ACHIEVING FINANCIAL SUSTAINABILITY FOR IMMUNIZATION IN UGANDA

1. ACHIEVING FINANCIAL SUSTAINABILITY FOR IMMUNIZATION IN UGANDA Presentation to stakeholders, Wednesday June 25, 2003

2. Presentation outline • Background information • Workshop objectives and outcomes • UNEPI programme objectives • Financial Sustainability and its process in Uganda • Present and future costs of the EPI programme • Strategies to ensure financial sustainability

3. Introduction • Immunization • Reduces unnecessary ill health, death and disability • Reduces service costs • Improves empowerment (averts disability) • Contributes to child survival, growth and development • Is the most CE intervention • Is imperative to have adequate, reliable financial resources on long term basis for continuity How to do this: Develop a FSP

4. Workshop Objectives • To sensitize key stakeholders in the FSP development process. • To share the results of the costing of the National Immunisation Programme, including demonstration of financial projections to 2010. • To show present and projected trends in funding for EPI. • To discuss proposed strategies to ensure financial sustainability of the EPI.

5. Desired outcome of workshop • Achieve consensus on relevant, realistic and specific strategies for financial sustainability of immunization program in Uganda.

6. UNEPIVision, Mission and Goal Vision:To ensure that the Ugandan population is free of vaccine-preventable diseases and disabilities Mission:To contribute to the overall objective of the HSSP in reducing morbidity,mortality and disability due to childhood vaccine preventable diseases, so that they are no longer of public health importance Goal:To ensure that every child is fully immunized by the first birthday, and every new born is protected from neonatal tetanus

7. UNEPI Program objectives • Strengthen service delivery to increase DPT coverage from 54% in 1999 to 88% by 2010. • Increase program effectiveness, efficiency and quality. • Introduce and sustain additional vaccines such as the DPT-Hepatitis B + Hib vaccine. • Improve disease surveillance. • Eradicate polio and eliminate MNT by 2005. • Reduce measles mortality and morbidity by 90% by 2006. The FSP addresses all these objectives

8. Financial Sustainability Plan • Financing strategy for immunization in Uganda • Assesses the key financial challenges facing the immunization programme, and describes the strategies to overcome these in medium to long term

9. Definition of Sustainability “Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the ability to mobilize and efficiently use domestic and supplementary external resources on a reliable basis to achieve current and future target levels of the immunization performance”

10. Developing the FSP for Uganda • On-going participatory process since 2002, involving MOH, MOF, and development partners. • Draft discussed with stakeholders (ICC, HPAC, HDP) • FSP process aims to fit within the Uganda national planning and budgeting cycle (MTEF, LTEF)

11. Value of the FSP • generates a clear picture of the financing situation and challenges. • identifies relevant, feasible and specific strategies for financial sustainability. • is an advocacy tool for discussion between the MOH, the MOFPED and other partners.

12. Costs of the immunization programme in Uganda

13. Cost items • Routine immunisation • Recurrent costs • Vaccines, injection supplies, personnel (center to HC2), transport, surveillance, maintenance and overhead. • Capital costs • Vehicles, cold chain, infrastructure • Supplementary immunisation activities • Polio, Measles, MNT Costs calculated since FY 2000/01

14. 2000/01 (Baseline year) • The baseline year is the financial year before any support was provided by the Global Alliance for Vaccines and Immunisation (GAVI) • Total routine costs in 2000/01 for provision of vaccines to target population: $4.49 million USD (USD $17.36 per child fully immunized, equivalent to USD $0.18 per capita).

15. Sources of funding, 2000/01

16. 2001/02 (First Year) • The first financial year in which Uganda received support from GAVI. This included financial support and vaccines for one month (June 2002) • Total first year costs including shared personnel: $6.38 million USD.

17. First year financing chart

18. Comparison of funding sources 2000/01 – 2002/03

19. Contributions from the Vaccine Fund (GAVI) in Uganda • Injection safety materials: Auto-disable (AD) syringes ($1,157,000 for 3 years) • Support funds (US$ 910,000 x 2 years) to strengthen the system and increase coverage • Addition of two antigens: • Hepatitis B (Hep B) • Haemophilus influenzae type b (hib) • Using “pentavalent” presentation: DTP+Hep B+hib ($50 million over 5 years)

20. Cost drivers: 2002 to 2007 • Cost of routine EPI • 2002: $20,375,520 • 2007: $23,363,763 (USD $0.79 per capita) • Costs rise due to: • population growth: annual increase in size of birth is 100,000 additional babies (result: 10% of programme cost increases) • coverage increase: 72% to 85% (result: 4% increase of programme cost) • Depreciation of exchange rate: rising costs of all vaccines

21. Cost of vaccines

22. Future resource needs by cost category

23. Funding gap chart

24. Funding gap implications for achievement of UNEPI objectives In 2007, when GAVI no longer provides vaccine, there will be a gap of $17.3 million • $16.5 million is the vaccine cost • $0.8 million funding gap for operational costs • Implications • Vaccine shortages • Increased disease burden of immunizeable diseases • Political credibility questioned • Overall Social and Economic development compromised • Social protection strategies of govt towards vulnerable groups questioned

25. What are costs of NOT providing hepatitis B and Hib vaccines? • Treatment costs incurred by system • Costs due to illnesses that are a result of a vaccine preventable disease • Refers to treatment costs to the health system, eg. due to Hib meningitis • Treatment and vaccine costs of a vaccine include costs of providing the vaccine, compared to cost of treatment of illnesses due to the immunizable diseases • As vaccine coverage increases, treatment costs decline

26. Estimated cost of an illness episode

27. Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007

28. Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007 The treatment cost to MOH with no Hep B / Hib vaccine is more than ten times the cost of DPT

29. Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007 Hepatitis B vaccine is very good value for money

30. Treatment and vaccine costs due to Hep B and Hib, Uganda, 2007 DPT-Hib vaccine without Hep B is an expensive option

31. Total per capita costs

32. Impact on disease burden

33. EPI expenditures in perspective

34. STRATEGIES TO ENSURE FINANCIAL SUSTAINABILITY OF THE PROGRAMME

35. Key strategies • Mobilize additional internal resources • Mobilize additional external resources • Increase reliability of resources • Increase program efficiency

36. Mobilizing additional internal resources

37. Strategy for mobilizing public resources • Health Financing Strategy allocates 4% of health budget recurrent costs for vaccines • Allocation been reducing annually to under 2% at present • Need to halt slide on proportion of health expenditure on vaccines/EPI

38. Strategy for mobilizing public resources • Govt to continue funding the full cost of traditional 6 antigens including the DPT cost and injection supplies. • Propose an increase in proportion of health expenditure for vaccines/EPI (1% increase in real terms annually starting 2004/05) • Govt budget not expected to fund 100% of vaccine costs in the medium term

39. YR Propn of health budget Propn of penta costs covered (bn. shs) GoU contribution Total Illness episodes averted Deaths averted Illness episodes averted Deaths averted 2003/04 2% 0.01 467 412 32,046 28,299 2004/05 3% 0.11 3,983 3,508 33,185 29,304 2005/06 4% 0.20 7,574 6,671 34,372 30,354 2006/07 5% 0.30 11,257 9,914 35,612 31,449 2007/08 6% 0.41 15,194 13,381 36,815 32,592 2008/09 7% 0.52 19,312 17,008 38,257 33,786 2009/10 8% 0.64 23,618 20,800 39,668 35,034 Impact of 1% annual increase in EPI allocation

40. Mobilization of other local resources • Immunization activities to be integrated into Local Government activities funded by local resources • Local Govts to mobilize resources for selected cost items, such as IEC and social mobilization

41. Mobilizing additional external resources

42. Strategies to seek external resources • Significant donor support for SIAs imply high confidence among donors in immunization as a disease prevention strategy • Advocate for routine vs SIAs support (e.g. rotary, red cross) design a menu for civil society partners and private sector • Negotiate with World Bank for buy-down: performance related external support • Private sector: corporate partners, lottery, e.g. advertising

43. Increasing reliability of resources

44. Strategies to increase reliability • Taper off vaccine fund support beyond 5 years (use performance grants from GAVI) • Protection of vaccine commitment in prog. 9 • Cost savings from donors to be maintained within programme, as opposed to remitting back • Incorporate FSP financial forecasts in govt planning and budgeting processes e.g. MTEF/LTEF • Improve district financial mgt. capacity • Advocate for sustainability of SWAp partnership

45. Increase programme efficiency

46. Strategies to improve efficiency • Reduce vaccine wastage • Vaccine management monitoring system & MDVP • Create immunisation logistics manager position • Maintain and upgrade cold chain NB. Most strategies to reduce wastage may also reduce immunisation coverage Reduce operational costs • Reduce distribution cost…Switch from gas to electric/gas • Rationalise outreach services/ intensify social mobilisation

47. Summary • Immunisation is most Cost Effective use of scarce resources, preventing disease, death and disability, & unnecessary treatment costs • UNEPI to continue providing the current 8 antigens • EPI programme costs shall continue to raise as newer vaccines are developed • Cost implications manageable if phased over time • Are many funding partners besides GoU budget, though this is expected to remain main source of funds (in line with SWAp strategy) • Inability to cover vaccine costs beyond GAVI support implies higher costs to the system

48. Discussion points • Rising costs of vaccination programme due to popn increase and better coverage. • GoU allocation for immunization activities. • Long-term vision to enable increased adaptation of newer vaccines over time: yellow fever, pneumococcal vaccine, malaria, HIV, etc.

49. Next Steps • READ the FSP • Submit comments on strategy to UNEPI for inclusion in FSP (is a full section on stakeholder comments for inclusion in final FSP) • Present strategy to Health Sector Working Group

50. FSP chapters • Section 1: Impact of country and health system context. • Section 2: Program characteristics, objectives and strategies. • Section 3: Baseline and current program costs and financing • Section 4: Future resource requirements, financing gap analysis • Section 5: Sustainable financing strategy, actions, indicators • Section 6: Stakeholder comments!!!!!