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 Proceedings ......................................................................................................... 3
Day One ............................................................................................................. 3
Theme I: Domestic Financing Arrangements.................................................... 4
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 ..................................................................................... 18
ANNEXES ........................................................................................................... 25
Annex A: Concept Note .................................................................................... 25
Annex B: Participant List ................................................................................. 29
Annex C: Agenda ............................................................................................. 34
Annex D: Small group results .......................................................................... 37
Annex E: Welcome Address, Dr. Ado Muhammad ............................................. 40
Annex F: Opening Remarks, Hon. Minister of Health ........................................ 42
Annex G: Keynote Address, Managing Director, Fidelity Bank .......................... 44
Annex H: Peer Review Raters’ Comments ........................................................ 51
Annex I: Country Action Points ........................................................................ 55
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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. 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.
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.
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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 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.
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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 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.
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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.
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.)
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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
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
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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
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
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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.
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
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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
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.
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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
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
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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.
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.
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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)
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,
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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. 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
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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 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
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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
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.
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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.
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
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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
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
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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
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
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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” 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
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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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.
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. 1. Perceived implementation status of innovative activities (n=100 ratings)
Operational Aspirational
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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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 [email protected]
2 MIKE McQUESTION DIRECTOR USA SABIN [email protected]
3 DANA SILVER PO USA SABIN [email protected]
4 SAIRA ZAIDI NIGERIA CHAI [email protected]
5 DIANA KIZZA SPO UGANDA SABIN [email protected]
6 CHIMAOBI CHUKWU SO IMO NABDA [email protected]
7 DR. EKENE OSAKWE ACSO NIGERIA NABDA [email protected]
8 ADOLPHUS T CLARKE
EPI, Dep LIB MOH [email protected]
9 WILLIAM V DAKEL MP LIB HOR [email protected]
10 HON.ABD SESAY MP SIERRA LEONE
PARLIAMENT [email protected]
11 FAITH MUTUKU PO CHA [email protected]
12 DR. KARAN SAGAR SCM GAVI [email protected]
13 DR. NAMADI M LAWAL
MO NPHCDA [email protected]
14 MAJIDAH ABDULWAHAB
A. O FCT NPHCDA [email protected]
15 OYEYEMI BANKE PEO II FCT NPHCDA [email protected]
16 DR. ADAMU NUHU DAC FCT NPHCDA [email protected]
17 JOY OSHINOWO SO FCT NPHCDA [email protected]
18 DR. HALIMA B TAFIDA
SMO FCT NPHCDA [email protected]
19 FIONA BRAKA EPI TL WHO [email protected]
20 ALOYSIUS CHIDIEBERE UGWU
PA/TA FCT HERFON [email protected]
21 EMMANUEL ABANIDA
ES FCT HERFON [email protected]
22 SABO M ADAMU CAO FCT NPHCDA
23 JUSTICE IGBOKWE AO I FCT NPHCDA [email protected]
24 ALIYU ABDULKADIR HEO FCT NPHCDA [email protected]
25 THERESA ABBA PSO FCT NPHCDA [email protected]
26 ADAMU GAMAWA EC BAUCHI BSPHCDA [email protected]
27 JOSEPHINE OBANDE AO I FCT NPHCDA [email protected]
28 KENNETH OSHIOBUGIE FCT VACCINE NETWORK [email protected]
29 SYLVESTER MUBIRU AG. PRO UGANDA MOH [email protected]
30 OLERU HUDA MP UGANDA PARLIAMENT [email protected]
31 M. ISHMAEL MAGONA
COMMISSIONER UGANDA MFPED [email protected]
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32 DR. OBINNA EBIRIM SPO FCT DCL/IVAC [email protected]
33 DR. HENRY EWUNONU
Rep. President FCT NMA NATIONAL [email protected]
34 ADEWUMI FUNMILAYO
PA FCT DCL/IVAC [email protected]
35 CHIKA OFFOR COO FCC WAVA/VACCINE NETWORK
36 ABDULAZEEZ M.M SCDO FCT NPHCDA [email protected]
37 DR. CHARLES MAMMAN
ZC NEZ NPHCDA [email protected]
38 DAVID KIULUKU CDH KEN MOH [email protected]
39 UMMAL-FADAL BABAGIRE
I.O FCT NPHCDA [email protected]
40 DR. ALIYU YABAGI SHEHU
EDSPHCDA NIGER SPHCDA [email protected]
41 EUGENE IVASE HOD Comm FCT NPHCDA [email protected]
42 DR. MOH'D ATIKU KENDE
PER SEC KEBBI SMOH [email protected]
43 DR. PETER S. COLEMAN
Senator LIBERIA LIBERIA [email protected]
44 PETER SAM-KPAKRA Deputy Financial Secretary
SIERRA LEONE
MIN OF FINANCE [email protected]
45 DR. SHOLA MOLEMEDDE
MANAGER FCT DCL/IVAC [email protected]
46 ANIEMA OKON PCS11 FCT NPHCDA [email protected]
47 DANIEL IYA HOC NASARAWA MOH [email protected]
48 DANGANA MUSA SAAD
ZC NCZ NIGER NPHCDA [email protected]
49 CELESTINA OBIEKEA NIFT FCT SLNI [email protected]
50 DR. UDUALE OFFION PAEDIATRICIAN FCT PAN [email protected]
51 SOJI TAIWO DD A&C NPHCDA NPHCDA [email protected]
52 SHARON WANYEKI ICT KENYA MIN OF FINANCE sharon.wanyeki@gmail com
53 GARBA SADEQ SSO NCDC NCDC FMOH [email protected]
54 DR DENNIS MARKE PRO. MGR S/ LEONE MOHS [email protected]
55 NDIDI CHUKWU ADV.& COM FCT CHR [email protected]
56 OJO FUNMILAYO SEO FMOH FMOH [email protected]
57 NOSA PRESTON IO FCT NPHCDA [email protected]
58 ABBA MUHAMMED I. PO FCT NPHCDA [email protected]
59 JOHN DANIEL NYSC FCT NPHCDA [email protected]
60 DR A.F. KOLAWOLE MO11 FCT NPHCDA dejokekolawole2gmail.com
61 MARYAM MUHAMMED
AO1 FCT NPHCDA [email protected]
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 [email protected]
66 GANIYU SALAU NIFT ABUJA NPHCDA [email protected]
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67 FELICIA B. UMOH ESQ
L. A. ABUJA NPHCDA [email protected]
68 GARBA ABDUL DIRECTOR ABUJA CHAI Gbduaclintonhealthaccess.org
69 DR. OGBU T.E. SHALFERKLUM ABUJA MD [email protected]
70 DR. KABIRU MOHAMMED
ZCNWZ KANO NPHCDA [email protected]
71 MUSA MOH NPHCDA NCZ NIGER CMO
72 DR. DAMARIS ONWUKA
NPHCDA ABUJA DDCI
73 DR. OBI EMELIFE DD FCT NPHCDA [email protected]
74 M.M ABUBAKAR DD FCT NPHCDA [email protected]
75 EMMANUEL SOKPO MD ABUJA NPHD [email protected]
76 SANNI ADENIYI O. A. (MRS)
DD ABUJA FMOH [email protected]
77 IRECHUKWU KELECHI
INTERN ABUJA DCL/IVAC [email protected]
78 ABIODUN AJAYI FCT HEALTH
79 JOHN AGBOR IMM. MANAGER UNICEF [email protected]
80 PETER ENALYWU EDITOR FCT LEODDWARD [email protected]
81 AISHA K. ABBA CCDO FCT NPHCDA [email protected]
82 PROF. ALEX AKPA DIRECTOR FCT NABDA [email protected]
83 DR. A.O. ADESOPE ZCSWZ OYO NPHCDA [email protected]
84 OLUREMI OLUBAJO HEAD HF FCT NPHCDA [email protected]
85 LAWAL BAKARE FOUNDER LAGOS EBOLA ALERT [email protected]
86 DR. HALIMA MUKADDAS
HON.COMM BAUCHI SMOH [email protected]
87 REMI JOSEPH HEAD R. MOB. FCT NPHCDA
88 AKINYEMI SAMSON.O
HEAD PROTOCO FCT NPHCDA [email protected]
89 OKEFE ALICE CECILIA
NYSC FCT NPHCDA [email protected]
90 OLUSEYI ADEJIYE ADVOCACY ADVISER
FCT SCI [email protected]
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 [email protected]
96 JAMILA ALIYU AO I FCT NPHCDA [email protected]
97 H. K. MUSA AO1 FCT NPHCDA [email protected]
98 AGBOGU OKWUDIH C.
AO1 FCT NPHCDA [email protected]
99 KAFARU OLUWAFEMI
FE FCT NPHCDA [email protected]
100 DR. AKIN OYEMAKINDE
CLE FCT FMOH [email protected]
101 DR. SALIFU M. S. PMO 11 FCT FMOH [email protected]
102 PHARM LAMI A. N. PHCD FCT NPHCDA [email protected]
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103 VICTOR EMGUINE Prog. Officer FCT Center for Social Justina
104 A. NASIDI NC/CEO FCT NCDC [email protected]
105 OLUWA JINADU PROTOCOL FCT NPHCDA [email protected]
106 NANCY D. SEMION ADMIN ASST ABUJA CHR [email protected]
107 BALOGUN A. A. PA FCT NPHCDA [email protected]
108 DR. NGOZI NWOSU ZC SEZ ENUGU NPHCDA [email protected]
109 DR. JOSEPH OTERI ZC SSZ BENIN NPHCDA [email protected]
110 ADEGBITE OLUFUNMILOLA
AD SO FCT FMOH [email protected]
111 UDEME PETER-IJEH Prog. Manager FCT CENTRE FOR THE Right to health
112 GOUDJO CEHZO ACSM Officer FCT CENTRE FOR THE Right to health
113 DR.D. NWODO CSG1 FCT NPHCDA [email protected]
114 DR. KAYODE FASOMINU
CONSULTANT FCT SOLINA [email protected]
115 IWEALA-OSHISKE N. CDO FCT NPHCDA [email protected]
116 DR. M. Z. MAHMUD DLHC FCT NPHCDA [email protected]
117 DR. ONWU NNEKA CSG11/HSIAs FCT NPHCDA [email protected]
118 STEPHEN SHAKARHO
Regional Manager FCT MAY & BAKER [email protected]
119 MUSA ABDULLAHI CDM FCT NPHCDA
120 IBRAHIM I. IBRAHIM CDM FCT NPHCDA
121 DR. NNENNA IHEBUZOR
D,PHCSD FCT NPHCDA [email protected]
122 DR. EMMANUEL ODU D-CHS FCT NPHCDA emmanodu@gmail
123 SAADU SALAHU HPRU FCT NPHCDA [email protected]
124 REMI ADELEKE PCDO FCT NPHCDA [email protected]
125 PROF. KABIRU I. DANDAGO
HC Finance KANO MOF [email protected]
126 DR. KABIRU I. GETSO
Hon. Commissioner - Health
KANO SMOH [email protected]
127 NASIRU MOH'D Hon. Commissioner - Finance
BAUCHI MOF [email protected]
128 EZE ONYEKPERE Lead Director Centre for Social Justice
129 DR. CHIZOBA WONODI
Country Lead FCT JOHN HOPKINS US IVAC
130 BONNY SUMAILI IMM SPECIAL UNICEF [email protected]
131 DOMINIC MUTIE NVIP DCP KENYA [email protected]@gmail.com
132 DR. BASSEY OKPOSEN
CMO/HEAD RI FCT NPHCDA [email protected]
133 ASHOGBON DANIEL DFA FCT NPHCDA [email protected]
134 HENRY OSAWE DIA FCT NPHCDA [email protected]
135 MOLOKWU NDIDI PO FCT NPHCDA [email protected]
136 H. D. GARNUWA HE FCT NPHCDA [email protected]
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137 ABIOLA OJUMU Snr Program Manager
FCT CHAI [email protected]
138 KABIDIRI IBRAHIM MERIT FCT CHAI [email protected]
139 L. B. HAMADU FCT NPHCDA
140 ONYEKWELU HENRY STATE CHAIRMAN ANAMBRA HERFON [email protected]
141 ONWUMAH UCHE STATE CHAIRMAN DELTA HERFON [email protected]
142 IBIKUNLE ADAMS DD FMITI FMITI [email protected]
143 BLESSING ADEBAYO OYO SABIN
144 JENNIFER FOTH C UGANDA CHAI [email protected]
145 YUSUF SULEIMAN FE FCT NPHCDA [email protected]
146 DR. LAZ UDE EZE SMT FCT DCL/IVAC [email protected]
147 DR. PETER EDAFIOGHO
HPRM FCT HERFON [email protected]
148 DR. H. H. ADAMU (MRS)
PM FCT HERFON [email protected]
149 DR. ABDUHRAHMAN D
RM FCT RHS [email protected]
150 DR. U. S. ADAMU STA-ED/CE FCT NPHCDA [email protected]
151 OBARD ODEGHE REP MD FIDELITY BANK
LAGOS FIDELITY BANK [email protected]
152 DR. RUI G. VAZ WR WHO WHO [email protected]
153 DR. ADO J. G. MOH'D ED-NPHCDA FCT NPHCDA
154 KAFARU O. FB FCT NPHCDA [email protected]
155 SARAH AZUBIKE INFOR. OFFICER FCT NPHCDA [email protected]
156 ABOLA EMMA ROVA FCT DIOVA [email protected]
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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
*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
6 (Nov-Dec)
Sylvester Mubiru
*inadequate legislation *legislative provisions for
immunization financing
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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
*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