Meeting Report. Regional Workshop on Strengthening the Impact of GAVI Health Systems Support on Immunization

Transcription

1 Meeting Report Regional Workshop on Strengthening the Impact of GAVI Health Systems Support on Immunization Hanoi, Viet Nam November 2013

2 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC REPORT REGIONAL WORKSHOP ON STRENGTHENING THE IMPACT OF GAVI HEALTH SYSTEMS SUPPORT ON IMMUNIZATION OUTCOMES Hanoi, Viet Nam November 2013 Manila, Philippines April 2014

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4 WPR/DHS/HSD(03)/2013 English only Report Series No.: RS/2013/GE/59(VNM) REPORT REGIONAL WORKSHOP ON STRENGTHENING THE IMPACT OF GAVI HEALTH SYSTEMS SUPPORT ON IMMUNIZATION OUTCOMES Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Hanoi, Viet Nam November 2013 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines April 2014

5 NOTE The views expressed in this report are those of the participants in the Consultation on the Health Care Quality Improvement Network in the Asia-Pacific Region and do not necessarily reflect the policies of the Organization. This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Members States in the Region and for those who participated in the Regional Workshop on Strengthening the Impact of GAVI Health Systems Support on Immunization Outcomes, which was held in Hanoi, Viet Nam from 19 to 23 November 2013.

6 CONTENTS SUMMARY 1. INTRODUCTION PROCEEDINGS Day One Day Two Day Three ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, SECRETARIAT AND RESOURCE PERSONS ANNEX 2 - AGENDA ANNEX 3 - PRESENTATIONS... 47

7 SUMMARY As agreed at a bi-regional workshop for member states in Bangkok, Thailand, in July 2012, the World Health Organization (WHO) Regional Office for the Western Pacific Region (WPR) organized a three day workshop in Hanoi, Viet Nam, from 19 to 21 November The workshop was attended by 35 participants including Extended Programme on Immunization (EPI) Program Managers and senior Health Systems and Planning representatives from Ministries of Health of six Member States, and WHO technical staff and counterparts from GAVI, UNICEF and Lux Development. The workshop included presentations and group exercises that provided background and updates on EPI and Health Systems Strengthening (HSS) at regional and country levels and considered opportunities, barriers and factors involved in planning effective and sustainable immunization for the future. Financial sustainability of immunization is a challenge, especially given the emergence of new vaccines that are more costly than traditional ones. A number of participating countries will soon graduate from eligibility for GAVI EPI/HSS support and others have already done so. A range of themes and issues relating to financial and programme sustainability emerged from plenary and exercise discussions during the course of the meeting: Preparing for graduation from GAVI support takes a long time and should be started years ahead. Political commitment and collaboration between health and finance departments are needed for effective and sustainable immunization programmes. Comprehensive multi-year plans for immunization should be integrated with national health plans. Plans should be based upon situation analyses and should be fully costed. Financial planning should not focus on vaccine prices alone: many of the costs in immunization relate to personnel, operationalization, service delivery, communication and other recurrent costs. There is a shortage of good data relating to non-vaccination costs in immunization programmes. Immunization planning requires a system-wide approach that considers the activities needed at every level and area of a health system. Integrating the delivery of immunization with delivery of other health services, especially MCH, presents opportunities for more effective delivery, higher uptake, and best use of human resources. Shortages of health, management and finance personnel and skills, poor staff training and retention, and poor distribution of human resources seriously affect immunization services. Health systems need to plan for sufficient human resources to sustain EPI programmes. The cold chain often receives too little attention. Establishing and maintaining effective cold chains for the delivery of vaccines are of critical importance, but seldom prioritized.

8 -2- Monitoring and evaluation is important in sustaining policy commitment and in monitoring and improving immunization implementation. There is a need in many countries for improved monitoring and evaluation and improved data quality, management and use. Communications strategies are important to raise awareness, understanding and demand for immunization and to counter anti-vaccine feelings. There is often low demand or fear of vaccines in at risk and hard to reach communities. Countries immunization services encounter problems reaching the last 20% : often remote communities, ethnic minorities and urban poor. There is a shortage of good data relating the specific challenges and costs in reaching these populations. Country participants appreciated the interaction with other national programme managers and with development partner EPI and HSS specialists. Through the workshop, development partner specialists became better informed of countries views and concerns regarding sustainable immunization services and mechanisms relating to support.

9 1. INTRODUCTION The Global Alliance for Vaccines and Immunizations (GAVI) provides grants for the implementation of the Expanded Programme on Immunization (EPI) and health systems strengthening (HSS) in countries worldwide. These include EPI and HSS grants to six Member States in the Western Pacific Region (Cambodia, Lao People s Democratic Republic, Mongolia, Papua New Guinea, Solomon Islands and Viet Nam) and EPI support only to a seventh (Kiribati). From early 2012, GAVI has refocused its HSS support in pursuit of improved implementation and immunization outcomes. New approaches and mechanisms have been introduced, including performance-based financing (PBF) based on intermediate indicators of programme implementation as well as immunization outcomes, and regular online monitoring of GAVI-supported HSS activities. In July 2012, the WHO regional offices for the South-East Asia Region (SEAR) and Western Pacific Region (WPR) along with GAVI co-hosted a biregional workshop for Member States in Bangkok, Thailand. The workshop was used to exchange updates on GAVI-supported implementation, share country lessons, and introduce new GAVI approaches. As a follow-up, the WHO Regional Office for the Western Pacific (WPRO) organized a further technical workshop in November 2013 in Hanoi, Viet Nam. The objectives of the workshop were: to review the implementation status of GAVI HSS grants, especially in the context of new mechanisms introduced by GAVI; to identify key health systems bottlenecks in the development of sustainable immunization programmes towards universal health coverage; to agree on measures to strengthen the operational linkages between GAVI EPI and HSS grants; and to agree on next steps to strengthen the impact of health systems support to countries. The workshop was used to continue the dialogue between countries, partners and GAVI in order to identify opportunities for further linkages between EPI and HSS support, with a special focus on the sustainability of immunization programmes. Sustainability of programmes is a key issue in the Western Pacific Region as many countries move towards or beyond the GAVI eligibility threshold of US$ 1550 Gross National Income (GNI) per capita. The three-day workshop was held in Hanoi, Viet Nam, from 19 to 21 November 2012 and was attended by 35 participants. Six Member States participated in the workshop: Cambodia, Lao PDR, Mongolia, Papua New Guinea, Solomon Islands and Viet Nam. Participants from the countries included EPI programme managers and senior health systems and planning representatives from ministries of health. Development partner participants included WHO HSS and EPI technical officers from the participating countries, WHO HSS and EPI staff and resource

10 -2- persons from WPRO, SEARO and Headquarters, and counterparts from GAVI, UNICEF and Lux Development. The first day s presentations provided background and updates on EPI and HSS status at regional and country levels, GAVI support, and barriers to immunization service delivery. On the second day, presentations and group exercises were used to focus on planning for effective and sustainable immunization for the future. The discussion on sustainability was split into: 1) Financial sustainability and 2) Programme sustainability. Financial sustainability issues are of particular importance as countries approach GAVI graduation status. Programme sustainability addressed the more service delivery-oriented issues. The third day s presentations provided overviews of performance-based funding and monitoring and evaluation (M&E) mechanisms recently introduced by GAVI, and of national health planning. In group exercises, participants considered in detail the different health system areas and levels within which their countries planned EPI and HSS activities would take place, and the financial and other resources that they would require.

11 -3-2. PROCEEDINGS 2.1 Day One Opening session Mr Sjoerd Postma, Team Leader for Health Services Development at the WHO Regional Office for the Western Pacific, welcomed the participants. Opening remarks were given by Dr Nguyen Hoang Long, Deputy Director, Department of Planning and Finance, Ministry of Health, Viet Nam on behalf of Dr Nguyen Thanh Long, Vice Minister of Health, Viet Nam. Dr Nguyen Hoang Long began by stating that immunization is one of the most cost-effective interventions for combating infectious diseases, is affordable to countries, and could be an entry point to health services that can assist in the attainment of universal coverage. He outlined some of the challenges and opportunities relating to EPI that would become major foci for the next three days. He reminded participants of the challenges of gaining access to the hard-to-reach populations: for geographical, financial and sociocultural reasons, vaccines often do not reach those who need them most. He commented upon the financial challenges of balancing the sustainability of existing immunization coverage and improving quality and equity, while at the same time expanding to include new vaccines. Dr Nguyen Hoang Long reflected that immunization is often organized in vertical, disease-focused programmes. But he reminded the participants that at community level the staff, facilities and financing for immunization are not separate. At the community level, immunization is delivered by the same staff that deliver other health care. Achieving and sustaining improved immunization outcomes requires strengthening of health systems from grassroots-level upwards. EPI and HSS can be mutually beneficial activities. For optimal effectiveness, immunization programmes need a well-functioning health system. Delivering vaccination services as part of broader public health activities affords opportunities for more cost-effective EPI. At the same time, immunization programmes can strengthen the system of delivering other health programmes by being an entry point for primary care in hard-to-reach areas, and an opportunity for delivering key health messages to mothers and communities. Dr Nguyen Hoang Long praised GAVI HSS and EPI support and wished the participants a successful meeting at which they could share experiences and lessons in order to work towards further strengthening of both health systems and immunization programmes Presentation 1-1 WPRO Workshop on Immunization Mr Postma presented an overview of the 2012 Bangkok workshop. He explained that the workshop was about working together to find ways to develop sustainable immunization programmes and maximize immunization outcomes. In order to do this, it is important to find synergies between HSS and EPI.

12 -4- He outlined the recommendations from the 2012 workshop and noted that many of those had not been achieved yet. In particular, there remains a need for countries and development partners to work together to: Ensure sustainable and predictable financing for the health systems, including for routine immunization. Help countries in conducting costing, fiscal space and gap analysis. Strengthen communication and coordination mechanisms for GAVI country support (e.g. regional technical working mechanisms involving regional partners with different comparative advantages) to link country TA needs to relevant partners. Clarify roles and responsibilities between WHO/UNICEF and GAVI in response to country demand. Define a clear set of procedures, timeframes and responsibilities for the financial management assessment (FMA). Create a platform for countries to share best practices Presentation 1-2a Western Pacific Region: Health Systems Strengthening overview Dr Ayesha de Lorenzo, Technical Officer (HSS) for the Division of Health Systems Development, WPRO, presented an overview of GAVI HSS and the changing health systems landscape in WPR. In the years inclusive, a total of US$ has been disbursed or committed by GAVI to Cambodia, Lao PDR, Mongolia, Papua New Guinea, Solomon Islands and Viet Nam. Both Cambodia and Viet Nam receive sizeable grants while others receive varying levels of support (Table 1). Table 1: WPR HSS Grants Total KHMR HSS Lao PDR HSFP* MNG HSS PNG HSFP* SLB HSFP* VTN HSFP* * Note: HSFP stream has been phased out; now HSS only Disbursed Approved

13 -5- Committed A review of the grants (Table 2) shows the main areas that the HSS investments are used for. Almost all countries used the funds for EPI-MNCH linkage, community mobilization and subnational planning. Only two countries were using the grants for their cold chain. Table 2: Areas supported by HSS grant aid KHM L ao PDR MOG PNG SOL VTN Subnational/microplanning X X X X Management - capacity, supervision and M& E X X X X HR training X X X IMCI X X MNCH/EPI-MNCH X X X X X Community mobilization/awareness X X X X X Outreach X X Cold chain X X Essential equipment for health facilities X Data collection and analysis X X X The countries in the Western Pacific Region boast improving economies along with improving health performance. As a result of this, they are also seeing a decrease in donor support. Dr de Lorenzo presented the eligibility status of each of the GAVI- supported countries: in Kiribati, Mongolia, and PNG, the GNI per capita has already exceeded the $1550 cutoff, with Viet Nam close at $1400. Despite economic growth, the resulting fiscal space may not be growing rapidly enough to compensate for reductions in, or loss of, donor funding. This challenges countries to develop more efficient systems that are financially sustainable in the long term. Additionally, this is happening in the context of the rapid introduction of new and often far more expensive vaccines, which pose financial and programmatic sustainability challenges of their own. In summing up, Dr de Lorenzo discussed the tension between the need for short-term support for health systems and for long-term health systems strengthening. Opportunities to address these challenges include designing new programmes and new applications, and ensuring that these change their focus from short-term support to long-term systems strengthening and programme sustainability. She stressed the importance of the comprehensive multi-year plans for immunization being aligned with national health plans, and sharing lessons already learnt.

14 Presentation 1-2b Regional overview EPI Dr Jorge Mendoza Aldana, Technical Officer (EPI), Division of Combating Communicable Diseases, WPRO, presented an overview of EPI in the Region, including the new vaccines introduced in recent years and those on the horizon. He also outlined the eligibility criteria for GAVI support based upon GNI per capita, adding that even graduating countries will still continue to be eligible for support for pneumococcal vaccines. Data show gradually increasing coverage for DTP3 in all countries from 1995 to GAVI support to WPR countries from inception to August 2013 ranged from $ in Kiribati to $ in Viet Nam, for a total of $ for the Region. Dr Mendoza Aldana also provided an update on the measles-rubella campaign and the polio endgame Presentation 1-3 Sustaining immunization financing: increasing fiscal space for vaccines Mr Santiago Cornejo, Senior Specialist in Immunization Financing for GAVI, discussed the challenge of ensuring the sustainability of vaccination programmes in developing countries, a challenge that is compounded by the development of new vaccines that are often more expensive than the traditional ones. Mr Cornejo focused on the development of national fiscal space in order to enable countries to continue to fund EPI after graduation from GAVI support. He described ways in which countries can generate the fiscal space needed to sustain EPI programmes: reallocating resources and expanding the resource envelope. Mr Cornejo then outlined GAVI s fiscal space analysis methods, with the important caveat that this methodology only accounted for the cost of vaccines and not for delivery and other related costs. Mr Cornejo presented analyses that showed the relationship between growth in GDP and increased public spending on health per capita. Western Pacific Region countries ranged from 0.2% to 0.6% of general government expenditure on health (GGHE) spent on vaccines. GAVI estimates that higher income countries (that are thus graduating) would need to spend 0.3% or less of their GGHE on vaccines. He described the GAVI co-financing policy as a prudent policy that would help countries move towards sustainable domestic EPI financing. Several challenges and areas that need improvement were identified: adequate fiscal space is not always the main problem; health systems development is often slower than economic development; and better coordination is needed, including the development of clear graduation plans. Dr Mursaleena Islam, GAVI Senior Specialist in Health Systems, clarified that even after graduation, all 73 GAVI countries would remain eligible for support for inactivated poliovirus vaccine (IPV). Several issues were raised by participants in response to the presentation. There was concern that the focus was on vaccination costs alone, rather than their delivery, and that there must be a greater focus on programmatic sustainability. A WHO country office participant described how in Papua New Guinea, the cold chain in particular was a major challenge and that this needed to be a major focus in the country s graduation plans and that it would be a considerable drain on finances in addition to the vaccinations themselves. Mr Cornejo said that

15 -7- little was known about the incremental costs of immunization delivery beyond the costs of vaccination and, to a lesser degree, the cold chain. In addition, work was needed to assess how many more vaccines any health system can absorb. A participant also pointed out that the fiscal space analysis seemed to assume that countries would invest increasing funds from rising GDP evenly across sectors and that therefore funds would be available for health; and further, that within the health sector these funds would be prioritized to cover the increasing costs of vaccination. Realistically, this may not be the case and will be dependent upon national priorities. He suggested that, given such issues and the implications of new and future vaccines, GAVI should consider a graduation grant. A participant mentioned that, while GAVI s co-financing approach was progressive, half of the GAVI-funded countries still did not fund their own traditional vaccines, despite cofinancing expensive new vaccines. It was also noted by many participants that GNI may not be a subtle enough indicator for determining eligibility as it does not reflect a country s development or social transformation. A WHO country office participant reminded the meeting that the delivery costs for the last 20% hard-to-reach population are the highest. Clarification was also sought on the degree to which GAVI considered, or is involved in, negotiations on affordable prices with the vaccine and cold chain suppliers. High prices can negatively impact the equity of vaccination programmes Presentation 1-4 Regional EPI programme update Dr Jorge Mendoza Aldana presented an overview of the history and current status of immunization strategies globally and in the Western Pacific Region. He outlined the goals of the Regional Framework for Implementation of the Global Vaccine Action Plan in the Western Pacific ( ) and discussed its strategic objectives: 1. Countries commit to immunization as a priority 2. Individual and communities understand the value of vaccines and demand immunization 3. The benefits of immunization are equitably extended to all people 4. Immunization programmes are integrated into a well-functioning health system 5. Immunization programmes have sustainable access to predictable funding, quality supply and innovative technologies 6. Country, regional and global research and development innovations maximize the benefits of immunization. The monitoring, evaluation and accountability framework for the implementation of the regional EPI framework includes three areas: monitoring results; monitoring and documenting commitments for immunization; and monitoring resources invested in immunization Presentations 1-5a g Country presentations In the afternoon sessions, each country gave a presentation which included an update on EPI and HSS, an update on GAVI support, and a short illustrative case history that reflected EPI

16 -8- in the country context. Countries also reported challenges affecting EPI service delivery. These are summarized in Table 3. Cambodia (Presentation 1-5a) EPI, HSS and GAVI support update Dr Chheng Morn presented an overview of EPI activities and achievements in the country. Immunization rates have steadily increased in recent decades, aided by GAVI support since Polio-free status is being maintained and no measles cases have been reported since Since 2010, the National Immunization Programme with the support of GAVI has introduced Hib, measles second dose and rubella vaccine into the EPI schedule with future plans for PCV and later Japanese enciphalitis, human papilloma virus (HPV) and rotavirus vaccine. Challenges that affect EPI delivery include: L ack of trained personnel, demographic changes, underfunding and poor availability of infrastructure and equipment, especially in rural settings. Lack of operational planning and financial management capacity in districts and health centres and uncertainty about monitoring data quality. Poor funding and incentives for outreach activities, lack of monitoring and low demand for immunization in at-risk communities. Assistance needs were identified as: Technical assistance in adjusting the HSS application following a recent internal review. Greater development partner support for GAVI HSS processes. Expansion of GAVI HSS support to cover the whole country. Case study Mrs Thavary Khout, coordinator of a GAVI/HSS grant, presented a case study of the use of the Outreach Management Guidelines. The guidelines were developed by the Ministry of Health in close collaboration with WHO and UNICEF, funded by GAVI, to improve health service packages and especially immunization programmes to reach the high-risk communities. That 20% of children are not immunized is in large part attributed to: Mobile populations Ethnic minorities with different languages and cultures

17 -9- Fragile poor urban communities that are difficult to access Geographically remote communities in which low demand for, and fear of, vaccination persists. The Outreach Management Guidelines advocate training of staff in micro-planning, monitoring and delivery of integrated health programmes that incorporate immunization with child and maternal health outreach services. Following the presentation, participants asked whether any assessment or review had been done to look at what the impact of introducing the new vaccines would be on Cambodia s health systems. Dr Morn said that Cambodia has a plan to introduce newer vaccines yearly up to Participants felt that there may be some lack of clarity about what the new vaccines may mean for the system. Lao PDR (Presentation 1-5b) EPI, HSS and GAVI support update Dr Anonh Xeuatvongsa, National EPI Manager and MCH Deputy Director, presented an overview of EPI activity and achievements. Vaccination coverage has increased notably in the past five years. The Strategy and Planning Framework for the Integrated Package of Maternal, Neonatal and Child Health (MNCH) Services was launched in At the 2011 World Health Assembly, the country s President made a commitment to achieve >90% BCG, DPT-HepB-Hib3, and measles vaccination coverage by 2015 and has personally been involved in immunization campaigns. Government funding of traditional vaccines started in 2012 along with co-financing of GAVI DPT-HepB-Hib vaccine and PCV 13. A National EPI review was conducted in 2012 to assess the progress of the National Immunization Programme (NIP), identify challenges and bottlenecks and provide policy options and technical recommendations to strengthen the immunization programme. In the financial year, the government plans to fund 100% of traditional vaccines and maintain the co-financing, and also to increase support for operational costs, although it is unclear to what extent. An expansion in the coverage of new vaccines is also planned. Health sector reform plans include a focus on outreach activities targeted at hard-toreach communities. Commenting on GAVI support, Dr Anonh Xeuatvongsa highlighted some areas that need strengthening: Timely disbursement of financial commitments by donors and government.

18 -10- Turning disbursements into tangible results. Increasing monitoring capacity to measure investments and results. Case study Dr Anonh Xeuatvongsa presented a case study of an HPV demonstration project that highlighted the importance of cross-sectoral work and communications strategies. Many stakeholders including schools and the Ministry of Education were involved in advocacy and awareness-raising about vaccination, which resulted in great interest and increased demand at grass-roots level. After the presentation, Dr Anonh Xeuatvongsa was asked whether there had been any community-level resistance to the rolling out of the HPV. The ensuing discussion focused on the importance of multisectoral approaches, high-level government involvement, as well as involvement of local leaders. Schools, village leaders and community organizations had been consulted and involved and little resistance was met. There was also discussion about how the cultural and political context of different countries can impact the acceptability of vaccines. Another question was whether the government had given thought to the relative costbenefits of introducing the costly new vaccines as opposed to trying to improve coverage levels of traditional vaccination. Dr Anonh Xeuatvongsa reflected that getting higher than 80 90% coverage may not be just a matter of finances. Lack of trained personnel and infrastructure are also issues. In addition, remoteness of populations affects coverage, because floods and poor roads mean that some areas are only accessible half the year. Vietnam (Presentation 1-5c) EPI, HSS and GAVI support update Dr Nguyen Thanh Long presented an overview of Viet Nam s health system development and EPI activity and achievements. Community health centers (CHCs) and workers play a major role, resulting in relatively successful implementation of primary health care and preventive health care programmes. Viet Nam s EPI programmes are already integrated with mainstream grass-roots health provision. CHCs responsibilities include: o o o o o early detection and control of epidemics; organization of campaigns for disease prevention and health promotion (including EPI); provision of first aid, examination and treatment; health care for mothers and children, assistance of normal delivery, and implementation of family planning programs; health consultation and management. Viet Nam has received very substantial GAVI HSS support exceeding $24 million aimed at developing human resources, service delivery capacity and management capacity. Dr

19 -11- Long reported that the programmes supported by GAVI had achieved excellent outcomes. Total government financing for EPI has increased markedly and steadily from 2005 to 2013, with a dramatic fall forecast for 2014 due to the country s slowing economy. In recent years the proportion of EPI spending coming from the government has increased while GAVI s proportion has decreased. Challenges to implementation and improved immunization coverage include: Lack of trained medical staff. Poorly trained and paid voluntary health workers. A lack of essential equipment at all levels. High out-of-pocket health expenditure. Disparities in health status indicators between population groups. EPI coverage is low in remote and mountainous regions and support for service delivery capacity has included outreach programmes for hard-to-reach populations. The budget shortfall in 2014 looks set to exacerbate these problems. Case study Dr Long described a joint EPI-MCH outreach programme for hard-to-reach communities In which children and pregnant women were vaccinated against tetanus and provided with communication and counseling services. The programme served to reduce inequity in EPI delivery in that the recipients were mostly poor ethnic minorities living in remote mountainous regions. After the presentation, Dr Islam, GAVI commented that Viet Nam has the largest GAVI grant in the Region, with components that are widespread and cross-cutting. She asked whether some experiences could be shared on the implementation of the grant, on lessons learnt and on monitoring and evaluation. A participant asked whether this village health volunteer approach had come about as a result of the grants or whether it already existed, and if it was sustainable. Dr Long replied that the national health plan (NHP) states that every village should have at least one health worker with training in local medical/health colleges. So this way of working is not just related to GAVI projects but is the way things are done normally. Having the same local personnel implement all health service delivery means that duplication can be minimized. A WHO country office participant asked how the massive in budget cuts planned for next year can be managed. Dr Long confirmed that the government has a cash shortage, and so less money will be available for the Department of Health (including the immunization department). He reflected that health planners can only try to work as effectively as possible, identify costsaving strategies and talk with the government to protect their programmes. When news of the health budget cuts became known through the mass media, a public outcry began because the people want to protect their health services too. Public support for immunization may be helpful in protecting funding.

20 -12- Mongolia (Presentation 1-5d) EPI, HSS and GAVI support update Dr D. Narangerel Dorj, National EPI manager for Mongolia, outlined the EPI and HSS situation in his country. Immunization outcomes have been good, with polio-free status sustained, measles elimination waiting to be confirmed, and targets on other diseases reached. The goal of GAVI-supported EPI HSS has been to improve population health through provision of integrated health care services package to vulnerable, disadvantaged and hard-to-reach populations through the reach every district (RED) approach. The integrated RED programme, implemented in collaboration with development partners, includes health services (immunization, MCH, nutrition, safe water) and social welfare (civil and health clinic registration, employment, health insurance). GAVI has provided support for both immunization and health systems strengthening and all associated HSS indicator targets have been met. The country is currently applying for support for introducing PCV13 into the national vaccination schedule starting from January Case study Dr Dorj described the situation analysis that has been conducted with GAVI and WHO support, and with the involvement of many stakeholders and government departments, and the resultant transition plan to inform the country s graduation from GAVI EPI and HSS support. The proportion of government support for immunization has gradually increased over recent years. In 2002, 100% of immunization was funded by donors, whereas in 2012 the government funded around 90%. It is intended that the transition plan will enable the Departments of Health and Finance to plan the fiscal and organizational changes necessary to achieve a sustainable, domestically-funded EPI plan in future. Following the presentation, Mr Postma asked when Mongolia started planning for graduation from GAVI support. Dr Dorj said that the government had been thinking of an immunization fund since 2001 and that work on transition plans had started in earnest in Mr Postma stressed that the lesson for other countries is that preparing for graduating from GAVI support and preparing for government support of immunization takes a long time. Papua New Guinea (Presentation 1-5e) EPI, HSS and GAVI support update Mr Gerard Sui presented an overview of the EPI and HSS situation in his country. Trends in immunization coverage have improved in the last decade, but not sufficiently to meet country targets and wide disparities exist between regions. Currently the government funds 100% of traditional vaccines and 80% of operational costs, with co-financing with GAVI and support from other development partners.

21 -13- A GAVI HSS grant of $3 million was approved in October 2013 to strengthen outreach delivery services and supervision, thereby strengthening the health system in line with the national health plan. New applications are in process for GAVI support for measles immunization. A major problem in the implementation of EPI is the decentralized nature of health administration, which saw a deterioration of EPI since the mid-1990s because local authorities were not compelled to follow national policies. At local levels, delivery of EPI programmes has been undermined by several factors: Poor management Shortages of personnel Poor monitoring and supervision Uncertain data quality and lack of skills in data use for planning Irregular disbursement of funds. Case study Mr Sui described how recent Provincial Health Authority restructuring and Direct Health Facility payments may improve management and financial barriers to EPI. In addition, programmes are being introduced to tackle personnel shortages. The geographic and cultural context in Papua New Guinea means that there are many hard-to-reach communities, and outreach work has been identified as a priority. Specific fund allocation for outreach work by local health centres has been introduced and public-private partnership arrangements are being considered to contract nongovernmental organizations to conduct EPI programmes. Following the presentation, a participant asked what plans Papua New Guinea was making for EPI, given that it was set to graduate from GAVI support. Dr Datta Siddhartha replied that while EPI is still supported by GAVI, the country now has funds to support EPI itself and that programmes (which end in 2015) will be reviewed in 2014 to assess the support that will needed for transition to 100% government funding. Dr Datta was also asked what steps needed to be taken before the rollout of the HPV vaccine in light of the problems and controversy experienced in the country with the mass campaign on tetanus toxoid, which provoked a major backlash in the country. Dr Datta responded that thought is being given to communication strategies that may improve acceptability and demand. Solomon Islands (Presentation 1-5f) EPI, HSS and GAVI support update Dr Divinal Ogaoga presented on overview of EPI activities in Solomon Islands. Coverage has improved markedly in recent years.

22 -14- Reductions in childhood illness have been observed. The government is now supporting EPI strongly, with some support from GAVI, but more so from UNICEF. An application has been submitted to GAVI for PCV-13 routine introduction and an MR catch-up campaign in However, several challenges affect EPI service delivery. Although Solomon Islands geography of some 900 islands divided by wide stretches of sea means that vaccine-preventable/infectious diseases spread more slowly than in some other contexts, the same geography poses problems to EPI service delivery in terms of logistics and maintaining the cold chain. Communications are critical for EPI, yet the country has limited communications strategies and more than 70 languages are used, posing problems for awareness-raising. It is thought that uptake of immunization has also been affected by the fact that some clinics have been charging fees, even though health care is in principle free. An organizational challenge is that EPI programmes are currently under reproductive and child health rather than having its own department, so that staff are often not well trained in EPI. Decentralized governance means that local authorities decide health expenditure at local level and vaccination funding, especially for outreach activities, is often delayed or not made available. Human resources are a problem for health care in general. Data management is often poor. Some very practical challenges also affect EPI activities, such as simple procurement of equipment and issues affecting the two-way radios used for communication. Case study It is hoped that several developments may improve the situation, including clearer role delineation, the universal health coverage policy, rezoning and micro-planning. In the Reach Every Zone strategy that was introduced at provincial levels in , micro-planning was used to improve service delivery in hard-to-reach communities. However, the programme was affected by insufficient budgeting for transport, lack of skilled supervisors, poor data management and lack of community participation with adequate social mobilization. The experience illustrated the need for effective engagement with local leadership so that they can advocate EPI, involvement of local communities in micro-planning for outreach, communication and awareness-raising strategies, and improved data skills. Following the presentation, Mr Postma discussed how the very different contexts of a country such as Solomon Islands meant that the challenges faced in EPI and the support needed may differ from other countries. In countries like Solomon Islands and Papua New Guinea there are widespread populations that are often hard to reach, so many of the costs of immunization arise from communication, transport, and operationalization rather than routine service delivery.

23 -15- Eligibility for aid is based on coverage indicators, but in such a small population the difference between 80% and 90% coverage can depend on a handful of people. These sorts of factors mean that it is important to consider the specific challenges that Pacific Island countries face. SEARO (Presentation 1-5g) EPI and HSS in SEARO Dr Pem Namgyal, Technical Officer for Vaccines and Preventable Diseases at the WHO South-East Asia Regional Office, gave a presentation outlining current EPI status and achievements in the Region. Bottlenecks affecting EPI service delivery vary from country to country, both in terms of their extent and nature, but mirror those affecting Western Pacific Region countries: There has been inadequate financial investment in health in some key countries so that a high burden of health costs falls on individuals. In some countries there is an insufficient number of health workers and often poor distribution of those that exist, skills mismatch, a lack of incentives and career ladders which result in labour migration, both within countries and abroad. In some countries, the health care infrastructure is inadequate, poorly equipped and poorly maintained. Changes in the GAVI approach to HSS Dr Namgyal outlined his views on changes in GAVI emphasis and practices in terms of EPI and HSS. Previously GAVI policy was that that HSS work should not be aimed at EPI outcomes specifically, but should rather address broader issues that could ultimately or indirectly improve EPI delivery. These included human resource development, improvements in financial organization and management, and the systems of supply, distribution and maintenance of drugs, equipment and infrastructure for primary health care. However, in recent years GAVI s focus has narrowed and there is now a requirement that any health system issues addressed in GAVIfunded programmes should have a direct impact on immunization outcomes. This change of emphasis may be interpreted as conflicting with the broader system development that the term health systems strengthening is associated with. Dr Namgyal outlined ways in which health service strengthening inputs had been seen to result in improved EPI outcomes, without the need for the vertical disease-specific approach that historically had been associated with immunization programmes and which GAVI s new monitoring requirements would reinstate. Dr Namgyal described an example from Bangladesh of how GAVI HSS support addressed general systems issues but still produced the desired results for immunization. After evaluation and identification of areas in which immunization targets were not being reached, MCH, general management capacity and infrastructure were improved, and all the targeted districts subsequently reached EPI targets. His concern was that if GAVI continues to focus narrowly on EPI-related systems support, then they should then not call this health systems support, because doing so may mean other potential funders may feel that HSS is adequately funded when in reality it is not. Dr Namgyal reminded participants that it is important to remember that the largest funder of the health system in any country is the government, and support for whole-of-system development is

24 -16- often needed. National Health Plans usually adopt system-wide approaches and if GAVI is to adhere to the Paris Declaration, their HSS support should be aligned with this rather than vertical programming. Table 3: Challenges to EPI implementation mentioned in country presentations Implementation challenge Governance Decentralized administration causing inconsistent implementation Lack of planning or management capacity Human resources Lack of trained health personnel Poor incentives for outreach/community-level EPI work Finance Underfunding L ack of financial management capacity at delivery level Disbursement not timely or predictable (government or donors) Infrastructure M&E Lack of infrastructure and equipment (including cold chain) Poor monitoring capacity or skills Poor data quality Communications Low demand for immunization in at risk communities Language differences Poor communication strategy Ethnic and cultural differences Community/demographics Demographic changes Remote populations hard to access Mobile populations hard to access Poor urban communities hard to access Number of countries End of day Following Dr Namgyal s presentation, Mr Postma made some comments to close proceedings for the day. Acknowledging that in a short space of time he could not do justice to

25 -17- the richness of the day s discussions, Mr Postma outlined what he considered to be the key points: 1. Countries are on track in developing and sustaining EPI efforts. 2. There may be a desire in countries to introduce the new vaccines. 3. Currently there is funding from GAVI, but in some countries there is lack of clarity about what happens after graduation. 4. A challenge that seems to be common to many countries is delivering EPI services to hard-to-reach communities and reaching the last 20%. Mr Postma commented that it was evident that the workshop was being held at the right time because many countries are graduating from GAVI eligibility and coming to the end of their national health plans and Millennium Development Goal timeframes. The purpose of the next two days was to think about how countries can move forward, planning for sustainable immunization programmes developed with the help of GAVI but sustainable thereafter. Themes emerging from the day s discussions: Preparing for graduation from GAVI support takes a long time and should be started years ahead. Sharing of experiences and approaches to preparation is very helpful to countries: a mechanism may be needed to formalize skill-sharing. There is a shortage of good data related to non-vaccination costs in immunization programmes in general, and to the incremental costs of reaching the hard-to-reach last 20% of the population. Given the context-specific difficulties of graduation, graduation grants might be useful to enable countries to address specific issues. Communications strategies are important to raise awareness, understanding, and demand for immunization, and to counter anti-vaccine feelings. There is often low demand or fear of vaccines in at-risk and hard-to-reach communities. Public understanding and support for immunization may be helpful in protecting funding of national immunization programmes in the context of declining donors and national funding. Countries felt it would be helpful if GAVI engaged in price negotiations for cold chain equipment; they also felt it would be very useful for GAVI to continue their role in negotiating prices for countries even after countries have graduated from GAVI grants. EPI can most effectively be provided as part of a wider health package, which can serve as a gateway to the health system. MCH can be a vehicle for EPI (or vice versa), along with screening, health promotion and parent and child monitoring. There is much focus on vaccine prices alone rather than operational costs; it is important to understand the cost to the health system of actually delivering the vaccines.

26 -18- The cold chain receives too little attention despite being a crucial component of immunization programmes. 2.2 Day Two Dr Paulinus Sikosana presented a recap of the previous day s proceedings Discussion of Dr Namgyal s presentation Mr Postma introduced a discussion of Dr Namgyal s thought-provoking presentation the previous day. Dr Namgyal looked at historical changes in GAVI s focus, in particular a narrowing from broader HSS to HSS that is directly related to disease-specific programmes and outcomes. The presentation provoked heated discussion and highlighted some of the tensions noted between countries and donors late on Day One, when there had been insufficient time for issues to be fully discussed or clarifications made. Discussions included challenges that countries may face as a result of GAVI s changes in focus and requirements for EPI-focused interim HSS monitoring indicators and EPI outcome indicators. Many participants felt that countries should not be called upon to narrow their HSS approaches as a result of changes in donor policies. There was also some discussion about existing difficulties with monitoring and evaluation which may be exacerbated by additional requirements for further indicators. A WHO country office participant commented that in Papua New Guinea, where M&E is already a challenge, GAVI requirements necessitate unnecessary changes in HSS and in M&E. Dr Islam reflected that what had emerged from country presentations was diverse, but that there was also some consistency: links between PHC and MCH and immunization, the need for cold chain strengthening, and working at community level. GAVI s investment in HSS is fairly small and can only be seen in the immunization context. From GAVI s perspective, it needs to be able to show its own donors that the HSS investments are effective. While countries have a lot of information about this in their own reports, GAVI cannot know about it unless it is shared. Hence the new requirements for interim process indicators as well as EPI outcome indicators. Dr Islam reassured the workshop participants that GAVI fully supports IHP+ and the Paris Declaration and seeks to work in line with countries NHPs. GAVI s intention is that countries should make applications to GAVI that include monitoring plans that are compatible with their countries existing or planned M&E frameworks. Mr Postma closed the discussion by reflecting that GAVI started as a small team in UNICEF and has since developed. Money was readily available in the mid-2000s, when grants were generous and their scope broad. It is not surprising that the focus has become tighter now that less money is available. But countries may need support in designing programmes and making applications and reports that comply with the new requirements. Additionally, feedback from countries and their thoughts on the shifts on HSS should be taken back to GAVI and incorporated into their discussions.