Report of the survey on private engagement in immunization in the Western Pacific region Ananda Amarasinghe, MD, Laura Davison MIA, Sergey Diorditsa, MD Expanded Programme on Immunization, WHO Regional Office for the Western Pacific Background The Global Vaccine Action Plan (GVAP), endorsed by the World Health Assembly in 2012, is a framework to prevent millions of deaths by 2020 through more equitable access to vaccines. 1 The important roles and responsibilities of private in achieving the goals of the GVAP have been recognized. The implementation of the GVAP and further improvement of vaccine coverage at sub-national, national and global levels requires optimization of the interaction between public and private health. Private sector partnerships have become critical to attaining immunization goals. However, it is unclear what percentage of total immunization services is offered through private and how this share, and its features, varies by country. It is also acknowledged that the impact of the private sector and its engagement will vary tremendously from one country to another based on the existence and contribution of this private sector to the country s delivery of care and preventive interventions such as immunization. The World Health Organization (WHO) Regional Office for the Western Pacific (WPRO) conducted this survey in the region as an attempt to map the scope and characteristics of the provision of immunization services by private. The intent was to share the results of the survey with and to inform the development of guidance to increase private contributions to national immunization programmes. Methods The survey had a cross sectional study design and was carried out during April June 2016. This survey was aimed at the 18 which had reported in the WHO/UNICEF Joint Reporting Form (JRF) 2015, that they have engagement of the private in immunization service delivery. 2 Two structured (mainly with close-ended questions) selfadministered questionnaires (one separate questionnaire for each public and private provider) were developed and pre-tested for data collection by the WPRO Expanded Programme on Immunization (EPI) Unit. The questionnaires were then shared with WHO Country Office (CO) focal points for them to orchestrate administrating questionnaires with targeted interviewees. Interviewees included EPI managers in National Immunization Programmes (NIPs), vaccine focal points at National Regulatory Agencies (NRAs), National Immunization Technical Advisory Group (NITAG) Chairs and selected members, and a 1
convenience sample of private immunization service who agreed to participate in the survey. In where no WHO CO is available, we directly contacted national authorities (NIP and/or NRA focal points) to assist with coordinating the administration of questionnaires with targeted interviewees. All completed questionnaires were sent to WPRO EPI Unit for analysis. In this survey, the term private provider refers to the provision of vaccination (and other health services) by any entity other than the government. This can be either an individual person or an institution. It can include full time or part time private practitioners (General Practitioners, Physicians, Pediatricians, Nurses, Pharmacists or even Midwives), private (forprofit and non-for profit) hospitals as well as non-governmental organizations (not funded by the government or by international donors). Results Eighteen were invited to participate in this survey. Of the 14 that responded, 5 are in the high income category (Australia, Japan, Korea, New Zealand, Singapore), 3 are in the upper middle income category (China, Fiji, Palau) and 6 are in the lower middle income category (Cambodia, Kiribati, Papua New Guinea, Philippines, Solomon Islands, Vanuatu). 3 Sixty respondents (32 public sector and 28 private ) from the 14 participating have completed the self-administered questionnaires. (Table 1) Public sector responses were received from all, but private provider responses were only received from 6. Of the 28 private, 11 were full time private practitioners while 12 were from private hospitals. We present data related to the contribution of the private in the following areas; (i) system in place to regulate private ' immunization service delivery, (ii) scope and extent of immunization service by private (iii) partnerships between NIP and private. (i) System in place to regulate private ' immunization service delivery According to the respondents, 13 out of 14 have policy and/or law and/or guidelines on the provision of immunization services by private (Table 2). The majority (n=12/14) of have system(s) or institution(s) to regulate and monitor (n=10/14) immunization services by private. This includes all 5 high income. However, around 50% of private who responded to this survey were unaware that such policies, laws or guidelines are available in their respective, indicating there is a need for better communication and likely implementation of such 2
regulations. Service fees for immunization service by private are regulated by the governments in most (n=11/14). (ii) Scope and contribution of private in immunization service delivery Private in all 14 are providing traditional vaccines (against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles) and new or underutilized vaccines (against cholera, haemophilus influenza type b, Hepatitis B, Human papillomavirus, Japanese encephalitis, serogroup A meningococcal disease, pneumococcus, rotavirus, rubella and typhoid) to the public. They give vaccines which are available through the NIP as well as those that are not available through the NIP. The public visits private mostly for underutilized or new vaccines, irrespective of their availability in the NIP. Private obtain vaccines either from the NIP or purchase them from private franchises. Therefore, sometimes private use vaccines from different manufacturers or in different product combinations than NIP purchased/procured vaccines. This survey revealed that in only 6/14, private followed the vaccination schedule recommended by the NIP (Table 3). The majority, 18/28 (65%), of private provider respondents reported that they do not follow the NIP schedules. Demand by the vaccine recipients, particularly expatriates wishing to follow their country of origins NIP schedules, is the main reason that private deviate from the NIP schedule. The proportion of the target population covered by private varies by country, from less than 1% to more than 90%, and by type of vaccine. The estimates given by respondents on the proportion of the target population covered by private are close to the estimates available for these in WHO/UNICEF Joint Reporting Forms. 2 In all, private reported that they serve mainly wealthy and urban populations across all age groups. However, in 11 respondents indicated that private also serve poor and rural communities, but to a lesser extent than wealthy, urban populations. Further, the survey revealed that private services are more visible in high income. For patients, the leading reasons to seek private services are the expectation that they will receive more attention, the convenience and saving time. In total 17/28 (60%) of private accepted that public was motivated to seek private sector service by private themselves (Figure 1). In addition to service delivery, private reported that they were also involved in vaccine storage, transport and distribution, but only in 5 of the 14 (35%). (iii) Partnership with NIP by Private provider In all private have received vaccines from the NIP at no cost. For these vaccines, private did not charge clients anything other than the service fee. Eleven reported that the NIP is providing training and also communication and advocacy materials to private. The majority of private acknowledged that they 3
have received training from the NIP, whereas only around 25% of them had received training from their own private institutions. The NIP has provided information to private in 12/28 (43%) and was the main source of information updates for private. Only 6/28 (20%) of private have received updates from manufacturers or immunization and vaccines related websites beyond the NIP. Further, private from 11 have reported that they shared EPI performance data and adverse events following immunization (AEFIs) data with the NIP (Table 4). However, according to respondents from the NIP, sharing EPI performance data and reporting of AEFIs by private is suboptimal. Private involvement in decision making processes such as involvement in immunization policy or guidelines development and reviews, serving in national technical advisory groups and other planning related to immunization logistics is significantly low. Only 7 (25%) private provider respondents from 6 acknowledged the involvement of private in immunization decision making processes. Discussion and Conclusions We have presented survey findings on scope and extent of immunization service by private. We did not focus this survey on private sector funding aspects in the immunization services but limited this survey to describe the immunization service provisions by private. Opinions provided by the respondents in this survey may not necessarily reflect the existing practices and/or situation, rather their own opinions and/or knowledge. This is a limitation of this survey and therefore, interpretation of these survey findings need to be done with caution. Immunization is a national public health programme in every country and is under the responsibility and authority of the public sector. In most NIPs are well designed and supported by policies, laws, regulations and guidelines. Further, implementation of an NIP is monitored and evaluated by designated public health authorities and/or institutions. Although immunization services are traditionally provided by the public sector, 18 out of 27 (67%) member states in the region have engaged with the private sector and have used it to help improve their immunization programme. 2 However, some are struggling to maintain a coherent immunization programme in face of private sector activities that are fast growing in other medical care services. Both our survey findings and the WHO/UNICEF JRF data suggest that in most the private contribution is limited to less than 10% of the total target population. 2 Although there is not a one-size-fits-all solution that may lead to a better engagement of the private sector, it is important to distil out the 4
characteristics of an efficient immunization programme, and to see how the private sector may fit in. The level of organization and degree of regulation of the private sector varies substantially across. This survey indicates that the public sector is largely regulating and setting standards for private sector immunization services. Having such systems in place will lead to higher quality and affordable immunization services by private, resulting in better overall immunization service in the country. In some, the performance of the private sector delivery of care is poorly understood and has led some to argue that private healthcare needs to be more carefully regulated and monitored to ensure that it upholds the standards of care set by the country. This survey highlights that most already have policies and regulations concerning private immunization service, but that awareness of these regulations is lacking. Raising awareness on existing regulations would benefit all stakeholders. While the NIP leads the delivery of immunization services, scope and contribution of the private varies. Further integration of private sector into the NIP has the potential to improve the overall efficiency of immunization service delivery. A frequent scenario in developing is that although many governments would like to provide all preventive health services, including vaccination, to their population, it is becoming increasingly challenging to do so because of many other reasons including prioritizing health issues, financial constraints, unmet patient demand, etc. Private often provide immunization services, particularly new vaccines, which have not been introduced in the NIP schedules. Because of their perceived benefit, some people prefer to pay for immunization services at private health facilities for vaccines not available in the public sector. This survey indicates that the leading reasons for public interest to seek immunization from private relate to convenience, saving time and the amount of attention that is given. These reasons are often the same as the preferences of the population for other private clinical health care services. A majority (>70%) of private provider respondents were of the opinion that the population may seek their services not because of they have any doubt on the quality of the vaccines used in the NIP, but mostly to get the new vaccines, which may not available at NIP. Identifying the reasons for using private service by the public is an important part of strengthening and expanding private-public partnerships in immunization. Private have identified that receiving training and communication materials from the NIP is useful, but claimed that there were few opportunities for training. Public also acknowledged the need for more training of private, but indicated that limited resources did not allow them to conduct the training. Use of NIP information sources rather than the manufacturers information for immunization updates by private is a sign of trust in the NIP. This survey indicates that lack of involvement of 5
private in decision making processes is a weak area of partnerships. The different views by both public and private on data sharing indicate communication and coordination gaps in partnership and areas to be improved. The findings are intended to be useful to in further strengthening public-private-partnerships and in providing immunization services to achieve country and regional immunization goals. Acknowledgments: The EPI Unit of WHO Regional Office for the Western Pacific acknowledges the support from the national stakeholders of 14 participated in this survey, other team members in the Unit and EPI focal points at country level in the region. The Unit also grateful for the valuable comments received from Dr Philippe Duclos and Dr Melanie Marti from the Department of Immunization, Vaccine and Biologicals, WHO headquarters and Dr Nikki Turner, University of Auckland, New Zealand. References: 1. World Health Organization. Global vaccine action plan 2011-2020. http://www.who.int/immunization/global_vaccine_action_plan/en/ 2. National immunization data, Western Pacific Region. WHO UNICEF Joint Reporting Form. 2015. http://www.wpro.who.int/immunization/documents/national_immunization_data 3. World Bank country and lending groups country classification 2016. http://data.worldbank.org/country 6
Table 1: Profile of Survey respondents Respondents High Upper Lower Public sector respondents* (n=32) 10 6 16 Private provider respondents** (n=28) 6 10 12 Private Hospital Staff Full time private practitioner Nurse/Pharmacist/Midwife - 6-4 3 3 8 2 2 *Public sector respondents include; National Immunization managers, Regulatory author higher officials, National Immunization Technical Advisory Group (NITAG) members ** All 28 respondents were from only 6 : ( 2 High income, 1 Upper, 3 Low ) High (Australia, Japan, Korea, New Zealand, Singapore) Upper (China, Fiji, Palau) Lower (Cambodia, Kiribati, Papua New Guinea, Philippines, Solomon Islands, Vanuatu 7
Table 2: Systems in place to allow for or regulate private sector delivery High Upper Lower All responding n=5 n=3 n=6 n=14 (%) Availability of policy or law or guidance on the provision of immunization services by private Availability of a system/institution(s) to regulate immunization services by private Availability of a system/institution(s) to monitor immunization services by private 5 3 5 13 (93%) 5 2 5 12 (86%) 5 1 4 10 (71%) Service fee is regulated by the government 4 2 5 11 (79%) High (Australia, Japan, Korea, New Zealand, Singapore) Upper (China, Fiji, Palau) Lower (Cambodia, Kiribati, Papua New Guinea, Philippines, Solomon Islands, Vanuatu) Table 3: Scope and contribution of immunization services by Private Providers High Upper Lower All responding n=5 n=3 n=6 n=14 (%) Kind of vaccines are provided to the public Traditional vaccines 5 3 6 14 (100%) New or Underutilized vaccines 5 3 6 14 (100%) Follow NIP schedules for vaccines under NIP programme 4 1 1 6 (43%) Service fee is charged 4 2 5 11 (79%) High (Australia, Japan, Korea, New Zealand, Singapore) Upper (China, Fiji, Palau) Lower (Cambodia, Kiribati, Papua New Guinea, Philippines, Solomon Islands, Vanuatu) 8
Table 4: Partnerships between NIP and private Vaccines provided by NIP to private High Upper Lower All responding n= 5 n=3 n=6 n=14 (%) 4 2 5 11 (79%) Training provided by NIP to private 4 2 5 11 (79%) Educational/awareness materials 5 2 5 12(86%) Share Immunization data by private Report Adverse Events Following Immunization 5 2 4 11 (79%) 5 2 4 11 (79%) Participate in decision making process 4 1 1 6 (43%) High (Australia, Japan, Korea, New Zealand, Singapore) Upper (China, Fiji, Palau) Lower (Cambodia, Kiribati, Papua New Guinea, Philippines, Solomon Islands, Vanuatu) 9
Figure1: Reasons for choosing private service 0 20 40 60 80 100 Convenience for the public Saving time Expecting more attention Assuming quality of the vaccine is better than NIP Motivation by Private Practitioners Financial affordability/cost covered by Insurance Public opinion (%) n=32 Private opinion (%) n=28 Social acceptance 10