Figure 1: Mozambique Administrative Map

Transcription

1 Republic of Mozambique Ministry of Health Expanded Programme on Immuniizatiion Comprehensiive Mulltii-Year Pllan ( ) i

2 Figure 1: Mozambique Administrative Map ii

3 Foreword The Mozambique Extended Programme of Immunization has, since its inception in 1979, been committed to the reduction of infant mortality and morbidity, by the provision of immunization services at all levels, to achieve the long-term objective of the reduction of vaccine preventable diseases. Considerable resources, both financial and human have been invested in the building and development of a health system capable of reaching the entire population with a range of health services. Results from different community surveys indicate that the proportion of one year old children fully immunized with DTP3 has increased from 47% in 1997 to 63% in 2003 and up to 64, 4 in Despite these progresses made over the years, Programme performance indicators are still poor and few districts have achieved 80% coverage in all antigens. The constraints related to weak performance of the EPI Programme in Mozambique were identified and highlighted in several external reviews of the Programme. They include amongst others, issues related to the structural and functional organization of the EPI Programme at all levels, poor Programme data management, inadequate logistic including poor vaccine stock management, insufficient cold chain capacity, poor cold chain management, deficient implementation of RED strategy, mainly due to poor micro planning process and insufficient financial resources and transport, shortage and insufficient training of health staff associated with inadequate supportive supervision at all levels of the health system, lack of updated EPI manual and technical guidelines, and non functional ICC, etc. This comprehensive Multi Year Plan aims to address the above mentioned weaknesses and the challenges foreseen in the coming years with a view to devising strategies in line with the global vision for immunization (GIVS). Annual achievement targets will be set to strengthen the EPI programme in the coming five years, as Mozambique strive to achieve the Millennium Development Goals and the national goals as defined in the Health Sector Strategic Plan (HSSP). The framework contained in the document provides a schedule of actions, that focus on supporting poorly performing districts to improve performance through integrated efforts, achieving and maintaining polio eradication status, vaccination of wider age groups to ensure control of vaccine preventable diseases such as measles and tetanus, sustaining availability of vaccines and expanding and improving the disease surveillance system, while introducing new vaccines as they become affordable and sustainable. The Ministry of Health, would like to express its appreciation to donor partners for their commitment to health provision over a wide range of health initiatives and it pledges government s full support in the implementation of this plan and looks forward to partner s continued support as the country strives to improve and achieve the challenging goals set out in the Comprehensive Multi Year Plan. iii

4 Executive Summary This comprehensive Multi Year Plan (cmyp) has been completed first as a planning document for EPI in Mozambique and then as a requirement for extended GAVI support for pentavalent vaccine for the EPI through the Ministry of Health of the Government of Mozambique. The Multi Year Plan contains a brief review of the country and its economic situation. The organization of health services provision is outlined and a brief history of the EPI programme provided. A comprehensive review of all aspects of the EPI programme was conducted in April 2006 at district level. A thorough and critical analysis of the coverage, service delivery, vaccine supply and logistics, advocacy, surveillance and monitoring, programme management and the ability of the EPI to secure sustainable financing was conducted. On completion of the situation analysis, an assessment of the Strengths and Weaknesses was conducted to determine how existing best practice could be maintained and where future management initiatives must be undertaken to enhance service delivery. Using the Comprehensive Multi Year Planning Costing Tool Vesrion 2.2, a full costing and financing of all aspects of EPI was conducted reviewing the cost of vaccines, personnel, transport, cold chain and the provision of shared services with a view to ascertaining estimated total cost for the period Analysis of current and future financing and the sustainability of the activities of the EPI were assessed. The conclusion drawn is that the EPI at present is heavily dependant on donor support. The final section of the cmyp sets out a comprehensive plan for 2009 setting out objectives and strategies for strengthening current service provision by increasing coverage, improvement of the cold chain, reducing dropout and provision of training for the introduction of the Pentavalent vaccine in The comprehensive Multi-Year Plan is one year longer than the National Health Sector Plan of Mozambique, and is to a great extent linked with the Medium Term Expenditure Framework (MTEF) of Mozambique , MDG 4 & 5, and IHP+. However, the Director of Planning has reassured the working team the last year of funding for the cmyp will be adequately catered for by her department. The cmyp sets out the priorities to strengthen EPI service provision at Central, Provincial, District and Health Facility levels. It will be the working document for the Ministry of Health and EPI management with the overall goal of achieving the Millennium Development Goals. iv

5 TABLE OF CONTENTS Foreword....ii Executive summary...iii Table of contents iv List of tables...vi List of figures.vi Acronyms and abbreviations.... vii 1 Introduction Country profile Macro economic situation National health system Health financing Human resources for health.3 2 The Mozambique expanded programme on immunization The EPI mission, goals and objectives Situation analysis of the national EPI programme EPI service delivery Vaccine preventable disease surveillance. 7 3 National priorities, objectives and milestones, Mozambique Strategies, key activities and timeline Costing and financing of Multi-year plan Costing and financing methodology Cost profile (routine only) Baseline financing Programme costs recourse requirement for Projected financing form all sources Future financing Additional cost of introducing pneumococcal vaccine..38 v

6 6 Financial sustainability Financial sustainability strategies, actions and indicators Opportunities Threats Alternative policy scenario for financial sustainability Strategies and actions for financial sustainability Mobilizing additional resources Increasing the reliability of resources Improving programme efficiency Progress monitoring Immunization programme annual work plan for List of appendices...55 vi

7 LIST OF TABLES Table 1 Immunization schedule in Mozambique...3 Table 2 Vitamin A supplementation schedule in Mozambique...4 Table 3 Target population estimates Mozambique Tables Situational analysis by accelerated disease control initiatives 9-10 Tables Situational analysis by routine immunization system component Tables Summary of strengthens and weaknesses by accelerated disease control initiatives Table National priorities, objectives and milestones Tables 7.1 Service delivery.23 Tables 7.2 Logistics, equipment maintenance, vaccine supply and quality Tables 7.3 Advocacy and communication...25 Tables 7.4 Disease surveillance and accelerated disease control.26 Tables Programme management Table 8 Programme costs and future resources requirements.32 Table 9 Resource requirements, financing and gaps...36 Table 10 Additional cost of introducing pneumococcal vaccine...38 Table 11 Immunization sustainability analysis for Mozambique and selected indicators 39 Table 12 Activities and indicators for follow up of financial sustainability strategies. 46 Table 13 Strategies, key activities and timeline 47 LIST OF FIGURES Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8 Mozambique administrative map. i New EPI structure at central level....5 New EPI structure at provincial level...5 Baseline cost profile (routine only) 31 Baseline financing profile...33 Projection of future resource requirements.34 Future source financing and gaps...37 Future secure + probable financing and gaps.37 vii

8 ACRONYMS AND ABBREVIATIONS AEFI BCG cmyp CDC CBOs DPT-HepB EPI FCH FSP FIC GAVI/VF GIVS GDP GNP HIV/AIDS Hib HMIS ICC IDSR IEC IHP+ IMCI JICA MCH MOH MoND MNT NHL NIDs Adverse Event Following Immunization Bacille Calmette-Guérin (tuberculosis vaccine) Comprehensive Multi Year Plan Communicable Diseases Control Community Based Organizations Diphtheria, Pertussis, Tetanus Hepatitis B Expanded Programme on Immunization Family and Community Health Financial Sustainability Plan Fully Immunized Child Global Alliance for Vaccines and Immunization/Vaccine Funds Global Immunization Vision and Strategies Gross Domestic Product Gross National Product Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Hemophillus influenzae type b Health Management Information System Inter-Agency Coordinating Committee Integrated Disease Surveillance & Response Information Education and Communication International Health Partnership Integrated management of Child Illnesses Japan International Cooperation Agency Maternal & Child Health Ministry of Health Ministry of National Development Maternal Neonatal Tetanus National Health Laboratory National Immunization Days viii

9 OPV PMBS PHC Oral Polio Vaccine Pediatrics Bacterial Meningitis Primary Health Care PROSAUDE PRSP RED RH SIAs STDs SWAP TT TNA UNICEF USAID WHO WPV Poverty Reduction Strategy Paper Reach Every District Reproductive Health Supplementary Immunization Activities Sexually Transmitted Diseases Sector Wide Approach Programme Tetanus Toxoid Training Needs Assessment United Nations Children s Fund United States Agency for International Development World Health Organization Wild Polio Virus ix

10 1. INTRODUCTION 1.1 Country profile Mozambique is located on the east African coast, and covers a total surface area of 799,380 km 2. It borders South Africa, Swaziland, Zimbabwe, Zambia, Malawi, Tanzania and the Indian Ocean. Administratively, Mozambique is divided into 11 provinces, which in turn are divided into 144 districts. Maputo city, which has provincial status, is also the country s economic and political capital. Of the 11 Provinces, the most populous are Zambézia and Nampula, which respectively have 20.34% and 19.47% of the Mozambican population. The average population density is 20 inhabitants per Km 2. This varies from 35 inhabitants/km 2 in Nampula to 6 inhabitants / km 2 in Niassa. The female population is 52% (INE); the urban population (people living in the provincial capitals) is only 23% of the total, which means that the country is essentially rural (IDSM, 1997). The country s population in 2009 is estimated at 21.3 million (INE projections based on the 1997 population census). According to the 1997 census, the current natural population growth rate is 2.4%. The proportion of people under 15 years old is 44.5% of the population and the dependency ratio is about 90%. The country has been affected by a prolonged period of conflict resulting in population displacement and settlement around the cities and towns, a situation that remained even after the end of the conflict. 1.2 Macroeconomic situation Mozambique has been successful in terms of economic growth and improving welfare, thanks to the mobilization of donor and domestic resources for investments in social and economic infrastructure to extend access to public services, reduce welfare inequities, and support the livelihoods of the average Mozambican. Despite this progress, Mozambique is still one of the poorest countries in the world, with a gross national product per capita of $387 1, and ranking 172 nd out of 177 countries (with data) in It is the lowest ranked country within SADC. Absolute poverty in the country is the expression of a series of economic and social factors such as low income, poor coverage of the health services (less than 50% of the population) and lack of potable water and basic sanitation. For instance, in 2004, only 32% of the population used improved sanitation and 43% improved water source. High illiteracy rate is 60% (male 39.4%; female 71.3%), inadequate roads, lack of food security-malnutrition (A/I < 2Z score = 41%) among others. 1 INE, *CFMP UNDP, Human Development Report, 2007/08 1

11 1.3 National Health System The health system in Mozambique consists of the public sector, the for-profit private sector, and the notfor-profit private sector. Of these, it is so far the public sector, i.e. the National Health Service (SNS), that is the main health service provider nationally. The SNS is organized into four levels of care. Levels I and II are the more peripheral levels intended to implement the Primary Health Care strategy (PHC) and to refer patients with clinical conditions that cannot be dealt with at level I, such as birth complications, trauma, medical and surgical emergencies etc. Levels III and IV are basically intended for more specialized curative action, and are the reference points for the levels immediately beneath them. In general, PHC remains the dominant strategy of health intervention to reduce the high rates of morbidity and mortality due to transmissible diseases. The reproductive health problems associated with high rates of maternal mortality are also priority areas in the sector s programme. All these interventions in the framework of PHC are important components of the Action Plan for the Reduction of Absolute Poverty (PARPA). 1.4 Health Financing Health sector expenditure for the implementation of National Health Service activities is financed either by the state budget or by bilateral or multilateral donors. The Ministries of Planning and Finance (MPF) assigns funds to the health sector on an annual basis in accordance with revenue received, either from the state budget or from families. Vaccines are purchased for the whole sector by the Pharmaceutical Purchasing Department, except for new vaccines such as pentavalent, which is purchased through UNICEF Supply Division. External funds are channeled to the sector through international organizations or agencies. International agencies contribute more than half of health sector expenditure (60%) and over 50% of EPI costs. However, the state budget's contribution to the health sector has grown significantly in real terms over the past few years. A successful Sector Wide Approach (SWAp) Programme, the cornerstone of the health sector s relationship with partners, is in place since Mozambique has more than 25 development partners supporting the health sector (Annex F). Despite a well coordinated SWAp and with the emergence of many new health initiatives, the need for improving donor harmonization and alignment has been recognized by all health partners. Issues like late disbursements, unpredictability of funding and lack of sustained long term financing agreements, agency specific reporting mechanisms and resistance of agencies to be coordinated remain some of the challenges to be addressed. The new memorandum of understanding between common fund partners and MoH removed in year triggers for disbursements as 2

12 one of the efforts to simplify the flow of development aid. The recent signing of IHP+ compact is an effort towards alleviating these problems. 1.5 Human Resources for Health The country s health system faces a chronic shortage of critical inputs for health service provision, which has a negative impact on the availability of services and the quality of health, particularly in rural areas (PESS, ). The lack of human resources capacity is by far the greatest barrier to overall health sector delivery in Mozambique. Mozambique has one of the lowest health worker densities in Africa, with less than 0.3 health workers per 1,000 population. It has only 0.03 doctors and 0.21 nurses per 1,000 population, lower than most neighboring countries (WHO Annual Report, 2006). Health staff distribution around the country still shows considerable regional asymmetries. This human resources crisis has been recognized as a major constraint towards attaining the health related millennium development goals. In order to address this workforce crisis, the MoH has agreed on an ambitious and comprehensive National Human Resources for Health Development Plan, THE MOZAMBIQUE EXPANDED PROGRAMME ON IMMUNIZATION Routine immunization is administered to all children under five years in all health service delivery points. The community involvement in immunization services is enhanced by the active participation of community members through non-governmental organizations and other community based organizations such as FDC and Village Reach. These partners remain valuable in ensuring social mobilization for immunization. The following routine antigens are administered to children under the age of one; BCG, OPV, DTP/HepB, Measles. Routine Tetanus Toxoid is administered to women of childbearing age. The immunization schedule in Mozambique is shown in Table 1.3 Table 1. Immunization schedule in Mozambique Vaccination for Infants Women of child bearing age (15-49 years) Age Visit Antigen Visit Interval Antigen Birth 1 BCG, OPV0 1 0 (as early as possible) TT1 6 weeks 2 DTP-HepB1, OPV1 2 At least 4 weeks after TT1 TT2 10 weeks 3 DTP-HepB2, OPV2 3 At least 6 weeks after TT2 TT3 14 weeks 4 DTP-HepB3, OPV3 4 At least 1 year after TT3 or in TT4 subsequent pregnancy 9 months 5 Measles 5 At least 1 year after TT4 or in TT5 subsequent pregnancy 6-59 months Vitamin A Supplement All post-natal mothers Vitamin A Supplement Source: MOH, EPI unit 3

13 Table 2. Vitamin A supplementation schedule in Mozambique Micronutrient supplementation to children and post-partum women 6-59 months Every six months Vitamin A Supplement All post-natal mothers Vitamin A Supplement Source: MOH, Nutrition unit 2.1 The EPI Mission, Goal and Objectives The Mission of the EPI is to enhance the lives of the people of Mozambique by protecting them from and striving to eliminate the suffering caused by vaccine preventable diseases. The Goal is to protect all mothers and their children less than five years of age from vaccine preventable diseases. The Objective is to reduce infant mortality, morbidity, and disability, using the best vaccines and medical technologies and safety practices available. To achieve these goals and objectives, the Programme focus on three major areas, namely strengthening immunization, conducting supplemental immunization activities and sustaining a sensitive disease surveillance system within the Integrated Disease Surveillance and Response framework. Within the MoH structure, the EPI is located in the Department of health promotion within the national directorate for health promotion and disease control. Its structure at central and provincial is shown in the figures 1 and 2. The central level has a role of setting policies, standards and priorities, building capacity, coordinating with partners, mobilizing resources, procurement of inputs such as vaccines and injection safety materials in coordination with CMAM, monitoring and technical support to provincial level. In turn, the provinces are responsible for capacity building, monitoring, supervision and technical support to districts. The districts and their health facilities are responsible for planning, management and delivery of EPI services. At that level, immunization is part of primary health care (PHC) and is integrated into the child survival activities. The community is involved in mobilizing and bringing children for immunization. 4

14 Figure 2. EPI new structure at Central Level National EPI Manager Logistics Maintenance Monitoring & Evaluation Training Figure 3. EPI New Structure at provincial level Provincial Chief Medic Chief of the Community Health Section Provincial EPI Manager Maintenance Logistics 5

15 2.2 Situation Analysis of the National EPI Programme Since its inception in 1979, the EPI Programme in Mozambique offers vaccination for the six traditional vaccines. In 2001, the Programme introduced AD syringes and HepB as tetravalent vaccine under GAVI Phase I support. Hib in pentavalent formulation will be introduced in 2009 under GAVI Phase II support.. Although, immunization services focus on children under one age and pregnant women, other groups such as under 5, under 15 and women of child bearing age are also targeted, within the framework of the accelerated disease control or elimination and eradication, to achieve the global targets of polio eradication, elimination of maternal and neonatal tetanus, and accelerated measles control. The targeted population for routine immunization, SIAs and their respective percentages of the population estimated using the 1997 census assuming a growth rate of 2.4% is as per Table 2.1. Table 3. Target Population (estimates), Mozambique % Total Population 20,854,057 21,350,08 21,854,387 22,367,907 22,891,294 23,424,298 Infants 0-11 months ,, , , , , ,972 Under 5 years ,566,044 3,650,851 3,737,100 3,824,912 3,914,411 4,005,555 Population 6-59 months ,420,065 3,501,401 3,584,119 3,668,337 3,754,172 3,841,585 Pregnant women 5.0 1,042,703 1,067,500 1,092,719 1,118,395 1,144,565 1,171,215 Women Child Bearing Age ,192,660 5,316,152 5,441,742 5,569,609 5,699,932 5,832, EPI Service Delivery In 2008, immunization services were offered in approximately 1160 health centres, which represents 91% of health unities in the existing health network with fixed vaccination sites. However, less than 50% of the country population is served by the existing health network. To reach the unreached, the country introduced new outreach strategies, namely monthly health days in 2000 and most recently, the Reach Every District (RED) strategy. The latter was implemented in 33 districts in 2008, and there is plan to expand to incrementally 66 in 2009, 99 in 2010, 132 in 2011 and then 144 districts in Although administrative reports of immunization coverage tend to be rather high in Mozambique, there are concerns about the reporting system and fluctuations in reported results, reflecting poor Programme 6

16 data management. Meanwhile, results from different community surveys (DHS 1997, DHS 2003 and routine coverage survey 2005) indicate that the proportion of one year old children fully immunized has increased from 47% in 1997 to 63% in 2003, and up to 64, 4 in A study of Vitamin A deficiency conducted by the MoH in 2004 found 69% of children aged between 6 and 59 months to be vitamin A deficient Vaccine Preventable Disease (VPD) Surveillance Mozambique initiated the AFP/Polio surveillance in 1998 in the context of Polio eradication. In 2005 the country introduced the NNT surveillance and in the following year the Measles case based surveillance. In the first four years of AFP surveillance, performance indicators were very weak, but they have witnessed a considerable improvement since 2002, achieving certification levels in 2003, a situation maintained until However, from 2006 through 2008, these indicators have seen a steady decline and they have always been under the desired performance level. While stool adequacy rates have been maintained above the minimum rate of 80% at the national level over the years, there are serious concerns about the stool adequacy at the sub-national level in several provinces, whose indicators are below the minimum 80% required. On the other hand, since the inception of the measles case-based surveillance in late 2005, the country has never attained the minimum 2.0/100,000 population detection rate at the national level, even though it has witnessed an improvement form a mere 0.6/100,000 in 2006 to 1.95 in Despite this global improvement, there are still big discrepancies at the sub-national level (Provinces). For instance, Maputo Province has the highest rate of 9.99 while Manica has the lowest rate of 0.23 per 100,000 inhabitants. While the proportion of cases investigated with blood samples has been above the minimum of 80%, the proportion of districts that reported at least 1 suspected case with blood samples collected remains critically low. This rate was 22% in 2006 and improved only to 48% in NTT surveillance remains a challenge to the country. Since its inception in 2005, very few cases have been reported, and almost none of them investigated properly. The constraints related to weak performance of the EPI Programme in Mozambique were identified and highlighted in several external reviews of the Programme. These include, amongst others, issues related to 7

17 the structural and functional organization of the EPI Programme at all levels, poor Programme data management, inadequate logistic including poor vaccine stock management, insufficient cold chain capacity and poor cold chain management. There are also deficient implementation of RED strategy mainly due to poor micro planning process, insufficient financial resources and transport, shortage and insufficient training of health staff associated with inadequate supportive supervision at all levels of the health system, lack of updated EPI manual, and technical guidelines, and non functional ICC, etc. Based on these findings, the cmyp recommended further improvement in coverage at district level using strategies like RED approach in order to meet targets for accelerated disease control, addressing training needs of mid-level managers` and operational level workers`, undertaking further assessments of disease burden in view of new vaccines introduction. It also plans to further strengthen surveillance activities at district level to meet standard indicators. The following tables summarize the situation analysis by system components and accelerated disease control initiatives. 8

18 SITUATION ANALYSIS OF THE NATIONAL EPI PROGRAMME Table 4.1: Situational Analysis by Accelerated Disease Control Initiatives, Mozambique, Component Indicators National Polio OPV3 coverage Proportion of districts with OPV3 coverage 80% No of AFP cases detected No of confirmed wild polio virus cases Non-polio AFP rate per 100,000 children under 15 years of age Proportion of districts with non polio AFP rate > 1 per 100,000 Stool adequacy rate Proportion of districts with stool adequacy 85% NIDs/ SNIDs: Number of rounds Coverage range % 9

19 Table 4.2: Situational Analysis by Accelerated Disease Control Initiatives, Mozambique, Component Indicator National MNT TT2 + coverage (pregnant women) Percentage of children protected at birth No of neonatal tetanus cases reported Number of districts reporting > 1 case per 1,000 live births N/A N/A N/A N/A N/A Was SIA conducted (Y/N) N N 1 (15 high risk Y districts) 1 (15 high risk Y districts) N Measles Measles coverage Measles coverage (SIA) Proportion of districts with measles coverage 90% Number of outbreaks reported No of suspected measles cases reported No of confirmed measles cases (Niassa) ,816 12, Proportion of districts with at least 1 blood specimen collected per year NID/SID Age group Coverage - < 15 years - - < 5 Years 10

20 Table 4.3: Situational Analysis by Routine immunization system component, Mozambique, Component Indicators National Service delivery National DPT3 coverage % of districts with DPT3 coverage 80% National DPT1-DPT3 drop out rate % of districts with DPT1-DPT3 drop out rate > 10% New vaccines New vaccines Hib prevalence in Mozambique - 60% DPT/HepB Logistics, equipment maintenance, vaccine supply, quality National stock out of vaccines reported. N N N N Y If Yes, specify duration in months N N N N 1.5 (1.0) If Yes, specify which antigen (s) BCG (Measles) Cold chain/logistics Advocacy and Communication Adequate and functional cold chain capacity at central level for routine vaccines (Y/N) Number of provinces with adequate and functional cold chain (benchmark 11) % of broken down refrigerators at health facility level repaired within 3 months Y Y Y Y N Availability of national communication plan

21 Table 4.4: Situational Analysis by Routine immunization system component, Mozambique, Component Indicators National Surveillance Programme management Monitoring & Supervision Human resources Financial sustainability Linkage to other health interventions Management planning % of surveillance reports received completed and on time at the national level compared to number of reports expected Number of ICC meetings held % of supportive supervisory visits at health facility level with written feedback (benchmark quarterly) % of timelessness and completeness of monthly coverage report form provincial to central level Number of health workers trained in MLM Training needs assessment conducted followed by remedial actions at all levels % of total routine vaccine spending financed using government funds. (including loans and excluding external public financing) Immunization services systematically linked with delivery of other interventions (malaria, nutrition, child health) established Are series of district indicators collected regularly at national level? (Y/N) in Niassa province only * N Y Y Y Y Y Y Y Y Y 0 NRA Number of NRA functions conducted Immunization safety % of districts that have been supplied with adequate number of AD syringes for all routine immunizations Programme efficiency Vaccine wastage monitoring at national level for all vaccine Timeliness of disbursement of funds to district and service delivery level * During 2008 tetravalente vaccine (DTHepB) was not purchased by the country because there was an overstock from previous years. Therefore during this period the Government purchased all other vaccines and that is the reason why the figure in 2008 is 100% of Government funding 12

22 Table 5.1: Summary of Strengths and weaknesses by Accelerated Disease Control Initiatives, Mozambique, 2008 Component Strengths Weaknesses Polio Eradication Measles control High coverage rate. No wild poliovirus detected in the past 9 years Stool adequate rate is good at national level. School based TT vaccination Programme in place SIA strategy in place to boost coverage Integration with measles, vitamin A supplementation and de-worming Neonatal Tetanus Elimination Service delivery Programme well established and running since 1979 There is committed health staff at all levels Reach difficult to reach areas by routine immunization through RED Experience in campaigns adopted in the routine immunization Low proportion of districts with OPV3 coverage above 80% Non Polio AFP rate is lower than expected Low reporting of suspected measles rate Low proportion of districts reporting measles coverage above 90% Poor data quality at health facility level Missed opportunities for TT immunization Limited integration between surveillance and EPI Less than 50% of the population has access to health services High national dropout rate up to 12.8%. 58% of the 144 districts have a drop out rate greater than 10% Inadequate staffing at the health facility level Programme heavily dependent on outreach which is an expensive strategy Difficulties by peripheral health facilities to go on outreach due to lack of transport, fuel and allowances Delay in sending data on the number of children immunized, wastage rate and communication activities from the provinces High incidence of Hib associated diseases 13

23 Table 5.2: Summary of Strengths and weaknesses by EPI system components, Mozambique, 2008 Component Strengths Weaknesses Logistics, equipment maintenance, vaccine supply and quality Injection safety and waste management Well-ventilated storage capacity at the central level Continuous power supply with back up from an automatic generator. Vaccine storage at recommended temperature, availability at all levels (central and provincial) of cold boxes, thermometers, vaccine monitors necessary to keep vaccines Deployment of specific logistic and maintenance personnel in all provinces Auto-disable syringes kept in safety boxes immediately after use, regularly collected, burnt and buried in pits Injection practices generally safe at vaccine service delivery point Low level of vaccine wastage reporting Vaccines and related injection safety materials (auto-disable syringes and safety boxes) are not supplied bundled Inadequate stock management at provincial and lower levels Poor recording of injection safety material at central level Vaccine Vial Monitor (VVM) discarding point not observed at health facility level No stock records at provincial level coordinated with central level to monitor vaccine wastage Existence of non recommended and different brands of equipment for EPI at provincial and lower levels Low cold chain capacity at central, provincial and district levels Weak coordination between central and provincial maintenance departments Inadequate maintenance mechanism for EPI equipment at provincial level In most health units, the pits are not adequately protected and are located in places of easy access to the communities. 14

24 Table 5.3: Summary of Strengths and weaknesses by EPI system components, Mozambique, 2008 Component Strengths Weaknesses Advocacy and communication Intense social mobilization campaign with the active participation of community leaders, use of microphones, T-shirts during measles campaign Health Promotion Department under restructuring to timely respond to the needs of the various programmes Strategy in place to boost community involvement through recruitment and training of community health workers (APE s) Surveillance Availability of disease surveillance manuals in all provinces Adequate disease reporting and vaccine register tools available at all levels Surveillance reports available National laboratory capable of making the serological diagnosis of measles. Programme Management Monitoring & Supervision Supervision activities carried out at all levels during integrated measles campaign Human Resources Existence of a national human resources for health policy and plan Basic training for staff at different levels of EPI All staff trained on the technical, operational and logistics aspects during campaigns Dedicated human resources for the EPI at all levels Absence of IEC materials on routine EPI at all levels especially at health facilities Limited use of mass media (TV, radio, newspapers) in routine message dissemination No staff dedicated to social mobilization of EPI at central and provincial levels Underreporting of surveillance data No systematic analysis of coverage, cases and deaths due to vaccine preventable diseases at district levels Weak integration between EPI, health information system and disease surveillance Surveillance of adverse events following immunization (AEFI) not yet in place Not all planned regular supervisions are carried out at all levels Absence of supervision reports in many health facilities and district directorates No follow-up on the recommendations of available reports Supervisory visits usually brief and in many instances do not take into consideration the main aspects of the EPI components No periodic evaluation meetings between different levels of EPI programme No implementation of DQS tool at district level No adequate supervision from central level to other levels No supervisory checklists for routine immunization. Non training needs assessment conducted in the last 10 years Few follow-up trainings held after the basic training of EPI staff Inadequate staffing at all levels High turnover of EPI personnel 15

25 Table 5.4: Summary of Strengths and weaknesses by EPI system components, Mozambique, 2008 Component Strengths Weaknesses Programme Management Financial Sustainability Existence of a SWAP, MTEF, for health sector Most routine vaccines purchased by Mozambican Government Budget line for vaccines in place Linkages to other health interventions Child health weeks adopted as a strategy for service delivery Routine activities are integrated (adopted the mother and child health package) Existence of a MDG 4 & 5 plan Signing of the compact (IHP+) Management planning Indicators are regularly collected from districts to national level Insufficient financial resources to implement EPI Plan of Action. Resources from government alone too small to guarantee financial sustainability Weak integration at central level (e.g. limited joint planning & monitoring) Limited sharing of information No synchronization between the central and provincial/district planning cycles Low quality of district operational plans No update of manuals & dissemination NRA NRA s not functional for EPI Immunization safety AD syringes supplies to all facilities Programme efficiency No systematic vaccine wastage monitoring in place Delayed disbursement of funds to districts 16

26 3. NATIONAL PRIORITIES, OBJECTIVES AND MILESTONES, MOZAMBIQUE Table 6.1 National Priorities, Objectives and Milestones, Mozambique Description of problem of national priority National objectives based on national priority Targets and Milestones Regional and Global Goals Order of Priority Service delivery 1. Low routine immunization coverage rate in many districts despite good national coverage rate above 80% (A) To achieve and sustain high routine immunization coverage at national level of at least 90% and 80% of all districts achieving at least 80% coverage supported by reliable data by the end of 2013, through successively increasing the number of districts implementing RED approach 2009*: establish a reliable data management system in at least 80% of the districts, increase National DPT3 coverage by at least 5% form the baseline of 80% in 2008 (see comment bellow) and National Measles coverage by at least 2% (from baseline of 85% in 2008), and achieve at least 66 districts with at least 80% DPT3 coverage and at least 90% Measles coverage. 2010: increase National DPT3 by at least 3% and National Measles coverage by at least 2%, and achieve at least 99 districts with at least 80% DPT3 coverage and at least 90% Measles coverage. 2011: increase National DPT3 by at least 2% and National Measles coverage by at least 1%, and achieve at least 132 districts with at least 80% DPT3 coverage and at least 90% Measles coverage. 2012: increase National DPT3 by at least 2% and National Measles coverage by at least 1%, and achieve at least 144 districts (100%) with at least 80% DPT3 coverage and at least 90% Measles coverage. 2013: increase National DPT3 by at least 1% and National Measles coverage by at least 1%, and maintain all districts (100%) with at least 80% DPT3 coverage and at least 90% Measles coverage : from a baseline of 33 in 2008, successively increase the number of districts implementing RED approach by 33 each year to reach 144 by and beyond: maintain implementation of RED approach by all districts : implement at least 80% of planned outreach activities in each of the districts implementing RED in that year : timely disburse at least 80% of funds planned for outreach in all districts implementing RED in that year. By 2010 or sooner, all countries will have routine immunization coverage of at least 90% nationally with at least 80% in every district (GIVS 2005) 2. 48% of districts with dropout rate < 10% (B) To achieve a DPT1-3 dropout rate of < 10% in at least 80% of districts by : At least 60% of the districts with drop out rates of < 10% 2011: At least 70% of the districts with drop out rates of < 10% 2012: At least 75% of the districts with drop out rates of < 10% 2013: At least 80% of the districts with drop out rates of < 10% 17

27 Table 6.2 National Priorities, Objectives and Milestones, Mozambique Description of problem of national priority National objectives based on national priority Targets and Milestones Regional and Global Goals Order of Priority 3. High rate of diseases associated with Hib (C) To begin introduction of pentavalent vaccine in the second quarter of : Introduce pentavalent vaccine in the whole country By the end of 2009, at least 80% of countries would have introduced Hib vaccine into their national immunization programme 2 * Please note that our administrative coverage is high in Mozambique, even at district level. For instance, national DPT3 coverage in 2008 was 101%, with 63% of districts with DPT3 coverage than 80%. However the quality of administrative data is questionable and this view has been supported by different coverage surveys and data quality audits. The coverage surveys have shown big discrepancies for less with administrative coverage and the data quality audits have demonstrated the weaknesses of the HISM and unreliability of data collected through this system. Therefore, we have decided to use as baseline for this plan our best DPT3 and Measles coverage estimates as presented in the JRF2008, that is, 80% for DPT and 85%for Measles coverage at national level. Please note also that there are discrepancies between routine administrative data and CAD matrix monitoring data. The reason is that the Joint Monitoring and evaluation (CAD matrix) is conducted at the beginning of the year, usually January, at the time when data is still incomplete, as district data for a given year is expected to be complete at provincial and national by March of the following year. Further, CAD matrix data is also based on the routine administrative system, which is unreliable as stated earlier. 18

28 Table 6.3 National Priorities, Objectives and Milestones, Mozambique Description of problem of national priority National objectives based on national priority Targets and Milestones Regional and Global goals Order of Priority Logistics, equipment, maintenance, vaccine supply and quality Inadequate vaccine management system, resulting in overstock of vaccines in many districts and health facilities. Inadequate and some nonfunctional cold chain equipment at national, provincial and district levels Old and depleted motorcycle fleet (A) To establish vaccine management system in all provinces by the end of 2009 and in 80% of districts by the end of 2013 (B) To update cold chain inventory on annual basis, and strengthen cold chain capacity by 100% at national, provincial and district levels by 2013 (C) To improve motorcycle maintenance and secure additional ones for the efficient running of the EPI programme at district level by : Vaccine management system established at all provinces. 2010: Vaccine management system established in at least 50% of all districts. 2011: Vaccine management system established in at least 60% of all districts. 2012: Vaccine management system established in at least 70% of all districts. 2013: Vaccine management system established in at least 80% of all districts. 2009: - Update 100% of the cold chain inventory - Move to the new central cold store -Develop cold chain rehabilitation plan - Train 22 cold chain technicians and - Procure old chain spare parts at central level to supply them to all provinces adequately 2010: Replace 25% of non compliant EPI and old cold chain equipment and repair 100% of broken cold chain equipment at all levels 2011: Replace 25% additional of non compliant EPI and old cold chain equipment Repair 100% of broken cold chain equipment at all levels 2012: Replace 25% additional of non compliant EPI and old cold chain equipment and repair 100% of broken cold chain equipment at all levels 2013: Replace 25% additional of non compliant EPI and old cold chain equipment and repair 100% of broken cold chain equipment at all levels 2010: 100% of all broken down motorcycles repaired, and purchase 99 additional motorbikes 2011: 100% of all broken down motorcycles repaired, and purchase 99 additional motorbikes 2012: 100% of all broken down motorcycles repaired, and purchase 99 additional motorbikes 2013: 100% of all broken down motorcycles repaired, and purchase 99 additional motorbikes By the end of 2009, all countries will have a vaccine monitoring system in place at all levels 3 19

29 Table 6.4 National Priorities, Objectives and Milestones, Mozambique Description of problem of national priority National objectives based on national priority Targets and Milestones Regional and Global goals Order of Priority Advocacy and Communication Inexistent National Global Communication Strategy To participate in the development of the Global Communication Strategy 2009: Integrate EPI message into the global communication strategic plan 2010: Produce and disseminate updated EPI routine IEC materials at all levels 2011: Continue the implementation of EPI Global Communication Strategic plan including strategy on hard to reach areas : Monitor and evaluate the EPI communication plan Surveillance Inadequate quality disease surveillance at provincial and district levels (A) To achieve and sustain high quality AFP surveillance of 2/100,000 non-afp rate of under 15 years in all provinces and districts in terms of detection rate and stool adequacy rate of 85% by : Achieve at least 2/100,000 of non-polio AFP rate of under 15 year population and stool adequacy rate of 85% : Maintain at least 2/100,000 of non-polio AFP rate of under 15 year population and stool adequacy rate of 85% By 2007, all countries will achieve at least 2 cases of AFP notification per 100,000 children less than 15 years of age Inadequate quality measles surveillance at district level and measles community based surveillance not in place Inadequate quality MNT surveillance cases and reported MNT cases are not investigated (B) To achieve and sustain high quality measles surveillance status of at least 80 % of the districts reporting 2 or more suspected measles cases per 100,000 population with one blood sample collected, and increase measles reporting rate to 85% by 2013 (C) To achieve and sustain high MNT surveillance and elimination status and advocate for an expert committee to study any single reported MNT case 2009: Achieve at least 80 % of the districts reporting 2 or more suspected measles cases per 100,000 population; : Maintain at least 80 % of the districts reporting 2 or more suspected measles cases per 100,000 population; : Integrate measles surveillance into AFP surveillance system and increase the reporting rate to 85% 2009: Establish an expert committee for MNT case study and achieve at least 30% reporting 2010: Community based MNT surveillance and reporting implemented in at least 60% of the districts; less than 1 case per 1,000 life births in all districts : Increase the community based MNT surveillance and reporting to 85% of the districts and maintain MNT rate of less than 1 case per 1000 life births in all districts; and all MNT reported cases investigated By 2010 or earlier, mortality due to measles will have been reduced by 90% compared to the 2000 level (GIVS) By 2009, at least 80% of countries will achieve maternal and neonatal tetanus elimination By 2009, all countries will have established case based surveillance for neonatal tetanus Inadequate Hib surveillance (D) To achieve and sustain high Hib surveillance status 20

30 Table 6.5 National Priorities, Objectives and Milestones, Mozambique Description of problem of national priority National objectives based on national priority Targets and Milestones Regional and Global goals Order of Priority Programme Management 1. Monitoring & Supervision Poor EPI data collection, analysis, late submission, monitoring and utilization at operational level To strengthen capacity at operational level in data collection, analysis, utilization and timely submission by : Establish proper data management system and implement DQS tools practices in 66 RED districts 2010: Establish proper data management system and implement DQS tools practices in 99 RED districts (33 additional districts) 2011: Establish proper data management system and implement DQS tools practices in 132 RED districts (33 additional districts) 2012: Establish proper data management system and implement DQS tools practices in 144 RED districts (13 additional districts) No institutionalized system for monitoring AEFIs To put in place a system for monitoring AEFIs by : Initiate the establishment of AEFI monitoring system in at least 30% of the districts 2010: AEFI monitoring system in place in 100% of the districts By 2009, all countries will report cases of AEFI from all districts 2. Human Resources Inadequate staffing (quality and quantity) at all levels Strengthen the EPI Programme by restructuring it to respond to the needs of the Programme 2009: Put in place a revised structure with all potential vacancies filled and staff trained at central and provincial levels : Put in place the revised structure with all potential vacancies filled and staff trained at district level 3. Financial sustainability Inadequate funding for EPI To advocate for increase in the Government funding for EPI : Increase government contribution to EPI by at least 20%. 4. Linkages to other interventions Weak integration of programmes at various levels To jointly implement and monitor MDG 4&5 plan : Jointly implementation and monitoring of the MDG 4 & 5 plan on annual basis 21