1. Developing a Financial Sustainability Plan for Cambodia
Grace Chee
National Immunization Conference
March 19, 2003

2. Cambodia Background
GAVI approved application for HepB in 2000 – phased introduction
Immunization financing assessment was done in 2000
GAVI approved application for systems strengthening funding in 2001
FSP Guidelines pre-test country (Mar 02)
Functioning Immunization Coordination Sub-Committee (ICSC)
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

3. Summary of FSP
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

4. Cambodia Health Context
Population: 13 million
Low health indicators: LE 54 years for men, IMR 95
Large increases in government health expenditures
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency
* Budget

5. Health Sector Reforms Since 1996, rebuilding health infrastructure
Approx 80% of the planned HCs functioning (mid-2002)
Staff salaries extremely low ($15-$30/month) – planned increases of 15%-30% per year for next few years
Fairly decentralized – including centrally procured drugs, 56% of MOH expenditures managed by the Provincial Health Departments (PHDs)
Financial management systems in need of reform – funding flows irregular
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

6. Issues Impacting Immunization
Weak health infrastructure has built a reliance on outreach as primary mode of delivery
Staff not very motivated to provide immunization
PHDs and Governors control flow of funds for outreach
New funding mechanisms developed to bypass this bureaucracy with mixed results
Accelerated District Development
Priority Action Program
Traditional budget – pre-audited
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

7. Routine Coverage Rates
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

8. Government & Donor Funding
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

9. Projected Immunization Costs
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

10. Projected Financing Gap
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

11. Key Strategies
Increase national government financial contribution to immunization services 
Increase provincial level expenditures for immunization services
Increase donor funding for immunization
Increase reliability of funding for immunization at all times
Reduce vaccine wastage
Improve efficiency of outreach sessions
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

12. Strategies and Indicators
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

13. FSP Development Process
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

14. Timeline of Cambodia FSP
Early awareness of FSP through pre-test
External consultant visit in July – data collection, developed workplan, preliminary financial projections
Draft FSP circulated Sept to broader ICSC
Consultant visit Nov to finalize FSP – finalize financial projections and FSP
Ministers invited to GAVI Partners Meeting
Cambodia was the first country to submit FSP!
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

15. Who Developed the FSP? Key participants: Other assistance from:
ICSC Technical Working Group (UNICEF, WHO, CVP, NIP Manager)
External Consultant
Other assistance from:
MOH Dept. of Finance
MOH Maternal Child Health Dept.
WHO Health Financing
MOF
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

16. Ideal vs. Reality
GAVI Ideal: all stakeholders (planning and finance depts of MOH, MOF, all donors) participate in all aspects of FSP development, including drafting document
Reality:
Limited time, human resources, technical capacity
May not require significant MOF input
Stakeholders have limited incentives to participate
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

17. Ownership vs. Efficiency
External consultant is likely more efficient at compiling necessary data for FSP
Participation of in-country stakeholders critical to developing ownership and realistic FSP
Tight deadlines sometimes force the more efficient approach
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

18. Lessons Learned from Cambodia
Concept and process of FSP is a good starting point for better planning and budgeting
Requirements of the FSP are time consuming and required outside assistance
Advocacy work is critical to success and there is limited capacity in-country
Difficult to predict program seven years into the future, and no donor can make such commitments
High profile meeting really spurred interest, but limited concrete actions

19. Broader Lessons Learned
Countries should be encouraged to adopt their own model of FSP development – there is no one ideal
Required financial information should be revised so that it is more easily useable for country planning
More global level advocacy is needed to generate additional resources for immunization
FSP is only the beginning – implementation is the real challenge

20. Issues to Consider
Is a technically correct FSP more important than ownership?
Will a good FSP lead to increased funding?
How can GAVI shift its focus to implementation?
How can GAVI lead the global advocacy effort?

21. Thank you Website: abt-safi.com
Abt Associates Inc. and the Bill and Melinda Gates Children’s Vaccine Program at PATH

22. Financial Sustainability Plans
Required by the Global Alliance for Vaccines and Immunization two years after approval of country support
Analyzes the current financing situation, estimates the future funding needs, and develops a strategy for meeting projected needs
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency

23. FSP – Required Information
Country and health sector context
Budget process and financial management
Program characteristics, objectives and strategies
Baseline and current program costs and financing
Future resource requirements and financing
Sustainable financing strategic plana nd indicators
Stakeholder comments
Achieve a shared understanding of the immunization financing situation and prospects between the authorities of the concerned country and actual and potential partners and assistance agencies
Permit steps to be designed to enhance the financing of the national immunization program, including mobilization of additional national and international resources and improvements in efficiency