the 1960 Public

Health Act.

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Uganda

Mr. Ishmael Magona gave a concise analysis of immunization financing trends in

Uganda. According to a recent (EPIC) costing study, fully immunizing a Ugandan child with the full complement of WHO-recommended vaccines now costs around US$62. [EDITOR’S NOTE: With an annual birth cohort of 1.7m that works out to a theoretical cost

of around $105m. WHO/UNICEF (JRF) estimate the 2014 measles vaccine coverage level to be around 82%. Adjusting for coverage, expenditures would have therefore been

around $86m.] In 2015-16, the government approved $16.4m for the immunization program, of which it reported spending (to JRF) $16.2m on routine immunization. Of this amount, $2.7m was for traditional vaccines and supplies (more than covering the $2.4m

Gavi co-financing obligations that year). Partner contributions for 2015-16 totaled $61.7m. [EDITOR’S NOTE: By deduction, government health system spending and

decentralized external contributions must have covered the remaining roughly $8m in R.I. expenditures.] The Government’s investment per infant rose from $3 in 2006 (13% of total JRF-reported R.I. expenditures) to $11 in 2014 (49%).

With its heavy dependency on external funding, Uganda is still far from its sustainable

immunization financing solution, acknowledged Mr. Magona. He then described two new practices that are helping move Uganda toward that solution. In October 2013, the

Ministry of Finance, Planning and Economic Development (MoFPED), the Ministry of Health and Parliament combined multiple health budget line items affecting immunization (eg, preventive, curative, administrative) into one. The single immunization vote function has

already improved resource tracking capacities. The Ministry of Health directs expenditures, MoFPED oversees budget formulation, implementation and tracking and

Parliament provides high-level oversight, advocacy and support during budget appropriation. Reports on immunization expenditures are produced quarterly. Local governments, CSOs, Sabin and other external partners all played supporting roles. There

are now much better working relationships between MoFPED, Parliament and the Ministry of Health, added Magona.

The second practice- a new National Immunization Act- is described in Theme II below.

Kenya

The Kenya case study was presented by Dr. Dominic Mutie. A new public immunization fund has been established. It corrects the previous removal of all central–level program

funding caused by the 2013-14 devolution of Kenya’s governance structure. In that process, failure of counties to purchase vaccines led to stockouts. Intervention by Gavi

and the federal government prevented expected epidemics from occurring. A second fund, for centralized, federal vaccine procurement, has also been established. Other innovations incubating include two new laws and a parliamentary advocacy network for immunization.

Facilitating these innovations was an EAC/ GAVI rapid assessment of immunization services covering all East African partner states. In Kenya, the plan is to extend the study

to all 47 counties. Results will be presented to a governors’ forum, hopefully in June. The hope is the governors will then agree on a way forward to remedy the severe

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immunization financing disruptions. Dr. Mutie expects that the 2016-17 federal health budget will cover vaccines and Gavi co-financing.

Q & A

Following the presentations, participants asked a series of questions. Speaking for UNICEF, Dr. John Agbor commended Liberia for having increased government

immunization spending tenfold. He went on to ask, what would the immunization investment case for all of Africa look like? Fifty years post-independence, African leaders

do not seem concerned with providing this valuable public good. Much advocacy, he observed, involved powerful people- CEOs talking to presidents- but the best advocacy comes from bottom up, when citizens demand that their governments provide

immunization.

Kenyan delegate Mr. David Kiuluku, Director, Health Planning and Administration, Makeuni County, described how Kenyan counties are carrying out an eight-pillar development strategy. One pillar is health and immunization rests within it. The problem

is competing interests. Overall, two years in, there is a more equitable distribution of resources in the country. Performance improvements in the health sector have been

documented. Sustainability, however, is a concern. New ways of working between federal and county governments must still be developed.

Dr. Oluseyi Abejide (Save the Children) noted the problem of global donor fatigue. He then asked all delegates to reflect on how the alternative financing arrangements they are

developing are helping to make immunization financing more sustainable. How have they worked and what percentage of the budgets do they cover? What new accountability,

tracking and reporting practices are promoting sustainable financing? Noting the case of Uganda, he asked what happened after 2013 to improve immunization financing.

Responding for Liberia, Hon. Dakel said that the new financing scheme is still in the early stage and reiterated that financial strains are limiting the process.

Dr. Clifford Kamara, Senior Program Officer, Sabin Institute, asked what it will take to bring about the changes needed to get public money to the right places. Currently, efforts

to push governments from the outside prevail. His approach is to use advocacy and communication to create demand for the services in the communities. They in turn will

decide to take charge and will demand that their children are fully immunized. This is the endogenous approach.

Dr. Damaris Onwuka, National Primary Healthcare Development Agency, asked the Sierra Leonean and Liberian delegates to describe the effects of the Ebola outbreak on

immunization. Ebola caused a collapse of the health system and immunization was seriously affected, responded Dr. Dennis Marke (Sierra Leone). Measles re-emerged after years of absence. The outbreak collapsed not just health services but the entire

economy. One benefit has been an increased disease surveillance capacity. Health workers had to learn new ways to educate and communicate with the public. The previous

one-way style of communication failed. The crisis induced more community involvement and this helped change the terms of engagement with the health system. Religious

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leaders and civil society groups played important roles in controlling the epidemic. Gavi is now trying to redirect those efforts to strengthen routine immunization.

Hon. Dr. Peter Coleman described how Ebola led to the total collapse of the Liberian

health care delivery system. Immunization was greatly affected with drop in immunization coverage from 85% to about 50%. As in Sierra Leone, that led to the re-emergence of vaccine-preventable diseases like measles. There is currently an outbreak of measles in

Liberia. Economic growth fell from 5-7% to -1%. The fragility of the health system revealed the country’s high dependency on external funding and technical support.

Liberians now realize they need to do things differently. Session Chairman Professor Nasidi added his own impressions, having led a team of

Nigerian public health workers to assist both countries during the outbreak. He then summarized the session. By 2050 the African population is projected to outgrow China’s

population. The cost of vaccine and volume of vaccine per child will increase. Africa needs to achieve self-sufficiency for vaccines. The main financing must come from governments. In Nigeria’s case, US$756m will be needed annually by 2020 for

immunization. The country is now hard pressed to provide $80m. Can the country reposition its immunization financing arrangements or will it remain externally dependent?

Only Rwanda and South Africa are allocating 15% of their budgets for health, he noted. All African countries must do so if they are to build robust systems – cold chain, local

vaccine production. The countries need to take a collective, integrated approach and find complementarities. He closed by thanking the participants for the privilege of chairing the session.

Small groups

Following lunch, participants were randomly assigned to six small groups. The theme: Developing and applying innovative financing arrangements. Partner agency counterparts

facilitated the groups, using the nominal group technique. Results were reported by rapporteurs from each group. They are summarized in Annex D.

Nigerian roundtable

The small group work was followed by a roundtable discussion on immunization financing by Nigerian institutional counterparts (Prospects for federal- state co-financing of routine

immunization). Prof. Anyene began the session with a presentation summarizing the illness burden attributable to vaccine-preventable diseases in Nigeria. He then outlined various advocacy strategies the NIFT is using to increase the domestic immunization

budget. The basic health fund, as set out in the new National Health Act, is not enough. As stated in an NPHCDA Discussion Paper provided to participants before the workshop,

Nigeria’s government immunization budget needs to increase from its current 29b Naira (US$145m) to 63b Naira ($315m) in 2020. For vaccine alone in 2020, the government must raise 53b N ($265m). The only way this can be accomplished, argued Prof. Anyene,

is with co-financing by the federal, state and LGA governments. He presented a plan whereby the federal government will pay 52% of the vaccine bill with states progressively

paying into the trust fund until reaching their full population- and income-weighted shares in 2021. If the states concur, a law must be passed formalizing the arrangement.

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The Commissioners for Health of Nigeria’s Nasarawa, Bauchi and Kebbi States all

commented on Prof. Anyene’s co-financing proposal. Dr. Daniel Iya (Nasarawa) expressed admiration for all the NIFT is doing. The formula appears feasible. Vaccines will

represent just 0.44% of all state revenues. However, in the long run, he felt, immunization must be financed through a community-based insurance scheme. Moving forward, the next step is to involve the state governors. Dr. Halima Mukaddas (Bauchi)

suggested that health indices be integrated into the state contribution matrix. In Kebbi, a prior concern is to assure there is at least one primary health care center for every 225

political wards so that immunization services can reach all of the population. Additional participants commented favorably on the proposed arrangement. Mike

McQuestion (Sabin) observed that the states must already be paying around half the immunization costs because they are financing their PHC delivery systems. To this Prof.

Anyene responded that state immunization spending levels are not generally known. Costing and resource tracking are additional tasks to be faced with the states. Summarizing, Prof. Anyene stated that all Nigerian states must accept that they ultimately

will need to fully finance immunization and that these immunization funds should not consist solely of federal transfers to the states but should also come from locally

generated revenues.

Day One ended at 6PM.

Day 2

Theme II: Legislative Provisions and Implementation

Day Two began with announcements and a recap of Day One by the NPHCDA rapporteurs.

The agenda then turned to Theme II: Legislative Provisions and Implementation. Dr. Mike McQuestion set the scene with a presentation describing the institutional work that

must happen to pass any law. Both government ministries and legislatures must collaborate to draft and ultimately enact immunization-related laws. Many projects begin but fail to reach fruition. In this regard, African countries are following the same

trajectories followed earlier by Latin American countries, most of which ultimately did pass immunization laws. Ms. Dana Silver (Sabin) then presented the provisions of a synthetic

“model” immunization law derived from the Latin American experience. With the arrival of Nigeria’s senior officials and dignitaries, the formal opening ceremony

began. Joining the meeting were:

Chairman, Senate Committee on Primary Health Care and Communicable Diseases, Senator Mao Ohabunwa

Acting Director, Department of Public Health, FMOH, Dr. Sunday Aboje

(representing the Honourable Minister of Health, Prof. Isaac Adewole) Director, Physical and Life Sciences FMST, Dr. Manasseh Gwaza (representing the

Honourable Minister of Science and Technology Dr. Ogbonnaya Onu)

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Mr. Ibikunle Adams (representing the Honourable Minister of Industry, Trade and Investment Dr. Okechukwu Enelamah)

Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr. Ado Muhammed

GM/ Regional Bank Head, Fidelity Bank Plc. Mr. Obaro Odeghe (representing MD Fidelity Bank Plc. Mr. Nnamdi Okonkwo)

Representatives of the Governors of Bauchi, Kano, Nassarawa and Kebbi States

Members of the press.

Welcome Address In his welcome address (Annex E), the Executive Director, NPHCDA, Dr. Ado

Muhammad, expressed his satisfaction with the participation of the private sector in the workshop, noting that the Managing Director of Fidelity Bank Plc. Mr. Nnamdi Okonkwo,

would be giving the keynote address. The workshop agenda, he said, showed a high level of commitment to the task ahead and clearly placed Nigeria as a front runner on issues of vaccine financing. Dr. Muhammed recalled that the NIFT was inaugurated on March 25,

2015 as part of Government’s efforts to secure sustainable immunization financing for the country. Whereas Nigeria paid US$85m for vaccines last year, the bill will be $355m by

2021. He expressed his belief that the workshop will play a vital role in shaping current strategies and the vision for sustainable Immunization financing in Nigeria as well as in

the other participating countries. Dr. Mohammad’s welcome address was followed by a round of good will messages.

The Chairman of the newly constituted Senate Committee on Primary Health Care expressed his satisfaction with the workshop. He assured the participants of his

commitment and promised to pass legislation that will further improve Primary health care services

The Nasarawa State Governor assured the participants of his commitment to the

health of women and children in Nasarawa State GAVI re-iterated its commitment to supporting vaccine financing in main countries

of interest, especially with regards to new vaccines HERFON urged the Federal Government to fund the National Health ACT IVAC called on all relevant organizations to support the government as the task is

enormous and cannot be borne by the Government alone CHAI enjoined the Federal Government to do more, stating that it would be

appropriate for the Legislature to champion the vaccine financing effort On behalf of visiting Country delegates, Uganda observed that Africa was mostly

reliant on donor funds for financing national immunization programs

The Honourable Minister of FMST said the National Research Innovation Fund will help to make funds available for research and new technologies in local vaccine

production The NIFT Chairman encouraged all participants to reflect on the objectives of the

meeting and look at opportunities within Nigeria and Africa that can move the

countries from financial uncertainty to a more predictable and sustainable means of immunization financing.

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Opening Remarks

The Honourable Minister of Health stated that the workshop was in line with the vision of the change agenda of the current administration which is focused on the reactivation of

basic Primary Health Care as proposed in the current Strategic Implementation Plan for the 2016 Budget. He recounted the recent success of the Federal Government in delisting Nigeria from WHO’s list of polio endemic countries and attributed the achievement of this

feat to increased Government commitment and support from donor partners. He also enjoined all delegates at the Workshop comprising of representatives of the Ministries of

Finance, Economic Planning and the Parliaments to ensure that funds allocated to health programmes are disbursed promptly and in full. His full remarks are found in Annex F.

Keynote Address

The MD of Fidelity Bank emphasized the need for high-level political and legislative support for the passage of laws defining how immunization is to be financed perpetually. He encouraged sub-national governments to explore the possibility of contributing more

significantly to the programme rather than depending solely on the central government. In any future arrangement, it will be essential to show clearly how immunization funds are

being used. Budget discipline must also be demonstrated. He also re-iterated the commitment of Fidelity Bank Plc in the development of a sustainable partnership with the

National Immunization Financing Task Team to find new immunization financing sources. The full keynote address is found in Annex G.

Special Guest of Honour

The Executive Governor of Bauchi State re-iterated his commitment to routine immunization, exemplified by the signing of an MOU with the BMGF. The new agreement has already had an enormous impact on the state primary health care system. He also

said that the state was committed to sustaining this progress by ensuring timely delivery of vaccines to all the children of Bauchi State.

The dignitaries stayed on to hear more about the workshop. Chairmanship of the session was passed to the representative of the Executive Governor of Bauchi State. At Professor

Anyene’s suggestion, Dr. Mike McQuestion again presented the introductory Sabin presentation, which included a discussion of the criteria the SIF Program uses to judge

when countries have reached the sustainable immunization financing goal. Work on Theme II then resumed. Four delegations gave updates on the status of immunization legislation in their respective countries.

Liberia

Senator Peter Coleman described how work on Liberia’s immunization bill began in 2013. The emergence of a parliamentary forum for immunization that year facilitated the

work. An initial draft law was prepared by the MPs. It was reviewed by the Ministry of Health and later revised to include a financing provision. With the Ebola outbreak,

fourteen months were lost but momentum has since been regained. At present, four MPs

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are recognized as immunization champions. They are passionate and committed to passing their Bill before parliamentary recess in September 2016.

Sierra Leone

There is currently no legislation for vaccine financing in the country, stated Hon. ABD Sesay, who has emerged as the leading champion for the cause. However, a bill is being

developed and will conform to a newly revamped National Immunization Policy Cabinet Paper. Among the institutions working together on the bill are the Ministries of Health and

Sanitation and Finance and Economic Development, the Law Officer’s Department and the Parliamentary Health and Sanitation Committee.

Uganda

Hon. Huda Oleru, who most recently led Uganda’s legislative project, outlined the history of that country’s new National Immunization Act. The work began more than five years ago when an MP introduced it as a private member’s bill. Backing him were over

forty MPs who had just formed Uganda’s parliamentary forum on immunization, which would eventually be led by the Speaker of the Parliament. Early technical support came

from the Parliamentary Research Office and from Sabin. A key step in the project was winning the approval of the Ministry of Finance, Planning and Economic Development. At

one point, 170 MPs signed a letter to the President calling for the Act to be approved. Important advocacy support came from Uganda’s national immunization technical advisory committee (NITAG) and from local media. The Act was passed in December

2015. With the President’s signature, it was enacted in March 2016, timed to coincide with the launch of the new Gavi-supplied pneumococcal vaccine.

The Ministry of Health is currently preparing regulations to implement the Act. The Immunization Act provides for the creation of a national trust fund, to be run by an

independent board of trustees. Efforts are now focused on creating the fund. One risk is that MPs engaged in the past are now replaced by newly elected successors. The

Parliamentary Forum on Immunization will hopefully provide the institutional memory to keep the legislative work going.

At that point, Dr. Nuhu (NPHCDA) thanked the dignitaries for their commitment to Sustainable Immunization Financing and all proceeded to lunch. Following lunch, Professor

Anyene presented Nigeria’s legislative project and summarized Theme II. Nigeria

Prof. Ben Anyene recalled how work on the National Health Act began in 2004, a time

when there was little or no Government commitment to health. The National Assembly consistently led the project. Finally passed in October 2014, the Act provides dedicated funding for health care delivery, including vaccines. One percent of the total budget is to

go to a new National Health Fund to provide a basic package of PHC services. Of this, 20% is earmarked for basic drugs and vaccines. Now gazetted, 2016 will be the first

budget (not yet passed) to implement the provisions of this law. (See roundtable discussion, Day One, for more on Nigeria’s immunization financing.) A set of technical

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working groups has been charged with implementing the Act. Rollout is expected to be piecemeal. There is a pressing need to clarify roles and responsibilities at all levels of

government. In Nigeria, the 37 states finance 60-70% of all health spending. Senator Mao Ohabunwa described his efforts to shepherd through the needed new financing

legislation, noting the fact there are a number of health-related bills before his Committee.

Q&A

Prof. Alex Akpa asked whether Sabin can help Nigeria develop an investment case for local vaccine production. Negative, replied Dr. Mike McQuestion. That would be beyond the scope of the SIF Program. However, Sabin will soon be implementing the ProVac

Program, which Nigeria could use to study the cost effectiveness of particular vaccines. Counterparts from the countries themselves carry out the ProVac studies. Sabin would

organize technical support if Nigeria requests it. Sabin indirectly helps countries increase financing, commented Dr. Clifford Kamara, by

encouraging greater budget transparency and reporting across sectors. He described how counterparts have analyzed their routine immunization budgets and used that financial

information to strengthen their investment cases. Impressed and informed by this budget transparency, parliamentarians often use the results to argue for increased immunization

budget appropriations.

Theme III: Budgeting, Resource Tracking, and Domestic Advocacy

The agenda turned next to Theme III: Budgeting, Resource Tracking, and Domestic Advocacy. Mike McQuestion began with a slide set outlining the main concepts of

transparency and accountability and the kinds of innovations observed in the countries in this domain. Using the case of DRC, McQuestion illustrated how MoH counterparts used

the Sabin budget flow analysis tool to improve budget execution. When asked whether anyone in the audience had ever used the tool, only one hand was raised. This was an indication of how difficult it is for managers and others to access financial data in the

countries.

The countries then presented their recent work in this area. Liberia

Mr. Adolphus Clarke (Ministry of Health) began by stating that the annual immunization

program work plan now explicitly incorporates advocacy (itself a new practice). Advocacy is needed to convince the government to invest more in immunization. The most effective new practice are regular in-year meetings between the immunization team and the

National Assembly Health Committee. During budget negotiations, the team presents the indicative immunization budget to the MPs. This information sharing and advocacy has led

to a tenfold increase in the government’s immunization budget (from $50k to $500k) since the practice started in 2013, reported Clarke. The Liberians decided to adopt the practice after observing it through Sabin-organized peer exchanges with other countries.

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The Liberian immunization team is now incorporating economic arguments into their

investment cases and communication and social mobilization messages. Media and CSOs are increasingly carrying and amplifying those messages. But there is a long way to go.

The government is funding just 25% of its vaccine bill. Sierra Leone

Mr. Peter Sam-Kpakra (MoFED) described how Sierra Leone has been developing better

resource tracking capacity for its immunization program. A locally adapted version of the Sabin budget flow analysis tool was developed by the MoHS immunization team in 2012. Complementing this is a simpler Excel spreadsheet developed for use by district health

management teams to cross analyze programmatic and financial data. These reports would be presented to the local development councils which oversee all government

spending and services. MoFED and the Ministry of Local Government and Rural Development have collaborated with MoHS on the project. The system has yet to be implemented because the requisite financial data are not available at central level. The

government uses an Internal Financial Management Information System which produces quarterly expenditure reports but the data are not down to program level. This structural

problem also causes severe under-reporting of the government’s annual JRF immunization expenditures.

Kenya

A county-level annual work planning tool was the practice presented by Kenya’s David Kiuluku (Makneni County Health Commissioner). Kiuluku and his team began developing

the practice in 2015. At that time there was no line item for immunization in the county budget. Making the annual plans requires county and sub-county health counterparts to carefully estimate projected costs activity by activity across 101 facilities offering

immunization, then to identify financing sources (government or external partners) to meet them. Fifty percent of the annual routine immunization budget is now financed by

the county. The budget is currently around US$675k- 40% more than the immunization budgets in other counties. About half the budget is executed by the county health management team and the other half is executed by the sub-county health management

teams. A county public health nurse, Ms. Roseline Kavata, has emerged as the champion for the new county budgeting practices.

The county resource tracking work is being assisted by CHAI, reported Ms. Jennifer Foth. The annual work plan model is now being introduced in five additional countries.

Engagement with the counties is improving, commented Mr. Dominic Mutie (MoH).

There are now immunization focal points in each. More work is needed to identify focal points at sub-county levels. There are also new resource tracking practices germinating at central level, he added. An online tool is being used to track movement of vaccines and

supplies.

Uganda

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Dr. Sylvester Mubiru (MoH) described how Uganda uses an output-based budgeting tool for the health sector and how this tool performs the needed sector-level resource tracking

function. The system generates budget projections based on unit costs (logistics, vaccines, supplies) and service coverage levels. It links resources to inputs, outputs and

outcomes. Once approved, budgets are disbursed quarterly. Expenditures are also reported quarterly from the receiving entities. Workshops have been used to introduce the system to local governments. It has been used to populate the National Health Accounts.

A newer version of the tool will be unveiled in 2017-2018. One problem is that it does not capture off-budget external financing. Nor was unclear whether the tool generates

program-level information. If not, adapting it to do so would be an important resource tracking innovation.

Nigeria

At present, there is no resource tracking practice specific to immunization. Periodic budget performance reviews are performed at federal and state levels. Key contacts for expenditure tracking are directors of finance and accounts (federal, state) and local

government treasurers (LGAs). Two key innovations, the use of a Single Treasury Account (STA) and the new zero budgeting technique (ZBB), may now make resource tracking

possible for the immunization program. ZBB is a method of budgeting in which all expenses must be justified for each new period. Budgets are built around what is needed

for the upcoming year regardless of whether it is higher or lower than the previous year. A third possibility are the PHC scorecards, mentioned Professor Anyene, which are used to monitor program performance at state level. Expenditure indicators could be added to the

scorecard or immunization expenditures could be cross analyzed with the current programmatic data.

Q&A

The presentations for Theme III triggered a number of comments and queries.

Dr. Daniel Iya (Nasarawa State) observed that Nigeria and Uganda face the same difficulties caused by external funds not being tracked by the government accounting systems. With the possible exception of polio, all donor funds should be on-budget, he

remarked.

A participant from Niger State observed the general difficulty in accessing any financial data. Another Nigerian participant asked about the Future Generations Fund.

Following the discussion, Theme III and Day Two came to a close.

Day Three

Minister of Health

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The day began with a summary of Day Two proceedings by the NPHCDA rapporteurs. Country delegations then worked together to prepare for the peer review exercise. The

group returned to plenary when the Honourable Minister of Health, Prof. Isaac Adewole, joined the meeting. In his remarks, the Minister declared that achieving local vaccine

production was a matter of national pride. He further commented that the health and immunization budgets would be increased in 2017. It is high time we public health people learn to speak the language of finance, he continued. He thanked the visiting delegates

for coming to Nigeria and for sharing their immunization financing work.

Peer Review Exercise

In this exercise peers reviewed each other’s efforts to achieve sustainable immunization

financing. Each country presented a case study. Participants were given four copies of a standard evaluation form, one for each of the other countries. Five poster sessions were set up around the perimeter of the room. The first three countries to present were Sierra

Leone, Liberia and Nigeria. Participants moved from one to the other. After 45 minutes, Ugandan and Kenyan delegates began their presentations.

Forty-three participants completed at least one review form. Of these, 20 (47%) were from ministries of health, 11 (26%) were from external partner agencies or CSOs, 5

(12%) were from ministries of finance, 3 (7%) were parliamentarians and 4 (9%) did not state their institutional affiliations.

One hundred seven completed forms were collected. Of these, 104 were analyzed. Table

1 shows the numbers of peer ratings contributed and received by each country.

Raters were asked to classify the cases by domain. The most common classification was “legislation” (48%), followed by “advocacy” (27%), “financing” (16%), “resource tracking”

(5%) and any “combination” of these (4%). By country, legislation dominated for Kenya, Liberia and Nigeria. The other countries were perceived as active in two or more of the

other domains. Raters were asked whether the activity is already happening or aspirational. Responses

are shown in Figure 1. Another item asked how long the innovative activity has been going on. Responses were almost evenly divided between “this year”, “past 1-2 years”

Country No. ratings contributed No. ratings received

Kenya 14 25

Liberia 12 17

Nigeria 51 13

Sierra Leone 13 22

Uganda 14 27

Total 104 104

Table 1. Number of raters and ratings by country, Anglophone

Africa Peer Review Workshop, Abuja, Nigeria, April 2016

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and “3+ years”. They were also asked to judge how advanced the activity is in terms of implementation. Most commonly, the raters classified the cases as “becoming

institutionalized” (41%), followed by “just talking about it (aspirational)” (27%), “fully institutionalized” (18%) and “now being tried (piloted)” (15%). Responses to this item are

shown by country in Figure 2. Seventy-two percent of the raters described the activity as being launched “top-down”,

28% perceived it to be “bottom-up” and 2% felt the activity was introduced from the outside, by a third party. Ratings on this item did not vary by country.

Looking at government involvement, 75% of raters saw the new activity as emanating from national authorities- most commonly, a combination of ministry of health, ministry of

finance and elected officials. This was the modal response in all five cases. National and subnational officials were seen as working together to develop the activity by 15% of

raters. Community service organizations were identified as part of the activity 49% of the time. Thirty percent of the ratings identified CSOs teaming up with business to support the activity. External partners were implicated in 17% of the ratings.

0

20

40

60

80

100

120

Kenya Liberia Nigeria Sierra Leone Uganda Total

Fig. 1. Perceived implementation status of innovative activities (n=100 ratings)

Operational Aspirational

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To finish their assessments, raters answered a battery of ten Likert-scaled items.

Responses to these items are shown in Table 2.

0

20

40

60

80

100

120

Kenya Liberia Nigeria Sierra Leone Uganda Total

Fig. 2. How advanced in the new practice?

Aspirational Piloting Spreading Institutionalized

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On whether or not the activity was well conceptualized, raters were generally positive.

Only Kenya (2/14), Nigeria (6/48) and Uganda (1/14) received any ratings of “unsure” or “unlikely” on this item.

The next item- whether a different approach to the problem would have been better- garnered doubts (“likely” or “almost certain”) by a few raters. They expressed these for

the cases of Kenya (6/14), Nigeria (13/49), and Sierra Leone (1/13).

On whether the activity engages the proper mix of institutions, raters gave affirmative responses 88% of the time. Each country received at least one, but no more than 11%, “unlikely” or “unsure” responses.

Item Description of Item Obs. (n) Mean Std. Dev. Min Max rho 1 95% C.I.

concept

The innovation is well conceptualized.

Proposed solution matches the

problem/opportunity it addresses. 98 1.36 0.68 -1 2 ----- -----

approach

Another approach would have been

more suitable for solving the problem,

improving sustainability. 99 0.48 1.16 -2 2 0.32** (0.03, 0.70)

mix_inst

The right mix of institutions is or was

involved in developing the innovation. 97 1.28 0.86 -1 2 ----- -----

resist

There is or was a lot of resistance to this

innovation. 91 0.31 1.29 -2 2 0.44*** (0.08, 0.84)

no_costs

This innovation is or was carried out

without incurring significant new costs. 94 0.33 1.06 -2 2 0.39*** (0.06, 0.79)

sustain

This innovation will help country reach

sustainable immunization financing

sooner. 95 1.21 0.78 -1 2 0.43*** (0.09, 0.81)

inst_nation

The innovation will ultimately be

institutionalized nationwide. 96 1.35 0.79 -2 2 ----- -----

ownership

The innovation will increase country

ownership of the immunization program. 98 1.55 0.58 0 2 ----- -----

likely

Considering all the factors, how likely is

the innovation to succeed, to become

institutionalized? 99 1.2 0.71 -1 2 0.12 (-0.11, 0.53)

my_ctry

This innovation would likely succeed in

your own country. 95 1.1 0.88 -2 2 0.33** (0.04, 0.71)

Table 2. Descriptive statistics, Likert Scaled items, Anglophone Africa Peer Review Workshop, Abuja, Nigeria, April 2016

1 rho is the intra-class correlation

* 0.05<=p<0.10, ** 0.01<p<0.05, *** p<0.01

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Raters perceived resistance to the new practice in all five cases. Responses to this item are shown in Figure 3. Highest resistance was perceived in Kenya (5/14 responses),

Liberia (2/7), Nigeria (14/47) and Sierra Leone (3/13).

On whether the new activity entails new, additional costs to the institutions, raters were divided. Twenty-six percent of the responses 24/94) were negative (“no chance”, “unlikely”) while 46% (43/94) said “likely” or “almost certain”. Kenya, Nigeria and Sierra

Leone were judged most likely to induce new costs.

Will the new activity help the country reach sustainable immunization financing sooner? Raters responded affirmatively 86% overall (82/95 “”likely” or “almost certain”). Only Kenya (2/14) and Nigeria (2/46) received any “unlikely” responses.

Response to the next item- whether the new practice will ultimately spread nationwide-

were similarly optimistic (91%). Doubts were expressed only for Nigeria (2/46 “no chance” or “unlikely”).

At 96% (94/98 responses), raters felt the new practices are advancing country ownership of immunization programs. No countries received “unlikely” or “no chance” responses to

this item.

Weighing whether the new practice is likely to succeed, raters were more guarded. Overall, the perceived probability of success was 85% (84/99 “likely” or “almost certain”). There were no differences among the countries on this item.

The final item asked whether rater thought the innovative activity would succeed in his or

her own country. Eighty percent (76/95) felt yes. Responses by country are shown in Figure 4.

0

10

20

30

40

50

60

70

80

Kenya Liberia Nigeria Sierra

Leone

Uganda Total

Fig. 3. Perceived resistance to new activity

none/unlikely likely almost certain

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The Likert-scaled items were used to construct an index of innovativeness. Of the ten items, five were found suitable- their responses were normally distributed and the raters

showed consistency in their responses to those items (intra-class correlations significant). Further analysis reduced the index to four items (approach, resist, sustain, my_cntry).

Table 3 shows the ranks of the five countries from most to least innovative.

Table 4 shows the ranks for each composite index item. Reviewers were encouraged to write down comments, critiques and recommendations for each delegation they interviewed. They are listed in Annex H. Country Action Points

0

10

20

30

40

50

60

70

80

90

Kenya Liberia Nigeria Sierra

Leone

Uganda Total

Fig. 4. Would this innovation work in my country?

no/unlikely likely almost certain

Rank Country

1 Uganda

2 Nigeria

3 Liberia

4 Kenya

5 Sierra Leone

Table 3. Countries ranked

on innovativeness index

Rank (high to low) approach resistance sustainable my_country

1 Sierra Leone Liberia Uganda Uganda

2 Kenya Sierra Leone Liberia Nigeria

3 Nigeria Uganda Nigeria Liberia

4 Uganda Kenya Kenya Sierra Leone

5 Liberia Nigeria Sierra Leone Kenya

Table 4. Countries ranked on innovative index items

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In the last workshop session, delegates worked by country to review their past action points and develop new ones for the coming months. The results are shown in Annex I. Each delegation then presented its action points in plenary. Workshop Evaluation A standard workshop evaluation form was circulated to delegates. Thirteen completed forms were collected, representing all five countries. Asked to state three personal objectives coming into the workshop, 7/13 (54%) mentioned peer learning. The next most frequent responses were to learn more about legislation, resource tracking and advocacy (3/13, 24%). Asked whether the workshop completed those objectives, 83% (10/12) responded affirmatively. Only 63% (8/13) felt the workshop was well organized. There was not enough small group work and too many speeches, several delegates commented. Seventy percent (9/13) stated they would recommend that a colleague attend a similar Sabin SIF peer review workshop. Recommendations for improvement included better time-keeping, more small groups and open plenary sessions, trying to measure impacts of the innovations, more policymaker involvement, a special session for financial decision makers and allowing the focus of country presentations to be more flexible. Overall, delegates felt the workshop would help them with their own work (92%, 11/12). Detailed results are tabulated in Annex J. Closing Comments To close the workshop, each delegation nominated a spokesperson to share final words about prospects for sustainable immunization financing. (Spokespersons: Professor Ben Anyene, Nigeria; Senator Peter Coleman, Liberia; Mr. Peter Sam-Kpakra, Sierra Leone; Dr. Dominic Mutie, Kenya; Hon. Huda Oleru, Uganda). A common theme was legislation. The three countries without immunization legislation accepted the challenge of getting new bills passed. A second theme was resource tracking. Delegations asked for more training in this area, including the routine use of the Sabin budget flow analysis tool. In a final vote of thanks, partner agency counterparts added their comments and expressed admiration for the work the delegates are doing in their respective countries. Certificates of attendance were distributed and the workshop came to a close at 13:00 hours.

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ANNEXES

Annex A: Concept Note CONCEPT NOTE ON A 2-DAY MEETING FOR SUSTAINABLE IMMUNIZATION FINANCING FOR

ANGLOPHONE AFRICAN COUNTRIES

DATE: March 2016

VENUE: …………… Hotel, TBD, Nigeria

Introduction

The Nigerian immunization program is facing a large funding gap arising from the country’s graduation from GAVI

support and dwindling government revenues/shortfall in annual budgetary allocation, among other factors.

Consequently, Program costs to the government will increase progressively and significantly too through the

stipulated GAVI graduation years (2016 – 2020). This has placed the country’s immunization program at a critical

juncture where urgent action is needed to ensure sustainable financing for vaccines, devices and related cold chain

infrastructure. The government of Nigeria (GoN) through the NPHCDA has made significant progress in Routine

Immunization (RI) coverage in recent years. However, without adequate funding for vaccines the RI system will

experience setbacks by way of stock outs that will ultimately lead to increased deaths from vaccine preventable

diseases. Therefore calls for action led to the suggestions to come up with a Nigeria Immunization Trust Fund

(NITF) that will serve as an independent body to advocate and mobilize funds for routine and supplemental

immunizations in the country in 2016 and beyond.

In line with the TOR for the Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing

(SIF), the Sabin Vaccine Institute’s Sustainable Immunization Financing Program has been working with a growing

number of countries on a range of advocacy activities which includes briefings on immunization financing and

legislation, peer exchanges between countries and support to the key public institutions as they develop particular

innovations, among other things

It is in line with bridging the gap in Sustainable Immunization Financing that Nigeria volunteered at the Anglophone

countries peer review meeting in Nairobi, Kenya in October 2015 to host a meeting in Nigeria on finalizing on a

framework necessary for setting up an Immunization Trust Fund with the support of SIF SABINVACCINE

INSTITUTE. The offer was approved and NIFT has established regular contact with Dr. Clifford Kamara through

whom SABINVACCINE INSTITUTE accepted to support and hold the Anglophone peer exchange meeting in

Nigeria. It is planned for the first quarter of 2016. The outcome is expected to be a huge step towards advocating for

the need and establishment of Immunization Trust Fund.

Vaccine Financing in Nigeria and GAVI Graduation

Vaccine procurement is centralized at the national level to ensure quality and security. The Federal Government

pays fully for traditional vaccines and co-pays for new vaccines with Global Alliance for Vaccines and Immunization

(GAVI) support. The federal government is also responsible for the cost distribution of bundled vaccines for a birth

cohort of 7.4 million children to all States and the states in turn distributes to the local governments within their

respective jurisdictions.

Since year 2000, Nigeria has received tremendous support from GAVI Alliance through various financing windows

(i.e. cash and kind) towards ensuring effective immunization service delivery in the country. Following the rebasing

of the economy, however, Nigeria’s GNI rose to US$ 2690, thus surpassing the eligibility threshold of US$ 1580 for

GAVI support. Nigeria has now entered a graduation period spanning 2015 to 2020, during which GAVI subsidies

will diminish by 20% every year for five years, after which Nigeria is expected to bear the full cost for vaccines.

Having entered graduation, 2015 is the last year Nigeria can apply for new vaccine support.

Funding for vaccines/devices and other aspects of the immunization programme is precarious and will become even

more uncertain with the phasing out of GAVI support in the country. The financial resource requirement for

immunization from the GoN for 2015 to 2020 is estimated at 16, 29, 34, 44, 45 and 53 billion1 naira respectively to

1Collated from the department of Accounts and Finance NPHCDA 2015

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cover traditional and new vaccines. Although funding for 2015 has already been secured with a facility from the

World Bank, financing for 2016 and beyond is yet uncertain.

Against the backdrop of the rising funding requirement, historic appropriations for vaccines have always fallen short

and even declined in recent years. Since 2010 the following amounts were appropriated for vaccines annually - 2.2,

5.0, 6.0, 4.15, 2.156 and 2.615 billion naira2, thus bringing the average annual appropriation for vaccines in the last

6 years to 3.68 billion naira; 23% of what is needed in 2015 and 7% of funding needed for 2020.

Besides the precarious funding situation facing the country, there are other significant cash flow problems as well.

Delays in budget passage and delays in release of actual cash are common experience. Efforts to address funding

gaps should also include considering action/s on how to make funding more predictable and available as planned.

Problem statement

Nigeria faces an enormous funding gap for the immunization programme due to the cost of additional vaccines,

expanding birth cohort, loss of funding following GAVI graduation and insufficient budgetary allocation to vaccines

and immunization given the dwindling government revenues profile. To fill the gap, Nigeria needs to secure

progressively more money for the vaccine program starting from 29 billion naira in 2016 and rising to 63 billion by

20203.

The Nigerian Immunization trust fund

Defining the Nigeria Immunization Trust Fund (NITF)

The Nigeria Immunization Trust Fund (NITF) will serve as an independent body that will advocate, coordinate and

mobilize funds for routine and supplemental immunizations in the country for 2016 and beyond.

This trust fund shall be managed by an independent governing body comprising men and women of proven

integrity and necessary financial clout and administrative prowess needed to propel the entity (NITF) towards

attaining the desired goals efficient and sustainable immunization financing in the country. The Fund shall be

subject to direction and control of the independent board in matters connected with receipt, custody and

disbursement of monies accruing to the Trust Fund from all sources. .

Rationale for the NITF

Considering the graduation of Nigeria from the GAVI eligibility criteria, it has become paramount for the country to

look inwards for immunization financing as government alone cannot bear the cost of sustaining the procurement

of both traditional vaccines and the new, expensive vaccines in addition to the costs of other essential immunization

components.

Leveraging on the passage of the Nigeria National Health Act 2014, a robust but sustainable source of financing for

immunization needs to be adopted to uphold and consolidate the gains already recorded. The elimination of

vaccine preventable diseases has health and economic benefits globally.

Such benefits include cost-effectiveness in healthcare service delivery as immunization serves to prevent the

outbreak of many contagious diseases which otherwise would cost government colossal amount of financial, human

and material resources to contain. Also, immunization seeks to ensure a healthy and productive population among

other advantages.

Objectives of the NITF

The objectives of the NITF are:

1. To source for funds that will bridge gap in immunization financing for 2016 and beyond.

2. To ensure that every child gets the appropriate doses of RI vaccine in the country

3. To ensure that benefits of immunization is extended to every manner of eligible persons living within

Nigeria.

4. To ensure national self-reliance and long term sustainability in immunization financing in the country,

5. To engender confidence of stakeholders in the management of national immunization funds.

2Collated from the department of Accounts and Finance NPHCDA 2015 3Culled from the NIFT concept note

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Legal Frame Work for the Establishment of a Trust Fund in Nigeria

The legality and viability of a trust depends on its establishment and management. A trust fund can be legally s

established by statute (Act of parliament), by registration as incorporated trustees under the companies and allied

matters act (CAMA) or by regulation.

Trust fund by statute: for the NITF, the preferred form of establishment is by an Act of the National

Assembly. This process will further reinforce the confidence of all relevant stakeholders in the trust fund as

all shades of opinions would have been taken into consideration before such an Act is approved. In

addition, such enabling law will make adequate provisions for the management and operation of the Trust

Fund. There may be provisions for mandatory contributions from some specified organizations/corporate

entities in form of taxation or levies/fines on some specific “harmful” consumer products e.g. Tobaco,

Sugar, Energy Drinks, electronic wastes – used computers, Dry Gins or even luxury consumables like

expensive Wines, etc; all these will guarantee continuous inflow of cash into the Fund. In addition,

voluntary donors, especially business corporations and private individuals would feel assured that their

funds are protected and will be used for the intended purpose(s). Example of such trust funds are

Education Trust Fund, Petroleum Trust Fund etc

Trust fund by incorporation: in a trust fund by registration, the contributors to the fund apply to Corporate

Affairs Commission (CAC) under part C of CAMA to be registered as incorporated Trustees. The

operating rules or provision for administering the trust fund are set out in the trust deed the incorporated

trustees are appointed by the trust deed. This can be amended or replaced at any time at a general meeting

convened for that purpose, as considered necessary the procedure of establishing a trust fund as

incorporated trustee is set out in section 679 of CAMA.

Trust Fund by regulation: the NPI and NPHCDA Act, have provisions under which an Immunization

Trust Fund could be established. Such power can be derived from sections 12 and 14 of the NPI Act and

section 7 and 8 of the NPHCDA Act.

Through the Minister of Health’s directive or regulations, the ITF can be set up in the interim pending

proceeding/passage of bill by the National Assembly or amending the National Health Act or the

NPHCDA Act to establish the Nigeria Immunization Trust Fund.

Alternatively, if the ITF is perceived as a Public Private Partnership (PPP) initiative, registering it as an

incorporated Trustee under the CAMA is recommended. In which case, the ITF will operate as an NGO

servicing immunization programmes.

THE TWO- DAY MEETING

This Anglophone Peer Exchange meeting shall have in attendance country delegates from SIF Anglophone

countries such as Liberia, Kenya, Nigeria, Sierra Leone and Uganda also in attendance will be members of the

NIFT, Government officials, development partners and the private sectors that will organize and work to mobilize

resources and technical support for a sustainable vaccine program in Nigeria.

Participants

The meeting will have in attendance member countries of the SIF Anglophone, Members of the National

Immunization Finance Task Team, Government official, Development Partners, Staff of the NPHCDA, FMOH,

other relevant ministries, National Assembly, States, the private sector, media and other stakeholders.

Objectives of the meeting

The meeting shall seek to achieve the following:

To identify, share, and cross-evaluate best domestic sustainable financing initiatives, budget tracking and

advocacy mechanisms, and legislative practices for immunization in Nigeria vis-à-vis other participating

countries.

To develop a set of main recommendations for achieving the ideals of Nigeria NIFT

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Sabin Vaccine Institute

To develop a global template for adoption by participating Countries.

Expected Outcome of the Meeting

It is expected that at the end of the 2-day meeting that:

Best domestic sustainable financing, budget tracking, advocacy, and legislative practices for immunization in

Nigeria would have been developed.

Set of recommendations for the Nigeria NIFT to pursue would have been developed

Acceptable template for participating Countries.

It is important to have a session to brief the meeting on the progress made by Nigeria on Local Vaccine Production

(LVP) as part of the decision at the Nairobi was for Nigeria to produce a credible platform for LVP that can serve

the need of sub-Saharan Africa rather than all countries engaging the process

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Annex B: Participant List

ATTENDANCE LIST FOR ANGLOPHONE AFRICA PEER EXCHANGE WORKSHOP ON SUSTAINABLE IMMUNISATION

FINANCING-NIGERIA

S/N NAME DESIGNATION STATE ORGANISATION E-MAIL ADDRESS

1 CLIFFORD KAMARA SPO SABIN cliff.kamara@sabin.org

2 MIKE McQUESTION DIRECTOR USA SABIN mike.mcquestion@sabin.org

3 DANA SILVER PO USA SABIN dana.silver@sabin.org

4 SAIRA ZAIDI NIGERIA CHAI szaidi@clintonhealthaccess.org

5 DIANA KIZZA SPO UGANDA SABIN diana.kizza@sabin.org

6 CHIMAOBI CHUKWU SO IMO NABDA chukwuchimaobi@yahoo.com

7 DR. EKENE OSAKWE ACSO NIGERIA NABDA ekeneosakwe@yahoo.com

8 ADOLPHUS T CLARKE

EPI, Dep LIB MOH adolphusclarke@gmail.com

9 WILLIAM V DAKEL MP LIB HOR wvdakel@yahoo.com

10 HON.ABD SESAY MP SIERRA LEONE

PARLIAMENT abdsesay64@gmail.com

11 FAITH MUTUKU PO CHA fmutuku@clintonhealthaccess.org

12 DR. KARAN SAGAR SCM GAVI ksagar@gavi.org

13 DR. NAMADI M LAWAL

MO NPHCDA namadih@yahoo.com

14 MAJIDAH ABDULWAHAB

A. O FCT NPHCDA majidahabdulwahab@gmail.com

15 OYEYEMI BANKE PEO II FCT NPHCDA oyeyemibanke50@yahoo.com

16 DR. ADAMU NUHU DAC FCT NPHCDA adamunuhu2001@yahoo.co.uk

17 JOY OSHINOWO SO FCT NPHCDA joyawu88@yahoo.com

18 DR. HALIMA B TAFIDA

SMO FCT NPHCDA drhalimatafida@gmail.com

19 FIONA BRAKA EPI TL WHO brakaf@who.int

20 ALOYSIUS CHIDIEBERE UGWU

PA/TA FCT HERFON ugwualoysius@gmail.com

21 EMMANUEL ABANIDA

ES FCT HERFON drabanida@gmail.com

22 SABO M ADAMU CAO FCT NPHCDA

23 JUSTICE IGBOKWE AO I FCT NPHCDA lytlejustice@gmail.com

24 ALIYU ABDULKADIR HEO FCT NPHCDA aliyujalaluddeenabdulkadir@gmail.com

25 THERESA ABBA PSO FCT NPHCDA tessyabah@yahoo.com

26 ADAMU GAMAWA EC BAUCHI BSPHCDA adamugamawa@gmail.com

27 JOSEPHINE OBANDE AO I FCT NPHCDA obandeori@yahoo.com

28 KENNETH OSHIOBUGIE FCT VACCINE NETWORK kenneth.oshiobugie@gmail.com

29 SYLVESTER MUBIRU AG. PRO UGANDA MOH sylvestermuibiru@yahoo.com

30 OLERU HUDA MP UGANDA PARLIAMENT holeru@parliamentgo.ug

31 M. ISHMAEL MAGONA

COMMISSIONER UGANDA MFPED ishmael.magona@finance.go.ug

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32 DR. OBINNA EBIRIM SPO FCT DCL/IVAC obinna.ebirim@dclnigeria.com

33 DR. HENRY EWUNONU

Rep. President FCT NMA NATIONAL henryewunonu@gmail.com

34 ADEWUMI FUNMILAYO

PA FCT DCL/IVAC funmilayo.adewunmi@dclnigeria.com

35 CHIKA OFFOR COO FCC WAVA/VACCINE NETWORK

vaccinenetwork@gmail.com

36 ABDULAZEEZ M.M SCDO FCT NPHCDA mahura2003@yahoo.com

37 DR. CHARLES MAMMAN

ZC NEZ NPHCDA charlesmamman@yahoo.com

38 DAVID KIULUKU CDH KEN MOH dkikiko76@gmail.com

39 UMMAL-FADAL BABAGIRE

I.O FCT NPHCDA fadalgirei@yahoo.com

40 DR. ALIYU YABAGI SHEHU

EDSPHCDA NIGER SPHCDA ayshehu@yahoo.com

41 EUGENE IVASE HOD Comm FCT NPHCDA eugeneivase@yahoo.co.uk

42 DR. MOH'D ATIKU KENDE

PER SEC KEBBI SMOH matiku28@yahoo.com

43 DR. PETER S. COLEMAN

Senator LIBERIA LIBERIA pscolemon2003@yahoo.com

44 PETER SAM-KPAKRA Deputy Financial Secretary

SIERRA LEONE

MIN OF FINANCE muyab@hotmail.com

45 DR. SHOLA MOLEMEDDE

MANAGER FCT DCL/IVAC sholamole@gmail.com

46 ANIEMA OKON PCS11 FCT NPHCDA Tommyekong@yahoo.com

47 DANIEL IYA HOC NASARAWA MOH dan_iya_dr@yahoo.com

48 DANGANA MUSA SAAD

ZC NCZ NIGER NPHCDA pharmdagana@yahoo.com

49 CELESTINA OBIEKEA NIFT FCT SLNI celestinalobiekea@gmail.com

50 DR. UDUALE OFFION PAEDIATRICIAN FCT PAN uroffiong@yahoo.com

51 SOJI TAIWO DD A&C NPHCDA NPHCDA sojitaiwo@yahoo.com

52 SHARON WANYEKI ICT KENYA MIN OF FINANCE sharon.wanyeki@gmail com

53 GARBA SADEQ SSO NCDC NCDC FMOH sadiggarba720@gmail.com

54 DR DENNIS MARKE PRO. MGR S/ LEONE MOHS dmarke@gmail.com

55 NDIDI CHUKWU ADV.& COM FCT CHR ndidi.chukwu@chrnigeria.info

56 OJO FUNMILAYO SEO FMOH FMOH dhmarke@gmail.com

57 NOSA PRESTON IO FCT NPHCDA nosapreston@gmail.com

58 ABBA MUHAMMED I. PO FCT NPHCDA isawa99@hotminl.com

59 JOHN DANIEL NYSC FCT NPHCDA johndanny2014@yahoo.com

60 DR A.F. KOLAWOLE MO11 FCT NPHCDA dejokekolawole2gmail.com

61 MARYAM MUHAMMED

AO1 FCT NPHCDA maryaham.habubakar@gmail.com

62 HAJ KYAUTA MUHAMMED

DD A&C FCT NPHCDA

63 MIKE ANYA FCT NPHCDA

64 AMINU MAGASHI D. DIRECTOR FCT CHR

65 DR. BEN ANYENE CHAIR NIFT HERFON benanyere@gmail.com

66 GANIYU SALAU NIFT ABUJA NPHCDA ganysal@yahoo.com

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67 FELICIA B. UMOH ESQ

L. A. ABUJA NPHCDA fumoh2000@yahoo.com

68 GARBA ABDUL DIRECTOR ABUJA CHAI Gbduaclintonhealthaccess.org

69 DR. OGBU T.E. SHALFERKLUM ABUJA MD toradoc@yahoo.com

70 DR. KABIRU MOHAMMED

ZCNWZ KANO NPHCDA kabirumd2003@yaho.CO.UK

71 MUSA MOH NPHCDA NCZ NIGER CMO

72 DR. DAMARIS ONWUKA

NPHCDA ABUJA DDCI

73 DR. OBI EMELIFE DD FCT NPHCDA kizobi@yahoo.com

74 M.M ABUBAKAR DD FCT NPHCDA mmusaabubakar@yahoo.com

75 EMMANUEL SOKPO MD ABUJA NPHD emmanuel.sokpo@gmail.com

76 SANNI ADENIYI O. A. (MRS)

DD ABUJA FMOH sanni57@yahoo.com

77 IRECHUKWU KELECHI

INTERN ABUJA DCL/IVAC ugireks@gmail.com

78 ABIODUN AJAYI FCT HEALTH

79 JOHN AGBOR IMM. MANAGER UNICEF jagbor@unicef.org

80 PETER ENALYWU EDITOR FCT LEODDWARD inap60@gmail.com

81 AISHA K. ABBA CCDO FCT NPHCDA drtukur@yahoo.com

82 PROF. ALEX AKPA DIRECTOR FCT NABDA akpaalex@yahoo.com

83 DR. A.O. ADESOPE ZCSWZ OYO NPHCDA funkeoyina@yahoo.com

84 OLUREMI OLUBAJO HEAD HF FCT NPHCDA leke_olu1@yahoo.co.uk

85 LAWAL BAKARE FOUNDER LAGOS EBOLA ALERT ibakare@abdladat.org

86 DR. HALIMA MUKADDAS

HON.COMM BAUCHI SMOH halima.mukaddas@gmail.com

87 REMI JOSEPH HEAD R. MOB. FCT NPHCDA

88 AKINYEMI SAMSON.O

HEAD PROTOCO FCT NPHCDA kayodeakinyemi07@yahoo.com

89 OKEFE ALICE CECILIA

NYSC FCT NPHCDA elsie_okefe@yahoo.com

90 OLUSEYI ADEJIYE ADVOCACY ADVISER

FCT SCI oluseyi.Abejide@savethechildren.org

91 FRANCIS MBA CDM FCT NPHCDA

92 NURU GARBA CDM ABUJA NPHCDA

93 JOSEPH AUDU CDM NPHCDA

94 DR. MANASSEH GWAZA

DIRECTOR FMST FMST

95 AGNES JIMMY PCDO FCT NPHCDA jimmyagues362@yahoo.com

96 JAMILA ALIYU AO I FCT NPHCDA Jymindady@yahoo.com

97 H. K. MUSA AO1 FCT NPHCDA khidr127@yahoo.com

98 AGBOGU OKWUDIH C.

AO1 FCT NPHCDA Ci_ment1@yahoo.com

99 KAFARU OLUWAFEMI

FE FCT NPHCDA kafdefemi@yahoo.com

100 DR. AKIN OYEMAKINDE

CLE FCT FMOH gbekelolwa2003@yahoo.com

101 DR. SALIFU M. S. PMO 11 FCT FMOH unenwa4@yahoo.com

102 PHARM LAMI A. N. PHCD FCT NPHCDA tonialamiamos@gmail.com

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103 VICTOR EMGUINE Prog. Officer FCT Center for Social Justina

victoremguine@gmail.com

104 A. NASIDI NC/CEO FCT NCDC a.nasidi@gmail.com

105 OLUWA JINADU PROTOCOL FCT NPHCDA esliomolakaba@yahoo.com

106 NANCY D. SEMION ADMIN ASST ABUJA CHR nannd.semion@gmail.com

107 BALOGUN A. A. PA FCT NPHCDA yemi_balogun@yahoo.com

108 DR. NGOZI NWOSU ZC SEZ ENUGU NPHCDA ngjpi@yahoo.com

109 DR. JOSEPH OTERI ZC SSZ BENIN NPHCDA josephoteri@gmail.com

110 ADEGBITE OLUFUNMILOLA

AD SO FCT FMOH lolu4Jesus@gmail.com

111 UDEME PETER-IJEH Prog. Manager FCT CENTRE FOR THE Right to health

UpeterIjeh@crhmigena.org

112 GOUDJO CEHZO ACSM Officer FCT CENTRE FOR THE Right to health

Cgoudjo@crhnigeria.org

113 DR.D. NWODO CSG1 FCT NPHCDA dnowdo@gmail.com

114 DR. KAYODE FASOMINU

CONSULTANT FCT SOLINA kayode.Fasminu@solinagroup.com

115 IWEALA-OSHISKE N. CDO FCT NPHCDA iwealanjideka@yahoo.com

116 DR. M. Z. MAHMUD DLHC FCT NPHCDA drmahmud@yahoo.com

117 DR. ONWU NNEKA CSG11/HSIAs FCT NPHCDA nnekaowun@yahoo.com

118 STEPHEN SHAKARHO

Regional Manager FCT MAY & BAKER ushakarho@yahoo.com

119 MUSA ABDULLAHI CDM FCT NPHCDA

120 IBRAHIM I. IBRAHIM CDM FCT NPHCDA

121 DR. NNENNA IHEBUZOR

D,PHCSD FCT NPHCDA nnennaihebuzor@yahoo.com

122 DR. EMMANUEL ODU D-CHS FCT NPHCDA emmanodu@gmail

123 SAADU SALAHU HPRU FCT NPHCDA bamssa@yahoo.com

124 REMI ADELEKE PCDO FCT NPHCDA adelekerm@gmail.com

125 PROF. KABIRU I. DANDAGO

HC Finance KANO MOF kidandago@gmail.com

126 DR. KABIRU I. GETSO

Hon. Commissioner - Health

KANO SMOH kabirgetso@yahoo.com

127 NASIRU MOH'D Hon. Commissioner - Finance

BAUCHI MOF Bhministoryoffinance@gmail.com

128 EZE ONYEKPERE Lead Director Centre for Social Justice

censei@gmail.com

129 DR. CHIZOBA WONODI

Country Lead FCT JOHN HOPKINS US IVAC

cwonodit@jhu.edu

130 BONNY SUMAILI IMM SPECIAL UNICEF KSUMAILI@UNICEF.ORG

131 DOMINIC MUTIE NVIP DCP KENYA dmintie@pie.epi@gmail.com

132 DR. BASSEY OKPOSEN

CMO/HEAD RI FCT NPHCDA basenokng@yahoo.com

133 ASHOGBON DANIEL DFA FCT NPHCDA billyduru@yahoo.com

134 HENRY OSAWE DIA FCT NPHCDA hosawee2@gmail.com

135 MOLOKWU NDIDI PO FCT NPHCDA ndidimolokwu@yahoo.com

136 H. D. GARNUWA HE FCT NPHCDA adgidave@gmail.com

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137 ABIOLA OJUMU Snr Program Manager

FCT CHAI AOJUMU@CLINTONHEALTHACCESS.ORG

138 KABIDIRI IBRAHIM MERIT FCT CHAI dmeritnews@gmail.com

139 L. B. HAMADU FCT NPHCDA

140 ONYEKWELU HENRY STATE CHAIRMAN ANAMBRA HERFON belonwunwankwo@yahoo.com

141 ONWUMAH UCHE STATE CHAIRMAN DELTA HERFON cdcnigeria@gmail.com

142 IBIKUNLE ADAMS DD FMITI FMITI Kunleadams04@yahoo.com

143 BLESSING ADEBAYO OYO SABIN

144 JENNIFER FOTH C UGANDA CHAI jfoth@clintonhealthaccess.org

145 YUSUF SULEIMAN FE FCT NPHCDA yusufjp22@gmail.com

146 DR. LAZ UDE EZE SMT FCT DCL/IVAC laz.eze@ddnigeria.com

147 DR. PETER EDAFIOGHO

HPRM FCT HERFON Petereda2a1@yahoo.com

148 DR. H. H. ADAMU (MRS)

PM FCT HERFON hh.adamu@gmail.com

149 DR. ABDUHRAHMAN D

RM FCT RHS kafiu005@yahoo.com

150 DR. U. S. ADAMU STA-ED/CE FCT NPHCDA drusaida@yahoo.com

151 OBARD ODEGHE REP MD FIDELITY BANK

LAGOS FIDELITY BANK obaro.odege@fidelitybank.com

152 DR. RUI G. VAZ WR WHO WHO Ruivaz@who.int

153 DR. ADO J. G. MOH'D ED-NPHCDA FCT NPHCDA

154 KAFARU O. FB FCT NPHCDA kafahefemi@yahoo.com

155 SARAH AZUBIKE INFOR. OFFICER FCT NPHCDA azubikesarah@yahoo.com

156 ABOLA EMMA ROVA FCT DIOVA rova_healthmgt@yahoo.com

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Annex C: Agenda

Agenda Day One: 19th April 2016

Time Content Presenters Location/Notes

Opening Ceremony

8:30-8:40 Introduction of Participants and Dignitaries Sabin

Plenary,

Moderator: Sabin

Vaccine Institute

8:40-8:50 Welcome & Workshop Objectives Sabin

8:50-9:10 Goodwill Messages

Partners and Private Sector:

BMGF, Gavi, HERFON, IVAC,

CHR, Pharma industry, others

9:10-9:20 Remarks by NIFT Chairman Dr. Ben Anyene

Collective Update

9:20-10:00

Panel Discussion: Progress since the October 2015

Anglophone Africa Peer Review Workshop &

Implementing the Parliamentary Statement, Ministerial

Conference on Immunization in Africa, Addis Ababa

Partners and country

delegates (One per country)

Plenary,

Moderator:

Sabin Vaccine

Institute

10:00-10:15 Coffee Break

Theme I: Domestic Financing Arrangements

10:15-10:30 Overview of domestic immunization financing

arrangements Sabin

Plenary,

Moderator: Nigeria

Senate Committee

Chairman on PHC

& Communicable

Diseases

10:30-11:00 New financing practices: Nigeria NIFT and Nigerian delegates

11:00-12:00 Case Study Presentations: New financing practices,

visiting countries

Country Delegations:

Liberia

Sierra Leone

Uganda

Kenya

Plenary,

Moderator: Nigeria

Senate Committee

Chairman on

Appropriation 12:00-12:15 Discussion and small group work instructions (first round) Sabin and delegates

12:45-13:45 Lunch Break

13:45-14:45 Small Groups: Developing and applying innovative

financing arrangements Randomized small groups Separate rooms

14:45-15:45 Group Presentations: Innovative financing arrangements Panel of rapporteurs Plenary

15:45-16:00 Coffee Break

16:00-17:00 Nigerian Roundtable: Prospects for federal- state co-

financing of routine immunization

NPHCDA, state

commissioners Plenary

17:00 End of Day One

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18:00-20:00 Reception

Day Two: 20th April 2016

Time Content Presenters Location/Notes

8:45-9:00 Recap of Day One NPHCDA rapporteurs Plenary

Theme II: Legislative Provisions & Implementation

9:00-9:30 Overview of legislative provisions and legislative project

implementation Sabin Plenary

Opening Ceremony

9:30-9:40 Introduction of Delegates and Dignitaries Sabin and Master of

Ceremony

Plenary,

Moderator: Sabin

Vaccine Institute

& Master of

Ceremony

9:40-10:00 Welcome Address Dr. Ado Muhammad,

Executive Director, NPHCDA

10:00-10:20 Opening Remarks by Co-hosts

Prof Isaac Adewole, Hon.

Minister of Health & Mrs.

Kemi Adeosun, Hon. Minister

of Finance

10:20-10:40 Keynote Address Mr. Nnamdi Okonkwo,

MD Fidelity Bank Plc

10:40-11:00 Remarks by Special Guest of Honor

H.E. Barr Mohammed A

Abubakar, The Executive

Governor of Bauchi State

11:00-11:15 Welcome & Workshop Objectives (repeat) Sabin

Theme II: Legislative Provisions & Implementation, continued

11:15-12:15 Vaccine legislative project implementation updates

Country Delegations:

Liberia

Sierra Leone

Uganda

12:15-12:45 Discussion

12:45-14:00 Lunch Break

14:00-14:20 Health and vaccine legislation in Nigeria Prof. Ben Anyene Plenary,

Moderator: Sabin

Vaccine Institute

& Master of

Ceremony

14:20-14:50 Discussion, Summary of Theme II Sabin

Theme III: Budgeting, resource tracking and domestic advocacy

14:50-15:00 Immunization budgeting, resource tracking and

domestic advocacy: best practices Sabin

Plenary,

Moderator: H. E.

Barr Mohammed

A Abubakar,

Executive

Governor of

Bauchi State

15:00-15:45 Case Study Presentations: Budgeting, resource tracking

and domestic advocacy case studies

Country Delegations:

Liberia

Sierra Leone

Kenya

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15:45-16:00 Coffee Break

16:00-17:00 Case Study Presentations, continued: Budgeting,

resource tracking and domestic advocacy case studies

Uganda

Nigeria Plenary

17:00-17:30 Discussion

17:30 End of Day Two

Day Three: 21st April 2016

Time Content Presenters Location/Notes

Peer Review: Innovations in Sustainable Immunization Financing

8:45-9:00 Recap of Day One NPHCDA rapporteurs Plenary

9:00-9:30

Country delegates meet to prepare peer review case

study presentations Country Delegations Small groups

9:30-10:00 Remarks by Honorable Minister of Health of Nigeria Prof Isaac Adewole, Hon.

Minister of Health Plenary

10:00-10:15 Peer review instructions and demonstration Sabin

10:15-10:30 Coffee Break

10:30-11:15 Peer review, part I: (Group A) Country delegates Plenary

11:15-12:00 Peer review, part II: (Group B) Country delegates

12:00-12:20 Country action points: Next steps Nigerian delegation Small groups

Way Forward

12:20-12:45 Discussion of next steps

Country delegates

Kenya

Liberia

Nigeria

Sierra Leone

Uganda

Plenary

12:45-13:00 Closing words & workshop evaluations Sabin, Country delegates

13:00 End of workshop

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Annex D: Small group results

Summary of small group results, Domestic Financing arrangements

Group/Rapporteur Other members

Problems Solutions

1 (Jan-Feb) Eugene

Ivase

Dr. Ekene Osakwe, Nigeria

Dr. Mohammed Atiku K.,

Nigeria

Dr. Charles Mamman,

Nigeria

Mahmud Mustafa, Nigeria

Dr. Ngozi Nwosu, Nigeria

Dr. Peter S. Coleman,

Liberia

Ms. Sharon Wanyeki, Kenya

Dr. Mike McQuestion,

US/Sabin

Ms. Diana Mugenzi,

Uganda/Sabin

*insufficient government

financing for R.I.

*new public policies, legislation

*high-level advocacy

*low public awareness of need

for immunization

*mass sensitization, more

community engagement

*low or no private sector

involvement in immunization

financing and local vaccine

production

*more regional institutional

collaboration for fast-tracking

local vaccine production (African

Union, ECOWAS, SADC, IGAD,

AfDB)

2 (Mar-Apr)

Peter Sam-Kpakra

Dr. Adefunke Adesope,

NPHCDA

Hon. Ohesu Huda, Uganda

Dr.Henry Ewuonwu, NMA

Nigeria

Balogun Abubaka,

NPHCDA

Danguma M. Saadu,

NPHCDA

Mohammed Sabo Adamu,

NPHCDA

Kenneth Oshiobugie,

Vaccine Network Nigeria

Dr. Kayode Fasominu,

Solina Health Nigeria

* insufficient government

financing for R.I.

*make adequate resources

available

*trust funds

*create regional vaccine industry

*lack of political commitment *sustained advocacy at all levels

*social mobilization

*enactment of laws

*poor or no stakeholder

coordination

*constant stakeholder

engagement

*streamlined bureaucratic

processes, including procurement

*inadequate data collection *more monitoring & evaluation

*proper data dissemination

*regular updates, feedback

*more efficient reporting system

*little or no accountability *public financial mgt training

*timely submission of financial

reports

*new tracking tools

*regular audits

3 (May-Jun)

Adolphus Clarke

*limited budget *grassroots advocacy

*more effective advocacy with

key institutional actors (Treasury)

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Faith Mutuku, CHAI

KENYA

Saira Zaidi, CHAI NIGERIA

Dr. Obinna Ebirim, SPO

DCL/IVAC Nigeria

Ndidi Chukwu,

Advocacy/Communication,

CHR Nigeria

Ojo Funmilayo, PO/FMOH

Nigeria

Dr. Onwuka, Director,

Disease Control &

Immunization, NPHCDA

*MoH budget line for advocacy

*poor advocacy, coordination,

legislative oversight

*increase advocacy work at all

levels

*include CSOs in budget process

*strengthen task teams for

coordinated advocacy

*poor demand creation *mass sensitization

*public information on VPD

epidemiology

*engage religious, traditional

leaders, CSOs

4 (Jul-Aug)

Dominic Mutie

Chika Offor, Vaccine

Network Nigeria

Shola Molemodile

DCL/IVAC Nigeria

Celestina Obiekea, SLNI

Nigeria

Dana Silver, SABIN USA

Ganiyu Salawu, NPHCDA

Nigeria

Dr Obi Emelife, NPHCDA

Nigeria

Felicia Umoh, NPHCDA

Nigeria

William V Dakel, MP

Liberia

Stephen Shakarho, May &

Baker,Nigeria

*inadequate financing *increase government revenues

*legislation

*engage domestic private sector

*reduce costs via local vaccine

production

*low country ownership *R.I. co-financing at all levels

*joint stakeholder advocacy

*investment (business) case for

private sector investors

*insufficient stakeholder

involvement

*co-financing at all levels of

government

*trust funds

*comprehensive accountability

framework

5 (Sept-Oct)

Dennis Marke

Clifford Kamara (SABIN)

Hon. Abdulkarin D. Sesay

Sierra Leone

Dr. Halima Mukaddas, Hon.

Commissioner for Health

Bauchi State

Aloysius Chidiebere UGWU,

HERFON Nigeria

Dr. Daniel Iya, Hon.

Commisioner Nasarawa

State

Irechukwu Kelechi, IVAC

M.M Abubakar, NPHCDA

Dr. Thomas Ogbu

*inadequate legislation *write new laws

*high-level advocacy

*high donor dependency,

inadequate government

funding

*new public-private partnerships

(fuel tax example)

*trust funds

*basket funds (increase gov’t

proportion)

*weak resource tracking *Strengthen monitoring &

evaluation

*Sabin budget flow analysis tool

*inadequate demand creation,

low awareness

*more sensitization (IEC, BCC)

*engage local leaders

*inadequate human capacity *train more health care

professionals, give them retention

incentives

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6 (Nov-Dec)

Sylvester Mubiru

Adegbite Olufunmilola-

Nigeria, NPHCDA

Dr. Chizoba Wonodi-

Nigeria, JHU/IVAC

Prof Alex U. Akpa- Nigeria,

NABDA, FMST

Ismail Magona- Uganda,

MoF

Pharm Lami Nebechi-

Nigeria, NPHCDA

David Kiuluku- Kenya, MoH

Adewumi Funmilayo-

Nigeria, DCL/IVAC

*inadequate legislation *legislative provisions for

immunization financing

*low country ownership,

insufficient private sector

involvement

*immunization budget line item

at all levels

*adequate financing of advocacy

efforts

*weak financial arrangements

(inadequate budgets, high

donor dependency, curative

bias, high immunization

program costs)

*minimize campaigns

*public- private partnerships

*implement comprehensive,

universal health care (UHC)

*resource tracking, budget

analyses at all levels

*lack of political commitment,

corruption

*help officials use immunization

support to build political capital

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Annex E: Welcome Address, Dr. Ado Muhammad

WELCOME ADDRESS BY THE EXECUTIVE DIRECTOR, NATIONAL PRIMARY HEALTH

CARE DEVELOPMENT AGENCY, DR. ADO J. G. MUHAMMAD AT THE ANGLOPHONE

AFRICA PEER REVIEW WORKSHOP ON SUSTAINABLE IMMUNIZATION FINANCING,

ABUJA. 19TH – 21st APRIL, 2016.

Protocols:

Distinguished ladies and Gentlemen, dear colleagues and our development partners, I welcome you all

to this very important peer review meeting. It is pleasing to note that you have left some of other

pressing issues seeking your attention to be here in Abuja today with us. This further underscores the

level of regard and commitment we have for our peoples health most especially the children and women.

It is very clear especially with the current decrease of our fiscal space, our collective commitment of

having permanent structures for sustainable immunization financing, its implementation and ensuring its

success across the countries of the sub region is by no means an easy one.

This peer review meeting will no doubt sustain the momentum that was stimulated by Sabin and

participating countries during the October, 2015 meeting in Nairobi, Kenya. It is my firm conviction that

the Abuja meeting will also give peers the opportunity to evaluate progress on the action points

formulated and agreed upon in the 2015 Nairobi workshop. In addition, we expect to take stock of new

practices and developments and set out new action points that will lead to consolidation on a number of

initiatives towards the establishment of structures in their countries for the sustainable immunization

financing objective.

On our part and in recognition of the need for more coordinated and concerted effort towards secured

Immunization financing, I, inaugurated the National Immunization Financing Task Team (initially

called National Vaccine Financing Task team) on March 25, 2015. This task team was mandated to

ensure amongst others:

1. Push for evidenced based Government increase in budgetary allocation and appropriations for

Immunizations

2. Explore alternative sources of vaccine financing (unlocking internal and external opportunities).

3. Proposed appropriate agreeable sustainable co-funding mechanism for the immunization value

by Federal Government, State Governments and the Private Sector

4. Development frame work for Local Vaccine Production

I am happy to note that various sub committees of the Task Team have made significant progress on

issues of Advocacy, Fundraising, achieving Local Vaccine production and Evidence generation.

It is worthy to note and appreciate the Federal Government under the current leadership of President

Muhammad Buhari for the continuous Government commitment in area of vaccine security. We have

already secured our funding for all RI vaccines for 2016 and those for 2017 will be finalized as soon as

the budget for 2016 is passed. Beyond vaccines security our vision is towards the complete

immunization financing that require funding and commitment for both the supply side (critical

infrastructure such as cold chain equipment, & building, Data, operational research and Human

resources) and the demand component that will involve community mobilization for active participation

in Immunization activities and CSO. Our expenditures should be very clear, unambiguous and

evidenced based. It is only we go this way, that we can favourably compete with other important sectors

that also require the attention of Government and donors. On our part we have already initiated some far

reaching reforms to improve value for money under our Immunization space. For example how can we

utilize our bulk purchasing power/advantage for our Immunization commodities to reduce price and

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improve on quality. On Human resources (health workers), what will happen on quality of care (through

a resilience and responsiveness health work ) and cost-effectiveness if we take Immunization training

back to teaching institutions?

It is my belief therefore, that this Peer review workshop will play vital role in shaping our strategies and

vision of a sustainable Immunization financing for Nigeria and other participating countries as well.

I, therefore, appeal to you all to work diligently to ensure the success of this meeting and to use the

outcome of the peer review for Continuous advocacy on sustainable immunization financing to

legislators, policy makers and the general public.

Once again, I welcome you and wish you all a rewarding time at this meeting.

Thank you and God bless you all.

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Annex F: Opening Remarks, Hon. Minister of Health

OPENING REMARKS BY HON. MINISTER OF HEALTH, PROF. ISAAC. F. ADEWOLE AT THE

ANGLOPHONE AFRICA PEER REVIEW WORKSHOP ON SUSTAINABLE IMMUNIZATION

FINANCING, ABUJA. 19TH – 21st APRIL, 2016

PROTOCOL

It gives me great pleasure to be in your midst today on the occasion of the Anglophone Africa Peer

Review Workshop on Sustainable Immunization Financing.

The theme of this Peer Review meeting which is; “Sustainable Immunization Financing” while the Sub-

theme is “Immunization Trust Funds and Legislation”, is quite appropriate as it captures the vision and

the change agenda direction of this administration under the able leadership of Mr. President,

Muhammad Buhari, GCFR. The current administration change agenda on health is focused on basic

PHC. The current Strategic Implementation plan for 2016 budget has PHC reactivation as one of the 33

concrete actions to be executed for the year and the strategic frame clearly identified collaboration and

partnership as one of its key strategies

The present administration is currently exploring ways of inviting and engaging the private sector in the

development of the health sector.

Presently the federal government of Nigeria pays fully for traditional vaccines and co-pays for new

vaccines, with Gavi support. The federal government then distributes bundled vaccines for a birth cohort

of 7.4 million children to all states, which in turn distributes to their corresponding local governments.

Since 2000, Nigeria has received support from Gavi through various funding windows. Following the

rebasing of the economy, Nigeria’s GNI rose to US$ 2690, surpassing the eligibility threshold of US$

1580 for Gavi support. Nigeria has now entered a graduation period spanning 2017 to 2021, during

which Gavi subsidies will diminish by 20% every year for five years, after which Nigeria is expected to

bear the full cost for vaccines. Having entered graduation, 2016 is the last year Nigeria can apply for

new vaccine support.

Distinguished delegates, ladies and gentlemen, the government of Nigeria has recorded huge successes

in the Routine immunization programme as a result of increased government commitment which led to

the interruption of polio virus and delisting from WHO’s polio endemic countries. Nigeria will therefore

qualify for delisting in 2017 if the country stays polio free. The contributions of development partners

and improved coordination of efforts among stakeholders in the immunization community has also been

of tremendous support to our health system. For instance, with the support of the Gavi Alliance, the

Gates Foundation, the EU, WHO, UNICEF, JICA and other partners, the country has expanded its cold

chain capacity and management, improved data monitoring and introduced new vaccine. Within four

years, three new vaccines, pentavalent, PCV and IPV were introduced into the routine system. Four

additional new vaccines (rotavirus, HPV, MR and MenAfriVac A) are planned to be introduced into the

routine system by 2018.

The ambition of these new vaccines introductions is unprecedented and represents additional

opportunities to save lives and prevent morbidity. However with the relatively costlier new vaccines, the

increasing infant population, and the expected phase out of support from Gavi due to graduation,

vaccine programme cost will increase progressively and significantly. Government alone cannot bear the

burden and immunization funding for 2016 and beyond remains precarious.

Without adequate funding for vaccines the RI system will experience setbacks such as stock outs of

vaccines that will ultimately lead to increased illness and or deaths from vaccine preventable diseases.

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The Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing holding from

April 19th to 21st, 2016 is therefore critical to the achievement of a lasting solution for vaccines and

immunization financing in Nigeria and the sub-region.

May I therefore use this opportunity to call on all country delegates and the representatives of all

stakeholders from the Ministries of Finance, Economic Planning and the Parliaments to ensure that

funds allocated to health programmes especially in promoting vaccination and public health in general

are disbursed in full and on time and that sources of public financing are made adequate and dependable.

I also urge other key public institutions to also work together in order to accomplish the establishment of

permanent structures in the Anglophone countries for sustainable immunization financing.

Ladies and gentlemen, from the going, it is clear that the stage is now set for Nigeria and other countries

of the sub region to work towards the institutionalization of a sustainable mechanism of immunization

financing.

At this juncture, I wish to appreciate the Sabin Vaccine Institute for their partnership with the Ministry

of Health and NPHCDA in staging this peer review meeting in Abuja.

I want to also commend the chairman and members of the NIFT, all government officials and

representatives of the organised private sector for their continued support and commitment.

Last but not the least, the Federal Ministry of Health acknowledges the collaboration from our

parliamentarians from the national Assembly, our sister Ministries of Finance, and Economic Planning

for their show of solidarity and commitment in making Nigerians healthy.

I wish you all a fruitful deliberation.

Thank you for listening.

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Annex G: Keynote Address, Managing Director, Fidelity Bank

KEY NOTE ADDRESS BY THE MANAGING DIRECTOR, FIDELITY BANK PLC,

MR NNAMDI OKONKWO; AT THE 3RD ANGLOPHONE AFRICA PEER EXCHANGE

WORKSHOP ON SUSTAINABLE IMMUNIZATION FINANCING.

ABUJA 20TH APRIL, 2016.

PROTOCOL.

May I begin by expressing my profound gratitude to the chairman, National Immunization Financing

Task team (NIFT); Dr. Ben Anyene for giving me the singular honor of delivering the keynote address

at this very auspicious occasion of the 3RD Anglophone African Peer Exchange Workshop on

Sustainable Immunization Financing.

THE IMPORTANCE OF PLANNING FOR FINANCIAL SUSTAINABILITY

Immunization programs can improve the health of the children only when the programs have adequate

and reliable funding, combined with the efficient procurement and use of resources. Secure financing for

the long term helps to make possible continuity in services and continuous increases in coverage, quality

and access to both traditional EPI and newer vaccines. Thus, understanding a programs current financial

status and future needs, and identifying and implementing a financing strategy that allows the program

to achieve its goals, are fundamental tasks in the planning and management of all immunization (and

other health) programs.

In general, there are four basic aspects of financial resources to consider: How much does it cost to

achieve program aims? How much funding is available now and in the future relative to what is required

for program expansion and improvement (the “gap”)? How do the funds flow from the source to the

eventual use? How are the funds used? All of these aspects influence the extent to which a program can

achieve its objectives, and can contribute to the overall aims of the health sector. For example:

• If the program seeks to maintain coverage, additional resources will likely be needed in the

future simply to keep up with the population growth.

• If the program wishes to expand coverage, the financial arrangements may need to ensure that

sufficient funds are allocated for personnel and other recurrent costs associated with new outreach

strategies

• And that the funds are disbursed on time, and are used effectively.

• If the program has identified better vaccine management in peripheral zones as a key challenge,

the financing targets must focus on obtaining funds for capital investments to revitalize the cold chain

and ensuring that the individuals responsible for maintenance of the cold chain have (and use) the funds

they need, when they need them, to make repairs.

• If the program has relatively high levels of coverage of the basic vaccines and is striving to

introduce new antigens, the main emphasis of the financing strategy might be to obtain and sustain much

higher levels of funding for vaccine procurement, as well as for the additional staff training, transport

and cold chain space required –and to make sure that there is timely access to foreign exchange, if

needed.

While broad health, as well as program-specific objectives are the starting point for determining how

much is needed to finance a program and how that financing should be organized, sometimes program

objectives themselves must be modified in the face of financial realities. For example, if immunization

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is deemed to be a lower priority than other uses of government funds, and/or a major donor terminates or

greatly reduces support and no alternative arrangements can be made, program managers may have no

choice but to slow down planned expansions. In this way, setting program objectives and determining

the right financing strategy both are parts of the same ongoing process of program planning.

It is important to note that planning for financial sustainability takes into consideration many levels of

decision making, and specifically requires attention to the district level. Increasingly, immunization

programs are seeking to address the needs across all geographic areas-and particularly in low-

performing districts- by establishing districts-level targets, strategies, and budgets (often in the form of

“micro plans”). In addition, in many countries there is a trend toward decentralization, and expanded

decision and budgetary responsibilities at sub-national levels. Thus, good program management and

planning, and therefore financing, takes into account the planning at multiple levels within a country

(district, province, national), to ensure that funding is both adequate and reliable at the level at which it

will be used.

BUILDING ON THE VACCINE FUND FOR LONG-TERM SUCCESS

How much will be needed to support the expansion of immunization coverage and improvement of the

quality of the vaccines and the immunization services? How will the immunization program be financed

in the future? How should the funds flow to ensure that they will be available when they are needed?

How can they be used effectively to meet program objectives? And what is the size and nature of the

gap in financing immunization services now and in the future. the long-term success of the

immunization depends on answering these questions, and then identifying and taking actions to improve

a programs financial prospects based on those answers. The immunization program will reach (or come

close to) its program objectives-attaining continuous improvements in coverage and quality- only if the

resources can be counted on to support those efforts.

While all Ministries of Health and immunization program managers should be considering how the

program financing can be sustained over the long term, such planning is particularly important for

recipients of vaccine Fund resources because of the way the fund works. The Vaccine Fund is designed

to be a catalyst to increase the financial resources for national immunization programs in a step-wise

fashion. The Vaccine Fund provides an initial allocation of resources to support the strengthening of

immunization systems (leading to increased coverage quality) and/or to introduce newer vaccines, some

of which are common in industrialized countries but not yet in widespread use in the developing world.

Once that initial allocation is disbursed (over a five-to ten-year period), it is currently expected that no

additional funds would be made available for the specific activities covered under the initial allocation.

It is expected that in each country domestic and supplementary external resources will be mobilized to

take up where the vaccine fund leaves off. A core challenge of planning for the programs future, then, is

determining the actions needed to maintain the current level and mobilize those new resources.

The Vaccine Fund intends to become a long-term mechanism in the global immunization effort. As the

Vaccine Fund phases out of providing the initial types of support, its focus will evolve to support the

introduction of vaccines now in the late stages of product development in the countries where such

introduction is justified epidemiologically and is backed by effective and efficient management capacity.

For example, the Vaccine Fund may provide some countries with resources to introduce anticipated new

vaccines, such as those against rotavirus, pneumococcus or meningococcal A. again, subject to

fulfillment of the requirements of the program, that support (which may also potentially be dedicated to

new means to improve program performance) will be for a specific period-five to ten years- with the

expectation that other sources of funding will fill in at the end of Vaccine Fund support.

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After that second round, the Vaccine Fund would again support the introduction of vaccines that are

now in the early stages of development, but show great promises for the future. These potentially

include vaccines against malaria, tuberculosis, HIV/AIDS. Although these vaccines are likely to be quite

costly at the start, their potential for reducing the burden of disease and associated treatment costs could

make them sound investments for many countries. As currently envisioned, the Vaccine Fund would

(subject to the fulfillment of the requirements of the program), once again provide resources for a five-to

ten-year period, and then phase out as domestic and external resources fill the gap.

In this way, the Vaccine Fund will benefit immunization programs- and many generations of children –

only if financing of immunization services changes significantly: New resources will need to be

mobilized and phased-in, and both existing and new sources of funding will have to respond to program

needs.

PATHWAYS TO A MORE STABLE EQUILIBRIUM

However, changes around the world are moving donors’ and governments’ incentives into alignment.

For example, mortality and fertility continue to decline as more people gain access to, and make

increasing use of, effective health services families are producing fewer and healthier children. More

people are living longer, more productive lives. Like primary education, immunization programs make a

sustainable contribution to this added productivity.

In the political sphere, free and open elections have become routine in a growing number of countries.

For the first time, newly elected parliaments are beginning to exercise effective oversight on government

programs and to represent heretofore forgotten areas and groups.

These changes lead to increased pressure on governments to find sustainable financing for the health

sector. Around the world, people’s expectations of health care are rising, and rising and governments

gain politically by investing more in health. This includes taking responsibility for programs initially led

by external partners and increasingly engaging citizens in the expansion of health systems.

BUDGET REFORMS

In the area of public finance, transparency and accountability become more important as government

expenditures increase and people become more dependent on public services. As noted above,

dependency on external partners tends to distort the budgeting process. Rather than build the capacity

needed to provide services. Governments take the part of least resistance by allowing managers of

immunization and other programs to bypass existing government channels and get funds from external

partners.

In the health sector, a logical place to start budget reforms is in a country’s immunization program. Of

all health programs, immunization has the richest stream of real-time data, which makes its budget the

easiest to monitor. The periodic Sabin briefings give members of parliament opportunities to scrutinize

the performance of the immunization budget. If they find that planned activities were not carried out

because of insufficient funding or interruptions in support from external partners, they use these facts to

argue for increases in the government’s routine immunization budget.

The legislators are often impressed to learn that health districts report numbers of children immunized

and cases of disease seen or investigated monthly, if not weekly. Combining these data with information

on expenditures- such as the cost of fully immunizing a child- makes it possible for elected officials and

other decision makers assess how well the program is using its resources (its absorptive capacity),

whether it is reaching all areas (its allocative efficiency), and whether it is achieving its goals (its value

for money\0. Budget reforms for immunization programs could serve as models for reforming other

programs, such as maternal care and malaria control.

An early step in budget reform must be to build a country’s own capacity to provide services such as

immunization. This involves establishing new business practices- for example, quarterly cash

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accounting and reporting- not only between government and donors but also across ministries, between

ministries and parliament, and between elected officials and their constituents. New approaches include

budgeting based on performance and output. In the latter, proposed outputs and expenditures are

compared to actual outputs and expenditures in each quarter. Program and budget performance are

evaluated together in relation to previously set objectives, and the next quarterly budget disbursement is

adjusted accordingly.

Uganda began implementing an output-based budgeting system in 2010. District governments report

expenditures and program outputs quarterly to the ministry of Finance, Planning, and Economic

Development. The ministry submits its analysis and recommendations to parliaments Public Accounts

Committee twice a year. Initial results show improved absorptive capacity in health and other sectors.

The amount of funds unused at the end of the year has decreased considerably. Yet this regular exchange

of programmatic and financial data is a rarity. In 2010 the Sabin program sponsored peer exchanges that

allowed finance officials from Liberia and Sierra Leone to observe Uganda’s new output-based

budgeting system.

DECENTRALIZATION

As governments devolve and decentralize states and provinces, are in principle, taking more ownership

of essential public services. In Nigeria, for example, states receive federal transfers of funds and execute

their own health programs. The federal government provides regulations and some technical oversight.

However, most decentralization programs are advancing at a snail’s pace. Technical capacity is a key

limiting factor. There are not enough skilled managers and technicians at the regional and local levels to

make the systems work properly.

One reform approach is to make decentralized work intrinsically more rewarding by ensuring adequate

access to computers and the internet, and by encouraging skilled workers to collaborate across

government ministries. In Kenya and Sierra Leone, for example, local governments have used a rapid-

results approach to improve service delivery. Immunization was one of several thematic areas in the case

of Kenya, where local governments achieved improvements within 100 days by engaging front-line

workers in the planning process and providing them with clear goals and intensive monitoring and

feedback.

Greater political accountability is also needed. Properly done, decentralization transfers budgetary and

fiscal control to regional and local officials. This gives elected officials at those levels a voice in the

programs- and a new way to win votes. Involving the community in preparing the local budget further

increases transparency and accountability. The equilibrium shifts when subnational governments move

from total dependence on funds from the national level to assuming a portion of recurrent program costs

using local revenues.

LEGISLATION

The goal of sustainable immunization funding is not achieved until parliaments pass laws defining how

immunization and other key programs for maternal and child health are to be financed perpetually. In

the Americas, where governments currently finance 90% of immunization costs, this goal has already

been reached.

Mobilizing elected officials was an important step in the process. In 1994 the Pan American Health

Organization engaged the Latin American Parliament in an analysis of national immunization financing

policies. In 2009 the latter produced a model vaccination law. By 2010twenty-seven countries in the

Americas had passed immunization financing laws and regulations. Of the fifteen countries in the

sustainable immunization Financing Program, nine have drafted or introduced into parliament legislation

relating to immunization financing. Members of parliaments in the other six countries have signed

declarations to the effect that they would advocate for more immunization resources.

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THE ROLE OF THE PUBLIC

Public support may be the essential factor that links budget reforms, decentralization, and legislation in a

way that leads to more sustainable health financing. In a 2009 paper, Matt Andrews noted a generalized

resistance to financial reforms on the part of government agencies. He cast doubt on the idea that

organizations change in order to become more efficient. Instead, he theorized that they change in order

to be legitimized- in other words, to meet popular expectations.

Reforms are thus more likely when the government’s operations are transparent and subject to scrutiny

by the public. Engaging new stockholders in immunization programs and allowing managers the chance

to tout their accomplishments provides an object lesson in how societies efficiently provide public

goods. The Sabin program facilitates this increased public involvement through its briefings and other

meetings.

THE ROLE OF PRIVATE SECTOR IN SUSTAINABLE NATIONAL IMMUNIZATION TRUST

FUND

In looking at a sustainable private sector funding for the National Immunization trust fund, the following

pertinent questions readily come to mind:

1. How important is the private sector’s role in immunization service delivery?

2. What functions does the private sector play and how does it affect the demand for and supply of

immunization services?

3. What are the characteristics of users of immunization services in the private sector?

4. How well integrated is private sector service delivery into the national immunization and health

systems?

A few studies report on examples of the integration of the public sector’s immunization programmes

with the private sector. In these countries, the public sector is collaborating with private sector

institutions so that the immunization service delivery and surveillance can be extended to parts of the

country without access to services. Often the government provides vaccines, equipment and other

supplies to private facilities. As a result, the programme managers can ensure that these adhere to

national standards. In addition, it can obtain data on the number of immunizations that are given in

private sector health facilities and / or pharmacies. In Cameroon, for example, each health area has a

lead health facility, which can either be public or private, and it coordinates the distribution of vaccines

and supplies and reports coverage rates of the area.

In Uganda, the government also entered into a public-private partnership with not-for-profit providers.

It provides vaccines, equipment and operational grants to these providers. Currently, 29 private not-for-

profit facilities (13.5%) in 214 sub-districts are overseeing referrals and management of other health

facilities in their sub-district. Other examples of integration occur through contracting and are found in

Cambodia, Rwanda and Afghanistan.

Despite the fact that immunization is a public good, has positive externalities and governments have an

interest in being the main provider of vaccination, the literature review indicates that the private sector,

in its different variants, is active and delivering a significant proportion of vaccinations in some

countries.

In low-income countries, private for-profit and NGO health facilities are providing immunization

services and helping to improve access to traditional EPI vaccines, particularly in Asian countries. In

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addition, these facilities are providing services to higher-income clients who are willing to pay for better

perceived quality, shorter waiting times and closer proximity. The literature review suggests that NGOs

often play a larger role in immunization service delivery than do private for-profit providers in low-

income countries, since their facilities are situated in rural as well as urban areas. Further, NGO services

are more likely to be coordinated with public services, either through formal contracts or through more

loosely-structured mechanisms in low-income countries.

In ‘fragile’ countries, the review suggests that NGOs are playing a particularly important role in

delivering immunization services, often under contracting-out arrangements with governments and their

partners. Other gaps in provision of vaccination are filled through ad hoc service delivery by for-profit

providers and non-profit providers.

In middle-income countries, the private for-profit sector is active and plays a number of roles. It often

acts to facilitate early adoption of new vaccines and technologies before introduction and generalization

by the public sector. In addition, the review suggests that private practitioners increase access to

services by offering traditional EPI vaccines. The extent that governments are regulating these

providers is not known.

Many of the strategies for engaging the private sector are being used in low-income countries, including

‘fragile states’, i.e. contracting, training, financing and coordinating; and paradoxically immunization

services may be more well-regulated in these countries than in middle-income countries. Contracting

and financing strategies have been shown to be effective at bringing services to the poor and at least

partially ensuring that quality services are provided. However, little is known about the extent to which

service provision is effectively regulated when formal contracting arrangements are not in place.

In middle-income countries, the private for-profit sector’s role in provision of immunization services is

more prominent than in low-income countries. The extent to which these services are regulated and

what type of regulation is most effective has not been documented. Given the concerns about the quality

of immunization service delivery in private health facilities, more research is needed on regulation of

private sector immunization services in middle-income countries.

Potential mechanisms that can be introduced to engage the private sector include: (1) involving the

sector in policy and programme setting – for example, private providers can be represented on national

immunization technical advisory groups (NITAG) as well as other policy-making organizations; (2)

introducing financial and other types of incentives to increase immunization coverage and / or access to

services; and (3) regulation of service quality, payment mechanisms and fees.

There are many geographical and thematic gaps in the literature on the role and regulation of the private

sector in the delivery of immunization services in low-and middle-income countries. Limited studies

exist on: (1) the adequacy of quality of dare of immunization service delivery in the private for-profit

sector; (2) the impact of private for-profit service delivery on disparities in services delivery; (3) the

effectiveness of regulating the private for-profit sector; and (4) the impact of private sector

immunization service delivery on demand for traditional EPI, new and underutilized vaccines.

IMMUNIZATION TRUST FUND

It has always been the sole responsibility of most governments to provide resources for their

immunization programmes. However, global and domestic socio-economic challenges may combine to

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mitigate the achievement of this major objective. Alternative innovative funding sources must be

explored such as the establishment of an independent privately managed immunization trust fund,

backed by law or regulation. This fund will complement the budgetary provision from the government.

Measures need to be put in place to ensure that persons selected to oversee the affairs of such trust fund

are eminent, resourceful and trusted citizens in the country. The main goal of the fund shall be the

support of immunization service delivery for the country. The managers of the fund will be held

accountable to the people and contributors to the fund. Contribution to the fund may come from many

domestic sources such as voluntary taxation of individuals, corporations and the organized private sector

as part of their Corporate Social Responsibility.

CONCLUSION

The health and economic benefits of immunization have been demonstrated globally. Continued external

funding sources for the immunization programme cannot be guaranteed. Nigeria must seek domestic

sustainable funding sources for its immunization programme especially with the introduction of the

more effective but costly new vaccines. Combined high-level political and legislative support for the

passage of laws defining how immunization and other key programs for maternal and child health are to

be financed perpetually are necessary within our countries.

Subnational governments must explore the possibility of contributing more significantly to the

programme rather than depending solely on the central government, other domestic innovative

approaches to the funding of the programme are also worth exploring.

Your excellences’, distinguished ladies and gentlemen, I would like to conclude by re-affirming the

commitment of Fidelity Bank Plc towards a sustainable partnership with the National Immunization

Financing Task Team {NIFT} and ensuring an enduring legacy for our National Immunization

Programme that meets international best practice.

Thank you and God Bless.

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Annex H: Peer Review Raters’ Comments

Table 5. Raters' comments to the delegations they assessed

Country Comment

Kenya *Availability of internet connectivity?

*Internet connection at ward level might be a problem. The country must ensure

that there is internet connection at ward level to operationalize the innovation.

*You need to move more institutions or organizations for collective regions only.

*This innovation will greatly assist in budget and resource tracking rather than

advocacy as being conveyed by the Kenyan delegates.

*There should be a legal framework in place for any innovative activity to be

sustainable.

*They should involve the private sector and also have an immunization trust fund.

This will make sure that there are no stockouts.

*I think community-level planning is the best approach for advocacy.

*No legislation backing it yet, but feel it would be of great help if it can be

incorporated.

*The approach should be replicated by other countries because it is a good

approach.

*The bottom-up microplanning should be implemented in all countries as only a

few counties are implementing it. The microplanning should enable the country to

move forward on legislation and development of a health act.

*Reduce donor reliance.

*Establish laws. Increase budget funding in the MOH budget.

*All along, they have been using top-down approach which has not been working.

*This is very innovative tool that will help in bringing out gaps in informational

components of immunization services. It will be good to assess how well this tool

is impacting the system, after which the strategy can be shared with other

countries to adopt. It is also important to carry the important stakeholders on

board, for example, ministry of finance and other relevant partners.

*That will definitely assure transparency and accountability.

*Parliament and MoF need to be brought to bear as effective sustainable

immunization Financing is ensured.

*A supporting legislation to back up the advocacy.

*Immunization issue should be party manifesto. Involve the media.

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Liberia *If this innovation is made a presidential deliverable, all sections will work to

achieve it.

*Involvement of community leaders, traditional leaders is key in the process.

*Involve traditional leaders.

*Continue working on advocacy and lobbying.

*The parliamentarian understood to need improvement in the present strategy will

be an advantage.

*Great advocacy. Agree that next level advocacy would include taking advocacy

to the president and making immunizations a presidential mandate.

*Conduct a review using M/E tools to evaluate performance. Continue lobbying

and advocacy for all to see immunization as a public good.

*So far, advocacy is producing results.

*Yes, law which will be long term in addressing the issue, and be permanent.

Nigeria *NIFT is taking the shape of the situation: PPP

*It is a well planned, innovative means of country ownership of the SIF Program.

*Local production is an interesting idea. I like the approach of trying to own the

whole value chain. But it will take a lot of time and investment.

*Good work. Must be shown with other analyses.

*The tempo should be sustained.

*How sustainable is this team?

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Sierra Leone *Need to advocate for increased budget provision for immunization specifically.

*Private member's legislative bill, need to convene major stakeholder

consultation, drafting of bill, passage of bill.

*The private sector should also be involved and also those efforts should be put to

actualize immunization budgeting by government.

*Identify communities opposed and engage them.

*Learned a lot from an abortion bill which did not get passed on time because

relevant stakeholders were not involved. So, hopeful this will work.

*There is no clear link on the incentives to contribute to the trust fund. They have

drawn comparisons between a fuel levy and road maintenance. This relation is not

clear in terms of the organizations that they want to apply levies on. The

incentives for phone company contributions is not clear. They need to clarify this.

*Great ideas. Advocate to key decision-making stakeholders early on so when the

bill makes it to the parliament it can be passed. If possible, get a presidential

mandate for vaccines- can facilitate the legislative process.

*Every situation requires varied strategies.

*Involve Ministry of Social Welfare, Gender and Children, too. Private sector,

too, should be involved.

*Continue with the same Innovation.

*Legislation is not enough you need to increase allocation for immunization with

laws and through advocacy.

*Top-bottom approach often not as successful as bottom-up approaches.

*Intensify efforts to pass the bill and get it signed into law.

*It's a good innovation but the delegates have to push hard for it. It has been in

existence for 1-2 years but still aspirational.

*Need for teamwork between parliament, executive and CSOs for sustainable

immunization financing to work well.

*Increase advocacy.

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Uganda *It is too early to know how successful the innovation will be as the bill became

active this March. However, it is structural so it probably will be impactful.

*Bill makes non-compliance punishable by fine or imprisonment (too strict?) and

not clear how it will be enforced. Immunization fund does not make clear what the

minimum contribution of parliament should be and does not indicate by what

percent that contribution should increase every year. There should be a minimum

quota for government contributions.

*In order to increase immunization budget, present a case study and have the

government commit to a percent or amount to be financed in accordance with the

immunization act.

*Advocacy for effective implementation of the law.

*Will address issues as they arise.

*Development of regulations and ramp up for implementation.

*I feel they shouldn't be compelled but be made to see it is beneficial. By means

of providing incentives to encourage them.

*Recommend follow-up on implementation of the law. It's not just enough to have

a law in place, although this is important. But follow-up is as important as having

the law.

*Guarantee an exact funding mechanism.

*The new health act in place should be operationalized at central, district and local

levels. Fund release should be ensured, complete and adequate. Implementation of

the immunization act should be monitored at all levels.

*There is need to enforce this legislation to ensure that the desired results are

achieved. The community members need to be sensitized adequately on this bill.

*Sensitization, moral suasion and the use of community leaders to mobilize

parents for immunization.

*There is need to make MoH and MoF as well as the CSOs, CBOs, FBOs, etc., to

buy in and comply fully with the provisions of the law for ensuring effective

sustainable immunization financing.

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Annex I: Country Action Points

Country Action Points Second Anglophone Africa Peer Review Workshop Abuja, Nigeria

19-21 April 2016

Kenya Action Points Continue advocacy efforts through May and June meetings with community

secretariat Work with Ministry of Finance to create immunization budget line Each specific county will have specific legislation on immunization financing

Have MPs as champions within Parliamentary Committee on Health Champions within county government

Advocate for more funds to meet Gavi co-financing requirements Institutionalize micro-planning across all levels of government

Liberia Action Points Propose executive legislative retreat

Establish direct communication with both legislative houses Tracking of immunization funds Re-introduce Immunization Bill in hopes of passing by end of May

Active advocacy at all levels involving media and stakeholders Have public hearing to ensure Bill is adequate and contains necessary immunization

provisions Nigeria Action Points

Joint reporting: HIS2 platform is open source platform, reporting on data collection in DHIS

NPHCDA finalized cMYP, a working document for country, includes joint reporting and monitoring provisions

Strengthening the PHC system, and developed the scorecard and will use for

advocacy Piloting an expedition tracking resource based financing and basket funding

National Health Act has been gazetted and Nigerians can now start to benefit from Act’s provisions

Local vaccine production: had meeting with all stakeholders to share information;

Nigeria plans to manufacture for Africa Need a policy on local vaccine production and create a business plan. Private sector

driven using international best practices. Policy brief. State government and federal government will co-fund immunization value chain

with support of President, Minister of Health and Minister of Trade and Investment,

Minister of Science and Technology. PPP trust fund arrangement driven by private sector. Set up committee to follow up

on this.

Sierra Leone Action Points Create Immunization task force following in Nigeria’s footsteps

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Convene stakeholders engagement meeting with MOH to discuss how to continue to take ownership of immunization financing

Multiple agencies will work to review Immunization Bill, currently in draft stage Expand resource tracking and capacity building

Peer exchange workshop by end of 2016 with Nigeria, hopefully in Freetown Uganda Action Points

Continue meetings between MOF and MOH to establish immunization resource utilization and reporting community of practice

Produce updated communication strategy to include financing and legislation messages to the public

Prepare budget allocation tools to capture finance and expenditure data at

subnational levels, capture budget immunization resource in order to enhance transparency

Disseminate Immunization Act and finalize the regulations to operationalize the Act Advocate for phased increase in the allocation of resources for the new vaccines