COMPREHENSIVE MULTI YEAR PLAN Protect More People Introduce New Vaccines Intergrate & Synergize Sustainability

Transcription

1 COMPREHENSIVE MULTI YEAR PLAN Protect More People Introduce New Vaccines Intergrate & Synergize Sustainability March 2011

2 Comprehensive Multi Year Plan (cmyp) M I N I S T R Y O F H E A L T H C O M P R E H E S I V E M U L T I - Y E A R P L A N Immunization Vision & Strategy i

3 Comprehensive Multi Year Plan (cmyp) CONTENTS List of Abbreviations Preface Foreword Acknowledgements Summary PAGE iii iv v vi vii Chapter 1 Background Socio-Economic & Health Status Immunization of the Health Sector Status of EPI Programme Components The EPI Multi Year Plan: A Strategic Resource Strategic Development Foundation & Process 5 Chapter 2 The Vision & Goals The Vision National Goals & Priorities The Guiding Principles 8 Chapter 3 The Strategic Framework 9 Pillar 1 Protecting more people 9 Pillar 2 Introducing New Vaccines & Technologies 11 Pillar 3 Integrating Immunization, other Health Interventions 11 Pillar 4 Sustainable Immunization Financing 12 Strategies, Key Activities, Indicators and Milestones15 Chapter 4 Financing and Sources of Funding 28 Chapter 5 Implementation Process The Road Map The Strategy Map Monitoring Progress: The Timeline & Milestones 30 Strategy Map: Immunization Vision & Strategies 31 ii

4 Comprehensive Multi Year Plan (cmyp) TABLES PAGE Table 1 Table 2 Table 3 Zambia Demographic & Socio-Economic Data The National Objectives & Related Global Objectives Annual Funding Situations for Immunization Vision & Strategy FIGURES Figure Immunization Vaccine & Strategy Map ANNEXES Annex 1 Zambia EPI Diseases ( ) Annex 2A Situational Analysis EPI System Components Annex 2B Situational Analysis EPI System Components Annex 2C Situational Analysis EPI Disease Control Immunization Annex 3 Financing the Strategy Annex 4 List of Participants Workshop on EPI, MYP ( ) iii

5 Comprehensive Multi Year Plan (cmyp) LIST OF ABBREVIATIONS ADS AEFI AFP cmyp DHMT DHS DQS EPI GAVI GIVS HC HCW HSS ICC IDSR IEC IMR ISS MDG MoH MTEF MYP NGOS NIDs PRSR RED SDBNIS SNIDs SOC MOB VII Auto Disabled Syringes Adverse Effects/Events Following Immunization Acute Flaccid Paralysis Comprehensive Multi Year Plan District Health Management Team Demographic Health Survey Data Quality Survey Expanded Programme on Immunization Global Alliance for Vaccines and Immunization Global Immunization Vision & Strategies Health Centre Healthcare workers Health Systems Strengthening Inter-Agency Coordinating Committee Integrated Disease Surveillance Response Information, Education and Communication Infant Mortality Rate Immunisation Strengthening Support Millennium Development Goals Ministry of Health Medium-term Expenditure Framework Multi Year Plan Non-Governmental Organizations National Immunization Days Poverty Reduction Strategy Paper Reaching Every District Strategy Strategy District Based National Immunization System Sub-national Immunization Days Social Mobilization Vaccine Independence Initiative iv

6 Preface Comprehensive Multi Year Plan (cmyp) The health system in Zambia has undergone a reform process since This involved transfer of power to the lower level in a bid to assent to become more responsible for their own programme activities and solutions thereby encouraging ownership. Although the morbidity and mortality pattern due to vaccine preventable diseases remains high, there has been a notable decrease in the rates. The immunization programme in Zambia has been recognized for its sustained high coverage levels, contributing to reduction in childhood morbidity and mortality rates. Zambia has drawn a comprehensive multi-year Plan for immunization for the next five years ( ). The processes will run along with the sectoral National Health Strategic Plan (NHSP) and the Mid Term Expenditure Framework (MTEF) to be implemented for the next five ( ) and for a period of three years respectively. This Multi-Year Plan seeks to address vaccine preventable diseases through integrated interventions, and; it is hoped that it will contribute towards the attainment of the Millennium Development Goals (MDGs) of Reducing by two thirds, the child mortality rate as compared to 1990 levels. Hon. Kapembwa Simbao, M.P Minister of Health 1

7 Comprehensive Multi Year Plan (cmyp) Foreword The Zambia Expanded Programme on Immunization has been recognized for its sustained high coverage and contribution towards economic development. Since its first campaign when it was launched in 1975, considerable achievements have been made especially during the acceleration phase; in which period, a lot of resources were put in place. The multi-year plan has been developed within the framework of Global Immunization Vision & Strategy (GIVS); and, adapted as the Zambia Immunization Vision & Strategy (ZIVS). The Multi-Year Plan for the national immunization programme that has been developed reflects a total picture of milestones to be achieved within the coming five years, taking into account constraints that the health sector is facing in human resource and infrastructure development. It forms a framework for operationalising the immunization goals, objectives and strategies that are aimed at reaching the millennium development goals. As immunization is one of the cornerstones of health and well-being, it contributes to improvement in health and life expectancy through its social and economic impact at national and community level; it is a cost-saving intervention which prevents needless suffering. The multi-year plan gives guidance to invest in future key players (children). Therefore, immunization should be seen as a critical part of a wider health system strengthening effort and a scaling up of efforts to meet the MDGs. The implementation of the multi-year plan strives to achieve the MDGs and contribute to reduction of childhood morbidity and mortality by two thirds between 1990 and 2015 ; measured by using as an indicator the proportion of one-year children immunized against measles. I wish to thank all the cooperating partners who contributed to the development of the multi-year plan. DR. P. MWABA [Permanent Secretary, Ministry of Health] 2

8 Comprehensive Multi Year Plan (cmyp) Acknowledgments The Ministry of Health would like to thank cooperating partners for providing financial and technical support that saw the development of the multi-year plan. Special thanks go to individuals for their contributions during the initial meeting for drafting and editing of the document. The updating of this document was supported by the World Health Organization, UNICEF and other cooperating partners. I wish to sincerely express my gratitude to the leadership of Ministry of Health for taking the lead in developing the Zambia Immunization Vision & Strategy for the future leaders of this nation, Our children, Our investment. I acknowledge with sincere gratitude the financial and technical support rendered by the World Health Organization, UNICEF for technical support and Last, but not least, the UCI secretariat of the Ministry of Health for their tireless efforts in drafting and editing the document. DR. V. MUKONKA Director, Public Health & Research 3

9 Executive Summary Comprehensive Multi Year Plan (cmyp) T his Comprehensive Multi Year Plan (cmyp) outlines the child health situation in the country, the strategies, and suggested solutions to direct the EPI programme for the five year period from It is an Immunization Vision and Strategy that states how Immunization programme will effectively contribute to improved child survival (MDG 4 to 6). It is a strategic document focusing the principles of the National Health Strategic Plan ( ) of the Ministry of Health and the Sixth National Development Plan ( ) of the Country. The core principles of this Strategic Plan include community and national ownership, partnership and responsibility, reaching every child in every district irrespective of gender or socio-economic status, strong district and facility-based system, evidence-based policies and practices, and sustainability through technical and financial capacity building. The Reaching Every District (RED) strategy provides a framework for strengthening routine immunization at district level and is key strategy for the immunization programme. Strategic planning for immunization requires reliable information on the costs and financing of the programme. The cmyp costing and financing tool has been used to estimate the past cost and financing of immunization, and to make projections of future costs, resource requirements, future financing needs and analysing funding gaps. The vision of immunization in Zambia for the period is one in which: Immunisation is highly valued as a national development issue; Every child, adolescent and adult has equal access to immunisation as provided for in the national schedule; More people are protected against various diseases through introduction new and under-utilised vaccines; Financing for Immunisation and related interventions is sustained; Immunisation is a critical part of a wider health system strengthening (HSS) in effort to achieving MDGs; and National targets and milestones have been set to track progress. 4

10 Comprehensive Multi Year Plan (cmyp) The Immunisation Vision and Strategy framework contains 16 key strategic elements. These elements fall into 4 categories or thematic areas the pillars of Zambia immunization vision and strategy: 5

11 Comprehensive Multi Year Plan (cmyp) 1. Pillar One: Protecting more people 1.1 Strategy 1: Use a combination of approaches to reach everyone targeted for immunization 1.2 Strategy 2: Increase community satisfaction and demand for immunization 1.3 Strategy 3: Vaccinate beyond the traditional target group 1.4 Strategy 4: Improve vaccine, immunization and injection safety 1.5 Strategy 5: Improve and strengthen vaccine management systems 1.6 Strategy 6: Strengthen and evaluate the immunization programme 2. Pillar Two: Introducing new vaccines and technologies 2.1 Strategy 7: Prepare for the introduction of Rotavirus vaccine, Pneumococcal vaccines and Measles second dose vaccine. 3. Pillar Three: Integrating immunization, other health interventions and surveillance in the health systems context 3.1 Strategy 8: Strengthen the management, analysis, interpretation, use, and exchange of data at all levels 3.2 Strategy 9: Improve human resources management 3.3 Strategy 10: Sustain and develop appropriate interventions for integration 3.4 Strategy 11: Strengthen surveillance and monitoring 3.5 Strategy 12: Provide access to immunization in emergency and special situations 3.6 Strategy 13: Strengthen linkages with stakeholders (e.g. clinicians, traditional healers, other programmes) 4. Pillar Four: Sustainable immunization financing 4.1 Strategy 14: Improve capacity for mobilization of financial and other resources 4.2 Strategy 15: Integrate new vaccines into medium-term expenditure framework (MTEF) and National Health Strategic Plan and Budget 4.3 Strategy 16: Increase partner financial support for immunization The Vaccine Preventable Diseases (VPDs) can be tremendously reduced and improve the quality of health of children through the use of vaccines. Processes and available resources for EPI have been aligned to the National Health Strategic Plan and National Development Plan. 6

12 1. BACKGROUND Comprehensive Multi Year Plan (cmyp) Z Ambia is a land locked country located in southern Africa consisting nine (9) provinces and seventy-two (72) districts. The health and socio-economic status has been outlined below: 1.1: HEALTH AND SOCIO-ECONOMIC STATUS. The country has continued to record high morbidity and mortality among children, arising from vaccine preventable diseases. The Demographic Health Surveys have revealed a declining trend in Infant mortality rate (IMR) from 109 in 1996 to 95 in 2002 and further to 70 in 2007 (DHS 2002, 2007). Under-five mortality has dropped from 197 in 1996 to 168 in 2002 (DHS ) and 119 in 2007 (DHS 2007). However, these rates are still unacceptably high. Trends in Health MDG Mortality impact indicators The burden of infectious but preventable diseases is high and contributes significantly to child morbidity and mortality. Neonatal conditions are the number one cause of morbidity and mortality, while respiratory infections (pneumonia), malaria and diarrheal diseases in that order contribute significantly too (WHO 2006). 25% 22.9% 21.8% 19.4% 20% 17.1% 16.1% 15% 10% 5% 0% Neonatal causes Pneumonia Malaria Diarrhoeal diseases HIV and AIDS Injuries 1.0% 0.3% Other 7

13 Comprehensive Multi Year Plan (cmyp) With a GDP per capita of USD 985 (2008), poverty remains a major barrier to improving child health. The proportion of government s budget spent on Health in 2009was 10.8% 1. Zambia: Demographic and socio-economic data Parameter Year Estimate Source Tottal Popul lattion (thousands) ,852 CSO Infant Mortality Rate / ZDHS Under Five Mortality Rate / ZDHS 1000 GDP perr capita,, (US$ )) BOZ % Goverrnmentt Budgett tto MoFNP Heal ltth Per Capiitta Expenditure on Heal ltth (US $) MoFNP Zambia: Demoraphic and socio-economic data Parameter estimate year source Total population 13,046, CSO Infant mortality rate 70/ ZDHS Under five mortality ZDHS GNI per capita (USD) Central Statistical office Percentage of Government 10.8% 2009 expenditure on Health Percentage of GDP 4.8% 2009 allocated to Health Total expenditure on health per capita at exchange rate 1.2: IMMUNIZATION AND THE HEALTH SECTOR The NHSP recognizes that despite a reducing trend, child mortality remains unacceptably high. The NHSP objective for child health is to reduce the UFMR 1 8

14 Comprehensive Multi Year Plan (cmyp) from 119/1000 live births to 63/1000 live births. Zambia has 18 general Hospitals, 44 District hospitals, and more than one thousand health centersr through out the country. The Ministry of Health is currently constructing health posts to increase access and availability of immunization (and other health care) services. To address the staff shortage, the Ministry of Health has introduced retention schemes with incentives to encourage health staff to stay, particularly in rural areas. Table 1: Summary of Health Institutions by Type, Size and Ownership Facility Type Total Number of Number of Facilities Owned by No of Units Beds Cots Gov t Private Missions Total 3rd Level Hospital 5 3, nd Level Hospital 18 5, st Level Hospital 73 6,795 1, Health Centres Rural 973 8, Urban 237 1, Health Posts Total 1,326 25,439 3,501 1, ,326 (Source: CBoH/MOH 2002) 1.3 STATUS OF EPI PROGRAMME COMPONENTS Zambia has been implementing routine Expanded Programme on Immunization (EPI) in the context of health sector reforms, a Sector Wide Approach (SWAp) and decentralization since the early 1990s. However, during the period of the NHSP, the health sector will work to finalize several different policies and review the Sector Wide Approach (SWAp) coordinating mechanisms in order to facilitate improved service delivery 2. At present, routine EPI is fully integrated into health service delivery system at the district level. The expanded Maternal Neonatal and Child Health, & Nutrition Inter-Agency Coordinating Committee (MNCH&N ICC) oversees implementation of the immunization programme and the Child Health Technical Working Group is currently the secretariat. Service Delivery - Access and Coverage. The Immunization programme aims at reaching all children with the targeted vaccines before they attain their first birthday. Immunization service 2 ZAMBIA, National Health Strategic Plan

15 Comprehensive Multi Year Plan (cmyp) delivery is organized and offered at all static points and outreach posts.;however, during the biannual Child Health Week, immunization is offered to children older than one year who may have missed their earlier opportunity. With a total surface area of 752,612 square kilometres and a population of million people (2010 CSO), some provinces are very sparsely populated. This, in addition to topographic characteristics of some areas poses a challenge in reaching the unreached through outreach services. In areas prone to seasonal floods, In this situation, reliable boats and canoes are usually required to reach affected communities living on the islands and across the rivers.. In terms of coverage, there has been a steady increase in the number of districts 45% in 2002 to 59% in 2004), reporting Fully Immunized Children of more than 80%, however, a third of them are still below 80%., as shown in Annex 2. I In terms of coverage, routine immunization, which peaked in 1994 with DPT coverage rates over 90%, showed a downward trend until the year 2000 when it stabilized at 80%. Sustaining high coverage was difficult due to shortage of human resource, poor cold chain and lack of attention to routine activities. This situation triggered the Zambian Government with support from partners to apply for Global Alliance on Vaccines and Immunizations (GAVI) support in 2001 in three areas: Immunization Services Support - 3 years Injection safety - 3years New vaccines The Support from GAVI was aimed at revitalizing routine immunization and to reach unreached children with life saving vaccines. This also provided an opportunity for the country to introduce new injection devices and new vaccines EPI Logistics. The GAVI Institutional Strengthening Support (ISS) window was used to improve the distribution system of EPI vaccines and supplies. The EPI cold chain system was revitalized with the support of JICA as 55% of equipment in the field was replaced in Selected sentinel health facilities are currently being used to monitor vaccine utilization and wastage in the country. Surveillance. Zambia s EPI Surveillance activities are implemented using an integrated approach (in context of Integrated Disease Surveillance and Response (IDSR). Focal point 10

16 Comprehensive Multi Year Plan (cmyp) persons at provincial, district and health facility levels conduct daily active surveillance activities and the high quality AFP surveillance is an indicator of the strength of the surveillance system. Advocacy, Communications and Community Mobilization. Information and community education to raise community demand and utilization of immunization services was scanty during the past few years until the nationwide measles immunization campaign in 2003 which heightened awareness about the value of immunization. An integrated communication strategy is now being developed to streamline and strengthen immunization communication activities. 11

17 Comprehensive Multi Year Plan (cmyp) Programme management In addition to government and cooperating partners contribution most of which contribute through the basket of the sector wide approach process, there has been additional support from the Global alliance on Vaccines and Immunization (GAVI), under the Immunization Services Support, material support of Auto-Disable syringes (ADs) and new vaccines with their injection materials (ADs & safety boxes). The Support from GAVI was aimed at revitalizing routine immunization and to reach unreached children with life saving vaccines. This also provided an opportunity for the country to introduce new injection devices and new vaccines. In total the government of Zambia has received US$46, 540,000 for pentavalent vaccine (DPT-Hib-HepB, US$8,812,000 for tetravalent vaccine (DPT-Hib), US$100,000 for new vaccine introduction, US$3,864,060 for immunization services support, US$ 771,00 for Injection Safety and US$6,605,500 for Health System Strengthening. The country also received a GAVI award of $2.17m in 2005 for high immunization performance. EPI Initiatives 1. Polio Eradication Initiative. Zambia documentation for polio-free certification was accepted in The country conducted three National & Sub-national Polio vaccine Immunization Days (NIDs/ SNIDs), the last of which was in The last indigenous case was identified in 1995 that was followed by an outbreak in Lusaka and Mwinilunga. Cases Wild-Polio Cases by Year Clinical polio cases Virological polio cases Imported Polio Cases Year 2. Maternal & Neonatal Tetanus Elimination The country achieved Maternal Neonatal Tetanus Elimination in A validation exercise using Lot Quality Assurance Cluster Survey (LQA-CS) methodology was conducted in Sesheke and Kaoma Districts. The country passed and was declared having eliminated the disease. 12

18 Comprehensive Multi Year Plan (cmyp) 3. Accelerated Measles Control Following the successful national measles catch-up and follow-up campaigns in 2003 and 2007 respectively, for which the country received an award for excellence from the African Regional Task Force on Immunization the burden of measles had reduced dramatically. However, in 2010, the country suffered a major outbreak of measles recording a total of 15,754 cases of measles with mortality of 160. Zambia: Measles cases and Routine Immunisation coverage, October, Under 5 measles campaign in 4 urban districts Under 5 measles campaign in 37 districts Under 15 measles campaign in all the 72 districts Measles cases Under 5 measles campaign in all the 72 districts Under 4 measles campaign in all the 72 districts Immunisation Coverage Year Measles reported/ confirmed cases Measles Immunisation Coverage Linear (Measles Immunisation Coverage) 4. Reaching Every District strategy: The Reaching Every District (RED) strategy adopted by the country in 2003 as an effective approach to reaching the un-reached children and the missed opportunities has been scaled up to all the districts. Preliminary findings from field assessment revealed an increase in coverage, increased community demand for immunization, and increased community participation. 5. Child Health Week: By 1999, Child Health Week (CHW) emerged as a key delivery strategy for vitamin A supplementation in Zambia. Initially this activity was supported by Cooperating Partners with UNICEF providing vitamin A capsules. Overtime the CHW package expanded to include various high impact interventions: Childhood immunization (Measles, Polio, Tetanus, Diptheria, Pertussis, Hepatitis B, Haemophilus influenzae type B); de-worming; distribution and treatment of insecticide-treated mosquito nets; health education; promotion of hand washing; screening for severe malnutrition; promotion of early infant diagnosis of HIV infection; and 13

19 Comprehensive Multi Year Plan (cmyp) management of childhood illness (IMCI). In 2004 Government institutionalized CHWk whereby it was budgeted for at various levels of the Ministry of Health within the annual action plans. CHWk has since become a sustainable flagship strategy for equitable delivery of high impact interventions twice yearly in all parts of Zambia. 1.4: THE EPI STRATEGIC (MULTI-YEAR) PLAN: A STRATEGIC RESOURCE This EPI Multi-Year Plan (MYP) for the National Immunization Programme will run for five-years ( ), and will feed into the Ministry of Health s National Health Strategic Plan , and the Government of Zambia s Medium Term Expenditure Framework (MTEF) which is implemented on a 3-year rolling phase. It will serve as a tool to mobilize resources, strengthen partnership, and implement identified strategies and activities in high priority areas. The plan will also be used to advocate for increased partner participation and contribution towards the programme. The MYP will be used as a tool for the Interagency Coordination Committee (ICC) to assess and monitor progress and align all resources and stakeholders towards the goals articulated in the document. The total resources required to finance the programme and the gaps are indicated in the table below Total resource requirements $32,352,320 $49,210,661 $48,942,979 $50,826,016 Total Secured Financing $36,924,105 $41,395,086 $44,622,787 $45,584,209 Funding gap (with secured funding only) -$4,571,785 $7,815,575 $4,320,192 $5,241,807 Funding Gap (with secured & probable funds) -$8,800,127 -$1,249,395 -$1,878,609 $207,528 Total percent of needs -27% -3% -4% 0% 14

20 Comprehensive Multi Year Plan (cmyp) 1.5: STRATEGY DEVELOPMENT - FOUNDATION AND PROCESS This EPI Multi-Year Plan (MYP) for the National Immunization Programme will run for five-years ( ). It will feed into the Ministry of Health s National Health Strategic Plan and the Government of Zambia s Medium Term Expenditure Framework (MTEF) which is implemented on a 3-year rolling phase. It will serve as a tool to mobilize resources, strengthen partnership, and implement identified strategies and activities in high priority areas. The plan will also be used to advocate for increased partner participation and contribution towards the programme. The cmyp will be used as a tool for the Interagency Coordination Committee (ICC) to assess and monitor progress and align all resources and stakeholders towards the goals articulated in the document. The strategy development process was inclusive and entailed intensive consultations with stakeholders during a 5-day workshop at New Safari Hotel, Arusha, July, The workshop was facilitated by WHO HQ Geneva and UNICEF New York Programme Officers 15

21 Comprehensive Multi Year Plan (cmyp) 2. THE VISION & GOALS T he vision, goals and guiding principles of the Multi Year Plan are articulated in this section. 2.1 THE VISION The Vision of the Zambia National Immunization programme for is ambitious. It is one in which: Immunization is highly valued as a national development issue Every child, adolescent and adult has equal access to immunization as provided for in the national schedule More people are protected against more diseases Immunization and related interventions are sustained Immunization is seen as a critical part of a wider health system strengthening and reforms effort and as a critical way to meet Zambia's MDGs; and Vaccines exert the maximum impact on Zambian health and security. 2.2 NATIONAL GOALS AND PRIORITIES The national goals and priorities are as follows: 90% of Zambian infants fully immunized Polio-free status sustained Measles mortality reduced by 95% Maternal and neonatal tetanus is elimination sustained New generations are protected against pneumonia Diarrheal disease burden from Rotavirus reduced Zambia on track to meet Millennium Development Goals Immunization programme financially sustainable Evidence used to make immunization decisions Strong synergies between immunization and related interventions Towards the attainment of the national goals, the national objectives and their related global objectives are shown below (Table 1). 16

22 Comprehensive Multi Year Plan (cmyp) TABLE 1: THE NATIONAL OBJECTIVES & RELATED GLOBAL OBJECTIVES National Objectives 98% Penta3 and fully immunized nationally by 2015 Related Global Objectives Coverage 1 1. By 2014 or sooner all countries will have routine immunization coverage at 90% nationally with at least 80% coverage in every district 80% of districts to have 80% fully immunized by 2013 Sustain Certification of polio-free status Polio 1 2. By 2014, the world will be certified polio-free Sustain Measles mortality reduction by 90% 3. Measles 2 90% reduction goal in infant mortality by 2010 compared to 2000 Sustain Elimination of MNT by 2015 NT 1 Elimination in every district by 2005 PCV10 introduced by 2012 Rotavirus vaccine introduced by 2012 New Vaccine introduction Measles vaccine second dose introduced by 2012 Safety Sustain the use of only auto-disable syringes for immunization. Policy developed to protect HCWs against HBV and in place Incinerator available in 85% of districts by

23 Comprehensive Multi Year Plan (cmyp) 2.3 THE GUIDING PRINCIPLES The following guiding principles inspired the formulation of the draft Multi Year Plan. Equity and gender Equality. All children, adolescents, men and women in Zambia have a right to equal access to the national immunization programme regardless of their socioeconomic status, religious or political affiliations. Ownership, Partnership and Accountability. The goals of the national programme on immunization are determined by the Ministry of Health, and other stakeholders, including co-operating partners and donor agencies. It is owned by the MoH; however, all stakeholders are accountable for the immunization policies and actions. Strong District-Based National Immunization System. The Districts carry out their EPI interventions, monitoring and evaluation services in a decentralized health care system, working in partnership and within the socio-economic context of their communities thus ensuring ownership and acceptability of the services. Quality-assured Immunization services. Immunization services are delivered according to best practices with products that meet internationally recognized standards. Sustainability through Technical and financial Capacity building. With the MoH and partners working collectively, financial and technical self-reliance is a key target toward sustainability. l Strategies based on evidence and best practices. The choice of strategies and practice is informed by data from operational research, surveillance, monitoring and evaluation, disease burden, and impact assessments, and economic analysis, and by the sharing of lessons and experiences from countries in similar circumstances. 18

24 3. THE STRATEGIC FRAMEWORK Comprehensive Multi Year Plan (cmyp) Reaching the challenging goals of the Comprehensive Multi Year Plan will require concerted, sustained action by government and all stakeholders. To chart the directions and show the key actions required to accelerate progress toward the goals, this section presents the strategic framework developed. The framework contains 16 key strategic elements. These elements fall into 4 categories the Pillars of the Immunisation and Vision Strategy: Protecting more people Introducing new vaccines and technologies Integrating immunization, other health interventions and surveillance in the context of the health system Sustainable immunization financing. Pillar 1: Protecting more people This pillar covers all the important activities required to reach all the un-immunized children in the hard-to-reach areas and those who are eligible of the newly introduced vaccines including the missed opportunities. The aims are to reach every under one year old child with at least five immunization service contacts, to immunize other age groups in order to maximize the impact of existing vaccines, and to improve vaccine management systems in order to ensure immunization safety, including the availability of safe and effective vaccines at all times. 1.1 Strategy 1: Use a combination of approaches to reach everyone targeted for immunization Strengthen national commitment to immunization services Scale up RED strategy in all districts Use Child Health Weeks to immunize children who were not immunized during infancy. 1.2 Strategy 2: Increase community satisfaction and demand for immunization Finalize Communication Strategy and implement it Assess the existing communication gaps Engage community members, NGOs and interest groups in immunization Define approaches to motivate community volunteers 19

25 Comprehensive Multi Year Plan (cmyp) Create awareness on benefits of immunization through different media Develop key messages to promote immunization Develop information, education and communication (IEC) materials to ensure good understanding of the benefits of existing and new vaccines Monitor community satisfaction Strategy 3: Vaccinate beyond the traditional target group Review current national policy to identify other target populations for vaccination appropriate to the national situation Explore mechanisms for delivering immunization services to school health and missed target groups Strategy 4: Improve vaccine, immunization and injection safety Ensure use of AD syringes and safe disposal for all injections Harmonize the injection safety disposal practices among key stakeholders Strengthen HCW access to post exposure prophylaxis and hepatitis B vaccination Advocate for involvement of Pharmacy and Poisons Board in quality control of vaccines Monitor injection practices and re-enforce safe injection practices including waste disposal Strengthen surveillance and response to adverse events following immunization Strategy 5: Improve and strengthen vaccine management systems Conduct regular demand forecasting at all levels to ensure uninterrupted supply Training of cold chain technicians and health providers on vaccine management Improve vaccine wastage monitoring Efficient distribution of vaccines at all levels Maintain well functioning cold chain system Build capacity for effective vaccine management through training and supervision Build capacity for effective supervision through training Advocate for the application of a coordinated and sector-wide management for transportation and communications Update and disseminate immunization guidelines Train in wastage rate monitoring and reduction Strategy 6: Strengthen and evaluate the immunization programme 1.3 Conduct regular immunization programme evaluations 1.4 Document best practices to improve the delivery of immunization 1.5 Strengthen the immunization component in the NHSP,MTEF,BHCP documents 20

26 Comprehensive Multi Year Plan (cmyp) PILLAR Two: Introducing new vaccines and technologies This focuses on introducing the new vaccines and technologies such as the Auto Disable syringes and their safe disposal. Strategy 7: Prepare for the introduction of Rotavirus and Pneumococcal vaccines Strengthen capacity to assess disease burden and cost-effectiveness of new vaccines (Rota, Pneumo, and others) Expand the sentinel sites for specific targeted diseases Develop introduction plans and proposals for new vaccines PILLAR Three: Integrating immunization, other health interventions and surveillance in the health systems context The pillar focuses on strengthening the health system through capacity building, improving logistics and ensuring financial sustainability and linking immunization to other child health activities. It also ensures that immunization is included in emergency preparedness plans. Strategy 8: Strengthen the management, analysis, interpretation, use, and exchange of data at all levels Advocate for revision of HMIS (indicators and tools for capturing data) Strengthen immunization/idsr information system Conduct National DQS Workshop Conduct Data Quality Self Assessments Conduct immunization coverage surveys Strategy 9: Improve human resources management Create an Immunization Team in MoH structure Strengthen pre-service training Strengthen in-service training in immunization Develop job descriptions for all levels Strategy 10: Sustain and develop appropriate interventions for integration Sustain frequency and increase interventions offered during Child Health Weeks Explore opportunities for combined monitoring meetings and supervisory visits Promote an integrated service delivery package for all facilities including NGOs and private sector 21

27 Comprehensive Multi Year Plan (cmyp) Strategy 11: Strengthen surveillance and monitoring Monitor service coverage, vaccine utilization and wastage rates Develop and submit polio-free document for certification Training of staff in the use of monitoring tools and appropriate response Develop and disseminate feedback bulletin on immunization in the context of IDSR Update clinicians, staff and policy makers in case based surveillance Update surveillance and monitoring guidelines Follow-up cases identified under case-based surveillance (e.g. AFP, measles, AEFI) Train staff in the use of computerized surveillance and monitoring tools Strengthen laboratories for surveillance activities Document experience gained by introduction of new vaccines and technologies Measure impact of Hib and HepB vaccine on disease burden Strategy 12: Provide access to immunization in emergency and special situations Strengthen planning for immunization in emergencies and special situations (e.g. refugee camps and outbreaks) Prepare immunization teams to better respond to complex humanitarian emergencies Strengthen epidemic and prevention plans relevant to specific diseases Strengthen regulatory capacity to respond urgent needs for epidemic preparedness Maintain adequate supply needed emergency vaccines Strategy 13: Strengthen linkages with stakeholders (e.g. clinicians, traditional healers, other programmes) Define roles and responsibilities of partners at all levels Set national immunization goals with key partners Encourage active participation of all partners in ICC Strengthen advocacy for immunization through the ICC PILLAR Four: Sustainable immunization financing This pillar focuses on sustainable financing of immunization services by all communities Strategy 14: Improve capacity for mobilization of financial and other resources Mobilize additional resources for immunization Advocate for prioritization of immunization in district action plans and budget Strategy 15: Integrate new vaccines into medium-term expenditure framework (MTEF) and National Health Strategic Plan and budget 22

28 Comprehensive Multi Year Plan (cmyp) Promote Vaccine Independence Initiative Advocate for long-term funding from government and supporting partners for immunization 1.6 Strategy 16: Increase partner financial support for immunization Increase number of partners contributing to immunization The Key Activities, Indicators and Milestones for each strategic element are shown below. 23

29 Zambia Immunization Vision and Strategy, 4. FINANCING THE STRATEGY Financing the Zambia Immunization Vision and Strategy will require increasing costs over the as in Annex 3-costing sheet. The marked increases in programme costs are driven mainly driven by: 1. Supplemental Immunization Activities 2. Introduction of new vaccines, and 3. Increases in population of children to be vaccinated due to coverage improvements and increase in the annual birth cohort. Over the period 2011 to 2015, the total programme costs are over USD $ 247 million. xx For these future programme requirements, the funding situation is presented in Table 4. The detailed are shown on Annex 3. Table 4: Annual funding situation for Zambia Immunization Vision and Strategy,

30 Zambia Immunization Vision and Strategy, Secure funding represents funds from GAVI, and Government. Probable funds represent those funds from multilateral agencies, JICA and the common basket. The funding from the multilateral agencies (WHO and UNICEF) is probable based maintenance of their respective current funding to the programme. The funding gap in the near future implies that the programme has to seek innovative means to raise resources to close this gap. The overall strategy shall seek to have Government (and donor) resources increasingly used towards vaccine purchases, with the bulk of the remaining programme operational costs covered by additional support mobilized from other sources. This strategic plan illustrates how the country will achieve financial sustainability within the Government mechanisms for resource mobilization and use. This is based on a mix of: Mobilization of additional resources (local and external), Increase in reliability of resources, and Strategies to increase programme efficiency. These are articulated in Pillar 4 of Immunisation and Vision Strategy. However, the opportunities and challenges to immunization programme financing are shown in Table 5. Table 5: Opportunities and Challenges to Immunization Programme Financial Sustainability Opportunities for financial sustainability Challenges to financial sustainability At the international level - Support for the programme particularly seen - Programme donors still too few in SIAs support - Vaccine pricing and supply - Other global initiatives imply competition for resources with other actors At the central level - Vaccine financing included in MTEF - Financial commitment to health low - SWAp process - A weak private sector - SWAp process with common basket - High reliance on donors to fund budget - EPI Government priority as seen in manifesto of ruling party. - Devaluation of the Kwacha when bulk of EPI requirements require foreign exchange At the health sector - Resource flows to the programme - Financial commitment to the programme is commenced low - Private sector contribution at SIAs - Very low population density in some areas making access expensive - Limited human resources at central level - Integration with other programmes At the implementation level 25

31 Zambia Immunization Vision and Strategy, - Decentralization - Limited resource mobilization capacity - Better strategies to improve access and use of health services - High wastage, with little appreciation of cost implications of vaccines and supplies - Services improving in rural areas, such as - Limited human resources and equipment electricity and radio communication - Unplanned expansion of infrastructure - No training for EPI field staff for over 10 years - Community involvement and participation low 26

32 5. IMPLEMENTATION PROCESS Zambia Immunization Vision and Strategy, Effective implementation of the EPI Multi-year strategic plan is crucial to the achieving the important milestones and goals. Important tools and systems that will ensure implementation of the MYP, make this strategy to work are the strategy map and keeping the timeline and milestones on the radar screen of programme managers at national, provincial and district levels. 5.1: THE STRATEGY MAP - THE ROAD MAP At the centre of the implementation process of the Zambia Immunization Vision and Strategy is the Strategy Map. This strategic map or roadmap is critical for all stakeholders as it: Illustrates the vision and strategy in simple terms so everyone can understand and more importantly contribute defines objectives clearly into simple language clarifies the key activities and processes to support those objectives determines the targets for all stakeholders Creates cause-and-effect relationship between the various strategies, objectives and goals. It may also be used as a foundation for a robust EPI programme performance management system. 4.2: MONITORING PROGRESS: THE TIMELINE AND MILESTONES Monitoring the progress in the implementation of the strategy is important for success. The major milestones along the timeline of this strategy are shown in Section 4. All efforts must be made to ensure that the key timeline and milestones remain on the radar screen of programme managers at national, provincial and district levels. 27

33 Zambia Immunization Vision and Strategy, 28

34 Zambia Immunization Vision and Strategy, Annex 29

35 Zambia Immunization Vision and Strategy, Annex 1: Zambia EPI Diseases Burden (2003 to 2008) Disease Polio AFP Rate* NNT *** 8 Measles** Rubella** Diphtheria Pertusis Hepatitis (suspected) No data Mumps 2,938 7,228 7,069 2,719 5,750 5,315 Tetanus Meningitis (H. Influ. Type b) *Rates 100,000 < 15 years old Campaign. *** Laboratory confirmed. ** Case-based surveillance for suspected measles started after the 2003 National Immunization 0 30

36 Zambia Immunization Vision and Strategy, Annex 2A: Situational analysis by accelerated disease control initiatives, based on previous years' data ( ) System components Suggested indicators National Polio MNT Measles OPV3 coverage 88% 97% 96% Non polio AFP rate per 100,000 children under 15 yrs. of age Extent: NID/SNID No. of rounds Coverage range Nil Nil 30 Districts under five, 1 dose -90% TT2+ coverage 71% 77% 76% Number of districts reporting > 1case per 1,000 live births Was there an SIA? (Y/N) NO NO NO Measles coverage 97% 90% 92% No. of outbreaks reported Extent: NID/SNID Age group Coverage 9-59 months- 88% Nil Nil It is useful to include the data source for each data set. Draft 3-Oct-11 31

37 Zambia Immunization Vision and Strategy, Annex 2B: Situational analysis of routine EPI by system components based on previous years' data ( ) System components Suggested indicators National Routine Coverage National DTP3 coverage 92% 95% 98% % of districts with > 80% coverage 74% 80 86% National DPT1-DPT3 drop out rate NA NA Percentage of districts with drop out rate DTP1-DTP3>10% NA NA New vaccines National HepB3 coverage 92% 95% 98% Routine Surveillance % of surveillance reports received at national level from districts compared to number 85% 90% 95% of reports expected Quality of surveillance data sufficient? (Y/N) Yes Yes Yes Cold chain/logistics Percentage of districts with adequate number of functional cold chain equipment Traditional + 10 dose penta Immunization safety and Waste Management Vaccine supply Percentage of districts supplied with adequate (equal or more) number of AD syringes for all routine immunizations 95% 60% 50% 100% 100% 100% Percentage of districts supplied with safety boxes 100% 100% 100% Percentage of districts with proper sharps waste management systems 100% 100% 100% Was there a stock-out at national level during last year? (Y/N) YES NO NO If yes, specify duration in months 2/12 NA NA If yes, specify which antigen(s). BCG, NA NA OPV Communication Availability of a plan? Communication Strategy (Y/N) NO NO YES It is useful to include the data source for each data set. Draft 3-Oct-11 32

38 Zambia Immunization Vision and Strategy, Percentage of districts which have developed EPI communication plans ND ND ND Financial sustainability Management planning Percentage of caretakers of children < 1yr understanding the importance of routine immunization. What percentage of total routine vaccine spending was financed using Government funds?(including loans and excluding external public financing) ND ND ND 30% 29% 37% Are a series of district indicators collected regularly at national level?(y/n) YES YES YES Percentage of all districts with microplans. 100% 100% 100% Research/studies Number of vaccine related studies conducted/being conducted 4 VMA, HIB, CCA, Post Campaign NRA Number of functions conducted Nil Nil Nil National ICC Number of meetings held last year Human Resources availability Transport / Mobility Waste Management Percentage of sanctioned posts of vaccinators filled Percentage of health facilities with at least 1 vaccinator Percentage of vaccinators time available for routine EPI 10% 10% 10 Number of vaccinators / population 117 Percentage of districts with a sufficient number of supervisory/epi field activity 60% 75% 70% vehicles/motorbikes/bicycles in working condition Availability of a waste management plan YES YES YES Vaccine wastage monitoring at national level for all vaccines? (Y/N) NO NO NO Linking to other Were immunization services systematically linked with delivery of other interventions YES YES YES Health Interventions (Malaria, Nutrition, Child health etc)? Programme Efficiency Timeliness of disbursement of funds to district and service delivery level YES YES NO 2 HIB, PIE 2 HIB VMA NloteSchool Immunization Activities Age Antigens provided Coverage 2007 TT BCG Vitamin A Mebendazole Coverage 2008 Coverage 2009 Draft 3-Oct-11 33

39 Zambia Immunization Vision and Strategy, Annex 2C: National objectives and milestones, AFRO regional and global goals National priorities NIP Objectives NIP Milestones AFRO Regional goals Order of Priority To increase and sustain proportion of districts attaining >80% coverage for DPT3, 90% OPV3 coverage in 85% of the districts, 90% Measles coverage in 85% DPT3 coverage in 85% of the districts by % OPV3 coverage in 85% of the districts by % of the districts 90% Measles coverage in 85% of the districts by Sustain MNTE status Vitamin A Supplementation 95% of districts with Vitamin A Coverage > 90% 60% TT2+ Coverage in 50% of the districts by % Vitamin A supplementation in 90% of the districts during CHWk by : Increase from 80% districts achieve DTP3 coverage of >= 80% to 85% 2010: Increase from 88% districts achieve OPV3 coverage to of >= 80% to 90% 2010: Increase from 86% districts achieve Measles coverage of >= 80% to 90% 2010: Increase from 43% districts achieve TT2+ coverage of >= 60% to 50% 90% districts achieve, sustain Vitamin A supplementation of 95% coverage By 2010 all countries will have routine immunization coverage of 90% nationally with at least 80% coverage in every district. By 2014 all countries will have routine immunization coverage of 90% nationally with at least 80% coverage in every district. Achieve 95% measles mortality reduction Elimination of MN Tetanus Pneumonia High pneumonia disease burden in U5 year olds, PCV not 85% Pneumo coverage in 85% of the districts by : To introduce PCV in all districts by , 60% districts achieve Pneumo coverage of >= 80% 1 Draft 3-Oct-11 34

40 Zambia Immunization Vision and Strategy, National priorities NIP Objectives NIP Milestones AFRO Regional goals Order of Priority implemented in Zambia Rota High diarrhoea disease burden (35-50% Acute diarrhoeal hospitalizations at Pead UTH due to Rota) in U5 year olds, Rota not implemented in Zambia High disease burden of cervical cancer needs to be addressed 85% Rota coverage in 70% of the districts by To introduce HPV vaccine beyond : To introduce Rota in all districts by achieve 70% districts achieve Rota coverage of >= 85% Support operational research on introduction of HPV vaccine 2 4 Immunization Safety Sustain 100% availability of AD syringes for the supply period in 100% of the HFs. Waste Management Sub optimal injection waste disposal practices and inadequate incineration facilities Sustain 100% use of AD syringes for immunization services in 100% health facilities % use of standard methods of injection waste disposal in 100% health facilities % of the health facilities provided with AD syringes 2010: 100% use of standard methods of injection waste disposal in 100% of the health facilities By the end of 2014, all immunization injections are administered safely. By the end of 2014, there is safe disposal of clinical waste. 1 2 Draft 3-Oct-11 35