Sabin peer review workshop on sustainable immunization financing Abuja, Nigeria April 2016 Country: Uganda Case: Pursuing financial sustainability for immunization services through legislation and expenditure tracking

Background Immunization is one of the best investments a country can make for the health and vitality of its population and the growth of its economy. In Uganda immunization services form a critical part of the minimum Health Care Package preventing more than 25% of child deaths. Currently with the new vaccines it costs over USD34 per child (conservative immunization schedule) or USD62 per child (ideal schedule) to fully immunize a child.

Background Uganda: Population-34.9 million (2014); GNI per capita of US$ 780 (2015) External funding (GAVI, WHO, UNICEF, others) contributes a substantial portion, however this is neither guaranteed nor predictable. When immunization funds are interrupted, as was observed with the GAVI fund suspension in 2005, widespread and devastating epidemics ensue. Additionally, with the population growth rate 3% p.a (Census 2014) and as national immunization programs expand and new vaccines become available, vaccination related costs are rising faster than budgets, putting a strain on the health programme.

Immunisation: Financing Structure Government of Uganda (GOU) funds:  the traditional vaccines and other supplies at annual cost of shs 9.0bn ( US $ 2.7 m)  contributes to pentavalent vaccines, Pneumococcal Vaccine (PCV) and Human Papiloma virus vaccine (HPV) U.shs 7.4 bn (US $ 2.4 m) for 2015/16..  With the introduction of more vaccines the obligation increases and as the country graduates to middle income status, the country will meet the entire cost.  Hepatitis B interventions among adults-10 bn (US $ 2.98 m)  logistics U.shs 860 m (US $ 0.26 m) annually GAVI contributes to the cost of vaccines at ( US $56 m) UNICEF US $ 1.68m WHO US $ 2.4 m MCSP USAID US $ 0.58 m CHAI US $ 0.41 m PATH`US $ 0.59 m 4

Trend in funding support to Immunization in Uganda in USD (000,000) Main Financing Source for EPI-in millions of USD2009/102010/112011/122012/132013/142014/152015/16 GOU UNICEF WHO USAID PATH, RED CROSS SOCIETY,SABIN, CHAI, MCSP, AFENET, MCHIP GAVI JICA TOTAL

Trend in funding support to Immunization in Uganda Main Financing Source for EPI- in bn UGX2009/102010/112011/122012/132013/142014/152015/16 GOU59%52%63%53% 26%21% UNICEF4%3% 12%10%3%2% WHO1%3%5%6%7%5%3% USAID PATH, RED CROSS SOCIETY,SABIN, CHAI, MCSP, AFENET, MCHIP5%0%5%4% 3%2% GAVI31%27%23%24%25%63%72% JICA0%15%0% TOTAL100%

Trend in funding support to Immunization in Uganda Main Financing Source for EPI-in UGX (bn)2009/102010/112011/122012/132013/142014/152015/16 GOU UNICEF WHO USAID PATH, RED CROSS SOCIETY,SABIN, CHAI, MCSP, AFENET, MCHIP GAVI JICA010.5 TOTAL

Immunisation: Financing Structure Note: 1USD=Shs 3500 In 2014, Government contributions rose to $11 per surviving infant, up from $3 in 2006 The Government share of total routine immunization expenditures rose from 13% to 49% over the period 8

Immunisation ( Planning& Budgeting) There are 4 health sector objectives in the National Development Plan II. Immunisation contributes to Objective 1: “To contribute to the production of a healthy human capital through provision of equitable, safe and sustainable health services.” The indicator is “Increase in DPT 3 Pentavalent immunization coverage”. Immunization is also one of the key interventions in the sector development plan under specific objective 1: To contribute to the production of a healthy human capital for wealth creation. 9

Planning for Immunisation Cont’d The 4 Objectives are mapped against 3 Sector Outcomes in Output Budgeting Tool. These are: i.Increased deliveries in Health facilities ii.Children under one year old protected against life threatening diseases iii.Health facilities receive adequate stocks of essential medicines Interventions on immunisation and the respective Budgets fall under outcome number 2: ◦ Children under one year old protected against life threatening diseases Performance on immunisation is measured at the service delivery levels:  HC II-HCIV, and hospitals 10

The new practice The new practices i.Consolidation of several immunization line items into a single vote function and vote function output ii.Enactment of the National Immunization Act iii.Resource mapping, tracking and reporting

What problem does the new practice address? Identify the problem a) Vote function, Resource mapping, Tracking and Reporting Co-mingling of sector funds with other programmes There was limited information on the distribution and extent of partner support b) Immunisation Act There was no documented law committing Government to fund immunisation activities There was no law requiring parents to immunise their children Regulations not in place

The New Practice How was the problem identified? External funding (GAVI, WHO, UNICEF, others) contribute a substantial portion, however this is neither guaranteed nor predictable. When immunization funds are interrupted, as was observed with the GAVI fund suspension in 2005, there was a significant drop in the immunization coverage from above 80% to 52% of Penta3 coverage. Accounting for routine immunization program expenditures revealed no baseline (expected costs) was available

The new practice cont’d Explain why the problem is important With the increasing population and increasing costs of supplies, Immunization program costs are rising. A strong investment case is needed to justify larger budgets. There is also need to reduce donor dependence for immunization logistics. How long has the new practice been underway? The single vote function started in October 2013 while the Act was passed in December, 2015 and signed into law in March 2016.

The New Practice Which institution(s) or organization(s) are involved in the new practice? Ministry of Health, Ministry of Finance, Planning and Economic Development, Parliament, Local Governments, Partners (Sabin), Civil Society and the Media. How does each organization/institution participate? Ministry of Health for policy formulation and technical stewardship, Ministry of Finance oversees budget formulation, implementation and tracking, Parliament for high level oversight, advocacy and budget appropriation, and Sabin for advocacy. Activities/ interventions/ inputs Advocacy meetings Consultative meetings, Planning and budgeting Resource tracking

Key individuals (positions) engaged Permanent Secretary of MoH PSST Director General of Health Services Programme Manager-Immunisation Partners (Sabin Vaccine Institute) How often does the activity take place (continuously, periodically, one-off)? The Law and vote function are institutionalized Resource tracing is quarterly

General Challenges Funding for immunisation still largely Donor funded (Sustainability & Predictability) New vaccine introduction poses a funding challenge as the new vaccines are quite expensive and pose additional storage and distribution loads Importation of wild polio virus from neighboring countries poses funding challenges for the recommended response campaigns 17

Challenges Cont’d Low staffing levels negatively affect implementation of community outreaches Inadequate transport at district level for distribution of vaccines and supplies, cold chain maintenance, support supervision Inadequate funding for routine immunization Inadequate production of EPI data collection tools such as child health cards, child registers, tally sheets etc Fast Growing Population 18

Way forward The new Innovations (Act and Vote function) are institutionalized and help strengthen Government Systems. The Vote function enhances advocacy, reporting requirements (Public Finance Management Act 2015) and monitoring at all levels. There is a now a much better working relationship between MoF, Parliament and the Ministry of Health.

THANK YOU 20