EMRO May (EMVAP) Action

Transcription

1 EMRO Framework for implementation Global Vaccine May Eastern Mediterr ranean Vaccine Action Plan (EMVAP) A Framework for Implementation of Global Vaccine Action Plan (GVAP)

2 Eastern Mediterranean Vaccine Action Plan (EMVAP) Executive Summary In May 2012, the Sixty-fifth World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) in resolution WHA65.17 as the operational framework for implementation of the vision of the Decade of Vaccines The ultimate success of GVAP depends on the commitment of Member States and partners. In this context, the Sixty-fifth World Health Assembly requested WHO regional offices to translate GVAP into regional vaccine action plans. The vaccine action plan of the Eastern Mediterranean Region EMVAP ) , has been drafted as a framework for implementation of GVAP in Member States of the Eastern Mediterranean Region, to guide prevention and control of vaccine-preventable diseases from 2016 to 2020 and beyond by defining the objectives, priority actions and programme indicators and taking into account specific needs and challenges of Member States in the Eastern Mediterranean Region. This document outlines the goals of the EMVAP and the objectives and priority action areas under each of the five EMVAP strategic objectives. Goals of the EMVAP: Goal 1: Meet regional routine vaccination coverage targets at all administrative levels. Goal 2: Meet regional disease elimination and control targets Goal 3: Introduce new vaccines of regional and national priority Goal 4: Attain interruption of wild polio virus transmission and sustain polio-free status Strategic Objectives of the EMVAP all countries commit to immunization as a priority; individuals and communities understand the value of vaccines and demand vaccination as their rights and responsibilities; the benefits of vaccination are extended equitably to all people through tailored, innovative strategies; strong immunization systems are an integral part of a well-functioning health system; immunization programmes have sustainable access to long term funding and highquality supply. This EMVAP includes also a monitoring and evaluation framework, the indicators of which will be used to monitor implementation of the priority actions of the different strategic objectives as well as progress towards achieving the goals of the EMVAP. As per

3 Resolution WHA65.17, a report on the progress made and remaining challenges will be submitted annually to the regional Committee (RC). This Eastern Mediterranean Vaccine Action Plan EMVAP, was submitted for consideration and endorsement by the sixty second session of Regional Committee for the Eastern Mediterranean, October Contents 1. Background Situation of vaccine preventable diseases and immunization in the Eastern Mediterranean Region Global Vaccine Action Plan (GVAP) Vaccine Action Plan of the Eastern Mediterranean Region Purpose Vision and Mission Structure of EMVAP Goals and targets of the EMVAP : Challenges facing achieving the regional goals: Strategic objectives and priority actions for achieving the regional goals Monitoring and evaluation framework for EMVAP Development and implementation of vaccine action plan at the national level: Role of the partners and stakeholders Annex 1. Eastern Mediterranean Vaccine Action Plan : Monitoring and Evaluation Framework... 19

4 Acronyms EMR EMRO EMVAP EPI GAVI GVAP IPV JRF LMICs MCV MCV1 MCV2 MICs MNT MoH NMVC NNT NRA NITAG OPV PEI RED RC RCC RCV Eastern Mediterranean Region Eastern Mediterranean Regional Office of the World Health Organization Eastern Mediterranean Regional Vaccine Action plan Expanded programme on Immunization Gavi, the Vaccine Alliance Global Vaccine Action Plan Inactivated polio vaccine WHO-UNICEF Joint Report Form on Immunization Low Middle Income Countries Measles-Containing Vaccine Measles-Containing Vaccine, first dose Measles-Containing Vaccine, second dose Middle Income Countries Maternal and Neonatal Tetanus Ministry of Health National Measles Verification Committee Neonatal Tetanus National Regulatory Authority National Immunization Technical Advisory Group Oral Polio Vaccine Polio Eradication Initiative Reaching Every District Regional Committee Regional Certification commission Rubella-containing vaccine

5 RMVC RTAG SIA VPDs WHA WHO Regional measles verification commission Regional Technical Advisory Group on immunization Supplementary Immunization Activity Vaccine-Preventable Diseases World Health Assembly World Health Organization

6 Eastern Mediterranean Vaccine Action Plan (EMVAP) Background 1.1. Situation of vaccine preventable diseases and immunization in the Eastern Mediterranean Region Immunization is one of the safest, most efficacious and cost-effective public health interventions. Immunization is a key element in preventing childhood illness and has brought about a remarkable reduction in child morbidity and mortality in the EMR over the past three decades. Countries of the Eastern Mediterranean Region (EMR) have achieved remarkable improvement in the routine vaccination coverage during the past 2 decades. The coverage with the third dose of diphtheria/tetanus/ pertussis-containing vaccines (DTP3) has been 90% or more in 14 countries in 2014 based on WHO-UNICEF estimates (figure 1). However, with the prevailing geo-political situation in the region, vaccination coverage dropped, slightly or remarkably, in some countries. As a result, the regional average of DTP3 coverage dropped from 86% in 2010 to 82% in 2014 and 3.2 million infants missed receiving their third dose of DTP vaccine in the same year, most of these infants are in 6 countries of the region (Figure 2). % coverage Afghanistan Bahrain Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan OPT Qatar Saudi Arabia Somalia Sudan Syria Tunisia UAE Yemen Figure 1: DPT3 coverage in countries of the Eastern Mediterranean Region, 2014

7 Figure 2: DTP3 unvaccinated infants in the EMR In 1997, countries of the EMR adopted the target of measles elimination by 2010 (Resolution EM/RC44/R ). Although significant progress has been made, the measles elimination target hasn t been reached and the target date of measles elimination was postponed to 2015 (Resolution EM/RC58/R ). Countries of the EMR have been implementing the regional strategy for measles elimination with variable levels of success. Based on WHO-UNICEF estimate of national vaccination coverage for 2014, coverage with the first dose of measles-containing vaccine (MCV1) was 95% in 11 countries, 90% 94% in 2 and <90% in 9 countries. In the same year, among the 21 countries that have introduced a routine second dose of measles-containing vaccine, MCV2 coverage was >95% in 7 countries only. Measles case-based surveillance is implemented in 20 countries, supported with a well-established global and regional laboratory network, and the majority of countries are meeting the targets of most of the surveillance system performance indicators. Since EMR countries first resolved to eliminate measles in 1997, substantial progress has been made. In 2014, 8 (27%) countries reported measles incidence <5/million populations, 3 of these countries have not reported any endemic measles cases for 2-3 years (figure 3) Incidence/million population Somalia Lebanon UAE Yemen Iraq Libya Syria Qatar Afghanistan Sudan Egypt Pakistan Djibouti Saudi Arabia Jordan Tunisia Iran Morocco Bahrain Oman Palestine Figure 3: Incidence of confirmed measles cases per million populations in 2014(reported data)

8 During the period , reported measles cases decreased by 77%, i.e. from 89,478 cases in 1998 to 10,072 in However, during , regional progress slowed down, and the number of reported measles cases increased >2-fold and reached 20,884 cases in Around 90% of reported measles cases during the period were from 5 countries: Afghanistan, Pakistan, Somalia, Sudan and Yemen. Despite the improvement that was observed in 2014, and considering the current situation as of September 2015, the Region s target of measles elimination by 2015 is not likely to be achieved on time. The long standing maternal and neonatal tetanus (MNT) elimination target is not yet achieved in 6 countries of the EMR: Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen. Prevention and control of hepatitis B virus infection is, also, one of the EMR priorities. In October 2009, Regional Committee (RC) of the Eastern Mediterranean passed a resolution adopting a regional Hepatitis B control target to reduce prevalence of chronic Hepatitis B virus infection to <1% among children aged <5 years by 2015(EMRC56R.5). While available information indicates that this target might have already been achieved in several countries, verification of reaching this target, through implementing hepatitis B serosurveys, is still to be done in most of the countries. The World Health Organization, Eastern Mediterranean Regional Office (WHO/EMRO) has developed regional guidelines to verify achieving this target. Introduction of the new life-saving vaccines witnessed remarkable progress in the EMR during the past few years. Haemophilus Influenzae type B (Hib) vaccine has been introduced in the national immunization programme in all EMR countries. Pneumococcal conjugate vaccine (PCV) has been introduced in 14 countries and rotavirus vaccine in 11 countries. IPV has been introduced in 18 countries and is expected to be introduced in the remaining countries in the coming few months. Sudan has completed the national campaign with meningococcal A conjugate vaccine (Men-Afri-Vac) and is planning to introduce this vaccine in routine immunization programme by early Sudan has also implemented the first phase of the campaigns with yellow fever vaccine. The support of GAVI, the Vaccine Alliance, to the GAVI eligible countries has been pivotal in facilitating introduction of new vaccines in those countries. Nevertheless, Middle income countries (MICs) specially the Low Middle Income Countries (LMICs) continue to face difficulty in introducing the new life-saving vaccines due to the combined effect of the high cost of the vaccine, inadequate allocation of the necessary domestic resources and inadequacy of the vaccine procurement systems in those countries. The overall share of total domestic expenditure for the vaccination programmes relatively increased in most of the EMR member states with introduction of the new vaccines and implementation of disease eradication and elimination strategies. However, that expenditure has not reached the level sufficient for ensuring sustainable immunization finance adequate for implementation of the strategies and activities necessary for achieving the global and regional immunization goals. Several challenges are facing the efforts to scale up immunization programmes in the EMR. The structure and managerial capacity are inadequate in several Member States, and there is need for stronger programme capacity at the central and peripheral levels. In addition, the relatively low government allocations for immunization programmes and the increasing needs for financial resources to meet the evolving demands of EPI, including new vaccines introduction and disease eradication and elimination requirements, threaten the gains of the immunization programmes. As well, the current vaccine procurement and regulation system

9 in several countries is inadequate, and there is a need for stronger mechanisms that ensure vaccine quality and security and best usage of available resources. The ongoing conflicts in some countries continue to be a major challenges faced by EPI in countries of the EMR. The crises in Afghanistan, Libya, Pakistan, Somalia, Syrian Arab Republic and Yemen, have resulted in setbacks to achieving routine vaccination targets Global Vaccine Action Plan (GVAP) The Sixty-fifth World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) in resolution WHA65.17 as the operational framework for implementation of the vision of the Decade of Vaccines (DoV). The DoV envisions a world in which all individuals enjoy lives free from vaccine-preventable diseases. GVAP defines collectively what the immunization community wants to achieve over the decade It describes a wide range of strategies and activities to achieve the DoV mission that s to ensure the full benefit of vaccination is available to all people, regardless of where they are born, who they are or where they live. The ultimate success of GVAP in achieving the DoV vision and goals will be possible only if all Member States and Partners involved in immunization commit and take actions to achieve the six Strategic Objectives, uphold the DoV Guiding Principles when implementing all the actions, and regularly monitor and evaluate progress towards achieving both the strategic objectives and the goals using a set indicators. In this context, the Sixtyfifth World Health Assembly requested WHO regional offices to translate GVAP into regional vaccine action plans. 2. Vaccine Action Plan of the Eastern Mediterranean Region Purpose The Eastern Mediterranean Vaccine Action Plan (EMVAP) provides a framework for implementation of the GVAP with taking into account the context of the EMR Member States. The EMVAP provides an opportunity, for Member States of the EMR and their partners, together with WHO/EMRO, to re-define their immunization vision for the region in the context of the DoV and GVAP. The EMVAP, therefore, sets a course, through regional vision and goals, for eradication, elimination and control of vaccine-preventable diseases (VPDs) through immunization from 2016 to 2020 and beyond. These can be achieved through defining the goals, targets and indicators, proposing a set of priority actions for each of the EMVAP strategic objective and defining key components of its monitoring and evaluation framework Vision and Mission EMVAP envisions a region in which all individuals enjoy lives free from vaccine preventable diseases. The EMVAP s mission is ensuring equitable access of all communities and individuals, especially those marginalized and in the hard to reach areas, to sustainable access to vaccines of assured qualities. The EMVAP vision incorporates regional principles and directions for immunization programmes during the period and beyond. The EMVAP vision reflects joint commitment to a common objective by the Member States, partners and stakeholders, with a long- term collective efforts towards achieving the goals of the EMVAP

10 2.3. Structure of EMVAP Within EMVAP, four goals have been set, aligned with the DoV and GVAP goals and within the context of the EMR. To attain these goals, five strategic objectives incorporating priority action areas have been developed. Progress towards achieving both the goals and the strategic objectives will be monitored through the proposed monitoring and evaluation framework Goals and targets of the EMVAP : Achievement of the vision and mission of the EMVAP will be measured against the following goals: Goal 1: Meet regional routine vaccination coverage targets at all administrative levels. Goal 2: Meet regional disease elimination and control targets Goal 3: Introduce new vaccines of regional and national priority Goal 4: Attain interruption of wild polio virus transmission and sustain polio-free status Achieving these immunization goals will result in saving thousands of cases and thousands of future deaths from vaccine preventable diseases, and, accordingly, millions of dollars of productivity will be gained from the saved years of productive lives. Goal 1: Meet regional routine vaccination coverage targets at all administrative levels: Achieving high routine vaccination coverage is the gate for achieving all targets of the immunization programmes. In line with GVAP, the following routine vaccination coverage targets by 2020 are adopted: Achieving at least 90% coverage with the third dose of DTP-containing vaccine (DTP3) and the last dose of all other vaccines provided through the national Expanded Programme on Immunization (EPI) among children less than one year of age at national level and at least 80% coverage of these vaccines among the same age group in every district through routine immunization Review of rationale As of 2014, 8 countries of the EMR still hadn t reached the target of DTP3 coverage of 90% at the national level. Consequently, 3.2 million infants missed their third dose of DTP vaccine in in the EMR in Furthermore, the vaccination coverage with the last dose of the other vaccines provided through routine immunization programmes is usually less than that of DTP3 vaccine While district level coverage increased significantly in several countries, based on national reported data for 2014, still 10 countries have not achieved the target of reaching 80% DTP3 vaccination coverage in every district. DTP3 coverage was less than 80% in 19% of the districts of the EMR in Goal 2: Meet disease elimination and control targets The regional elimination and control targets of vaccine preventable diseases in the EMR include: measles elimination, maternal and neonatal tetanus elimination (MNTE) and reduction of chronic hepatitis B virus infection. Goal 2.1: Achieving measles elimination Under the EMVAP, the following target will be adopted:

11 Interruption of endemic measles virus transmission soonest possible, latest by Countries of the EMR will strive to achieve measles elimination soonest possible. Verification of achieving measles elimination in any Member State that fulfils the elimination criteria will be conducted, by the Regional Measles Verification Commission (RMVC), immediately without waiting till the new target date of Review of rationale In 1997, the RC for the EMR adopted a resolution for measles elimination in countries of the EMR by 2010 (EM/RC44/R.6). In 2011, due to the delay in achieving measles elimination target, the RC decided to revise the target date of measles elimination to 2015 (Resolution EM/RC58/R ). Countries of the EMR have been implementing the regional strategy for measles elimination with variable levels of success. Based on WHO-UNICEF estimate of national vaccination coverage for 2014, coverage with the first dose of measles-containing vaccine (MCV1) was 95% in 11 countries, 90% 94% in 2 and <90% in 9 countries. In the same year, among the 21 countries that have introduced a routine second dose of measles-containing vaccine, MCV2 coverage was >95% in 7 countries only. The Region has witnessed significant progress. The number of reported measles cases decreased by around 80% between 1998 and As of 2014, 8 countries reported incidence <5/million population. However, the Region is not currently on track to achieve the measles elimination target by Goal 2.2: Achieving and sustaining elimination of Maternal and Neonatal Tetanus (MNTE): The following target is adopted: Achieving and sustaining incidence of neonatal tetanus of less than 1/1000 live births in every district in all countries of the region Review of rationale The forty-second World Health Assembly called for elimination of neonatal tetanus by The goal was expanded in 1999 to include elimination of maternal tetanus. So far, 16 EMR Member States have documented MNT elimination. The current incidence of MNT in the remaining 6 countries (Afghanistan, Djibouti, Pakistan, Somalia, Sudan and Yemen) and the routine TT coverage denote that serious action needs to be undertaken to achieve the target. Goal 2.3: Achieving the regional hepatitis B reduction goal The following target is adopted: Reducing Prevalence of chronic hepatitis B virus infection to less than 1% among children less than 5 years of age (EM/RC56/R.5) and verification of achieving the target by 2020 Review of rationale In October, 2009, the RC for the EMR passed a resolution adopting a hepatitis B reduction target, that s reducing prevalence of chronic hepatitis B virus infection to less than 1% among children less than 5 years of age by 2015 (EM/RC56/R.5).

12 Available information indicates that the target has been achieved in several Member States. However, conducting hepatitis B serosurveys to document achieving the target is yet to be implemented in the vast majority of the member states. The main problems that might delay achieving the target in some Member States include the delayed implementation of the HepB birth dose in the national immunization programme in 9 Member States. Implementation of the birth dose within 24 hours of life is not consistent in several countries of those who have introduced it. In addition, Routine coverage with the third dose of hepatitis B vaccine (HepB3) hasn t yet reached the targeted minimum 90% coverage in 8 member states of the EMR. Goal 3: Introducing new vaccines of regional and national priority The following target is adopted: introducing new vaccines (Rubella, Pneumococcal conjugate, rotavirus and HPV vaccines) in all countries with demonstrated disease burden Review of rationale Vaccine-preventable diseases account for more than 20% of child deaths and, hence, immunization is one of the main tools for prevention of childhood mortality. Deaths due to Pneumococcal and rotavirus diseases account for up to 16% of deaths among children < 5 years of age in some of the EMR Member States that haven t introduced these vaccines. To-date, pneumococcal conjugate vaccine hasn t been introduced in 8 EMR Member States and half of the EMR Member States haven t introduced rotavirus vaccine yet. Still rubella vaccine is not in use in 5 Member States and HPV vaccine has been introduced in the national immunization programme in only one Member State of the EMR. Member States are encouraged to establish appropriate surveillance system and conduct cost effective analysis in order to strengthen their evidence-based decision-making on introduction of these new vaccines. Strengthening the national immunization technical advisory groups (NITAGs), in order to make evidence-based decisions on introduction of the new vaccines is also required. Goal 4: Attain interruption of wild polio virus transmission and sustain polio-free status Polio eradication is dealt with in other documents under PEI 3. Challenges facing achieving the regional goals: Security situation in many EMR countries creates difficulties achieving the immunization targets. It affects implementation of planned activities, specially outreach and mobile activities for improving routine vaccination coverage and implementation of supplementary immunization activities in several countries. It also significantly increases the operations cost. Inadequate managerial capacity and the multiple competing priorities in some countries; Inadequate attention to or visibility of the immunization goals and lower priority given by the respective authorities to routine immunization in some countries;

13 Uncertainty about the target population (denominator) in many countries due to inadequate civil registration systems and poor/old census data; Poor disease surveillance and inadequate immunization data quality, often linked with unreliable and inconsistent denominators, that hinders use of EPI and surveillance data for action; Inadequate financial resources coupled with non-judicious use to implement the planned activities, especially those related to implementation of measles and tetanus supplementary immunization activities (SIAs), new vaccines introduction in MICs and co-financing in GAVI eligible countries; Occasional global Vaccine shortage and rigidity of some countries and procuring only from specific manufactures and ignoring alternate globally available WHO prequalified vaccines; Inadequate social mobilization and failure to create adequate community demand for vaccination in low coverage countries. 4. Strategic objectives and priority actions for achieving the regional goals The strategic objectives of EMVAP and the priority action areas are the technical and operational components required to achieve the goals. EMVAP incorporates the strategic objectives of GVAP that are relevant to the Region; priority action areas are defined to address the regional priorities and the challenges faced by the Member States of the EMR. Strategic Objective 1: All countries commit to immunization as a priority Political commitment and countries ownership to immunization programmes, allocation of adequate national resources and monitoring the progress, are crucial for achieving the immunization goals. The international community has recognized that children are people who have rights for vaccination and the countries should recognize the importance of vaccination as a critical public health intervention and a public good and, therefore, acknowledge the value that immunization represents in terms of health, social and economic returns. An appropriate legislative framework, which allows ministries and concerned national authorities to define national priorities and to make a sustainable commitment to immunization should be in place. Immunization needs to be aligned with the broader national health strategic plans. Integration of the immunization plans into broader health plans provides a platform for sustainable financial investment. Strengthening the national decision-making capacity and establishing formal, credible and independent structure for evidence-based decisions, are also crucial. Priority Action Areas: Strengthening governance of the immunization programme and developing and updating policies, legislation and regulations to commit the country to immunization as a priority. The legislation should also cover the vaccine hesitancy/refusal issues that are increasingly noticed in some EMR Member States, specially with vaccination of adolescents and adult age groups. Vaccination policies and related legislations should also address the specific needs of the Members States hosting expatriate population or witnessing special events that requires specific vaccination programmes

14 Developing and endorsing comprehensive Multi Year Plans (cmyp) for the national immunization programme, aligned with the national health plan, with accurate estimates of costs and financial commitments needed, and developing annual immunization work plan with framework for monitoring and reporting on progress towards achieving national immunization goals; Engaging and involving decision makers, opinion leaders, private sector and stakeholders in advocating systematically and continuously regarding the value of vaccines and immunization to increase visibility of the immunization goals and enhance commitment to immunization as a priority; Establishing and strengthening independent national immunization technical advisory group (NITAG) to help formulate evidence-based immunization policies within the national context. Strategic objective 2: Individuals and communities understand the value of vaccines and demand vaccination as their rights and responsibilities Significant improvements in immunization coverage and programme sustainability are possible if individuals and communities are aware about availability of immunization services, understand the benefits and also risks of immunization (albeit insignificant); are encouraged to seek immunization services; and have ownership of the planning and implementation of the immunization programmes within their local communities. The high demands for immunization was a main reason for sustaining high vaccination coverage in several Member States of the EMR, despite the difficult geo-political situation that those countries have faced during the period In contrast, the low population demand to immunization in some other Member States, despite the continuous availability of the vaccines and partners support, is a main factor behind the low vaccination coverage and continued outbreaks of vaccine preventable diseases in those Member States. Accessing hard-to-reach populations, attaining higher coverage levels and achieving equity objectives, require additional approaches to stimulate demand for vaccination. As more and more new vaccines are becoming available, improving their usage and their impact on disease incidence, depend on individuals understanding of the benefits of vaccination and spectrum of the diseases prevented. Therefore demanding vaccination as the individual s right and responsibility, making evidence-informed choices, being encouraged to seek immunization services, taking responsibility to protect children, adolescents and adults throughout the life-course are essential to maximize benefits from the immunization programmes. Maintaining the individuals demand for immunization services and addressing vaccine hesitancy will require use of traditional and new social communication platforms, especially optimizing the role of front-line health care workers, identifying and leveraging immunization champions, tailoring immunization programme advocacy and communication to the populations in need, reaching mobile, marginalized and migrant populations, and communicating the benefits of immunization and the risks presented by vaccinepreventable diseases. Priority Action Areas Developing and implementing comprehensive communication and social mobilization strategy to increase individuals and community awareness about the

15 risks of vaccine-preventable diseases, the benefits of vaccines and the relative minimal risks of vaccination and enhance trust in vaccines and immunization; Creating partnership and continuously and proactively engage with the media, social media and other communication routes to engage the public in the benefits of vaccines and vaccination; Studying, with individuals and community groups, the best community-based communication approaches to provide the related information. Engaging the civil society, religious leaders, partners, advocates and champions to convey messages on the value of vaccines and the responsibility of individuals, parents and community to ensure that everyone is protected through vaccination; Identifying anti-vaccines, vaccine hesitancy and refusal groups and address their concerns using of traditional and new social communication platforms and then transmit information and responds to people s concern. Building and conducting social research and risk communication activities to identify the vaccination barriers based on reliable research and evidence. Strategic objective 3: The benefits of vaccination are equitably extended to all people through tailored, innovative strategies To achieve the immunization goals of eradication, elimination and control of VPDs, all individuals, specially the vulnerable ones, should have equitable access to immunization services. In 2014, one out of every five children in the EMR was not reached with basic immunization and 3.2 million children in the EMR missed their third dose of DTP vaccine. Most of these children are in the low income countries (figure 2). In addition, 6 countries in the region have not extended the national vaccination programmes beyond 2 years of age. Achieving this strategic objective means that every eligible individual will be immunized with all appropriate vaccines, irrespective of geographic location, age, gender, disability, educational level, socioeconomic level, ethnic group or work condition, thereby, reaching underserved populations and reducing disparities in immunization both within and between countries. Because disease burdens tend to be disproportionately concentrated more in marginalized populations, reaching these populations will not only achieve a greater degree of equity, but will achieve a greater health impact and contribute to economic development as well. Implementation of this strategic objective means also that the benefits of immunization will be more equitably extended to all children, adolescents and adults. Priority Action Areas: Developing suitable system for identifying underserved and marginalized groups on a regular basis and conducting research studies to determine barriers to access to immunization in the low coverage communities Developing district based/community based micro-planning for reaching every community and population group and implementing tailored country context and community specific strategies to address identified causes of inequity in delivery of and access to immunization Extending the scope of national immunization programmes to provide vaccination services to all age groups

16 Enhancing coordination with disaster/emergency bodies and identify mechanisms to insure that vaccination programmes are included within the national emergency plans; Monitoring progress in decreasing disparities and increasing equity in access to immunization services Strategic objective 4: Strong immunization systems are an integral part of a wellfunctioning health system The success of national immunization programmes in attaining its goals and becoming financially sustainable depends upon the presence of a well-functioning health system. The several components of an immunization system require multi-disciplinary attention in order to build a cohesive, non-fragmented and well-functioning programme that coordinates and works in synergy with other primary health care programmes. Health systems encompass a range of functions from policy and regulation to information and supply chain systems, human resources and overall programme management and financing that are all fundamental for a successful immunization programme. Health systems include both the public and private sectors, and in some countries of the EMR, the private sector plays a major role in vaccine delivery. Integration of immunization into the broader health Sector plan is essential for a coordinated, multidisciplinary approach to building well-functioning immunization services, focusing on equitable approaches and reaching underserved populations while working in synergy with other public health programmes. Well-trained, sufficient and competent human resources, with adequate knowledge and skills, are the most important elements for ensuring the success of the increasingly complex immunization programmes. In addition, strong programme management, high-quality immunization data, laboratory-based surveillance of vaccine-preventable disease, effective monitoring, evaluation and supportive supervision besides availability of sufficient financial resources are success elements of immunization programmes. A strong and functional national regulatory authority is a critical component for assuring vaccine quality and security. Priority Action Areas: Strengthening the different components of the immunization programmes within the context of overall health system strengthening, including human resource capacity building, procurement and logistics system, vaccine-preventable diseases surveillance, laboratory capacity, improving immunization data quality, and monitoring and supervision; Ensure that immunization activities that are focusing on eradication and elimination goals are well incorporated into the overall national immunization programmes; Ensuring coordination between the public and private sectors for all aspect of EPI programmes, including, vaccine procurement, vaccine delivery, new vaccine introduction, reporting of vaccine-preventable diseases and immunization data; Developing and strengthening functional national regulatory authorities.

17 Strategic objective 5: Immunization programmes have sustainable access to long-term funding and quality supplies Increasing the total amount of available funding for immunization, from both countries and development partners, is important for implementing the activities pertaining to achievement of the goals. Countries should ensure financial sustainability of national immunization programmes through regular evaluation of resource needs; efficiency in service delivery; availability of adequate domestic financing; and resource mobilization from development partners to meet any funding gaps. Governments also need to explore alternative and innovative financing mechanisms. Although financing of immunization services is first and foremost a core responsibility of the governments, development partners should support national strategies through more predictable longer-term financing. Emphasis needs to be placed on mutual accountability between countries and their development partners in terms of immunization financing. As of 2014, 16 of the 22 Member States in the EMR have been fully financing their immunization programmes. However, the allocated domestic funds in several of those countries is not enough to implement all the activities necessary to achieve the immunization goals, including those related to diseases elimination and control as well as introduction of the new vaccines as per WHO recommendations. In addition, the immunization programmes in some Member States is donor-driven and the domestic contribution to financing the immunization programme, though critical for programme sustainability, is minimal. The success of the immunization programme in reaching its goals is intimately tied to the efficiency of the national vaccine management and logistics system across the country (vaccine storage, delivery, assurance of regular supply and logistics capacity). Ensuring that sufficient vaccines and supplies of assured quality are available, at the right time and place, is essential in order to reach vaccination coverage goals across the country. Post-marketing surveillance is also of particular importance for informing decision-making on risk mitigation and responding to vaccine safety concerns whenever raised. Priority Action Areas: Establishing government commitment to invest funds in vaccines and immunization programmes through development of appropriate policies and legislations, developing long-term financial sustainability plans for immunization programmes that commit to sustaining national budget allocations (at all levels) in line with national health systems budgets; Seeking alternate and innovative ways for immunization financing, e.g. establishing trust funds, use of dedicated tax resources, engaging new potential domestic and development partners and diversifying sources of funding; Developing fully functional national regulatory authorities and supporting other countries to build networks of regulators and suppliers to share best practices and to improve quality assurance capabilities and quality control Strengthening vaccine procurement and vaccine management system Sharing information, like vaccine price, with other Member States to improve procurement practices and negotiation power.

18 5. Monitoring and evaluation framework for EMVAP As per Resolution WHA65.17, the World Health Assembly requested Member States to report yearly to the regional Committee on the progress made and remaining challenges. The Secretariat will prepare annual progress reports on implementation of EMVAP and on the progress towards achievement of the goals, using the proposed monitoring and evaluation framework, which will be reviewed by the Regional Technical Advisory Group (RTAG) on immunization and, then, will be submitted to the RC. The proposed monitoring and evaluation framework for monitoring progress towards achieving each regional immunization goal and progress in implementation of each strategic objective are summarized in annex 1. In order to decrease reporting burden, data reported on the WHO/UNICEF Joint Reporting Form (JRF) and WHO-UNICEF estimates of national immunization coverage will also be used as sources of data for EMVAP monitoring and evaluation. 6. Development and implementation of vaccine action plan at the national level: Developing effective national policies and strategies on vaccine-preventable diseases and immunization and setting up plans for their implementation and monitoring, require active involvement of all stakeholders, guided by national immunization programmes. The starting point would be the recognition, by all stakeholders, of the need for a national immunization plan that addresses national priorities and challenges and provides clear strategic and operational guidance on meeting national targets that are aligned with regional and global goals. EMVAP provides a framework to EMR Member States for formulating short and long term national immunization plans that reflect key national and regional priorities, issues and challenges. It, thus, orients the governments, partners and other stakeholders towards a unified immunization vision. It provides strategic and operational guidance for policy-makers and planners for addressing national priorities and challenges most efficiently and effectively through the proposed strategic objectives and priority actions. The Member States are required to review, prepare or update their national immunization plans in line with the strategic framework provided by EMVAP, reflecting the national priorities and context, with the engagement of all partners and stakeholders. Member States of the EMR should consider undertaking the following steps for development of the national vaccine action plans, in line with the framework provided by the EMVAP: Developing and regularly updating comprehensive multi-year immunization plans (cmyps) with annual integrated operational plans that fully reflect the specific challenges facing immunization services in the Member State, at all levels, and the corrective action needed; Costing the cmyp and identifying the funding gap, allocating adequate domestic resources to implement the plan, within the context of the broader health system, and mobilizing partners support to bridge the funding gaps. Developing sustainable mechanisms to enhance multi-sector collaboration and partnerships. Promoting synergies between immunization and other health services as well other sectors such as education, economic development and financing and the

19 private sector, in development and implementation of priority interventions of the action plans. Documenting lessons from the implementation of the past strategic plan and identify best practices for replication and scale up. Ensuring that monitoring and evaluation and accountability framework are part of the action plan to monitor implementation and apply corrective action on time. 7. Role of the partners and stakeholders Member State actions and initiatives to reach EMVAP goals should be technically and, where appropriate, financially supported and complemented by the activities of the Regional and national immunization partner stakeholders and donors. The partners should, therefore, support in the following: Advocating for and providing technical support to promoting country ownership and strengthening national capabilities and regional infrastructure. Continue defining norms and developing guidelines to improve vaccine and immunization services, striving to achieve greater equity and sensitivity to inequity among population groups, including, the hard to reach populations. Promoting synergies between immunization and other health services as well with other sectors such as, education, economic development and financing. Supporting bridging the gap in financing the multi-year plan, promoting sustainable national funding, pursuing innovative financing and engage rapidly emerging economies as potential funding partners. Developing mechanisms for mutual accountability that hold the governments and development partners responsible for the committed levels of support. Promoting a dialogue between manufacturers and countries to align supply and demand and pursue procurement mechanisms that reinforce country ownership, and promoting equity and affordability of vaccines for low- and middle-income countries.

20 Annex 1. Eastern Mediterranean Vaccine Action Plan : Monitoring and Evaluation Framework Goal/Strategic objective Goal 1: Meet regional routine vaccination coverage targets at all administrative levels Goal 2.1: Achieving measles elimination Target Reach at least 90% DTP3 coverage among children less than one year of age at national level and at least 80% DTP3 coverage among the same age group in every district through routine immunization Interruption of endemic measles virus transmission soonest possible, latest by Operational definition Number of Member States with at least 90% coverage at national level with three doses of DTP-containing vaccine among children less than one year of age Number of Member States with at least 80% coverage in each district or equivalent administrative level with three doses of DTP-containing vaccine among children less than one year of age Number of countries that report zero cases of endemic measles virus transmission for 12 or more consecutive months with presence of high quality surveillance Indicators Baseline Target (2014) (2020) Data source and collection JRF Technically sound vaccination coverage survey WHO-UNICEF estimates of national vaccination coverage JRF Technically sound vaccination coverage survey 3 22 Country reports to the regional measles lab case based surveillance network Reports of field review of national measles elimination programmes Reports of the annual country updates submitted by national measles elimination verification committees (NVC), verified by the regional measles elimination verification commission (RMVC)

21 Goal 2.2: Achieving neonatal tetanus elimination Goal 2.3: Achieving hepatitis B control Achieving and sustaining incidence of neonatal tetanus of less than 1/1000 live births in every district in all countries of the region Reducing Prevalence of chronic hepatitis B virus infection to less than 1% among children less than 5 years of age Number of countries that achieved and documented incidence of neonatal tetanus less than 1/1000 live births in each district or equivalent administrative level Number of countries that achieved and documented reduction of HbS antigen prevalence to less than 1% among children aged < 5 years Reports of field review and documentation of achieving MNT elimination 4 21 Reports of Hepatitis B serosurveys conducted according to protocols conforming with WHO guidelines for documenting impact of HepB vaccination progremme Goal 3: Introduce under-used and new vaccines of regional and national priority Introduction of pneumococcal conjugate vaccine in all countries with documented disease burden Introduction of rotavirus vaccine in all countries with documented disease burden Introduction of rubella vaccine in EMR countries Number of countries that have introduced pneumococcal conjugate vaccine in the national EPI Number of countries that have introduced rotavirus vaccine in the national EPI Number of countries that have introduced rubella-containing vaccine in the national EPI JRF Country reports JRF Country reports JRF Country reports

22 Strategic Objective 1: All countries commit to immunization as a priority Strategic Objective 2: Individuals and communities understand the value of vaccines and demand vaccination as the individual right Presence of national mandate for EPI Presence of independent national technical advisor group (NITAG) that meets defined criteria High Individuals and community acceptance to immunization Number of countries that have high level document (law, decree,..) making childhood immunizations a national priority/child right Number of countries that established functioning national immunization technical advisory group Number of countries that measured public acceptance of vaccination, through the administration of surveys Percentage of un- and undervaccinated children in whom lack of confidence was a factor To be assessed through a survey 50% increase EPI review National reports Country reports and documents on fulfilling the WHO defined criteria 0 10 Survey reports very low very low Survey reports Strategic objective 3: The benefits of vaccination are equitably extended to all people through tailored, innovative strategies Strategic objective 4: Strong immunization systems are an integral part of a wellfunctioning health system Reach at least 80% DTP3 coverage among children less than one year of age in every district and community through routine immunization Sustaining high vaccination coverage Number of countries with at least 80% coverage in each district or equivalent administrative level with three doses of DTP-containing vaccine among children less than one year of age Number of countries that sustained coverage with three doses of DTPcontaining vaccine at 90% or more nationally for three or more years JRF Technically sound vaccination coverage survey Review of the immunization JRF High quality Vaccination coverage survey WHO-UNICEF estimates of national vaccination coverage

23 Sustained DTP1- DTP3 drop out ratio less than 10% Number of countries that sustained DTP1-DTP3 drop out ratio less than 10% for 3 or more years WHO-UNICEF estimates of national vaccination coverage Strategic objective 5: Immunization programmes have sustainable access to long-term funding and quality supplies Immunization coverage data assessed as being of high quality by WHO and UNICEF Domestic Expenditure on immunization Number of countries with 5% difference between administrative coverage data for DTP3-containing vaccine and that of WHO-UNICEF estimates of national immunization coverage Number of countries that sustained financing 100% of the cost of routine immunization programme Number of GAVI support-receiving countries that fulfil the co-financing commitment on time JRF WHO-UNICEF estimates of national vaccination coverage JRF 4 6 Country report Report from Gavi the vaccine alliance Presence of strong vaccine procurement and management system Number of countries reporting no stock out of any vaccine at the national level during the calendar year Number of countries that have conducted EVM assessment and are implementing EVM improvement plans JRF 9 22 Country reports WHO field assessment