Multi Year Plan for Immunization Timor Leste

Transcription

1 Final May 19 th 2011 Multi Year Plan for Immunization Timor Leste 19 th May 2011

2 Table of Contents 1.0 Introduction and Background Country Profile Health Sector Strategic Plan Health care system in Timor-Leste Current Situation of Health Sector Immunization Services in Timor-Leste Historical perspective Progress Towards Control of Vaccine Preventable Diseases Hepatitis B Immunization Schedule Vaccine Regulation Introduction of New Vaccines Issues and Constraints for Immunization Services Other programme issues National Goal and Vision Objectives, Strategies, Monitoring Indicators and Key Activities for Strengthening Immunization Services AREA 1 PROGRAM MANAGEMENT AND TRAINING Objective 1 Programme management AREA 2 SERVICE DELIVERY Objective 2 Service Delivery Strategy Objective 3: Routine Immunization Objective 4 Strengthening Demand of Services Objective 5 Integration with Other Services AREA 3 SYSTEM STRENGTHENING Objective 6 Cold Chain and Injection safety Objective 7 Polio Eradication Objective 8 Maternal and neonatal tetanus elimination Objective 9 Measles Control Objective 10 New Vaccine Introduction Objective 11 AEFI Surveillance Systems Objective 12 VPD Surveillance Objective 13 Monitoring vaccine wastage Costs and financing of the cmyp of Timor-Leste Health Sector Analysis... Error! Bookmark not defined. 4.2 Baseline Programme Cost and Financing Baseline Programme Cost and Financing... Error! Bookmark not defined. 4.3 Recurrent costs analysis Vaccines and injection supplies Personnel costs and Transport costs Vehicles & transport costs Cold chain equipment Campaigns Building and building overheads Projected EPI resource requirements Financial Gap Analysis Future Financial Sustainability References Annex 1: Programme Cost Estimates (Based on costs for year 2010)

3 Executive Summary Timor-Leste is a new country that officially came into existence on 20 May The birth process for the country was a difficult one. Because of the difficulties the new Government inherited a severely damaged health infrastructure and a serious shortage of trained health staff. Since coming into existence the country has made great progress in restoring public and curative health services, but there is still far to go. This plan is an update of the initial comprehensive multi-year plan (cmyp) that was developed by the Government of Timor-Leste for immunization activities for It comes 6 years after the Government began the task of re-building and expanding health services for the population. It has been developed in recognition of the need for a framework for future programme development. This initial plan has been updated into the second cmyp for the period based on the following considerations: 1. The need to align with the new health sector strategy 2. The need to consider strategies and costs for new vaccine introduction (pentavalent vaccine from 2012) 3. The need to accommodate new program strategies, particularly in relation to surveillance, cold chain management and the development of AEFI systems Since it was created, the Ministry of Health has been systematically establishing a foundation for expanding basic health services to all people in the country. The health services infrastructure is being rebuilt and expanded. There is a Basic Services Package for child survival that focuses on the health and well-being of newborns and young children. More recently the MOH has begun implementation of an initiative (SISCa) to promote the availability of integrated community health services to all villages and hamlets of the country. In the 1990s, prior to independence, childhood immunization services were quite good. Up to 1997 vaccination coverage for the usual childhood vaccines was reported to be 80%-90%, depending on the antigen. With the increasing political instability of the late 1990s, immunization activities were disrupted, and for a period of months, completely suspended. In March of 2000 work was begun to rebuild the immunization program. Since then there has been a steady increase in coverage, but the increasing trend began to plateau several years ago and the proportion of each birth cohort receiving the full schedule of childhood vaccinations seems to have stabilized at 60-70%. Considering the difficulties that have been faced in the country this is quite good, but not good enough to fully control, or eliminate the target diseases. Activities need to be strengthened and expanded. In particular, greater efforts are needed to make services readily available to the most remote populations. The strategic focus of this second cmyp is therefore on: Expanding access to remote populations for immunization and other MCH services using a combination of fixed facility, SISCa and outreach services Developing the capacity of middle level managers and senior managers for health microplanning and VPD surveillance (including the strengthening of AEFI systems) Maintaining and strengthening cold chain and vaccine management capacity Tetanus elimination and improved measles control Improving sustainable demand for EPI through improved partnerships with volunteer networks, local authorities and NGOs Introduction of underutilized vaccines (pentavalent) and putting in place decision making process for introducing new vaccines from 2013 (PCV and others). 2

4 The Government of Timor-Leste is already supporting a relatively large proportion of the costs of its immunization program. It intends to continue doing so. However, the costs of strengthening the infrastructure and capacity of the health services, improving health information, improving disease surveillance and expanding health services will require partner assistance if Timor-Leste is to continue moving forward in these areas. Development of the plan has required thought about important activities that up to now have not been an integral part of immunization activities. It has forced recognition of the fact that steady improvements in immunization activities will require the immunization programme to work with different departments of the MOH and sometimes with other Government ministries. All vaccines are currently procured by the Government of Timor Leste. However, partner support will continue to be crucial for achieving the ambitious objectives set forth in the plan. Hopefully the plan will serve as a solid basis for discussions with partners on how its objectives should be prioritized and how partners can best support MOH immunization activities over the next 5 years. Immunization targets Baseline BCG 71% 76% 83% 90% 93% 96% DPT1-Hep B 1 75% 80% DPT3-Hep B 3 72% 77% Polio3 72% 77% 82% 87% 90% 92% Pentavalent 1 85% 90% 93% 95% Pentavalent 3 82% 87% 90% 92% MCV1 66% 71% 80% 81% 86% 91% TT 2 33% 70% 70% 70% 70% 70% No of Districts < 80% DPT

5 1.0 Introduction and Background 1.1 Country Profile Geography and Climate Timor-Leste is a small country of 15,410 sq km (5,400 sq mi) in size. It is located about 640 km (400 mi) northwest of Darwin, Australia. Timor-Lesté comprises the eastern half of the island of Timor, plus the District of Oecusse, which is an enclave situated on the north coast of the western (Indonesian) half of the island. The island of Timor lies in the Malay Archipelago and is the largest and easternmost of the Lesser Sunda Islands. To the north of the island are the Ombai Strait and Wetar Strait. To the south, the country is separated from Australia by the Timor Sea. The western half of Timor Island, except for Oecussi, is the Indonesian Province of East Nusa Tenggara. Figure 1.1 Timor-Lesté Cities and Main Roads Except for the coastal areas, most of Timor-Leste is mountainous, with the mountains generally dividing the country into its northern and southern halves. The most mountainous area is the western part of the country. Mount Ramelau (also known as Mount Tatamailau) is the highest point of TimorLesté (2,963 meters, or 9,721 ft) and is located on the border between Ermera and Ainaro Districts. The climate of Timor-Lesté is tropical and generally hot and humid. There are two distinct seasons, the rainy season (lasting from November to April) and the dry season. The easternmost part of TimorLesté consists of the Paitchau Range and Iralalaro area. This is a sparsely populated part of the country and contains the last remaining tropical dry forested area within the country as well as a number of unique plant and animal species. 4

6 Religion, Demography and Language Timor-Leste is a predominantly Roman Catholic country. The 2009 estimated population of the country is 1,066,582 (census 2010) with approximately 47,385 live births annually (2010 MoH JRF). The population is young, with approximately 45% of the population below the age of 15. Population growth in 2010 was 2.41% (Census 2010). The largest city, Dili, has a population of more than 234,331. The next largest city is Baucau, which has a population of 46,530. Both these cities are located on the northern coast. The majority of the population in Timor-Leste is rural, and lives in the northern half of the country. Much of the population lives in dispersed communities in mountainous areas. The two official languages of Timor-Leste are Portuguese, and Tetum. Tetum belongs to the Austronesian family of languages spoken throughout South East Asia. Political History The Democratic Republic of Timor-Lesté became a new sovereign state in Its emergence as a sovereign state followed more than 400 years as a colony of Portugal, known as Portuguese Timor and almost 24 years of occupation by Indonesia. The process of decolonization began in 1974, in the wake of Portugal s Carnation Revolution. It culminated in a unilateral declaration of independence of the Republica Democratica de Timor-Leste, on 28 November Before the declaration could be internationally recognized, Indonesian forces invaded and occupied the new republic, eventually annexing it as the 27 th Indonesian Province (in Indonesia was called Tim Tim Province). The United Nations never recognized the integration of Timor-Leste into Indonesia. Both the UN Security Council and the General Assembly called for Indonesia s withdrawal. During the period of Indonesian occupation, Timor-Leste s official international status remained that of a non-selfgoverning territory under Portuguese administration. By the 1990 s Indonesia was subject to increasing negative international publicity for its occupation of Timor-Leste. The 1997 Asian financial crises set in motion a series of events in Indonesia that ultimately led the Indonesian Government to offer Timor-Leste an opportunity to vote on independence. On 30 August 1999, the Timorese population voted overwhelmingly (78.5%) for independence. The Indonesian armed forces responded brutally to this vote. This response led to the arrival of a UN-authorized multinational force with a mandate to restore peace and security. On 25 October 1999, the Security Council established the United Nations Transitional Administration in Timor-Leste (UNTAET), with a mandate to administer the country until such time as power could be handed over to an elected Timorese Government. Preconditions for the hand-over of power were met in early On 20 May 2002 the Constituent Assembly (which has been established under UNTAET) transformed itself into the national parliament. On that same day the first Government was sworn in and Timor-Leste s independence finally became a reality. On 27 September 2002, Timor-Leste formally joined the United Nations. Economic Conditions and Basic Health Indicators In 2010 the World Bank estimated the gross national per capita income in 2008 as $2644. An IMF report in 2007 estimated that 40% of the population lives below the poverty line. A recent DHS survey confirms that infant mortality rates have declined from 68 to 45 per 1000 live births between the last two surveys. Timor-Leste does have oil and gas resources. Revenue from these sources has increased substantially in recent years which has contributed to the recent rise in GNI. 5

7 Administration, Transportation and Communication Administratively, the country is divided into 13 districts, 65 sub-districts (postos), 442 villages (sucos), and 2,228 hamlets (aldeias). The capital, largest city, and main port is Dili, which is located on the northern coast of the country. Baucau, the second-largest city is also on the northern coast, about 100 km east of Dili. There is a reasonably good road network in the country, linking Dili with major areas of population. Dili has the only international airport but there are three airstrips used for domestic flights, one each in Baucau, Suai (Covalima District) and Oecusse. There is a single telecommunications provider in the country (Timor Telecom), although the Government has announced that other providers will be accepted from Relative to other countries in the region, telecommunication services at present are costly and moderately reliable. There is no international postal service. Electricity supply in Dili is reasonably good, but outside of Dili exists only in larger cities and towns, and is usually available only in those locations for several hours per day. Proposed electrification of the country in the coming years will result in rapid increase in the supply of energy. Figure 1.2 Map and District Boundaries of Timor-Lesté 1.2 Health Sector Strategic Plan In September of 2007 the Timor-Leste MoH completed a Health Sector Strategic Plan (HSSP) for the 5-year period In this plan it is stated that the Ministry of Health is committed to providing and regulating quality health services for all while promoting community and stakeholder participation. The HSSP outlines future directions for the national health system and states that they are to take place within the framework of three overarching goals : Improved accessibility to, and demand for, quality health services; Strengthened management and support systems; and Strengthened coordination, planning and monitoring. The MoH had adopted 57 strategies to promote progress towards achieving these three goals. Prioritization of activities has led to the identification of 32 cross-cutting strategies, of which 17 form an essential core in ten priority areas of work. The 10 priority areas of work are: Health services delivery, Behavioral change/health promotion Quality improvement Human resources development Health financing 6

8 Asset management Institutional development Health management information systems (HMIS) Gender equity, and Research. The components of this MYP address all 10 priority areas of work in some way, but there is a particular emphasis on health services delivery, quality improvement, institutional development, human resources development, and HMIS. The Ministry of Health is currently undertaking the development of a Health Sector Strategic Plan up until Within this long time period, the plan will be organized into 5 year cycles. Three component areas of the plan will include health system management and sector coordination, human resources for health, and health service delivery. The health service delivery component has many characteristics of the current health sector plan. This component of the program is expected to focus on primary health care, services to the community (including SISCa) and on strengthening central and district level capacity in management. 1.3 Health care system in Timor-Leste Health Care Infrastructure: Timor-Leste has 6 hospitals. There is a national hospital in Dili. The national hospital is served by 5 referral hospitals. The five referral hospitals are located in Baucau, Maubisse (Ainaro), Suai (Covalima), Maliana (Bobonaro), and Oecussi. In addition to the 6 hospitals there are 65 Community Health Centers (CHCs). Some of these have inpatient facilities but generally these facilities provide primary care and out-patient services. The National Immunization Programme provides vaccinations through the CHCs. The referral hospitals provide only birth doses of BCG and OPV. Children not born in a hospital must receive their birth doses at a CHC. Referral Hospitals do not provide antenatal care for pregnant women. Women seeking antenatal care must go to CHCs. Even if they intend to give birth at a hospital they must obtain their antenatal care, including TT vaccinations, at a CHC. In addition to referral hospitals, most CHCs have facilities for attending births, but up to 80% of births still take place at home, and only a small proportion of those births are attended by trained health staff. The lowest level Government health facility is the health post. There are 172 functioning health posts in the country. Health posts in each sub-district are an extension of the services provided by the CHC in the same sub-district. Some health posts are staffed by a resident mid-wife, nurse, or assistant nurse, but most provide services one time each month with staff from the CHC. The health posts provide only basic primary care services, but the services usually include immunizations. Some CHCs also support what are called mobile clinics. The services provided by mobile clinics are usually limited to provision of vaccinations and some medicines. A fixed site (usually a suco chief s house, but sometimes a health post) is visited on a regular basis (not more than monthly) by CHC staff to provide these services. Ideally, every district outside Dili would have its own referral hospital. This will eventually happen but presently there are 7 districts that do not have a hospital. The ideal is also that each sub-district would have a CHC and that each suco not having a CHC would have a health post. Currently all sub- 7

9 districts have a CHC, but there are only 172 functioning health posts. This means that of the 442 sucos, there are more than 200 which have neither a CHC nor a health post. In addition to government health facilities there are 32 health facilities supported by the private or NGO sectors. Curative and primary care services for young children and pregnant women are based on the Basic Service Package for child survival (BSP). These services are provided through the health care infrastructure, which, as outlined above, reaches all sub-districts but only about half the sucos. Populations in sucos and aldeias not having easy access to a CHC, or at least a Health Post or mobile clinic, are to be reached through the MOH initiative called SISCa. SISCa aims to promote good health practices and provide basic integrated health services to these communities, but relies on the communities themselves to form SISCa groups for this purpose. Basic Service Package for child survival (BSP): Timor-Leste is committed to improving child health. The National Development Plan targets a reduction of the under 5 years mortality rate (U5MR) from 165 to 55 and a reduction of the infant mortality rate (IMR) from 126 to 42, by Significant action and active district level management will be required to meet these targets. The Basic Services Package (BSP) is based on information from the Lancet series of articles (2003, 2005) which showed that two-thirds of deaths could be prevented by universal coverage with 23 interventions. Health planners in Timor-Leste concluded that a focus on the proven interventions for neonatal and U5 survival would accelerate Timor-Leste s success in achieving MDG4 and National Development Plan objectives. Based on the best practice interventions declared in the Lancet articles, Timor-Leste officials decided that an essential package for child survival should include: Skilled attendance during pregnancy, delivery and the immediate postpartum Antenatal Care Essential Newborn Care Care of Sick and Small babies Improved nutrition of children and mothers including micronutrient supplementation Breastfeeding and complementary feeding Treatment of Children with Severe Malnutrition Immunization of children and mothers Integrated management of pneumonia, diarrhoea (including ORT) ) and malaria Insecticide treated bed nets Delivery of the Basic Services Package is to be achieved through integrated service delivery so that missed opportunities can be avoided. Complementary Strategies for Child Survival. Complementary strategies for child survival include: Birth spacing, Prevention of Mother to Child Transmission (PMTCT), and Pre-pregnancy education. 8

10 SISCa (Servisu Integradu da Saude Communitaria): SISCa is an acronym derived from the Portuguese term for Integrated Community Health Services. The objective of SISCa is to make sure that every community down to the aldeia (hamlet) level has access to integrated health services. SISCa groups are to be formed by communities to bring community members together for the promotion of good health practices and access to basic integrated health services. The objectives of SISCa are: To allow easy and nearby access of integrated health assistance to the aldeia level based on the BSP. To improve population data collection for children and pregnant women in order for them to receive proper health interventions To expand health promotion and education efforts on how to change unhealthy behaviors To increase the participation of community members in community health. SISCa is intended to reach all sucos or villages (and ideally all aldeias within sucos) in every district of the country. It is intended to reach all citizens. SISCa activities should occur once per month, if possible. SISCa sessions should apply a Six Table Assistance System. The six tables are: Registering basic data Nutrition assistance Health assistance for pregnant women and children Personal hygiene and sanitation Health assistance by health workers (for targeted diseases) Health promotion and education There is potential for using SISCa sessions to deliver vaccines. Health Staff in the Country: Health staff in Timor-Leste include the following (2008): National Doctors 78 District Health Service Chiefs 13 Public Health specialists (SKM, Masters, Post Masters) 35 D3 Diploma 133 Midwives 241 Nurses 803 Cuban medical staff Current Situation of Health Sector The following information has been provided through a recently completed Demographic and Health Survey (2010) and National Census (2010). Table 1.1 Selected Health Indicators for Timor-Leste Indicator M F TOTAL Total Population Infant mortality rate (per 000 live births) 45 Under-5 mortality rate (per 000 live births) 64 Maternal mortality rate (per live births) 557 Births attended by skilled health personnel (%)

11 1 year-old children immunized against measles (%) % Children Under 5 sleeping under ITN Proportion of Population (15-24) with comprehensive correct n/a knowledge of HIV AIDS % of population with access to an improved water source improved to an improved water source % of population with access to improved sanitation Literacy rates (15 to 24 year olds) n/a Ratio of Medical doctor/population 1/3401 Nurse & midwife/population 1/876 Hospital bed/population 1/2380 Clinic (Health Centers and Health Posts)/population 1/4000 Source (except when indicated otherwise): Demographic Health Survey, 2010 and Health Information System, Ministry of Health Selected indicators to be achieved in the context of MDGs and betterment of Human Development Index Table 1.2 Indicators to be Achieved Other information: Indicator FY 04/05 FY 09/10 FY 14/15 Under-5 mortality rate (per 000) Infant mortality rate (per 000) Crude Birth Rate: 33.2 Fertility rate: 5.7 (decreased from 7.8 in 2003 DHS), Contraceptive prevalence rate: 22.3 % Population Growth Rate: 2.41 (Census 2010) Census, DHS data and MOH projections reflect a steady decline in the IMR and U5MR in line with The National Development Plan. Although the population growth has declined to 2.41%, it still remains one of the highest growth rates in the Pacific. With declining IMR and U5MR, life expectancy is increasing. 2. Immunization Services in Timor-Leste 2.1 Historical perspective Immunization services for the general population were first established in Timor-Leste during the time of Indonesian occupation. Initially the services offered BCG, DPT, OPV and measles vaccines. The Indonesian system made vaccinations available through Puskesmas and Posyandus, which correspond to the Timorese CHCs and Health Posts. Indonesian records for Tim Tim Province indicate that routine immunization coverage was high during the 1990 s but deteriorated substantially from late 1998 to the end of Indonesian occupation in Reported coverage from 1995 to 1998 was close to 100% for BCG, 80%+ for DPT3 and close to 90% for measles. In the last reporting year from Indonesian records (July 1998 to June 1999) the reported coverage was 63.5% for BCG, 55.6% for DPT3 and 55.1% for measles. 10

12 Immunization services were disrupted during the events surrounding the end of Indonesian occupation. In March 2000, during the UNTAET period of administration, the re-establishment of immunization services was begun. The system for making vaccinations available was basically the same as during the Indonesian period. The major difference was that many facilities were damaged and the number of health staff available had been greatly diminished. It has taken time to rebuild the infrastructure and system capacity. This rebuilding is still in process. Presently routine immunization services are mostly provided through the CHCs, Health Posts and SISCa. Hospitals offer only BCG and OPV0 to newborns. Many CHCs offer vaccinations daily. The remainder offer vaccinations at least one time per week. UNICEF also supports outreach beyond the SISCa covered areas. Not all health posts offer vaccinations, but those that do usually have only one vaccination session per month. If there are no health staff permanently assigned to a health post, vaccinators travel from the CHC to administer the vaccinations. CHCs may also have mobile clinics, which is a term used to describe a vaccination team traveling from the CHC to an agreed upon site, often the home of a suco chef, but which may sometimes be a health post. Vaccinators are qualified nurses or midwives. Re-established services included the same standard package of childhood vaccines offered during Indonesian times (BCG, OPV, DPT and measles). As was the case in Indonesian times TT vaccine is offered to pregnant women. In December of 2007 Hepatitis B vaccine was introduced into the vaccination schedule by replacing DPT vaccine with tetravalent DPT/HepB vaccine. Reported vaccination coverage during the late 1990 s was very high. During the transition period coverage declined. Since 2000 Timor-Leste has worked to improve immunization coverage. Lack of reliable denominator data has made it difficult to assess coverage with great accuracy, but it appears that by 2004 national coverage reached levels of about 70% for BCG, 55% for DPT3 and 50% for measles. Since that time estimated coverage appears to be increasing slowly. Coverage for 2010 was reported through the JRF as 71% for BCG, 72% for DPT3 and 66% for measles. DHS 2010 data reports coverage of 76.8% for BCG, 66.4% for DPT3 and measles 67.8%. While there are reliability issues with the data, it is unmistakable that vaccination coverage is increasing. Reviews of recent records at the CHC level confirm this. However, a substantial proportion of the population lives in difficult-to-access areas, and these areas have the lowest immunization coverage. Increases in vaccination coverage above 80% will come only with improved access of the target-age populations in difficult-to-access areas. TT coverage for child-bearing-age women is also subject to data reliability issues. The way TT vaccinations are recorded in the country suggest that coverage may actually be higher than what is estimated from reported data. DHS 2010 data demonstrates that the % of women receiving two vaccinations of tetanus in the last pregnancy was 75.8% and the % whose last birth was protected against neonatal tetanus was 79.8%. In terms of equity of coverage, 10 out of 13 districts remained below 80% coverage for DPT3 in There are no significant variations in coverage based on gender in the 2010 DHS Survey. (DPT3 male 66% and DPT3 female 64%). 11

13 2.2 Progress Towards Control of Vaccine Preventable Diseases A review of the national EPI program in 2008 highlighted significant challenges in relation to the functioning of surveillance systems in Timor Leste. These challenges include the lack of a National Committee on Immunization practice, absence of multiyear planning mechanisms, absence of AEFI systems, the need for strengthening of VPD surveillance and absence of a national certification committee for polio eradication. This cmyp will plan to address many of these shortcomings, particularly given the plan for disease control (measles), disease elimination(tetanus) and disease eradication (polio), but also due to the plan to introduce new and underutilized vaccines. Polio From 1975 to 1999 Timor-Leste (as Tim Tim Province) reported AFP cases within the Indonesia national AFP surveillance system. The last known case of polio in Timor-Leste was reported in From the time Timor-Leste ceased to be a province of Indonesia in 1999, through 2004, no cases of AFP were reported. After the wild poliovirus outbreak in Indonesia in 2005, and with the help of the World Health Organization (WHO), Timor-Lesté again began reporting AFP cases. Timor-Leste has reported at least one AFP case annually since 2005 but has not been able to achieve regional target indicators for surveillance excellence. Table 2.1 Timor-Lesté AFP surveillance quality indicators. Indicator 1998¹ ² 2006² 2007² 2008² ² AFP cases Wild Polio Compatibles AFP Rate Non-Polio AFP Rate³ Adequate Stool Collection % 0 Rate Total Stool Samples Collected %NPEV % Reported within 28 days % 0 ¹Estimates based on 1998 UN estimated population ²Rates based on population projections from 2004 There is no circulating WPV in Timor-Leste at present and the risk of WPV importation is small. Additionally Timor-Leste s low population density and the dispersed distribution of most of the population would possibly make it difficult for WPV transmission to be sustained. However, Timor- Leste has the obligation to meet polio-free certification standards for AFP surveillance. If polio-free certification standards are to be met, AFP surveillance must be strengthened. Maternal and Neonatal Tetanus (MNT) Timor Leste is among one of the countries still considered at high risk of maternal and neonatal tetanus. According to the DHS , 86% percent of women receive some form of ante-natal care from a skilled health provider, representing a significant improvement from the DHS conducted in Nevertheless, 78% of women still deliver at home with almost 20 % attended by traditional birth attendants. WHO/UNICEF estimates of those protected at birth against tetanus are 66% (2008). 12

14 Over the past three years, the neonatal tetanus (NT) cases reported have increased, which may reflect the greater recognition of NT as well as the improved surveillance in the community. In 2008, 1 case of NT was reported, 6 cases in 2009 and 7 cases in Case investigation and response must continue to improve, with the implementation of SISCa offering ongoing opportunities for community-based surveillance. The total fertility rate in Timor Leste is the highest in South East Asia, at 5.7 per woman. Because of poor TT screening, it is not unlikely that women are receiving two doses of tetanus toxoid with each birth. 75% of women who had given birth in the past five years had received two doses of TT and 80% were protected against tetanus during their last birth (DHS, ), suggesting that there are relatively good levels of protection. To further help boost tetanus toxoid protection levels and attain the goal of MNT elimination, Timor Leste conducted three rounds of tetanus toxoid campaigns over the period of October 2008 to June With a total of 242,530 women aged 12 years to 45 years targeted, the percentage of women having received at least two doses of tetanus toxoid after three rounds was 87%. After several district data reviews, the EPI team decided to conduct additional immunization activities in targeted districts (Ermera, Ainaro and Aileu) to address low-performing pockets during the campaign. These corrective activities were undertaken September-November 2010, with an additional 27,703 women vaccinated in the age group years.. Timor Leste will undergo a MNTE validation exercise in Measles Routine immunization coverage for measles appears to have leveled off at 55-65% over the past several years. Prior to June 2009, the last year for measles supplementary immunizations was in 2006, when children in IDP camps 6 months-14 years of age were offered measles vaccine. The number of vaccinations given at that time was about 167,000, of which about 62,000 were under the age of 5 years. Prior to 2006, the most recent measles SIA activity was in This campaign targeted children 9-59 months. The number of children vaccinated was reported as 158,000. If most of these vaccinees were within the target age range, estimated coverage would be about 100%. During the 3 rd round of the current TT campaign (June 2009), measles vaccine was offered to all children in the country aged 6-59 months. It is likely that measles surveillance is not as sensitive as it should be, but interviews with hospital and CHC clinicians invariably elicit the response that few, if any, cases of measles are being seen. Clinicians often say they have not seen any measles cases for several years. Routine measles coverage would not appear to be good enough to have any dramatic impact on measles incidence. In 2007 and 2008 no cases were reported at all and in cases were reported. Table 2,2 Reported Measles Cases, Timor-Leste, Year Measles Source: WHO-UNICEF Joint Reports 13

15 However, in 2011, an outbreak of cases has been reported in several districts, which has resulted in planning for a national SIA in As coverage remains below 80% for measles, a second routine dose of measles vaccine is currently not being considered, with the second dose delivered through SIA strategy being the preferred option at this stage. Measles surveillance must be strengthened. It is hoped that through the SISCa network it will be possible to extend measles surveillance to the community. Diphtheria and Pertussis The status of diphtheria and pertussis in the country is not known. No cases of diphtheria have been reported since During the same period of time pertussis cases have been reported in only one year, 2006, when 26 cases were reported. It is thought that surveillance for both diphtheria and pertussis is not strong, so the lack of reports is not considered a reliable indicator of low incidence. Hepatitis B Improved hepatitis B control has been demonstrated through introduction of tetravalent vaccine in 2007 and through gradually improving routine immunization coverage. The new health sector strategy is proposing significant developments in health system infrastructure. There will be an increased facility delivery rate as a result of these developments (current rate is 21.4% DHS 2010). This being the case, consideration will be given in this planning cycle to the introduction of a hepatitis B birth dose for facility deliveries Immunization Schedule The current immunization schedule in Timor-Leste is presented in following table: Table 2.3 Current EPI Schedule Antigen BCG DTP-HepB (3 doses) OPV (birth dose + 3 doses) Measles Tetanus Toxoid (TT) (5 doses) Age of Administration Birth to 1 year 6 weeks or 1 st contact after 6 weeks, + 1 month, + 1 month 0-2 weeks, 6 weeks or 1 st contact after 6 weeks, + 1 month, + 1 month 9 months Pregnant women: 1 st contact, + 1 month, + 6 months, + 1 year, + 1 year In addition, Vitamin A is to be offered at 6 month intervals from age 6 months to 5 years. Children over 1 year of age may receive vaccinations as needed. 2.4 Vaccine Regulation As yet, Timor-Leste has no drug or vaccine regulation body. The country has no pharmaceutical industry and currently relies on imports for its entire requirements of medicines, vaccines and reagents. It also relies on WHO collaborating laboratories in the region for testing the quality of imported drugs and vaccines. All vaccines used for the immunization programme are purchased through the UNICEF procurement mechanism and therefore have met WHO prequalification standards. The post-marketing surveillance system needs to be improved (see below). In 2009, the Timor Leste Ministry of Health began financing entirely its national supply needs for traditional vaccines and DTP-HepB. 2.5 Introduction of New Vaccines Until 2007, the Timor-Leste vaccination schedule included only the EPI standard vaccines, namely BCG, DPT, OPV and Measles. In December 2007, with AusAID funding channeled through 14

16 UNICEF, Hepatitis B vaccine was introduced into the vaccination. This was accomplished by replacing DPT vaccine with tetravalent DPT/HepB vaccine. In the first quarter of 2011, the Ministry of Health decided to introduce pentavalent vaccine into the routine immunization schedule from February Timor-Leste will also consider the possibility of introducing additional vaccines into its vaccination schedule. Candidate vaccines include Rubella, Pneumoccocal, JE and Rotavirus vaccines. Examination of the justification for new vaccines will include a measurement of disease burden. VPD surveillance does not presently provide high-quality information on disease burden for the target diseases of these new vaccines, but it is expected that much better information will become available during the next several years. It is proposed also that, building on the experience and expertise of the existing Technical Working Group for EPI, efforts will be made in 2012 to establish an NITAG in order to support the decision making process for new vaccine introduction. As described above, Timor-Leste is also considering the introduction of monovalent HepB vaccine as a birth dose in health facilities in locations where an increasing number of births are taking place. 2.6 Issues and Constraints for Immunization Services The primary constraints for increasing routine immunization coverage to a high level (80% FIC or greater in all districts), and maintaining that level are the following: Proportion of population living in remote, or difficult to access areas Lack of qualified health staff for making the services available, including management capacity Low proportion of births attended by trained health staff Low sensitivity for detecting and reporting VPDs The MYP for intends to address the first two of these constraints directly, through the extension of services to remote areas not currently being regularly accessed. The second two will be addressed through the immunization programme as much as possible but will generally have to occur as part of the overall development of the health sector. 2.7 Other programme issues Cold Chain Improvement Activities and Planning The vaccine cold chain system in Timor Leste extends from the Primary Central store in Dili to 13 District Stores to 65 CHCs. Since most facilities do not have 24 hr/day electricity, 75% of cold chain refrigeration equipment in the country is LP-Gas powered, with the balance either electric or solar powered. It is anticipated that electrical supply will extend to all sub-districts by the end 2012, so the inventory of cold chain equipment purchased in the future will gradually shift away from absorption units. Prior to the introduction of DTP-HepB in 2008, the Government began to prioritise improvements to its cold chain and logistics systems. In 2007, a consultant was engaged by UNICEF to develop a comprehensive cold chain inventory and a five-year cold chain rehabilitation plan ( ). It was noted that 90% of equipment was in good working order and that a third of equipment was over six years old (life-expectancy at years). As a consequence, as illustrated in the chart below, over the period UNICEF provided financial and technical assistance to purchase and install a total of 34 fridge/freezer units, 7 freezers, 16 ILRS and 15 solar units, and subsequently train district staff 15

17 in the proper maintenance of the new equipment. The five-year cold chain rehabilitation plan will need to be updated and work must continue to develop an effective cold chain maintenance strategy. Table 2.4 Cold Chain Refurbishment Cumulative cold chain refurbishement, Fridge/Freezer units Freezer ILR Refrigerator & Freezer, Vestfrost Freezer, Vestfrost Ice-lined icepack freezer, Sibir 110 MF 314, PIS E3/98-M MF 214, PIS E3/97-M refrigerator, Vestfrost MK 304 Refrigerator & icepack freezer, Sibir 170 GE Ice-lined Ice-lined refrigerator, refrigerator, Vestfrost MK 144 Vestfrost MK Solar pow ered Refrigerator Solar Solar pow ered Refrigerator Total Units A comprehensive vaccine management assessment was conducted using the WHO/UNICEF Vaccine Management Assessment Tool in November At that time, the consultant found that cold chain capacity for DTP-HepB was adequate at primary and service delivery levels (except one sub-district of Dili) and the standard of equipment satisfactorily functional. However, knowledge about appropriate vaccine management handling was not well understood, and skills tended to diminish from national to service delivery level. In response to recommendations made by the consultant, a Cold Chain and Vaccine Management (CCVM) training curricula was developed and 21 national and district staff were trained over a fiveday course in mid The same staff then participated in a training skills course and vaccine management refresher training at the end of 2009 to then facilitate sub-national CCVM trainings. During a series sub-national CCVM trainings were then conducted to train health workers, covering topics such as reading vaccine vial monitors, multi-dose vial policy, temperature monitoring, vaccine forecasting and calculating wastage. The CCVM trainings will continue as staff rotates and a new cadre of staff roll-in. In early 2009, in preparation for a tetanus and measles immunization campaign, and a follow up evaluation of the Primary Store was conducted using the WHO/UNICEF Effective Vaccine Store Management (EVSM) tool. As illustrated in Table 2.5 below, while weaknesses in the central store management persist, there have been notable improvements to the system, particularly in the areas of vaccine arrival and handing, monitoring of temperatures and stock management. While cold chain capacity for all routine and campaign doses of tetanus and measles was deemed quite sufficient, it was noted the vaccine storekeeper needed further training on volume capacity analysis, hence the lowered score. Overall, vaccine management practices have improved at all levels in the past five years due to the investment in training and system improvements. The cold chain and logistics systems is being established and stabilised and new technologies like digital freeze indicators have been widely introduced. To best prepare for future new vaccine introduction, efforts will continue on raising awareness and understanding among health staff -- particularly the newer work force expected over 16

18 the next cmyp cycle of vaccine temperature sensitivity, the importance of temperature monitoring and good vaccine handling, and proper record-keeping. One recent area of work that has been under-taken is vaccine wastage monitoring, as this is still not a concept that is well-understood or proactively managed. High wastage in not unexpected in a country that is still in the process of establishing an immunization delivery structure, and certainly in one with the harsh geographical conditions that Timor Leste confronts. Up to present, there has not been a culture on recording and monitoring vaccine wastage trends, and health workers are only beginning to be trained in the concept and purpose of this activity. As newer, more expensive vaccines become introduced, increased care for vaccine management takes on higher importance. For this reason, within the past year the MOH developed a recording format for monitoring discarded and administered vaccines, as well as instituted better practices at the Central Store to record vaccine and diluents movements. The programme of work in this area, as for many countries, will be challenging and will lead to gradual improvements. Table 2.5. Assessments conducted of Primary Store, Dili (target: 80% achievement or higher) WHO/UNICEF Vaccine Management Assessment (VMA) Oct-Nov 2007 WHO/UNICEF Effective Vaccine Store Management (EVSM) March Vaccine arrival process 55% 67% 2 Vaccine storage temperature 58% 77% 3 Cold storage capacity 92% 67% 4 Building, cold chain equipment 96% 75% 5 Maintenance of cold chain equipment 67% 58% 6 Stock management 23% 80% 7 Effective vaccine delivery 50% Timely and sufficient deliveries 35% No damage during distribution 56% Injection Safety Injection safety is another area where the immunization programme needs strengthening. Existing staff need additional guidance and training on safe injection practices. There is also a need for guidelines, guidance and resources for ensuring the safe disposal of used injection material. Surveillance and AEFI A review was conducted of the EPI program and AFP and VPD surveillance in Timor Leste in The review concluded that there were major shortcomings in the surveillance and reporting system that included the following: The national certification committee was not sufficiently developed to support polio eradication efforts The National EPI Technical Working Group was equally not sufficiently developed to support disease control and elimination and eradication efforts The vaccine preventable disease surveillance systems required significant strengthening and requires increased logistics and human resources support 17

19 Monitoring, reporting and investigating AEFI is an important component of any immunization programme, but is typically one of the last components of an immunization programme to be properly addressed. This is because effective monitoring for AEFI requires a sophisticated programme management and reporting system. During programme establishment there is a tendency to focus first on vaccine delivery. AEFI typically receives attention only when most major vaccine delivery issues have already been addressed. In Timor-Leste it is time to give more priority to AEFI. In 2010 the programme recorded more than 300,000 routine vaccinations. More than 30,000 DPT1 vaccinations were administered. When so many immunizations are given, particularly when vaccine management practices are not optimal, there is potential for AEFI. AEFI can embarrass and discredit an immunization programme. Programme officials and all vaccinators should know what constitutes AEFI for each programme vaccine, and what to do when AEFI occurs. Officials at the DHS and MOH level should have a protocol for responding to AEFI reports of serious consequence. As of March 2010, the AEFI system is functional in an ad hoc manner. Currently if an AEFI occurs, a joint investigation team consisting of the MOH, WHO and UNICEF conduct investigations and recommend actions. In response to this situation, a proposal is currently being put to the MOH to establish a national AEFI committee. WHO in Timor Leste, in partnership with the MOH, is establishing a surveillance unit at the MOH. The initial focus of this surveillance unit will be on vaccine preventable disease surveillance, including AEFI. As part of this process, system guidelines and standard operating procedures will be developed in 2011 with the technical support of WHO. A middle level management training program will also be conducted in 2011 which will introduce district and sub district managers to the main AEFI concepts and operational responses. Many of these challenges of surveillance and AEFI will be addressed during the time frame of this cmyp. In support of efforts for polio eradication, the Minister of Health in April 2011 signed the decree for establishing the National Certification Committee for Polio Eradication. 18

20 3.0 Multi Year Plan for Immunizations, In Timor-Leste the primary official documents guiding the development of immunization objectives are the Health Sector Strategic Plan for (HSSP), the Basic Service Package for child survival (BSP, May 2007), the National Immunization Strategy (February 2007, Updated April 2011), and the implementation guide for the Minister s initiative for Integrated Community Health Services (SISCa). The broad strategic directions of the proposed Health Strategic Plan have also been taken into account in preparing this plan. 3.1 National Goal and Vision The overall objective of the national immunization programme is to reduce child morbidity and mortality associated with vaccine preventable diseases. Immunization programme activities are an important component of the overall Government effort to achieve Millennium Development Goal 4, which is the reduction of under five child mortality by two thirds by year Since 2002, immunization coverage of each birth cohort in Timor-Leste has improved from about 45-50% to 60-70%, depending on the antigen. Over the past 2-3 years routine immunization coverage seems to have reached a plateau at this 60-70% level. This is not surprising since some 25-30% of the national population is difficult to access on a regular basis. Other main constraints limiting increases in routine coverage are the need for improved management capacity of DHS and CHC health staff, and the need for increased numbers of trained health staff. The coverage objective for the 5-year period covered by this MYP is to provide high-quality vaccine in a safe manner to at least 90% of the newborns in each birth cohort in every district every year by Doing this will require extending high-quality routine services beyond the CHC facility level so as to make immunization services available to populations in all sucos and aldeias one time per month whenever possible. Such an extension of routine immunization services will require more trained health personnel than currently exist and improved management of immunization and all other health services at the DHS and CHC level. If all sucos and most aldeias are to be reached monthly, a strengthening of community-based health services along the lines proposed by the SISCa initiative will be required. 19

21 3.2 Objectives, Strategies, Monitoring Indicators and Key Activities for Strengthening Immunization Services As outlined in the National Immunization Strategy (2007) the Overall Objective of the Timor-Leste Immunization Programme is: To reduce under-five morbidity and mortality caused by vaccine-preventable diseases among children in Timor-Leste. Specific Objectives: Specific objectives outlined in the MYP are the following: AREA 1 PROGRAM MANAGEMENT AND TRAINING 1. PROGRAM MANAGEMENT Strengthen programme capacity through: a. Management training b. In-service training c. Increased Numbers of trained health staff. AREA 2 SERVICE DELIVERY 2. DELIVERY STRATEGY Support the expansion of basic health services, including immunizations, to sucos and aldeias not presently having regular access to such services through a community-based approach (SISCa). 3. ROUTINE IMMUNIZATION Achieve routine immunization coverage of at least 90% of each birth cohort for all antigens in the vaccination schedule and TT2+ for all pregnant women at national level and at least 80% in all districts. 4. INCREASING DEMAND Increase public utilization of immunization services through intensification of promotional activities and community participation. 5. SERVICES INTEGRATION Incorporate micronutrient and other supplementation into vaccination activities as appropriate and feasible AREA 3 SYSTEM STRENGTHENING 6. COLD CHAIN AND VACCINE MANAGEMENT Ensure the availability of safe and efficacious vaccines, improved quality of service delivery, effective cold chain and excellent logistics for immunization activities. 7. POLIO Achieve certification standards for AFP surveillance; maintain polio-free status. 8. MNTE Achieve and maintain validation of neonatal tetanus elimination status. 9. MEASLES Reduce morbidity and mortality due to measles by 90% in 2010 compared to 2000 and maintain high control standards. 10. NEW VACCINES Consider new vaccines for inclusion in the vaccination schedule, and begin their introduction. 11. AEFI SYSTEMS Establish a strong AEFI surveillance system, including appropriate response to severe AEFI, with the objective of improving the quality of immunization service delivery. 12. VPD SURVEILLANCE Strengthen surveillance for diphtheria, pertussis and non-neonatal tetanus through improved diagnosis, reporting and investigation (polio, measles and neonatal tetanus are covered in objectives 5-7). 13. VACCINE WASTAGE Set and achieve vaccine usage objectives for each vaccine used in programme. 20

22 AREA 1 PROGRAM MANAGEMENT AND TRAINING Objective 1 Programme management Strengthen programme capacity through: Management training In-service training Increased numbers of trained health staff Supervision and monitoring (covered in Objective 4) Strategies Management training for district health managers and supervisors (MLM Training) In-service training for nurses and midwives (Immunization in Practice). Engage additional health staff Updating cmyp Updating National Immunization Strategy Monitoring indicators Number of person-days of management training received by national level staff supporting immunization activities (District Health Managers, DHO programme supervisors) Type and number of person-days of in-service training received by CHC nurses and midwives Number of additional trained health staff assigned to districts Key activities with time line Activities Development of continuing training strategy Management training of national level and district level staff In-service training for nurses and midwives Annual district inventory of health staff, by sub-district Updating cmyp Updating National Immunization Strategy 21

23 AREA 2 SERVICE DELIVERY Objective 2 Service Delivery Strategy Support the expansion of basic health services, including immunizations, to sucos and aldeias not presently having regular access to such services through a community-based approach (Fixed site, SISCa and outreach) Strategies: Identify and list, by District and Sub-District, all sucos and aldeias requiring priority targeting for expanded services. Identify and implement strategy for extending regularly occurring services for target sucos and aldeias. Determine number of sessions to be completed annually in target sucos and aldeias Engage partners for support in implementing strategy in as many target sucos and aldeias as resources allow. Maintain and expand fixed facility, SISCa and outreach services according to local planning need, including immunization services to all health posts. Monitoring Indicators Number of Districts in which all sub-districts have been assessed for sucos and aldeias requiring priority targeting for expanded services. Proportion of target sucos/aldeias in which the strategy is being implemented Proportion of target number of immunization sessions below CHCs level taking place annually (through SISCa, Health Posts, or mobile clinics) Proportion of women in each of these aldeias receiving antenatal care, including TT immunizations Proportion of newborns up to 12 months of age in these aldeias that have received BCG and DPT/HepB/Hib1 Number of districts with DPT3 > 80% Key activities with time line Activities Agreement on Strategy All 13 districts assessed completely, target list of sucos and aldeias for each assessed district developed by 2011 Number assessed districts with strategy implemented in 80% of target sucos/aldeias Number assessed districts with 80% of target sucos/aldeias having target number vaccination sessions below CHC level annually Number assessed districts in which 80% of pregnant women in target sucos and aldeias receive antenatal care Number assessed districts in which 80% of newborns in target sucos and aldeias receive BCG and DPT/HepB1 13 dist total 13 dists 6 dists 3 dists 3 dists 13 dist total 13 dists 10 dists 6 dists 6 dists 13 dist total 13 dists 13 dists 10 dists 10 dists 13 dist total 13 dists 13 dists 13 dists 13 dists 13 dist total 13 dists 13 dists 13 dists 22

24 Objective 3: Routine Immunization Achieve routine immunization coverage of at least 90% of each birth cohort for all antigens in the vaccination schedule and TT2+ for all pregnant women at national level and at least 80% in all districts by Strategies Ensure the availability of sufficient quantities of all vaccines at all facilities Ensure adequate health staff in all districts and sub-districts for meeting coverage objectives Promote integrated community health services in all sucos and aldeias through the SISCa initiative, with special attention to underserved areas. Promote improved communication and community mobilization through support for IEC activities Improve programme management capacity at DHS level Improve vaccination coverage monitoring at DHS and CHC levels Periodic coverage evaluations Monthly supervisory visits from DHS to CHS, recorded on standardized supervisory check lists with records kept at DHS Development of health micro-planning systems for delivery of integrated package of services including immunization (support for strengthening of District and sub District implementation plans. Monitoring Indicators DTP3 and/or measles coverage 85% nationally, and by districts, >80% DTP1 DTP3 drop out < 10% in all districts 80% of women giving birth for 1 st time have had 2 valid TT doses; Number of CHCs with costed microplans Key activities with time line Activities Ensure the availability of sufficient quantities of all vaccines at all facilities through annual vaccine supply plans including forecast for vaccines, injection equipment, safety boxes, etc Ensure number of health staff in all districts and sub-districts is adequate for achieving coverage objectives (related to objective 2) Promote integrated community health services through the SISCa initiative (related to objective 3) Strengthen communication and community mobilization through improved IEC activities (related to objective 12) Improve programme management capacity at DHS level Strengthen vaccination coverage monitoring at DHS and CHC levels Strengthen supportive supervision at all levels Development and Implementation of strengthened microplanning systems at District and sub District levels 23

25 Objective 4 Strengthening Demand of Services Increase public utilization of immunization services by intensifying promotional activities and community participation. Strategies Develop and disseminate promotional messages (for radio, publications, etc.) Develop and utilize promotional and educational materials (e.g. flip charts) Support SISCa activities Train and orientate other stake-holders in the community including local leaders, teachers (Health promotion training on on basic service package). Train and utilize PSFs for house to house visits in sucos Consider development of a reward system for increasing utilization of immunization services. Monitoring Indicators Annual number of ANC visits, by sub-district Annual number of DPT/HepB1 and DPT/HepB3 vaccinations, by sub-district Annual number of measles vaccination, by sub-district Key activities with time line Activities Develop radio messages that can be used long term Airing of messages through national and community radio (ne w vaccine introduction and routine immunization) Develop promotional/education materials Begin using materials at CHC and in sucos Support health promotion table of SISCa Begin discussion of reward system Training/orientation programs for local stakeholders Objective 5 Integration with Other Services Incorporate micronutrient and other supplementation into vaccination activities as appropriate and feasible. Increase coverage of Vitamin A supplementation to at least 90% of the children 6-59 months of age through routine immunization services, SIAs and Child Health Care Weeks. Combine distribution of ITNs, de-worming tablets, iron folate tablets, etc., with immunization services whenever feasible. 24

26 AREA 3 SYSTEM STRENGTHENING Objective 6 Cold Chain and Injection safety Ensure the availability of safe and efficacious vaccines, effective cold chain and excellent logistics for immunization activities. Strategies Continue to ensure that only vaccines which are WHO prequalified are procured for the programme Strengthen cold chain and vaccine logistics systems through conduct of Effective Vaccine Management Assessment (EVM) and development/implementation of system strengthening plan Improve skills and knowledge of health staff in proper vaccine handling and management practices through CCVM training Review and update cold chain inventory and rehabilitation plan and refurbish cold chain equipment where needed Strengthen immunization safety and injection waste management knowledge and practices Strengthen post-marketing surveillance to improve monitoring of adverse events following immunization Monitoring indicators All procured vaccines are WHO prequalified Performance assessment of national store (EVM) and development of improvement plan Number of staff responsible for vaccine management and logistics at Central, DHS and CHC levels who have received refresher training in the past two years. Number of districts where cold chain technicians are present and appropriately trained. Number of stock-outs by districts: target zero Development of wastage monitoring system Development of injection waste management guidelines Key activities with time line Activities Ensure that only WHO prequalified vaccines are procured for the programme Conduct Effective Vaccine Management (EVM) assessment Develop and implement EVM recommendations and cold chain system strengthening plan Conduct CCVM and refresher training to national, district and CHC staff Review and update cold chain inventory and rehabilitation plan Provide refresher training to cold chain technicians Continue upgrades and replacement to cold chain as necessary Further establish system for vaccine wastage reporting and continue ongoing vaccine wastage monitoring Conduct injection safety and waste management assessment Development of waste management guidelines for safe disposal of used injection material Develop of SOPs for vaccinator injection safety 25

27 Objective 7 Polio Eradication Achieve certification standards for AFP surveillance; maintain polio-free status Strategies Refresher training for clinicians and CHC staff on AFP diagnosis and reporting Active surveillance at National Hospital and Referral Hospitals Timely response to AFP reports resulting in investigation and stool collection, if warranted. Update response plan for importation of WPV or detection of cvdpv Maintain high routine OPV coverage of each birth cohort. Establish a National certification Committee for Polio eradication Monitoring indicators Refresher training of clinicians, including Cubans, on AFP diagnosis and reporting. Regularize weekly active searching for AFP at National Hospital Implement active searching for AFP at Referral Hospitals Achieve and maintain a non-polio AFP rate of at least 2 per 100,000 population under the age of 15 years Achieve and maintain an adequate stool collection rate of at least 80% for reported cases of AFP Updated plan for response to imported WPV and detected cvdpv Achieve and maintain routine OPV3 coverage of 90% in all districts by 2015 Key activities with time line Activities Establishment of NCC Refresher training of all government health facility clinicians on AFP diagnosis and reporting Regularized weekly active surveillance for AFP at National Hospital Achieve and maintain certification standard non-polio AFP rate Investigation initiated within 48 hrs of receiving AFP report 80% of time Achieve and maintain certification standard adequate stool rate Revise/update an outbreak response plan in the event of importation of WPV or detection of cvdpv 80% districts achieve OPV3 coverage of 90% of each birth cohort by 2015 Objective 8 Maternal and neonatal tetanus elimination Achieve and maintain elimination of maternal and neonatal tetanus Strategy Validate elimination of MNT in 2011 Maintain high routine TT coverage for pregnant women by ensuring availability of TT immunization services at all levels, including through SISCa activities. 26

28 Promote clean deliveries through increased rates of births conducted in facilities or attended by trained health staff Strengthen NT case detection and response through improved community-based surveillance Maintain elimination status by conducting regular district data reviews of core and surrogate indicators and address pockets of low-performance Consider introduction of booster dose of tetanus-toxoid containing vaccine Monitoring Indicator Validation of elimination of MNT Steady increase in national proportion of births attended by trained health staff 80% pregnant women receiving ANC services 80% of pregnant women in every district having had at least 2 valid TT doses prior to giving birth. Less than 1 NT case per 1000 live births in all districts Key activities with time line Activities Validate elimination of MNT Maintain 80% pregnant women receiving ANC services Maintain high routine TT coverage for pregnant women Steady increase in national proportion of births attended by trained health staff Conduct annual district data reviews and address pockets of low-performance Conduct NT case investigation and response Evaluate feasibility of introducing booster dose of tetanus toxoid containing vaccine Objective 9 Measles Control Reduce morbidity and mortality due to measles by 90% in 2015 compared to Strategies Implement Measles SIAs in 2011 and 2015 Achieve and maintain high routine vaccine coverage for measles Implement outbreak-based measles surveillance nationally Timely and appropriate investigation of every reported measles outbreak. Appropriate specimen collection for measles outbreaks according to guidelines. Strengthened measles laboratory capacity for timely diagnosis and feedback for specimens taken from suspected measles cases Maintain case based surveillance for measles Begin implementation of community-based surveillance. Assess need for introduction of measles routine second dose in 2014 and 2015 based on assessment of routine immunization coverage Monitoring indicators Measles mortality reduced to less than 1% of cases reported Measles SIA conducted Routine immunization coverage for measles 90% by district for each birth cohort by % of measles reports investigated according to guidelines 27

29 Specimens collected and analyzed for investigated measles outbreaks according to guidelines 90% of time Laboratory results fed back to DHS in timely manner Key activities with time line Activities Conduct Measles SIA Achieve and maintain 90% routine vaccination coverage for measles by district for each birth cohort by 2015 Implement and maintain outbreak-based measles surveillance for all districts Maintenance of case based surveillance Measles laboratory capable of timely and accurate analysis of specimens and feedback of analysis results laboratory for timely diagnosis and feedback to programme Objective 10 New Vaccine Introduction As appropriate, identify candidate new vaccines for inclusion in the vaccination schedule, begin their introduction if all criteria for doing so are met. Strategies Assess disease burden to be addressed by vaccines being considered to evaluate public health impact of their introduction (introduction of hospital sentinel sites for assessment of meningitis, encephalitis and pneumonia) Introduce pentavlent vaccine as per MOH decision into the routine schedule from February Establish NITAG in 2012 (with representation of clinicians and professional associations) and conduct vaccine decision making process and costing analysis for PCV vaccine, rotavirus vaccine, JE vaccine and rubella vaccine introduction Advocate for the introduction of new vaccines as appropriate (include resource mobilization) Introduce new and under-utilized vaccines into national immunization schedule in accordance with need and national capacity to sustain them Monitoring indicators Disease burden assessments or estimates conducted and available Estimation completed of full cost to introduce new vaccines being considered (including storage implications) Assessment completed of country capacity to absorb and sustain full cost for foreseeable future Recommendation made to MOH Introduction begun within one year of MOH agreement Key activities with time line Activities Apply decision-making process for new vaccines being considered Advocate for the introduction of new vaccines as appropriate Introduce Pentavalent vaccine into routine EPI schedule Establish NITAG Explore establishment of sentinel surveillance for meningitis, 28

30 encephalitis and pneumonia Conduct decision making process for new vaccines Objective 11 AEFI Surveillance Systems As a component of the effort to improve the quality of immunization service delivery, establish an AEFI surveillance system for vaccines included in the vaccination schedule, including recognition and appropriate response to severe AEFI. Strategies Designate an AEFI focal person in the MOH in the newly established Surveillance Unit Establishment of National AEFI committee Training by SEARO/WHO of focal person. Develop guidelines for recognition and response to AEFI. Develop SOPs for investigation of reported AEFI, including investigation forms. Develop guidelines for how to respond to media reports of AEFI. On-site training of DPHOs and clinicians Implement regular AEFI surveillance reporting Introduce AEFI concepts and operational responses into MLM training commencing in 2011 Monitoring Indicators Designation of AEFI focal person. Training of AEFI focal person by SEARO/WHO. Development of guidelines and SOPs Initiation of regular AEFI surveillance reporting Key activities with time line Activities Official designation of AEFI focal person by MOH Establishment of National AEFI committee. MLM training on AEFI Training of AEFI focal person by SEARO/WHO Guidelines developed for recognition and response to AEFI SOPs and forms developed for investigation of reported AEFI Guidelines developed for response to media reports of AEFI On-site training for DPHOs and clinicians Regular AEFI surveillance reporting initiated in all 13 Districts Objective 12 VPD Surveillance Strengthen surveillance for diphtheria, pertussis, and non-neonatal tetanus through improved diagnosis and reporting, and improved outbreak investigation capabilities. Strategies Refresher training of clinicians and CHC staff on disease recognition and how to report Develop guidelines and standard operating procedures for surveillance and outbreak response Strengthening of community based surveillance Monitoring indicators 29

31 Number of clinicians in government health system successfully completing refresher training on recognition of VPDs reporting procedures Development of SOPs for recognition and reporting of VPDs and dissemination to government reporting facilities and members of Medical Association Official contacts with Medical Association regarding surveillance for these diseases. Key activities with time line Activities Refresher training for all government health facility clinicians on disease recognition and reporting Development and dissemination to government health facility clinicians of SOPs for disease recognition, reporting, and outbreak control procedures. Refresher training for non-government clinicians on disease recognition and reporting Explore possibilities for community-based surveillance through SISCa activities. Objective 13 Monitoring vaccine wastage Establish a method for monitoring vaccine usage for each vaccine used in programme; set vaccine usage objectives. Strategies Focus on system-related wastage of unopened vials (incorrect/inappropriate vaccine storage and transportation practices), and the reasons for the wastage, at the Central, DHS and CHC levels. Establish and implement monitoring and reporting procedures for system wastage of unopened vaccine vials at these facility levels. Monitoring indicators Establishment of monitoring and reporting procedures for Central, DHS and CHC levels. Number of facilities at which monitoring and reporting procedures are implemented. Completeness and timeliness of reports received at next highest level. Vaccine wastage rates available monthly for each vaccine from Central, DHS and CHC levels Key activities with time line Activities Establish monitoring and reporting procedures for Central, DHS and CHC levels Implement monitoring and reporting procedures at: Central, 3 DHS and 5 CHC facilities Additional 5 DHS and 25 CHC facilities Additional 5 DHS and 35 CHC facilities Completeness and timeliness for reports to next level reaches and maintains between 80% and 90% Central, 3 DHS and 5 CHC facilities Additional 5 DHS and 25 CHC facilities Additional 5 DHS and 35 CHC facilities MOH to analyze and provide quarterly feedback on vaccine waste monitoring to the DHS that have implemented reporting procedures 30

32 4.0 Costs and financing of the cmyp of Timor-Leste 4.1 Baseline Programme Cost and Financing The table in Annex 1, Programme Cost Estimates, , is based on actual 2010 costs. The year 2010 was chosen as the baseline for cost and financing projections because it is the most recent year for which full costing and financing information is available. EPI data for the estimations and projections were supplied by the Department of Finance of the Ministry of Health, UNICEF and the WHO Country Office. Economic data were obtained from both Ministry of Health and World Bank publications and the WHO NHA data. Baseline Programme indicators of the EPI Timor-Leste are presented in the Table 4.1. Table 4.1. Baseline Cost Indicators EPI Timor-Leste Baseline Indicators 2010 Total Immunization Expenditures $1,618,029 Campaigns $99,366 Routine Immunization only $1,518,663 per apita $1.4 per DTP3 child $52.4 % Vaccines and supplies 11.1% % National funding 61.1% % Total health expenditures 1.9% % Gov. health expenditures 2.7% % GDP 0.05% Total Shared Costs $59,940 % Shared health systems cost 4% TOTAL $1,677,969 In 2010, estimated total cost of the Timor-Leste EPI was $1.68 million, including shared cost, of which amount $1.5 million were spent for routine immunization, and an estimated $99,366 thousand for supplementary immunization activities (MNTE campaign high risk areas): In December 2007, the Timor-Leste EPI replaced DTP vaccine in its immunization schedule with tetravalent DTP-Hepatitis-B vaccine, thus adding one more antigen to the immunization schedule. Figure 4.1 below presents the baseline cost structure for Personnel costs and recurrent operational costs turn out to be the biggest expenditure categories of the EPI program in 2010, accounting for roughly 32 % of total outlays per category. Vaccines accounted for nearly 20 % of 2010 EPI expenditures. Tetravalent DPT/HepB vaccine replaced DPT in the immunization schedule in This new vaccine accounted for slightly more than half of all vaccine costs in This underscores the point that introduction of new and underutilized vaccines into the national immunization schedule will greatly impact programme costs. The substitution of pentavlent for tetravalent DPT/HepB vaccine (both 10 dose vials) for DPT will not require any expansion of vaccine storage capacity but other new and under-utilized vaccines such as PCV or rotavirus could. The cmyp for allows for that possibility during the later years of the plan. Any introduction of additional new or under-utilized vaccines will be dependent on the 31

33 country s ability to support the recurrent costs of such vaccines as well as any necessary expansion of vaccine storage capacity. Figure 4.1: Baseline Cost Structure 2010 In 2010, the government was responsible for the larger part of EPI financing. This contrasts with the experience of earlier years, where development partners represented a greater part of the financing profile (see first cmyp ). UNICEF provided nearly 17% of total expenditures, mainly for support for operational costs of immunization campaigns conducted in the country during At the same time, National Government was responsible for financing all the EPI staff, immunizationrelated transportation costs, and for the premises used by the EPI and for the financing of all traditional and underutilized vaccines. The proportion of the total cost borne by the MOH was 79% in 2010, which contrasts with the previous baseline assessment of 43.5% in

34 4.2 Recurrent costs analysis Vaccines and injection supplies Until 2008, procurement of all vaccines and injection supplies for the EPI, both for routine immunization and campaign activities, was financed by EPI partners, predominantly by the Government of Japan. At the end of 2007, the EPI underwent two major changes. First was the introduction of DTP/HepB vaccine as a replacement for the traditional DPT. This replacement was fully accomplished by mid AusAID financed the procurement of the tetravalent DPT/HepB vaccine during Second, beginning in 2008, the Government of Timor-Leste assumed responsibility for the cost of procuring all traditional vaccines. Beginning in 2009, the Government of Timor-Leste has assumed complete financial responsibility for the procurement of all vaccines included in the national immunization schedule as well as related costs for injection supplies (known as bundled vaccine purchases). Bundled vaccine procurement will continue to be undertaken through UNICEF vaccine procurement mechanisms thus assuring delivery of quality vaccines and supplies to the country. Vaccines for routine immunization will continue to constitute a moderate share of EPI costs, from 33% in 2010 to 34 % in 2015 (there was a higher baseline in 2010 due to campaign costs). This proportion of program costs attributable to vaccine costs is likely to shift significantly later in the plan period should the decision be taken to introduce newer vaccines including PCV, rotavirus and JE vaccines. The share of vaccines procured for any campaigns conducted during the period covered by the cmyp will be considered an extraordinary expense, and will be negotiated when the decision to conduct a campaign is being made. Overall, campaign-related activities are expected to claim about a 11% of total EPI expenditures for This rather high cost is explained by necessarily high operational costs due to the fact that a substantial portion of the population lives in rural and hard-to-access locations. The cmyp anticipates that there could be a measles campaign conducted in 2011 and Personnel costs and Transport costs The proportion of total EPI costs represented by programme personnel will increase rise considerably during the cmyp lifetime. This reflects the first of the two most critical issues that the Timor-Leste EPI must address in the immediate future if it is to achieve and sustain high coverage of its target populations. This is the current lack of sufficient staff for making routine immunization services available to all Timorese. The second most critical issue is also staff-related. Namely, the need to upgrade the knowledge and skills of current and future staff. It is anticipated that the EPI will have to recruit at least one cold chain technician to oversee the maintenance and repair of cold chain equipment. If only one technician is engaged, the employee would be placed at the National vaccine store and would be responsible for supporting technicians at the district and sub-district levels. It may make sense to have cold chain technicians assigned to several of the districts and given Regional responsibilities. Given the relatively small amounts of cold chain equipment at individual sub/district facilities, it would not be practical to have full-time cold chain maintenance technicians at the sub-district level. It is also considered critically important to increase the number of nurses/midwives at the sub/district level as this category of staff is directly responsible for provision of immunization services. It is also 33

35 expected that nurses/midwives will have major involvement in the expansion of regular SISCa activities, which will include an immunization component. The cmyp anticipates that at least one additional nurse/midwife FTE (full time equivalent) will be added to the health staff in every one of the 65 sub-districts. While the need for these additional staff is well understood by the MOH, it is not clear that the Government will be able to budget, allocate and channel these funds through the decentralized financing system 1. Therefore financing for these additional positions is represented in the cmyp as probable financing and not secure. At the district and sub-district levels managerial and service delivery staff divide their workload responsibilities between immunization-related tasks and other healthcare duties. The greatest proportion of staff cost for EPI activities is directed to the sub-district level Vehicles & transport costs Transport of vaccines from the national vaccine store to the service delivery level is a major challenge for the EPI. While the national road infrastructure is relatively good, it is poor in some areas. During the rainy season some areas become inaccessible by road. Mountainous terrain with dispersed populations also presents vaccine delivery problems as many areas are difficult to reach by road even during the dry season. These challenging conditions dictate that EPI transportation needs be coordinated with those of other parts of the health care system. It is estimated that at present one vehicle at the National level, 13 at the district level and 65 at the sub-district level are used part-time for EPI activities. There is now one vehicle provided through UNICEF that is dedicated full time to EPI functions. The cmyp anticipates that EPI activities, including surveillance for vaccine-preventable diseases, will require the acquisition of one EPI-dedicated vehicle at the National level each year during the period Similarly there are no vehicles at the district level dedicated for EPI use. While dedicated vehicles at the district level may not be appropriate, it is important that serviceable vehicles are available at the district level for EPI use when needed. Routine monitoring and supervision of service activities, including immunizations, transport of vaccines, IEC/social mobilisation interventions, oversight of SISCa implementation, and VPD case investigations will require the regular availability of vehicles for use in support of EPI activities. The cmyp anticipates that each DHO should add 2 new vehicles each year during the period to assure that transport for EPI-related activities will be available when needed. Similarly, sub-district level facilities will need vehicles of appropriate numbers and types that are available for EPI use when needed. All vehicles currently being used for EPI purposes are maintained by the Government. Financing for the purchase of new vehicles is not yet assured and this line item is reflected as an unfunded need. The vehicle unit costs used in calculations represent their estimated replacement value based on the price tags for respective types of vehicles. Fuel consumption is expected to be at 13 litres per 100 km, taking into account the status of road infrastructure. Based on earlier experience, the average number of useful life years (ULY) for vehicles Timor-Leste is estimated to be 7 years which was taken into account in the calculations. Overall, during the cmyp lifetime, vehicles and their maintenance is expected to consume 5.64% of total EPI resources. 1 Decentralized financing system means that the Ministry of Health is not directly responsible for financing district and sub-district healthcare facilities. Instead, Local Authorities (seam to) receive transfers from the National Government to perform the functions they have been delegated. 34

36 4.2.4 Cold chain equipment Equipment quantities, balance values and maintenance costs were provided by a comprehensive cold chain inventory conducted with UNICEF support during Overall, EPI cold chain capacity is adequate for present purposes. During the period the Government of Japan supported via UNICEF the purchase of much needed cold chain equipment for use at the sub-district level. At the national level, EPI vaccine storage capacity consists of two cold rooms (10 cubic m) and one freezer room (8 cubic m each). At the sub-district level EPI needs are being served by 88 refrigerators and freezers as well as numerous cold boxes, vaccine carriers and ice-packs.current cold chain storage capacity at the national level is adequate for handling vaccines included in the current immunization schedule. However, if the EPI should decide to include additional new or under-utilized vaccines in the immunization schedule (excepting pentavalent DPT, HepB, Hib) it will surely be necessary to reassess the need to expand capacity at all storage levels.. It was assumed that average useful life years (ULY) for cold chain equipment in Timor-Leste is 5 10 years. Replacement costs for cold chain are therefore projected for the year During the period of the cmyp, cold chain costs are expected to consume around 5% of total EPI expenditures Campaigns Two rounds of supplementary TT vaccinations were conducted in Timor-Leste in 2008, targeting 225,000 females aged years. In June of 2009 there was a 3 rd round of the TT campaign. During this round measles vaccine was added for children 9-59 months of age, Vitamin A for children 6-59 months of age, and Iron/Folate for females aged years. The cmyp anticipates the possibility of another measles campaign in 2011 to respond to the current outbreak, and a second national campaign in 2014 or TT campaigns in high risk areas are also proposed. Based on the experiences of previous campaigns, operational cost for conducting campaigns was estimated at $2.0 per immunised person for a single antigen Training, Programme Management, Disease Surveillance, and IEC and Social Mobilization Timor-Leste is a new country. Its ministries and their programmes are likewise new. The immunization programme, like other programmes, has had to recruit new staff from candidates that often have limited knowledge and skills. Thus it is important for the programme that the skills and knowledge levels of existing staff be increased. Successfully addressing the challenging tasks ahead for the EPI will require considerable investment in staff capacity development in all areas of programme activity. During 2011, UNICEF is proposing to spend $225,000 on health outreach, MLM training and preparation of modules and strengthening of the vaccine management and cold chain system. Additional funds were made available from the UNICEF Regional Office for vaccine management. UNICEF will continue focusing on short-term training, IEC, social mobilization and programme management issues, but will likely be able to offer some operational cost support for any forthcoming campaigns. The WHO Contribution to the Timor-Leste EPI has been primarily in support of programme management and disease surveillance activities. The support level is similar to that of UNICEF s support for training. It is expected that WHO will continue to support disease surveillance, programme management and any forthcoming campaigns, but no funding commitments can be made beyond 2012 at the present time. Additional support is proposed through USAID programs to strengthen management, planning, supervision and delivery of basic health service programs up to Additional and specific program investments are proposed in this plan for investments in development of surveillance and AEFI systems, the establishment of surveillance sites for meningitis and encephalitis and investments in Middle Level management and Immunization in Practice Training. 35

37 4.2.7 Building and building overheads None of the buildings used for EPI purposes in Timor-Leste belong exclusively to the EPI. For example, the national vaccine store is located on the premises of an autonomous commercial unit responsible for supplying medicines and medical goods to the MOH. Another example is that vaccinations at the sub-district level (i.e., great majority of the vaccinations) are provided mostly at the Community Health Centres (CHC) or less often, at Health Posts. In both cases the premises are shared by immunization and other healthcare services. Another difficulty in attributing building and building overhead costs to the EPI is that there is poor access to accounting (balance value) data. 4.3 Projected EPI resource requirements Projected resource requirements for the EPI for the period of 2011 to 2015 are presented in Figures 4.3 below. The total resource requirements for amount to around $ million. Vaccines for routine immunization combined with injection supplies are expected to account for about 30% of these requirements. It should be noted that, while Timor Leste is taking on an increased financial investment in EPI due to pentavalent vaccine introduction, significant gains in efficiency will be achieved through reduction in vaccine wastage from 50% in 2011 to 20% in Figure 4.3 EPI Resource Requirements