1

TABLE OF CONTENTS List of Abbreviations & Acronyms Acknowledgement Executive Summary Introduction Section I: Impact of Country and Health System Context

1.1 Geography and Climate 1.2 Demographic Situation 1.3 Socio-economic background 1.4 Federal administrative structure 1.5 Ethiopian National Health Policy 1.6 The Health System 1.7 Organization of the Health System 1.8 Health Care financing 1.9 Total Health Expenditures 1.10 Functional distribution of expenditures 1.11 Government planning budgeting and reporting process

Section II Program Characteristics, Objectives and Strategies

2.1 Immunization Schedule 2.2 Supplemental Immunization Activities 2.3 Vaccine wastage 2.4 Future plan for EPI 2.5 The role of UN agencies and NGOS in the national immunization program

Section III Pre-vaccine fund and vaccine fund year program costs and financing

3.1 Pre vaccine fund year (2001) expenditure and financing 3.2 Vaccine fund year (2003) expenditure and financing

Section IV Future Resource Requirements and Program Financing / Gap Analysis 4.1 Projections of future program costs 4.2 Future financing for the immunization program, and funding gap analysis 4.3 Financial impact of selected alternative policy options to decrease

program costs Section V Sustainable Financing Strategy, Actions and Indicators

5.1 Opportunities for financial sustainability: 5.2 Challenges of financial sustainability 5.3 Strategy for financial sustainability 5.3.1 Mobilizing additional resources 5.3.2 Increasing reliability of resources 5.3.3 Improving Program Efficiency 5.4 Action Plan, monitoring process and indicators for FSP

2

Tables and Illustrations Tables:

Table 1.1: Total and per capita health expenditure by major source classifications, 2000

Table 2.1 The national EPI schedule. Table 3.1 Past EPI expenditure by cost categories, 2001 – 2003, in US $ Table 4.1 Future program costs by cost categories, 2004 - 2013 Table 4.2 Secure, and probable resources from different partners Table 5.1 Indicators for follow up of progress of implementation of the financial

sustainability plan Figures

Figure 1.1 Health care expenditure by source in Ethiopia Figure 1.2 Government health expenditure in Ethiopia Figure 1.3 Breakdown of PHC expenditures in Ethiopia Figure 2.1 Trends in immunization coverage in Ethiopia, 1996 - 2004 Figure 2.2 Routine immunization coverage by regions Figure 3.1 Program costs (US$ millions) by category for 2001 – 2003 in Ethiopia Figure 3.2 Financing sources for immunization in 2001 Figure 3.3 Financing sources for immunization in 2003 Figure 4.1 Projection of immunization costs by strategy, US$ millions, 2004 - 2013 Figure 4.2 Secure and probable financing for immunization, US$ millions, 2004 - 13 Figure 4.3 Impact on total program costs, and funding gap of different new vaccine

policy options

3

Acknowledgements

The Federal Ministry of Health would like to take this opportunity to thank all partners

particularly, UNICEF, WHO and World Bank for their technical and financial support to develop

the Financial Sustainability Planning for Ethiopia (FSP). We extend our gratitude to all ICC

members and technical group of the national immunization program for their active participation

in the development of this important document. .

4

Abbreviations and Acronyms AD syringe Auto-Distract Syringe AEFI Adverse Effect Following Immunization AFP Acute Flaccid Paralysis BCG Bacillus Callmunt Guirine CDC Center for Diseases Control CIDA Canadian International Development Agency CHW Community Health Workers CMH Commission on Macroeconomics and Health CSA Central Statistic Authority DFID Department for International Development DPT Diphtheria Pertussis and Tetanus EFY Ethiopian Physical Year EPI Expanded Program on Immunization FSP Financial Sustainable Plan FMOH Federal Ministry of Health GAVI Global Alliance for Vaccines GDP Gross Domestic Product HDI Human Development Index Hep B Hepatitis B HEP Health Extension Program HEW Health Extension Worker Hib Hemophilus Influenza type B HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome HSDP Health Sector Development Program ICC Inter Agency Coordinating Committee IEC Information Education Communication JICA Japan International Cooperation Agency MDGs Millennium Development Goals MNT Maternal Neonatal Tetanus MOFED Ministry of Finance and Economic Development MOH Ministry of Health NGOs Non Governmental Organizations NHA National Health Account NIDs National Immunization Days NIP National Immunization Program NORAD Norwegian Agency for Development Cooperation OPV Oral Polio Vaccine PHCU Primary Health Care Unit RED Reaching Every District RHB Regional Health Bureaus SDPRP Sustainable Development Poverty Reduction paper SIAs Supplemental Immunization Activities SNIDs Sub- national Immunization Days SNNPR Southern Nations and Nationalities People SOS Sustainable Outreach Services TFR Total Fertility Rate TT Tetanus Toxoid UN United Nations UNDP United Nations Development Program UNICEF United Nations International Children’s Fund USAID United States Agency for International Development WHO World Health Organization ZHB Zonal Health Bureau

5

Executive Summary Introduction In order to control vaccine preventable diseases, the World Health Organization and member countries including Ethiopia have established the Expanded Program on Immunization (EPI). The Ethiopian EPI program was launched in 1980, with the objective to reach 100% coverage to all children under two by 1990. Progress in coverage has been slow and up know the Ethiopian EPI program has not achieved the target coverage. However, with the introduction of the two new approaches known as Reaching Every Districts (RED) and Sustainable Outreach Services (SOS) significant improvement has been documented in the last few years. Currently the national DPT3 coverage stands at 65%. The Health System The Ethiopian health system currently reaches about 61% of the population. There are too few facilities, particularly at the levels closest to the community, and there are long-term shortages of skilled human resources. The FMOH is responding to this recognized need through two major initiatives in the context of the Health Sector Development program: • A plan for expansion of primary health facilities and staff, which will raise health coverage

to 85% by 2009. • The health extension program (HEP) institutionalizes the community health system. The

Health Extension Workers (HEWs) are intended to be the main change agents for health in the community. Their primary task will be to mobilize and empower households and communities to take responsibility for their own health by involving them in the planning and execution of community health activities and services. HEWs, working with other community-based workers and supported by their local health center will be trained and equipped to provide a wide range of promotive and preventive services including provision of routine vaccines

Health Care financing

The health services in Ethiopia are financed from four main sources: • Government (both federal and regional) • Bilateral and multilateral donors (both grants and loans) • Non-governmental organizations, and • Private contributions, both from out-of-pocket payments and through private

sector investment in health services The routine immunization program is funded primarily by the Government and partners like, UNICEF and Irish Aid. Whilst vaccines are financed by UNICEF and salaries by the government, funding for a number of other components such as cold chain equipment, transport, social mobilization and some operational costs have been made available by WHO and other donor agencies under the Polio eradication initiative.

Program characteristics, objectives and strategies The overall aim of the immunization program is to improve the quality and coverage of national immunization services. The Ethiopian EPI program focuses mainly on four objectives:

• Strengthening the immunization system: strengthen and optimize the delivery of sustainable, quality immunization services by increasing DPT3/ measles coverage to 95% by 2009.

• Introduction of new vaccines: it is planned to introduce Hepatitis B vaccine as monovalent in 2005-2006 and Hib vaccine as pentavalent in 2007. The target is to achieve 95% coverage by 2009.

• Minimizing vaccine wastage: the wastage rate should be properly calculated and

minimized by focusing on accurate forecasting and proper stock management, effective cold chain system and improvement in the ratio of children to vials opened.

• Accelerated disease control: accelerate effort to achieve polio eradication, measles control/ elimination, and neonatal tetanus elimination.

Ethiopia has a five year EPI plan which was developed in 2001. The prime focus of the plan was to increase the coverage by 5% annually, and likewise decrease the vaccine wastage rate. Trends in immunization coverage in Ethiopia, 1996 - 2004

25

30

35

40

45

50

55

60

65

70

75

1996 1997 1998 1999 2000 2001 2002 2003 * 2004Year

%

BCGDPT3Measles

Supplemental Immunization Activities To reach the remote zones of the country and to synergize the routine immunization activity, supplemental immunization was introduced in 1996. Supplemental immunization was designed mainly for Polio and Measles and since 1999 SIA for MNT was also started. Note : * 2004 annualized report

6

Vaccine wastage Vaccine wastage is a problem in Ethiopia. At present the wastage rate is more than 65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT. It is due to poor planning of static and out reach sessions, lack of awareness of the community and poor management of the cold chain system and also the current policy which recommends to open a vial of vaccine, even for a single child and discard opened vials of BCG and measles after 6 hours or at the end of the session. Pre-vaccine fund and vaccine fund year program costs and financing 1 This section presents the review of the total program expenditure and financing from 2001 – 2003. This is broken down by the program expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to costs for the program are also represented. Program costs (US $ million) by category 2001-2003

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

2001 2002 2003

Other optional information

Other SIAs

Measles Campaigns

Polio Campaigns

Cold chain equipment

Other routine recurrent costs

Personnel

Injection supplies

Traditional Vaccines

Total expenditure on immunization activities in the country was at approximately 25 million US dollars in each of these years. Projection of future program costs and gap analysis Based on the program objectives and strategies, a costing is estimated for the future program costs and financing. By the year 2005 & 2006, the program costs are just over US$ 30 million. There is then a large increase to over US$ 60 million in 2007, with the costs being maintained at that level.

1 Pre-vaccine means before the GAVI fund was available and vaccine fund year is when the GAVI fund is available

7

8

The main cost driver from 2007 onwards is the new, pentavalent vaccine. This will cost the program over US$ 30 million each year. The share of the routine program costs to the total immunization costs in the country increases from just over 40% to 80% when the pentavalent vaccine is introduced. Future financing is either secure, or probable. Secure funding represents resources for which there is a very high certainty that will be available. These include resources from Government for health workers salaries, contribution to maintenance (based on present contributions), and estimated proportion for immunization of shared costs for building, personnel, and transport. In addition, secured resources include regular budget funds from WHO and UNICEF (up to the end of their present programs of work, 2005 for WHO and 2006 for UNICEF), and support to the program activities for 2004, and secured funding for 2005 from GAVI, USAID, Ireland Aid, Netherlands, DFID, Government of Japan, and a host of other partners. These funds are largely for the planned campaigns in 2005 (detailed breakdown of each partner’s contribution in Annex 3). Secured funds represent only 18% of the total resource requirements from 2004 – 2013. A series of resources have been classified as probable and these include:

• Continued support beyond the present agreed program of work for WHO and UNICEF (US$ 50,000 for WHO, and US$ 2,500,000 for UNICEF per year),This is still probable money as the country proposal for support is still to be submitted and approved

• Funds for SIA activities have always been mobilized in the past, and the respective SIA will not be done (so won't be a program cost) if funds are not mobilized.

• Inclusion of these probable funds reduces the funding gap to 40% of total resource requirements.

Sustainable financing strategy The ultimate goal of the financial sustainability plan is "self sufficiency". The ultimate goal of the financial sustainability plan is “Self Sufficiency”. That is to be able to cover all costs related to immunization, including the purchase of vaccines and required logistics, personnel and operational costs, etc. However, for a country like Ethiopia, where the overall health expenditure is still at a lower level, the rational way of formulating the FSP will be mobilization and efficient use of domestic and supplemental external resources on a reliable basis to achieve the targeted goals of national immunization coverage. The central and regional governments have already started funding for about 15% of the total EPI program expenditure. In addition, the FMOH covers the taxation cost, which is estimated to be 18% of the total cost of injection material. This effort has to grow significantly, so that, at least by the year 2015 the government will be able to cover an additional 10% of the total cost for vaccines. The strategy for moving forward to financial sustainability plan will be on identifying key activities for sustainable financing, which include;

• Mobilizing additional resource: - From central and local governments - From private sector, civil societies and NGOs and -from funding agencies • Increasing reliability of resources both governmental and external resource • Improving program efficiency by; -minimizing vaccine wastage -improving EPI program management and - Maximum use of health extension program

9

INTRODUCTION In order to control vaccine preventable diseases, the World Health Organization and member countries including Ethiopia have established the Expanded Program on Immunization. The Ethiopian EPI program was launched in 1980, with the objective to reach 100% coverage to all children under two by 1990. In 1985, the target was reviewed to 75% coverage for the target age group was changed to under ones. However, progress in coverage has been slow and up to date the Ethiopian EPI program has not achieved the target coverage. Low coverage is an acknowledged weakness of the national EPI program. However, improvement has been documented in the last few of years, with the introduction of a new approach known as Reaching Every Districts (RED) and Sustainable Outreach Services (SOS) for immunization. The above two approaches were launched in 2003, to maximize the coverage and accelerate the effort of the national immunization program, so that, the country is able to achieve immunization goals set by United nations General Assembly special session to ensure 90% coverage at national level and 80% in all districts by the year 2010. This should support the country immunization. program achieve its expectations towards the achievement of the Millennium Development Goal. To this effect, in the last few years the national immunization coverage has shown significan improvement. Currently the national DPT3 coverage stands at 65%. As with other health services, immunization coverage varies significantly by region. Over 80% of children in, Tigray, Dire Dawa and Harari regions are immunized for DPT3 by age one, while the figure dramatically drops to less than 5% in Somali region. Immunization coverage rates in the three most populous regions -Oromia, Amhara and SNNPR has started picking up, but remains still low, to influence the national average. In terms of health financing and budget provisions, the government has taken steps to reallocate resources away from urban hospital-based curative services towards more preventive and promotive care, targeting the rural population. The overall focus has been on communicable diseases, common nutritional disorders, environmental health and hygiene, safe and adequate water. The routine immunization program is funded primarily by the Government and its partners that largely channel their funds through UNICEF and WHO. Whilst the bulk of vaccine costs are financed by UNICEF and salaries by the government, funding for a number of other components such as cold chain equipment, transport equipment, social mobilization and some operational costs have been made available by WHO,UNICEF and other donor agencies under the Polio eradication initiative.

10

______________________________________ SECTION ONE Impact of country and Health System context

Ethiopia is confronted with multiple economic, social and geographical natural complications, which render allocation of resources to particular programmes such as immunization very competitive. This section gives us a complete panorama of the overall country situation including the budget and monetary developments, all of which have a bearing on public financing of health programmes. The section also covers Ministry of health priorities in terms of allocation of little resources, methods and procedures of budgeting, procurement, disbursing and reporting on the use of funds for immunization.

1.1 Geography and Climate Ethiopia is situated in the Horn of Africa. The total area of the country is around 1.1 million square kilometers, and it shares borders with Djibouti, Eritrea, Sudan, Kenya and Somalia. Ethiopia is a country with great geographical diversity, with topographic features ranging from 4,550m above sea level to 110m below sea level2. More than half of the country lies above 1,500 meters. There are broadly three climatic zones: the “Kolla”, or hot lowlands, below approximately 1,500 meters, the “Weyna Dega” at 1,500-2,400 meters and the “Dega” or cool temperate highlands above 2,400 meters. In general the highlands receive more rain than the lowlands. The country is prone to recurrent droughts and famines.

1.2 Demographic Situation According to the 2004 mid-year population projection, the population of Ethiopia is approximately 71.2 million.2 The average household size is 4.83. About 85% of the total population is rural, making Ethiopia one of the least urbanized countries in the world. Only nine urban centres have populations of over 100,000, and Addis Ababa is the only urban centre with a population of over a million, accounting for 26% of the total urban population and 3.9% of the total population. At an annual growth rate of 2.9%, the total population is expected to reach 106 million by the year 20204. Rapid population growth exacerbates critical gaps in basic health services, especially when growth of the economy is low or per capita incomes are in decline. The average population density is 52.2 per square km, with great variation among regions. Population densities are highest in the highland regions and lowest in the eastern and southern lowlands. Most of the woredas along the borders of the country have densities of less than 10 persons per square km. 23.2% of the population is concentrated on 9% of the land area.

2 Central Statistical Authority (Ethiopia) and ORC Macro (2001). Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Authority and ORC Macro. [EDHS 2000] 2 Central Statistical Authority (1994). The 1994 GC Population and Housing Census of Ethiopia: Analytic Report. Addis Ababa: Central Statistical Authority 3 EDHS 2000, ibid 4 Central Statistical Authority (1994). The 1994 GC Population and Housing Census of Ethiopia: Analytic Report. Addis Ababa: Central Statistical Authority

11

Roughly 50 percent of the land area represents sparsely populated areas with nomadic or semi-nomadic pastoral ethnic groups living in arid plains or in a semi-desert environment. The settlement pattern of the population and its density greatly affect the provision of health care, including the accessibility and utilization of existing health care facilities. About 17.5% of the population is aged less than 5 years, 43.5% of the population are under 15 years, 51.9% are between 15 and 59 years and 4.6 % are aged 60 years and above. Twenty four percent of the total population is women in the reproductive age group (15-49 years). The Ethiopian Demographic and Health Survey 2000 indicate a total fertility rate of 5.9 children per woman. Fertility is highest in the Oromia Region (6.4 births per woman) and lowest in Addis Ababa (1.9 births per woman). The level of fertility is significantly lower in urban (TFR of 3.3) compared to rural areas (TFR of 6.4). The general level of education has marked influence on the spread of diseases, the acceptability of health practices and utilization of modern health services. However the literacy status of the population is low. The adult literacy rate is 49% for males and 34% for females. The gross enrolment ratio in primary schools at national level is 64% (53% for girls).5 Ethiopia is home to around 80 ethnic groups that vary in population size from more than 18 million to less than 1006. Christianity and Islam are the main religions, with 51% Orthodox Christians, 33% Muslims, and 10% Protestants, the rest following a diversity of other faiths.

1.3 Socio-economic background Ethiopia is one of the least developed countries in the world with an estimated annual per capita income of US$ 100. Forty seven percent of the total population lives below the poverty line. The 2003 UNDP Human Development Index (HDI) for Ethiopia stands at 0.309.

The socio-economic and health development of the country has been hindered by a combination of rapid population growth, poor economic performance and low educational levels. Economic performance, which in the 80s was characterized by low or negative growth rates in real GDP and per capita incomes, resulting from decades of civil war, drought and economic mismanagement, was reversed in the 90s. Over the decade, the Government initiated a comprehensive economic reform program which has had an important bearing on the development of the key socio-economic sectors including health.

The new economic policy is aimed at establishing a market-based economic transformation and redirecting Government interventions to the development and strengthening of social services such as education, health, investment in roads and water resources. The policy environment created by the economic reform and macro economic stability helped address poverty in a comprehensive way through the adoption of the Sustainable Development and Poverty Reduction Program (SDPRP), which is now giving attention to poverty-related health program targets. The government is also committed to meeting targets set by global initiatives, notably the Millennium Development Goals (MDGs) and the recommendations of the WHO Commission on Macroeconomics and Health (CMH) aimed at strengthening the link between improved health and economic development.

5 Ministry of Education (2003). Education Statistics, Annual Abstract EC 1993. Addis Ababa: Ministry of Education 6 CSA (1998).

12

1.4 Federal administrative structure Ethiopia is a Federal Democratic Republic. It has a bicameral parliament: the House of Representatives, whose members are elected from the regions, zones, woredas (districts) and kebeles, and the House of Federation, whose members are designated from their respective regions. Administratively, there is extensive decentralization of service delivery, with relatively autonomous regions largely responsible for service delivery. These regions are subdivided in to further administrative units of zones, woredas and kebeles. At present the country has nine regional states and two City Administrations. The highest governing body of each regional national state is the Regional Council, which has elected members and is headed by a president nominated by the party that holds the majority of seats. The president is assisted by heads of various regional bureaus, including Health. Each region has its own parliament and is responsible for legislative and administrative functions except for foreign affairs and defense. The National Regional States and City Administrations are further divided into 75 zones, 580 woredas, and approximately 15,000 kebeles. There are also two zones and seven woredas designated as "special". These are medium sized towns or traditional sites of ethnic minorities. The woreda is the basic administrative unit and has an administrative council composed of elected members. The woredas are further divided into kebeles, representing urban dwellers associations in towns and peasant associations in rural villages. With the devolution of power to regional governments, public service delivery, including health care, has fallen largely under the jurisdiction of the regions. The approach has been to promote decentralization and meaningful participation of the population in local development program. For administration of public health care, there is a Regional Health Bureau (RHB) at the Regional level, and a Zonal Health Department (ZHD) at the zonal level. An increasing number of woreda health offices are currently being established, as it is expected that the zonal level will be phased out in favor of a strengthened woreda structure. Therefore, decentralization has brought an opportune moment for the EPI program as the implementing bodies (woreds) are more capable both politically and economically to play their own role in resource mobilization and allocation for immunization program in their own respective areas. Some regions and woredas have already started allocating budget for operational costs, and few have also started contributing for capital costs by procuring refrigerators. However contributions, for purchase of vaccines and injection materials by the regions and woredas are yet to be started. 1.5 Ethiopian National Health Policy Following the change of Government in 1991, a number of political and socio-economic reform measures were put in place. Two of these were the development and introduction of a new National Health Policy in 1993 and, in 1997, the formulation of a comprehensive rolling 20-year Health Sector Development Plan (HSDP). Both are the result of the critical assessment and analysis of the nature and causes of the country’s health problems. The HSDP is now in its second period (HSDP II). The major foci of the health policy are democratization and decentralization of the health care system, development of the preventive, promotive and curative components of health care, assurance of accessibility of health care for all segments of the population and the promotion of participation of the private sector and NGOs in the health sector.

13

1.6 The health system The Ethiopian health system currently reaches about 61% of the population. There are too few facilities, particularly at the levels closest to the community, and there are long-term shortages of skilled human resources. The Federal MOH is responding to this recognized need through two major initiatives in the context of the Health Sector Development Plan: • A plan for expansion of primary health facilities and staff, which will raise coverage to

85% by 2009. • The health extension program (HEP): This institutionalizes the community health system.

The Health Extension Workers (HEWs) are intended to be the main change agents for health in the community. Their primary task will be to mobilize and empower households and communities to take responsibility for their own health by involving them in the planning and execution of community health activities and services. HEWs, working with other community-based workers and supported by their local health center will be trained and equipped to provide a wide range of promotive and preventive services including provision of routine vaccines.The HEP is seen as an opportunity to strengthen all the health services for mothers and children at the community level.

1.7 Organization of the health system The Federal Ministry of Health, Regional Health Bureaus and Woreda Health Offices, depending on the level and type of health facility, shoulder responsibility for administration and operation of government health services. Other health institutions are owned and managed by private and non-governmental organizations. The national health policy emphasizes the importance of achieving access to a basic package of quality primary heath care services for all segments of the population, via a decentralized state system of governance. This package includes preventive, promotive and curative services. In order to attain this goal, HSDP I introduced a four-tier system for health service delivery. This is characterized by a primary health care unit (PHCU) comprising one health center and five satellite health posts, and the district hospital, zonal hospital and specialized referral hospital. A PHCU was planned to serve 25,000 people, while district and zonal hospitals are each expected to serve 250,000 and 1 million people respectively. The growing size and scope of the private health sector, both for profit and not-for-profit, offers an opportunity to enhance health service coverage and utilization, and HSDP has explicitly recognized the complementarities between the two sub sectors with the articulation of a strategy to promote the private sector in health care delivery.

1.8 Health care financing The health services in Ethiopia are financed from four main sources:

• Government (both federal and regional) • Bilateral and multilateral donors (both grants and loans) • Non-governmental organizations, and • Private contributions, both from out-of-pocket payments and through private

sector investment in health services.

1.9 Total health expenditures According to the second National Health Account (NHA), conducted using 1992 EFY data, the total health expenditure in EFY 1992 was estimated to be ETB 2.9 billion (355.5 million US$). The first NHA conducted using EFY 1988 data estimated the total health expenditures at ETB 1.45 billion or 230 million US$. The per-capita health expenditure has increased by about one dollar from 4.5 US$ to 5.6 US$ per person per year between the two time periods. Although the share of GDP allocated to health, at 5.5%, compares reasonably well with other low income countries, the per capita expenditure remains one of the lowest in the world and significantly lower than the US$12 that is the average among sub-Saharan African countries. The global estimate of the minimum per capita expenditure for effective health care in developing countries is US$34. Therefore, there is a need for considerable increase in health financing in Ethiopia, combined from all sources, including making full use of the willingness of families to contribute financially to health care.

Table 1.1 Total and per capita health expenditure by major source classifications, 2000

Source Amount in Birr Amount in USD Per Capita

USD Percent

Government 978,960,122 118,731,993 1.87 33%

Bilateral& Multilateral 471,443,092 57,178,404 0.90 16%

Households 1,057,826,612 128,297,219 2.02 36%

NGOs(local& international) 290,082,327 35,182,285 0.55 10%

Private 132,849,569 16,112,499 0.25 5%

Total 2,931,161,723 355,502,340 5.60 100%

Source: Ethiopia’s second NHA draft report, 2003

Figure 1.1 Health care expenditure by source in Ethiopia, 2000

,

Government , 33%

External donors, 16%

Household , 36%

NGOs, 10%

Private , 5%

Source: Ethiopia’s second NHA draft report, 2003.

14

The major source of funding for health in 2003 was households, which account for 36% of total health expenditures, but their proportional contribution has significantly declined from about 53% in 1992. Government financing from taxes, general revenue and loans stands next, covering 33% of total health expenditures. The rest of the world through bilateral and multilateral assistance comes third with 16%. Since financing from the rest of the world mostly comes through the government, the second round shows that about 50% of health expenditures are financed from public sources. The share of NGOs has also increased to about 10% from the previous 7%. In terms of per capita expenditures, households spend $2.02, government $1.87, the rest of the world $0.9, NGOs $0.55 and the private sector $0.25 US per person per year. 1.10 Functional distribution of expenditures Health expenditures are dominated by curative care. Pharmaceuticals consumed about 39% of total health expenditures. Curative care services took about 19% of total expenditures. Considering non-vaccine pharmaceutical expenditures and considering the rest as a part of curative treatment, the share of curative care increases to about 57% of total expenditure. Overall, expenditure on primary health care accounted for about 16%. Including immunization, sanitation, and environmental health functions that are categorized under ‘health-related’ increases the share to 18%. The share of health administration stands at a reasonable level of 8%. Figure 1.2 Government health expenditure in Ethiopia, 2000

,

Curative care , 19%

Training, 2%

Drugs, 38%

PPHC, 16%R&D, 1%

Administration, 8%

Capital, 15%

Environmental health, 1%

Immunization cost, 1%

Source: Ethiopia’s second NHA, draft report, 2003.

A breakdown of expenditure on PHC shows that in 2000, about 41% was spent on mother and child health, while 29% was used for expansion of primary health care and 12% for controlling communicable diseases. Other services like IEC, non-communicable disease control, sanitation and environmental health together consumed 18% of resources.

15

Figure 1.3 Breakdown of PHC expenditures in Ethiopia

MCH41%

CDC12%

Expansion29%

Others18%

Source: Ethiopia’s second NHA, draft Report, 2003.

1.11 Government planning budgeting and reporting process The over all-financial planning, budgeting and reporting process follow the bottom up principle. The financial year starts on the eighth of July and ends on the seventh of July of the subsequent year. The Family health department, which is the main pioneer of the immunization activity, develops the annual plan of action with the budge in the beginning of the financial year. The higher bodies of the FMOH scrutinize the budget before it is submitted to MOFED for approval. MOFED scrutinizes further the budget according to the national plan, priority areas of the country and the available resources. There after, the annual budget for each sector will be allocated. MOFED presents the annual budget of each sector to the House of Representatives for final approval. Once the budget is known the finance division of the FMOH requests MOFED to release the monthly budget according to the plan of action of each department. Every month, the finance division of the FMOH reports back to MOFED, about every detail of all capital and recurrent expenses used by each department. Failure to adhere to this, the subsequent monthly budget of the FMOH may not be released. At the end of the year, MOFED sends its own auditors to FMOH to evaluate the over all annual budget utilization of the MOH.

16

______________________________________ SECTION Two Program characteristics, objectives and strategies

This section provides basic information about the scale, scope, performance, management and future plans of the national immunization programme, highlighting the specific types of improvements that are to be achieved over the planning horizon of approximately five to seven years. It contains quantitative and qualitative information about programme performance and targets, information about possible change in programme objectives in light of financial constraints, some data from the district level, and information about the roles and responsibilities of partners in immunization financing, service delivery and other aspects of the programme.

17

The overall aim of the immunization program is to improve the quality and coverage of national immunization services. The Ethiopian EPI program focuses mainly on four objectives:

Strengthening the immunization system: strengthen and optimize the delivery of sustainable, quality immunization services by increasing DPT3/ measles coverage to 95% by 2009

Introduction of a new vaccine: it is planned to introduce Hepatitis B vaccine as monovalent in 2005-2006 and Hib vaccine as pentavalent in 2007. The target is to achieve a coverage of 95 % by 2009

Minimizing vaccine wastage: the wastage rate should be properly calculated and minimized by focusing on accurate forecasting and proper stock management, effective cold chain system and improvement in the ratio of children to vials opened.

Accelerated disease control: accelerate effort to achieve polio eradication, measles control/ elimination, and maternal and neonatal tetanus elimination

To realize the above objectives, the national EPI program gives special attention to the following priority areas of interventions.

Capacity building at all levels; including full involvement and maximum use of the health extension program.

Conduct regular monitoring and supportive supervision; Improve the cold chain and vaccine management at all levels; Strengthen further the participation of NGOs and the private sectors in EPI activities Conduct social mobilization activities by using the existing community health workers

and the newly coming HEWs, to create demand in the community for immunization; Facilitate participation of community leaders in mobilizing community and defaulter

tracing to decrease drop -out rate; Implement Reaching Every District(RED) approach in all low performing regions and

zones; Local resource mobilization

2.1 Immunization Schedule Immunization is mainly provided through state run health facilities and associated outreach activities. The national guidelines for EPI recommend that health workers should use every opportunity to immunize eligible children, and all eligible children attending outpatient clinics should be immunized according to the recommended schedule. Table 2.1 The national EPI schedule

Vaccine Ages of administration Supplemental BCG/OPV0 at birth DPT1/OPV1 6 weeks DPT2/OPV2 10 weeks DPT3/OPV3 14 weeks Measles 9 months Vitamin A Tetanus for pregnant women first contact during pregnancy

for TT1, after 4 weeksTT2 and after 6 months TT3,T4 and T5

Ethiopia has a five year EPI plan which was developed in 2001.The prime focus of the plan was to increase the coverage by 5% annually, and likewise decrease the wastage rate. The graph below shows the actual rise in the immunization coverage since 1996. Figure 2.1 Trends in immunization coverage in Ethiopia, 1996 - 2004 75

70

65

60

55

50

45

40

35

30

25

Immunization coverage significantly varies by regions. The coverage ranges from DPT3 coverage of more than 80% in Tigray, Diredewa and Harari regions to less than 10% coverage in Somali and Afar regions. The most populous regions, like Oromia, Amhara and SNNPR have started showing an increasing trend; however, a lot has to be done from these regions to make a significant impact on the national coverage rate.

1996 1997 1998 1999 2000 2001 2002 2003 * 2004

Year

% BCGDPT3Measles

Note : * First six month annualised

18

Figure 2.2 Routine Immunization coverage by regions (2003-2004)

0

10

20

30

40

50

60

70

80

90

100

%

Tigra

yAfa

r

Amhar

a

Oro

mia

Som

ali

B/Gumuz

SNN

P

Gambela

Har

ari

Addis Abab

a

Dire

-Daw

a

Nat

ional

Region

DPT1

DPT3

Measles

2.2 Supplemental immunization activities To reach the remote zones of the country and to synergize the routine immunization activity, supplemental immunization was introduced in 1996. Supplemental immunization was designed mainly for Polio and Measles and since 1999 SIA for MNT was also started. Polio supplemental immunization activity Ethiopia joined polio eradication efforts in 1996 by conducting supplemental immunization activities in 9 selected cities followed by full NIDs from 1997 to 2002. The number of children immunized increased from about 8 million in 1997 to 14 million in 2001. Today, Ethiopia has been polio free for three years, and AFP surveillance has achieved certification level standard. In 2003 SNIDs were conducted in areas poorly covered during previous NIDs. In 2004 SNID was also conducted in densely populated areas of central Ethiopia. and in Woredas bordering Sudan. The threat to the national polio eradication initiative is the risk of importation of wild polio from polio endemic countries. Measures are being under taken to prevent the threat of wild poliovirus importation. Measles supplemental immunization: Measles is a major public health problem in Ethiopia. Catch up measles supplemental immunizations have been conducted for children under 15 years of age in most parts of the country and more than 30 million children received supplemental doses. The plan is, to continue conducting the catch up immunization in the remaining parts of the country, and strengthen routine immunization at the same time. After 3 to 4 years, follow up campaign will be conducted in phases all over the country for children under five years of age.

19

MNT supplemental immunization: Neonatal Tetanus is one of the leading causes of mortality in infants less than one month of life. The national coverage of routine TT plus was too low to impact on the neonatal morbidity and mortality. The FMOH has therefore, decided to undertake Maternal & Neonatal Tetanus (MNT) elimination campaign using a high risk approach. In 1990, the FMOH in collaboration with UNICEF and other partners launched an accelerated maternal &neonatal tetanus elimination pilot project in Gedeo Zone of the SNNPRG. Based on the success of the pilot project in Gedeo Zone, a similar campaign for MNT was implemented in high risk zones of SNNPR, Tigray,Oromia and the Amhara regions. 2.3 Vaccine wastage Vaccine wastage is a problem in Ethiopia. At present the wastage rate is more than 65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT. It is due to poor planning of static and out reach sessions, lack of awareness of the community and poor management of the cold chain system and also is due to the current policy which recommends to open a vial of vaccine, even for a single child and discard opened vials of BCG and measles after 6 hours or at the end of the session. 2.4 Future plan for EPI The future plan of action for EPI implementation is structured in line with the recently developed child survival strategy and therefore, the EPI plan will mostly depend up on the new and innovative community health program, "the health extension program". Through the expansion of primary health facilities and training of more than 24800 health extension workers, it is planned to raise the health coverage to 85% by 2009. Although there are major barriers to overcome like, limited access to health facility, widespread shortage of skilled human resource and supplies for immunization activity at all level, the moment is right to scale up immunization activities in the country. Limited access will be addressed through the accelerated primary health service expansion program which is targeting at 85% access by 2009 and the health extension program addresses the human resource issue at the grass root level .Therefore the future plan focuses more on increasing coverage and minimizing Wastage, by making maximum use of the health extension program. The over all EPI plan is to:

Increase DPT3 by 5% annually and reach 95% coverage by the end of 2009 Increase Measles immunization coverage to 95% by 2009 Increase TT2 plus coverage to 80% in women of childbearing age, by 2010 and Reduce drop out rate of DPT1-DPT3 and DPT1-measles to less than 5% by 2007 Reduce preventable Adverse Events Following Immunization (AEFI) to very minimal

Level by the year 2005 Reduce vaccine wastage rate drastically (BCG and measles to less than 20%, DPT, TT

and OPV to less than 10%) By 2009 Rehabilitate the cold chain in line with the cold chain maintenance

and rehabilitation plan by 2009 In line with the Health Extension Program implementation make sure that the health

20

extension workers are fully involved in the routine and supplemental immunization activity as of 2005

Increase the number of antigens provided to the population by introducing the pentavalent vaccine (introduce antigens for Hepatitis B and Haemophilus influenza type b)

Strengthening both in service and pre-service training Mobilize both internal and external resource for EPI

The national child survival strategy has recommended adding Hib vaccine to the traditional EPI program. The national plan is to introduce the Hepatitis B vaccine in 2005-2006 and Hib vaccine as pentavalent in 2007. Expected future challenges of the national immunization program

GAVI support for injection materials will expire in 2004.After that the government shall seek funding resources from partners to fill the funding gap for the cost of injection materials

The country has planned to expand primary health facility and plans also to deploy a large number of health extension workers to the community which ultimately may increase the demand for immunization service and like wise increase the coverage. But mobilizing equivalent amount of resources to cover the rising capital, investment and operational costs will probably be a threat

2.5 The role of UN agencies and NGOs in the national immunization program UNICEF is the main source of funding agency for vaccine and some of the injection materials and may continue supplying vaccines in the future. Major funding for SIAs, AFP surveillance, short-term training, and injection supplies, cold chain and other operational cost came from USAID and the Japan government /JICA during the period of 2001 to 2004. The Irish government has been contributing for strengthening of the routine EPI program since 2001. In addition, the Irish government has supported the procurement of injection materials for 2005. After 2005, the fund for injection materials is not yet secured. About 15% of the fund used for polio campaign during the 2001-2003 has come from CDC. WHO and UNICEF have been paying salary for most of the national EPI experts for the last three years. In addition, WHO has also supported short-term training, AFP surveillance, supervision and monitoring and other operational costs. The Rotary International, Netherlands, NORAD, CIDA, Belgium and DFID have also significant contribution in the funding of the SIAs and routine immunization program during the period of 2001-2004.

21

______________________________________ SECTION Three Pre-vaccine fund & vaccine fund year Program costs and financing (2001-2003)

This section provides and analyzes basic information about the total cost of the national immunization program, broken down by core cost categories (vaccines, personnel, transport and others), and by funding source (government, international donors, and others) from 2001 (before any GAVI support was available) to 2003 (the first full year of GAVI support)

This section presents the review of the total program expenditure and financing from 2001 – 2003. This is broken down by the program expenditure categories of routine recurrent expenditure, routine capital expenditure, and expenditure on supplemental immunization activities. Other optional information relating to costs for the program are also represented. Routine recurrent expenditure represents those expenses for the routine program for activities that require regular input of funds (recurrent expenditure). On the other hand, routine capital expenditure represents the expenses on capital investments used for the routine program. Supplemental immunization activity expenditure relates to expenses incurred during the respective campaigns. Other information not included in these above categories is an estimate attributable to immunization activities for buildings, personnel and transport expenditure (as these are used extensively by other health related activities), disease surveillance costs, and costs for technical assistance from partners. Program costs for the above years are illustrated in figure 3.1 below. Figure 3.1 Program costs (US$ millions) by category for 2001 – 2003 in Ethiopia

$-

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

2001 2002 2003

Other optional information

Other SIAs

Measles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other routine recurrent costs

Transportation

Personnel

Injection supplies

Traditional Vaccines

Total expenditure on immunization activities in the country was at approximately 25 million US dollar which is 0.35/capita per year. About 5% of the total government health expenditure goes for immunization services. Actual expenditure is illustrated in table 3.1 below

22

23

Table 3.1 Past EPI expenditure by cost categories, 2001-2003, in US dollars

Cost Category 2001 2002 2003

Routine Recurrent Cost US$ (%) US$ (%) US$ (%) Vaccines (routine vaccines only) 1,853,142 6.9% 2,109,646 7.7% 2,239,418 9.3%

Traditional Vaccines 1,853,142 2,109,646 2,239,418 Injection supplies 555,721 2.1% 1,079,276 3.9% 1,335,146 5.5% Personnel 1,972,217 7.4% 2,018,220 7.3% 2,044,851 8.5%

Salaries of full-time NIP health workers (immunization specific) 1,781,446 1,823,556 1,848,551 Per-diems for outreach vaccinators/mobile teams 190,771 194,664 196,300

Transportation 2,822 0.0% 29,088 0.1% 56,399 0.2% Fixed site and vaccine delivery 2,647 27,280 52,894

Outreach activities 175 1,808 3,505 Maintenance and overhead 1,085,985 4.1% 1,151,286 4.2% 1,205,716 5.0% Short-term training 50,000 0.2% 402,448 1.5% 647,682 2.7% IEC/social mobilization 23,810 0.1% 90,510 0.3% 82,925 0.3% Supervision and Monitoring 74,568 0.3% 1,074,533 3.9% 614,330 2.5% Other routine recurrent costs 154,005 0.6% 0 919

EPI reviews/surveys 154,005 0 919 Subtotal Recurrent Costs 5,772,270 21.6% 7,955,007 28.9% 8,227,386 34.1% Routine Capital Cost

Vehicles 10,564 0.0% 70,991 0.3% 122,080 0.5% Cold chain equipment 777,633 2.9% 825,038 3.0% 865,436 3.6% Other capital costs 10,964 0.0% 10,964 0.0% 24,804 0.1%

Subtotal Capital Costs 799,161 3.0% 906,993 3.3% 1,012,320 4.2% Supplemental Immunization Activities

Polio Campaigns 14,584,779 54.5% 10,473,130 38.1% 1,841,301 7.6% Vaccines 3,337,560 4,365,687 747,027

Other operational costs 11,247,219 6,107,443 1,094,274 Measles Campaigns 911,390 3.4% 3,191,142 11.6% 8,857,835 36.7%

Vaccines 295,726 553,353 3,040,043 Injection supplies 61,652 234,966 1,931,656

Other operational costs 554,012 2,402,823 3,886,136 MNT Campaigns (CBAW) 1,813,843 6.8% 2,625,980 9.6% 814,217 3.4%

Vaccines 219,047 302,112 54,419 Injection supplies 202,932 534,257 58,073

Other operational costs 1,391,864 1,789,611 701,725 Subtotal Supplemental 17,310,012 64.7% 16,290,252 59.3% 11,513,353 47.7% Shared cost and other optional information

Shared Personnel Costs 849,158 3.2% 866,487 3.2% 873,769 3.6% Shared Transportation Costs 14,842 0.1% 47,617 0.2% 62,574 0.3% Building 389,738 1.5% 397,691 1.4% 405,808 1.7% Other optional information 1,626,596 6.1% 1,024,022 3.7% 2,016,928 8.4%

Technical assistance 8,574 53,072 98,800 Disease surveillance 1,618,022 970,950 1,918,128

Subtotal Optional 2,880,334 10.8% 2,335,817 8.5% 3,359,079 13.9% GRAND TOTAL 26,761,777 27,488,069 24,112,138

Routine (Fixed Delivery) 9,260,819 11,001,345 12,398,980 Routine (Outreach Activities) 190,946 196,472 199,805 Supplemental Immunization Activities 17,310,012 16,290,252 11,513,353

3.1 Pre vaccine fund year (2001) expenditure and financing In the year 2001, SIAs contributed over 60% of the total program costs, while the routine recurrent program was responsible for just over 20% of the total expenditure. The major expenditure driver for the program was the polio SIAs. These represented just under 60% of the total program costs. Vaccines represented 7% of the total program costs, and injection supplies 2%. In addition to polio campaigns, there were also campaigns for measles (4% of total program expenditure), and MNT (7% of total expenditure). These expenditures were financed from a series of sources. The different sources of these funds are illustrated below.

Figure 3.2: Financing sources for immunization in 2001

Ireland Aid2%

Netherlands1%

DfID1%

USAID12%CDC

15%

Govt of Japan/JICA14%

UNICEF20%

Sub-national Gov.3%

National Government

12%Others (UNF, RI, NORAD, SIDA, CIDA, Sweden,

Norway)20%

* 49% of the total cost w as covered by CDC, USAID, DfID, Netherland and others through WHO

We see that there were a number of different partners supporting immunization efforts. The major partners were UNICEF (20% of program expenditure), and CDC, together with Government and USAID. Government was funding only 12% of the total program expenditure. Of these partners, only WHO, UNICEF, CDC has funds that went to supporting the routine recurrent program activities. The rest were contributing funds to the SIAs. WHO and UNICEF were contributed a great deal on hiring EPI program officers for the program management at central and the populous regions.7. Government funding represents 12% of the total program expenditure, equivalent to an estimated 3.2 million US$. Of this, over US$ 1.2 million is the proportion estimated due to shared costs for immunization for personnel, transport, and building expenditures.

24

7 Reflected in the expenditure are the salary costs based on Government salary scales, and not actual amounts paid by donors. This is because these amounts are not sustainable, and future staff will need to be employed by Government based on its salary scales.

Over US$ 1.7 million represents salary expenditure by Government for the different cadres of health workers involved in immunization activities. In addition, the Ministry of Health also contributes an estimated 18% of the cost of injection materials and cold chain equipment by paying for the tax of the above materials. It should be noted that not all the program activities were funded. Funding gaps were seen for activities relating to maintenance and overheads, with funding provided for this significantly less (by over US$ 1 million) than what is estimated as required. 3.2 Vaccine fund year (2003) expenditure and financing In the year 2003, the total program expenditure was approximately US 25 million. In this year, we see the share of the SIAs reducing from over 60% to under 50% of the total program expenditure. This is because, the strategies for SIAs were different and the target populations for the polio measles and MNT campaigns were significantly smaller than in 2001. The difference from 2001 was significant, leading to a reduction of total SIAs expenditure from over US$ 17 million to just under US$ 12 million. There was also a relative increase in the routine recurrent program costs. This was due in part to the change from disposable, to AD syringes, and the increased supervision and monitoring activities. Capital investments increased over the same period. This was a result of vehicles (motorcycles) and other capital equipment that were purchased in this year. Regarding the sources of financing, as with 2001, there were series of partners supporting the Government efforts. These are illustrated in the figure 3.3 below.

Figure 3.3: Financing sources for immunization in 2003 2003

National Government16%

Sub-national Gov.1%

GAVI - Vaccine Fund9%

UNICEF14%

WHO1%

USAID18%

Ireland Aid2%

CDC2%

Netherlands8%

DfID5%

Govt of Japan/JICA9%

Others (UNF, RI, NORAD, SIDA, CIDA,

Belgium)15%

In this year, we see the introduction of GAVI support, which is for the routine program injection supplies, and additional money to support immunization system strengthening. Additional funding was also received from USAID, which goes mainly towards the campaigns, and surveillance activities. Government funds represent an increased proportion of the total program expenditure (16%). This however is not an increase in funding, but a reflection of the reduction in costs for the overall immunization activities in this year.

25

26

______________________________________ SECTION Four Future Resource Requirements and Program Financing / Gap Analysis

This section takes the information about program objectives and strategies from Section 2, and the basic cost information from Section 3, and translates them into projected future costs, based on assumptions about the inputs required to achieve the targets. Then, this section estimates and analyzes the gap between future resource requirements – linked to the program objectives – and available financing over the medium to long term (up to 2015)

4.1 Projections of future program costs Based on the program objectives and strategies, a costing is estimated for the future program costs and financing. As mentioned in section 2, major strategies the program intends to adopt, which may lead to a change in the program costs include:

Maintenance of the SIA activities, particularly for measles and MNT to maintain high population coverage with the respective antigens. Measles campaigns shall be held each 2 years, covering the full target population over a 2 year period, while MNT campaigns are

estimated at covering 10% of the target population each year. As at this stage, it is known there will be polio campaigns up to 2005.

Introduction of new antigens for Hepatitis B in 2005-2006 and Haemophilus influenzae type b as pentavalent in 2007.

Rehabilitation of the cold chain system in the country to a more efficient, and manageable system by 2009. This is based on the cold chain rehabilitation plan.

Supporting the capacity building for the proposed health extension workers, through whom the bulk of immunization activities in the country shall be provided.

With these strategies taken into consideration, the program costs in the future (2005 – 2013) are illustrated in figure 4.1 and table 4.1 below.

Table 4.1 Future program costs by cost categories, 2004-2013 Cost Category 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ Vaccines (routine vaccines only) 3,105,927 5,001,683 5,299,381 40,877,317 34,997,924 36,128,288 37,258,045 38,452,937 39,594,464 40,852,178

Traditional Vaccines 3,105,927 3,000,776 3,233,299 2,411,211 2,651,651 2,843,974 3,008,485 3,210,140 3,329,626 3,535,660 New and underused vaccines 2,000,907 2,066,082 38,466,106 32,346,273 33,284,314 34,249,560 35,242,797 36,264,838 37,316,518

Injection supplies 1,736,912 2,591,019 2,880,314 2,497,007 2,754,192 2,997,947 3,197,396 3,447,030 3,631,655 3,867,646 Personnel 3,304,526 3,869,950 4,102,207 4,580,642 5,476,269 6,316,418 7,031,638 7,270,111 7,518,203 7,776,347

Salaries of full-time NIP health workers (immunization specific) 1,891,440 2,008,878 2,072,726 2,123,350 2,176,104 2,187,193 2,132,663 2,175,317 2,218,823 2,263,199 Per-diems for outreach vaccinators/mobile teams 1,413,086 1,861,072 2,029,481 2,457,292 3,300,165 4,129,225 4,898,975 5,094,794 5,299,380 5,513,148

Transportation 62,245 88,208 100,616 82,762 65,731 73,355 75,557 73,196 75,391 153,991 Fixed site and vaccine delivery 35,281 49,997 57,030 46,910 37,257 41,578 42,826 41,488 42,732 87,283 Outreach activities 26,964 38,211 43,586 35,852 28,474 31,777 32,731 31,708 32,659 66,708

Maintenance and overhead 1,427,096 1,795,044 2,629,476 3,475,034 4,299,621 4,935,894 5,025,879 4,051,442 4,069,896 4,103,640 Short-term training 374,044 381,525 389,155 396,938 404,877 412,975 421,234 429,659 438,252 447,017 IEC/social mobilization 67,063 68,404 69,772 71,168 72,591 74,043 75,524 77,034 78,575 80,146 Supervision and Monitoring 1,177,441 1,201,167 1,225,371 1,249,879 1,274,876 1,300,374 1,326,381 1,352,909 1,379,967 1,407,567

Other routine recurrent costs 52,674 53,728 54,802 55,898 57,016 58,157 59,320 60,506 61,716 62,950 EPI reviews/surveys 52,674 53,728 54,802 55,898 57,016 58,157 59,320 60,506 61,716 62,950

Subtotal Recurrent Costs 11,307,928 15,050,728 16,751,094 53,286,645 49,403,097 52,297,451 54,470,974 55,214,824 56,848,119 58,751,482 Routine Capital Cost

Vehicles 39,882 317,322 270,608 92,007 93,847 95,724 350,349 99,591 101,583 920,341 Cold chain equipment 1,348,646 2,839,843 5,359,791 5,022,260 4,349,640 2,256,927 1,137,332 Other capital costs 62,560 495,800 741,300 809,300 742,300 796,800 62,560

Subtotal Capital Costs 1,451,088 3,652,965 6,371,699 5,923,567 5,185,787 3,149,451 412,909 1,236,923 101,583 920,341

27

28

Supplemental Immunization Activities Polio Campaigns 299,403 4,158,407

Vaccines 62,068 848,606 Other operational costs 237,335 3,309,801

Measles Campaigns 5,355,787 4,495,938 4,684,364 5,086,627 5,301,251 5,759,597 6,004,224 Vaccines 1,217,909 1,009,803 1,039,088 1,100,229 1,132,135 1,198,751 1,233,515 Injection supplies 802,932 665,734 685,040 725,348 746,383 790,301 813,220 Other operational costs 3,334,946 2,820,401 2,960,236 3,261,050 3,422,733 3,770,545 3,957,489

MNT Campaigns (CBAW) 3,458,576 2,679,807 2,234,395 2,299,193 2,365,870 2,434,479 2,505,079 2,577,727 2,652,481 2,729,403 Vaccines 473,081 361,751 305,632 314,495 323,616 333,000 342,657 352,594 362,820 373,341 Injection supplies 687,671 525,840 444,266 457,150 470,407 484,049 498,086 512,531 527,394 542,689 Other operational costs 2,297,824 1,792,216 1,484,497 1,527,548 1,571,847 1,617,430 1,664,336 1,712,602 1,762,267 1,813,373

Subtotal Supplemental 9,113,766 11,334,152 6,918,759 2,299,193 7,452,497 7,735,730 2,505,079 8,337,324 8,656,705 2,729,403 Shared cost and other optional information

Shared Personnel Costs 979,428 1,378,471 1,528,422 2,026,044 3,039,678 4,114,336 5,237,508 5,464,557 5,702,211 5,950,982 Shared Transportation Costs 64,452 66,385 68,377 70,428 72,541 74,717 76,959 79,267 81,645 84,095 Building 413,924 625,588 837,358 1,049,237 1,261,227 1,473,330 1,479,208 1,485,203 1,491,318 1,497,556

Other optional information 1,586,966 1,618,705 1,651,079 1,684,101 1,717,783 1,752,139 1,787,181 1,822,925 1,859,383 1,896,570 Technical assistance 54,552 55,643 56,756 57,891 59,049 60,230 61,434 62,663 63,916 65,194 Disease surveillance 1,532,414 1,563,062 1,594,323 1,626,210 1,658,734 1,691,909 1,725,747 1,760,262 1,795,467 1,831,376

Subtotal Optional 3,044,770 3,689,149 4,085,236 4,829,810 6,091,229 7,414,522 8,580,856 8,851,952 9,134,557 9,429,203 GRAND TOTAL 24,917,552 33,726,994 34,126,788 66,339,215 68,132,610 70,597,154 65,969,818 73,641,023 74,740,964 71,830,429

Routine (Fixed Delivery) 14,363,736 20,493,559 25,134,962 61,546,878 57,351,474 58,700,422 58,533,033 60,177,197 60,752,220 63,521,170 Routine (Outreach Activities) 1,440,050 1,899,283 2,073,067 2,493,144 3,328,639 4,161,002 4,931,706 5,126,502 5,332,039 5,579,856 Supplemental Immunization Activities 9,113,766 11,334,152 6,918,759 2,299,193 7,452,497 7,735,730 2,505,079 8,337,324 8,656,705 2,729,403

29

Figure 4.1 Projection of immunization costs by strategy, US$ millions, 2004 – 2013

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Other optional information

Other SIAs

Measles Campaigns

Polio Campaigns

Other capital costs

Cold chain equipment

Vehicles

Other routine recurrent costs

Transportation

Personnel

Injection supplies

New and underused vaccines

Traditional Vaccines

By the year 2005 & 2006, the program costs are just over US$ 30. There is then a large increase to over US$ 60 million in 2007, with the costs being maintained at that level. The main cost driver from 2007 onwards is the new, pentavalent vaccine. This will cost the program over US$ 30 million each year. The share of the routine program costs to the total immunization costs in the country increases from just over 40% to 80% when the new vaccine is introduced.

1.2 Future financing for the immunization program, and funding gap analysis

The known financing sources for these activities are illustrated below. Figure 4.2: Secure and probable financing for immunization, US$ millions, 2004 - 13

Secure and Probable Funding and Gaps (US$ Millions)

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Funding Gap

Others (UNF, RI, NORAD,DfID, SIDA, CIDA, Belgium)Govt of Japan/JICA

DfID

Netherlands

CDC

Ireland Aid

USAID

WHO

UNICEF

GAVI - Vaccine Fund

Sub-national Gov.

National Government

Actual resources from the different sources are illustrated in table 4.2 below.

30

31

Table 4.2 Secure, and probable resources from different partners Secure Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ National Government 3,290,112 3,552,394 3,874,035 3,928,422 4,758,414 5,241,012 5,815,633 7,275,366 8,625,510 9,606,350 10,074,145 10,403,831 10,604,518Sub-national Gov. 1,865,450 1,415,271 1,495,416 1,513,255 1,013,224 1,102,803 2,537,621 3,373,116 4,205,479 4,976,183 5,170,979 5,376,516 5,624,333GAVI - Vaccine Fund 0 1,596,324 2,058,820 3,352,268 1,928,000 1,928,000 0 0 0 0 0 0 0

UNICEF 5,058,246 6,525,719 3,427,877 4,348,642 4,559,857 2,239,734 0 0 0 0 0 0 0WHO 74,735 64,171 212,968 79,171 64,171 0 0 0 0 0 0 0 0USAID 3,073,263 3,907,359 4,403,066 1,187,260 95,000 0 0 0 0 0 0 0 0Ireland Aid 413,739 119,048 372,713 133,798 1,654,070 0 0 0 0 0 0 0 0CDC 3,899,482 4,239,957 396,190 0 0 0 0 0 0 0 0 0 0Netherlands 200,004 3,491,598 1,994,695 1,690,204 2,934,992 0 0 0 0 0 0 0 0DfID 213,442 0 1,097,405 724,505 0 0 0 0 0 0 0 0 0

Govt of Japan/JICA 3,655,037 1,602,911 2,033,749 1,575,849 1,425,142 0 0 0 0 0 0 0 0Others (UNF, RI, NORAD, DfID, SIDA, CIDA, Belgium) 5,195,697 899,639 3,659,813 5,292,539 0 0 0 0 0 0 0 0 0

Total Secure Funding 26,939,206 27,414,390 25,026,746 23,825,913 18,432,871 10,511,549 8,353,254 10,648,482 12,830,989 14,582,533 15,245,123 15,780,347 16,228,851 Total Cost / Resource Requirements 28,558,368 29,321,099 25,960,342 24,917,552 33,726,994 34,126,788

66,339,215 68,132,610 70,597,154 65,969,818 73,641,023 74,740,964 71,830,429

Funding Gap 1,091,639 15,294,123 23,615,239 57,985,96

1 57,484,128 57,766,165 51,387,285 58,395,900 58,960,617 55,601,578 Probable Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$

GAVI - Vaccine Fund 0 2,000,907 2,066,082

38,466,106 32,346,273 33,284,314 34,249,560 0 0 0

UNICEF 0 0 2,234,395 4,799,193 4,865,870 4,934,479 5,005,079 5,077,727 5,152,481 5,229,403WHO 0 4,495,938 4,734,364 50,000 5,136,627 5,351,251 50,000 5,809,597 6,054,224 50,000

Total Probable Funding 0 6,496,845 9,034,841

43,315,299 42,348,770 43,570,044 39,304,639 10,887,324 11,206,705 5,279,403

Total Resource Requirements 24,917,552 33,726,994 34,126,788

66,339,215 68,132,610 70,597,154 65,969,818 73,641,023 74,740,964 71,830,429

Funding Gap 24,917,552 27,230,149 25,091,947 23,023,91

6 25,783,840 27,027,110 26,665,179 62,753,699 63,534,259 66,551,026 Secure + Probable Funding 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ National Government 3,928,422 4,758,414 5,241,012 5,815,633 7,275,366 8,625,510 9,606,350 10,074,145 10,403,831 10,604,518

Sub-national Gov. 1,513,255 1,013,224 1,102,803 2,537,621 3,373,116 4,205,479 4,976,183 5,170,979 5,376,516 5,624,333GAVI - Vaccine Fund 3,352,268 3,928,907 3,994,082

38,466,106 32,346,273 33,284,314 34,249,560 0 0 0

UNICEF 4,348,642 4,559,857 4,474,129 4,799,193 4,865,870 4,934,479 5,005,079 5,077,727 5,152,481 5,229,403WHO 79,171 4,560,109 4,734,364 50,000 5,136,627 5,351,251 50,000 5,809,597 6,054,224 50,000USAID 1,187,260 95,000 0 0 0 0 0 0 0 0Ireland Aid 133,798 1,654,070 0 0 0 0 0 0 0 0CDC 0 0 0 0 0 0 0 0 0 0Netherlands 1,690,204 2,934,992 0 0 0 0 0 0 0 0DfID 724,505 0 0 0 0 0 0 0 0 0

Govt of Japan/JICA 1,575,849 1,425,142 0 0 0 0 0 0 0 0Others (UNF, RI, NORAD, DfID, SIDA, CIDA, Belgium) 5,292,539 0 0 0 0 0 0 0 0 0

32

Total Secure + Probable Funding 23,825,913 24,929,716 19,546,390

51,668,553 52,997,252 56,401,033 53,887,172 26,132,447 26,987,052 21,508,254

Total Resource Requirements 24,917,552 33,726,994 34,126,788

66,339,215 68,132,610 70,597,154 65,969,818 73,641,023 74,740,964 71,830,429

Funding Gap 1,091,639 8,797,278 14,580,398 14,670,66

2 15,135,358 14,196,121 12,082,646 47,508,576 47,753,912 50,322,175

33

Future financing is either secure, or probable. Secure funding represents resources for which there is a very high certainty that will be available. These include resources from Government for health workers salaries, contribution to maintenance (based on present contributions), and estimated proportion for immunization of shared costs for building, personnel, and transport. In addition, secured resources include regular budget funds from WHO and UNICEF (up to the end of their present Programs of work, 2005 for WHO and 2006 for UNICEF), and support to the program activities for 2004, and secured funding for 2005 from GAVI, USAID, Ireland Aid, Netherlands, DfID, Government of Japan, and a host of other partners. These funds are largely for the planned campaigns in 2005 (detailed breakdown of each partner’s contribution in Annex 3). Secured funds represent only 18% of the total resource requirements from 2004 – 2013. A series of resources have been classified as probable and these include:

Continued support beyond the present agreed program of work for WHO and UNICEF (US$ 50,000 for WHO, and US$ 2,500,000 for UNICEF per year),

5-year support for the new vaccine from GAVI, starting in 2006, this is still probable money as the country proposal for support is still to be submitted and approved

Funds for SIA activities have always been mobilized in the past, and the respective SIA will not be done (so wont be a program cost) if funds are not mobilized.

Inclusion of these probable funds reduces the funding gap to 40% of total resource requirements. However, it should be noted that the bulk of the funding gap is for the routine program activities, including purchase of traditional vaccines, rehabilitation of the cold chain and operational cost for the routine EPI program 4.3 Financial impact of selected alternative policy options to reduce program costs Maintenance of this funding gap will require the program to modify its strategies in line with the financial realities within which it is operating. This would entail scaling back on its strategies. As the introduction of the new vaccine is the key cause of increased costs, this document reviews the financing for the program if alternative approaches are attempted. These are:

Introduction of only Hib vaccine is done (as a tetravalent), Introduction of only Hepatitis B vaccine is done (as a tetravalent) Introduction of only Hepatitis B vaccine is done (as a monovalent)

Impact on the funding gap of each of these approaches is illustrated in the following page

Figure 4.3 Impact on total program costs, and funding gap of different new vaccine policy options

The if th

It isplan

Pentavalent option (2005- 2006 only HepB) by 2007

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

HepB tetra option

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

funding gap reduces in each option, and reduces most if He DTP-Hib option is taken. It should however be emphasiz

The absolute size of the gap, up to 2010 is similar in al money is considered, as the GAVI/vaccine fund will su 2010. It is after this that the impact of the different opti

There are significant programmatic implications for ea change in options will have a significant impact on dise hamper efforts towards achievement of long-term deve

because of these that the preferred option is to have thes to ensure this is done is highlighted in the next section.

34

Hib tetra option

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

HepB monovalent option

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

epB as monovalent option is introduced, but least ed that:

l options if the probable pport the program up to ons would most be felt. ch of these options. A ase burden, and will

lopmental goals.

two new vaccines introduced. How the country

35

______________________________________ SECTION Five Sustainable Financing Strategy, Actions and Indicators

In this section, we present the strategy for moving forward to financial sustainability plan. Focus will be on identifying strategies for sustainable financing, feasible actions and indicators.

The previous sections of this document have described the context, with constraints and opportunities, the programme objectives and plans; and cost implications and the financing options. We have illustrated the financial requirements in the medium to long term for the immunisation programme. In this section, we define the strategic plan that illustrates how the country will pursue financial sustainability for immunisation within existing and new mechanisms for resource mobilisation and use. Following a review of the opportunities and challenges, the section presents the proposed combination of strategies to be adopted. 5.1 Opportunities for financial sustainability There are a series of opportunities the program can exploit as it tries to achieve financial sustainability. These, we discuss in the sub section, as they occur at the international, national, and sub national levels. 5.1.1 International /Bilateral and multilateral level

The existence of numerous partners (UN, Bilateral, Multilateral, NGOs, etc) funding/willing to fund for vaccine and supply purchase, and operational costs for EPI program

There is an ongoing mobilization for supplementary funds for both EPI and campaigns Injection safety has already been introduced with the support of GAVI and has enabled the use of AD

syringes in the immunization program at all levels Mobilization of EPI commodities (motorcycles, motor boats, micro phones, etc.) vaccines, and program

operational cost through Local Rotary International for campaign The existence of functional ICC is playing a major role in resource mobilization for NIP

5.1.2 Government/Health Sector

Ethiopia has launched the Sustainable Development and Poverty Reduction program (SDPRP). The health component of SDPRP is the Health Sector Development Program (HSDP).One of the prime focus of HSDP is prevention of communicable diseases with special emphasis on immunization

Government readiness to agree on the use of loan money for procuring polio vaccine There is strong national and regional government commitment to achieving the child survival MDG's

through budgeting for personnel, building, transportation and other running cost (water, electricity, fuel) required for the immunization program

There is an ongoing decentralization of health planning and financing at woreda level The recent introduction of an innovative health delivery strategy to reach grass root levels, the Health

Extension Program( HEP) is believed to bring tremendous impact on the national immunization coverage and on the reduction of vaccine wastage

The launching of the new civil service reform Accelerated primary health service expansion targeted at 85% access by 2009

5.1.3 Community level

Increasing trend of community awareness about immunization activities as a result of the series of campaigns conducted in the last seven years

There is an increasing community involvement and participation in health post construction at the community level

Involvement of civil societies in mobilizing the community for support of the immunization programs (routine, campaigns)

5.2 Challenges of financial sustainability On the other hand, the program is operating in an environment that has a series of issues that may hamper efforts towards achieving financial sustainability. This will be discussed at different levels including international, national and sub national levels. 5.2.1 International level

The present GAVI support for injection material and operational cost will cease in 2005 without securing an alternative means of funding for the immunization at the local level

There is inadequate coordination within the program which has resulted in discordance of immunization planning, flow of required funds and efficient resource utilization

Competing funding priorities by partners. At times, funding priorities of partners move more for emerging problems like HIV/AIDS, malaria, etc which may negatively affect the NIP

5.2.2 Government level/Health Sector

The National Health Expenditure (NHE) is relatively low and is dominated by curative care The immunization coverage and utilization of the service is low, with wide regional variations Currently there is no government contribution for vaccine procurement There is limited access, wide spread shortage of skilled human resource and supplies for immunization

activities at all levels Decentralization is in progress but there are wide spread problems of information flow and inadequate

management and accountability at all levels Inadequate motivation of health personnel at all levels The under utilization of the funds secured from donors observed in some regions may result in reduction

or termination of future budget opportunities Weak health information system making planning, monitoring and reporting difficult at all levels There is a high vaccine wastage rate for almost all antigens particularly, for BCG and Measles. Weak supervision, monitoring and evaluation systems

36

37

5.3 Strategy for financial sustainability The ultimate goal of the financial sustainability plan is “Self Sufficiency”. That is to be able to cover all costs related to immunization, including the purchase of vaccines and required logistics, personnel and operational costs, etc. However, for a country like Ethiopia, where the overall health expenditure is still at a lower level, the rational way of formulating the FSP will be mobilization and efficient use of domestic and supplemental external resources on a reliable basis to achieve the targeted goals of national immunization coverage. 5.3.1 Mobilizing additional resources Additional resources from Central and local Government The central and regional governments have already started funding for about 15% of the total EPI program expenditure. In addition, the MOH contributed to an estimated 18% cost for injection materials by exempting taxation. This effort has to grow significantly, so that, at least by the year 2013 the government will be able to cover 10% of the total cost for vaccines. Ethiopia has a decentralized political and administrative system, therefore, the regional governments should start planning and allocating for vaccine purchase and start to contribute also for other vaccine related expenses. At both central and regional level, strengthening immunization activities should be considered as one major investment in development, as it ultimately will impact on the overall development of the country. Additional Resources from Private Sector, Civil Societies and NGOs The experience gained during the past SIAs has clearly shown the importance of mobilizing potential private companies, civil societies and NGOs to generate additional resources for EPI activities. Though, the contribution from these organizations was very little in the previous SIAs, it was still possible to secure some additional resources from some of these groups, which was used for operational costs. Therefore, every opportunity should be looked to mobilize resources from potential private companies. Additional Resources from funding agencies: Up until now, the procurement of vaccines, injection materials and cold chain equipment have been fully supported by bi-lateral and multi-lateral organizations through UNICEF and WHO. This significant support is assumed to continue for the next few years. However, after a couple of years, there will be a definite funding gap which will require an additional source of funding to fill the gap. Besides, there is also a need to shift the attention of funding organization (bi-lateral and multi-lateral) organizations from funding supplemental immunization activities to funding of the routine immunization program. In Ethiopia about half a million children die annually. And most die from preventable communicable diseases, which could partly be due to low immunization coverage. Therefore, both the government and international partners should work hard towards mobilizing for doubling resources to improve the immunization coverage and quality of immunization. It is also necessary to start introducing the new vaccines like Hib vaccine, which is proven to be high impact key intervention for child survival.

5.3.2 Increasing reliability of resources Increasing reliability of government resources What is really important in this regard is to make sure that, adequate fund is available for the program objectives, and that the funds flow continuously and regularly to ensure that they are available when they are needed. It is also equally important to make sure that they are used efficiently to meet the program objectives. Increasing reliability of External resources

Usually the funding organization provides funding in the form of regular and supplementary budget. In which case, the regular budget is normally secured and the supplementary to be mobilized. Therefore, in the future plan, special attention should be given to ensure that, the regular budget is adequate and available when it is needed. 5.3.3. Improving Program Efficiency

The three potential areas which can improve EPI program efficiency are:

Minimizing vaccine wastage rate Improving EPI program management Maximum use of Health Extension program

Minimizing vaccine wastage rate Vaccine wastage is a serious problem of EPI program in Ethiopia. It is due to poor planning of static and out reach sessions, lack of awareness of the community and poor management of the cold chain system and also the current policy which recommends to open a vial of vaccine, even for a single child and discard opened vials of BCG and measles after 6 hours or at the end of the session. By adhering to the above policy, it is still possible to minimize vaccine wastage through; proper planning of both static and out reach sessions, by increasing the awareness for the community, and by improving the cold chain management at all levels. Improving EPI program management The civil service reform was recently introduced in Ethiopia, and has become the back bone of all sectors providing social service to the community at various levels. Having this on the background, the EPI program should focus on the following activities to improve EPI program management at all level

Revise the current immunization policy to include issues related to new vaccines. Design a mechanism of proper communication system to secure regular reporting from the woreda to the

regions and from the regions to the center Conduct continuous and regular supervision, monitoring and evaluation and strengthen further the in –

service and pre-service training on immunization at all level 38

39

Health Extension Program

The ultimate result of the HEW involvement in the EPI program will be, reduction in wastage rate, increasing coverage and finally improving EPI program efficiency. The high vaccine wastage rate is mainly due to poor social mobilization and poor selection of outreaches. Involvement of the community in the planning and programming stage of EPI program is therefore very crucial.

It will be a golden opportunity for the NIP to have 24,800 HEW in the next five years, who will be fully trained on immunization, including management of cold chain system at the periphery. The role of HEW will include:

Coordinating the other community health workers (CHW) in mobilizing the community for immunization

Being directly involved in vaccinating children Tracing the defaulters, and that way minimize the drop outs Reduce missed opportunities by providing integrated child health services

5.4 The action plan monitoring process and indicators for FSP are illustrated in the table 5.1 5.1 Action Plan, monitoring process and indicators for FSP

Indicators trategy Mobilizing additional resources Actions

Responsible Body Freq FP*

Indicator Baseline Target2009

GOV/LOCSL Create forums for sensitization, Dialogue and consensus building meeting both at national and regional level on funding of EPI program

FHD/RHB, One at national and one at regional level

Proportion of total vaccine cost funded by Govt resources (an increase of 1% per year)

0% 5%

Accelerating ongoing support, such as personnel, transportation, M&E, implementation of system-wide programs, etc

FMOH/RHB/MOFED Availability of transportation , human resource

Mobilize communities to contribute to EPI activities, such as Health Post construction

RHB/Woreda Health Office

Proportion of health posts constructed by the communities

5% 10%

Proportion of health posts for which communities are contributing for operational costs in applicable region

--- 5%

PRIVATE Create a forum for sanitization for fund raising for EPI activities Identify potential private companies to fund national EPI activities Create a mechanism to cost for immunization services to capable individuals

FHD/RHB/Private health sectors

Number of private organizations contributing to EPI activities

5 10

PARTNER/INT. ORG. Mobilize new partner support for additional funding based on program outputs Mobilize current partners for doubling their resources for immunization

Foreign Ministry /MOH/MOFED

Number of new partners supporting the routine EPI program

Increasing reliability of resources

Provide regular feedback (accountability and outputs) based on resource use to funding partners/ICC and sub national level

FHD/RHD/Partners Number of feedback reports on costing and financing provided to funding partners/ICC and sub national levels per year

0 4

Strengthen system for receipt, proper utilization of resources, reporting and follow up based on partner requirements

Regular update, and discussion among ICC partners of costing and financing information for immunization in the country

Number of ICC meetings at which program costing and financing information is discussed per year

0 4

Seek longer term partner and Govt resource contributions/commitment based on elaborated longer term needs particularly for vaccines

Improving programefficiency

40

41

Minimize wastage rate - Create demand and utilization of EPI services through continuous sensitization and IEC/BCC at the community level

RHB/Woreda health offices

Explore feasible areas for integrating of activities with other programs

FHD/RHB Number of programs collaborating with immunization at all levels

3 5

Proper planning and forecasting of both out reach and static immunization sessions

BCG vaccine wastage rate 20%

Measles vaccine wastage rate

15%

DPT- vaccine wastage rate 10%

Effective management of a cold chain system Proportion of cold chain equipment replaced annually according to the cold chain rehabilitation plan

100%

Proportion of facilities assessed using the cold chain monitoring chart correctly

100%

Improving EPI program management

Implement capacity building for health workers at all levels related to both pre service area, and in service personnel

MOH/THD/FHD/Higher training institutions

Seek alternative means to motivate health staff implementing EPI activities

Capacity building Ministry ,MOH

Retention mechanisms in place

Ensure proper implementation of the cold chain rehabilitation plan

MOH/Partners, RHB, Woreda Health office

Work with finance and administration program for maximal utilization of resources

FHD/FA Service Increased utilization rate 5% per annum 25%

Strengthen system to follow up on program efficiency across different regions

Number of supervision visits annually at all levels 4

Maximum use of Health extension program

Ensure proper utilization (maximal use) of the new health extension workers for implementing immunization activities

Proportion of health posts providing regular immunization services

100%

Improved community mobilization for EPI activities Make sure that the HEW are capable of providing vaccine and managing cold chain system

Proportion of eligible children immunized per outreach session

100%