November 7-8, 2015

Eka Paatashvili

Sabin Vaccine Institute

November 7-8, 2015

Policy Dialogue for a Sustainable Immunization Program

Borjomi, Georgia

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Table of Contents Introduction ..................................................................................................................................... 2

Proceedings ..................................................................................................................................... 2

Day 1 ........................................................................................................................................... 3

Theme 1: Immunization at global and national agendas ........................................................ 3

Theme 2: Financial Sustainability of the National Immunization Program ........................... 5

Theme 3: Legislative Framework for Immunization .............................................................. 9

Theme 4: Performance of the National Immunization Program: Recent Trends and Plans . 11

Theme 5: Discussion on Institutional Linkages for a Sustainable Immunization Program .. 12

Day 2 ......................................................................................................................................... 13

Theme 6: Best Practices for NIP Performance and Sustainability ....................................... 13

Group work: Solutions for Country Ownership and Sustianability ...................................... 14

Conclusions ........................................................................................................................... 15

Follow-Up ............................................................................................................................. 16

ANNEXES .................................................................................................................................... 17

Annex A: list of participants ..................................................................................................... 17

Annex B: Agenda ...................................................................................................................... 20

Friday, November 06, 2015 .......................................................................................................... 20

Saturday, November 07, 2015 ...................................................................................................... 20

Sunday, November 08, 2015 ......................................................................................................... 21

Annex C: Discussion Questions................................................................................................ 22

Annex D: Workshop evaluation................................................................................................ 24

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Introduction For decades, immunization has been a priority in the Republic of Georgia. Consistently strong

performance by the National Immunization Program (NIP) has eliminated poliomyelitis and other

vaccine-preventable diseases. With the introduction of new technologies and costlier vaccines,

immunization program costs have significantly risen and will likely continue to do so. In 2011,

Georgia entered the GAVI support graduation phase and donor support started progressively

decreasing. In 2018, Georgia will take full ownership of its NIP, which means it will be responsible

for adequate financing, budget execution and effective performance of the program.

As a signatory to the 2012 Global Vaccine Action Plan and implementer of European Vaccine

Action Plan, Georgia has pledged to achieve global and regional strategic objectives, including a

sustainably financed and well-performing immunization program. There are the questions to be

discussed at the policy level: How will the government of Georgia commit to a sustainable

immunization program? What are the concerns and plans of decision-makers for country

ownership? How informed are key stakeholders about NIP needs and how coordinated are their

efforts? How will current financial trends and legislative frameworks meet the existing challenges

and help support a strong immunization program?

Since 2014, the Sabin Vaccine Institute has been working with national counterparts in Georgia to

advocate for domestic financing and legislative arrangements to build a strong national

immunization program. This advocacy work includes analyzing immunization budgets, examining

legislation relevant to immunization financing, and organizing opportunities for government and

parliamentary counterparts to exchange information and collaborate in these areas.

Borojomi, Georgia was the setting for Georgia’s first Sabin-sponsored Policy Dialogue on

Immunization. Sabin Senior Program Officer Dr. Eka Paatashvili together with the Parliamentary

Committee on Healthcare & Social Issues coordinated the event, which took place on 7-8

November 2015. Attending were 38 participants representing a variety of Georgian institutions:

Parliament of Georgia; Ministry of Labor, Health & Social Affairs; Ministry of Finance; National

Center for Disease Control; Georgia’s NITAG; the Ministry of Health of Adjara Autonomous

Republic; the Local Government of Tbilisi; Curatio International Foundation; Family Doctors’

Association; Family Medicine Study Center; Tbilisi State University. Also attending were

counterparts from the WHO and UNICEF country offices (Annex A: List of participants).

This report: (a) conveys the workshop objectives, (b) highlights the workshop proceedings, (c)

analyzes institutionalized, implemented, or aspirational innovations, (d) determines the role of key

stakeholders in the processes, and (e) closes with next steps.

Proceedings The Policy Dialogue on Sustainable Immunization aimed to increase the awareness in key national

stakeholders and decision-makers about achievements and challenges to the NIP, as well as best

practices.

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Specific objectives included:

1. Advocating for resource mobilization for the state immunization program and support

smooth GAVI graduation process; target the hearing process of the state budget bill of

2016;

2. Discuss the existing regulatory framework and its influence on prioritization, financing and

performance of NIP; identify key legislative provisions enabling sustainable NIP;

3. Explore successful practices of using NIP resources effectively and improving decision-

making;

4. Support collective effort and involve key stakeholders for political commitment.

The agenda of Policy Dialogue can be found in Annex B. The participants’ presentations addressed

five key domains: (a) Global and national policies, (b) domestic financing arrangements, (c)

budgeting and budgetary process, (d) legislation, and (e) program performance. The group work,

moderated by the public health experts of Curatio Foundation, identified key priorities for

increasing the sustainability of the NIP.

Day 1 Welcome Address

The session was led by Dr. Khundadze, Chairman of the Parliamentary Committee on Healthcare

& Social Issues. He welcomed the participants and acknowledged his high hopes for the

collaborative efforts of national stakeholders and international partners at the workshop. He also

thanked the Sabin Vaccine Institute for organizing the workshop. Dr. Khundadze noted that

immunization remained high among health priorities, which is proven by significantly increased

government contributions in the state budgets of the recent years; maintaining that trend is

extremely, yet challenging due to the graduation process.

As participants introduced themselves, Dr. Eka Paatashvili explained the objectives and agenda

of the meeting. She presented the evidence on the benefits and cost-effectiveness of immunization,

and underlined the importance of collective action for immunization as public good. Key public

institutions must act collectively to secure and maintain herd immunity in order to protect the entire

population. As conditions change or new incentives arise, the institutions must adapt their practices

accordingly. These institutional innovations are observable. They are an indication that the

immunization program, and its financing, are moving toward the sustainable/country ownership

goal. Dr. Paatashvili highlighted how SIF (Sabin’s Sustainable Immunization Financing Program)

contributes to collective action and innovative approaches in immunization programs.

Theme 1: Immunization at global and national agendas Dr. Georgi Kurtsikashvili, a Medical Officer based in WHO’s Tbilisi office, and Lia Jabidze,

National Immunization Manager, summarized the Global and European Vaccine Action Plans and

illustrated how Georgia’s own health and immunization program policies are carrying them out.

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Dr. Kurtsikashvili explained the context of GVAP and EVAP and their phases of development. He

described the steps of EVAP resolution and explained regional goals, objectives, indicators and

actions stated by the document (Table 1). The Action Plan can be used as an operational instrument

for developing a national action plan for Georgia. Dr. Kurtsikashvili discussed the advantages of

EVAP’s monitoring and evaluation format, and its compatibility with the global and national

structures. He suggested innovative strategies, including of establishing a NITAG, TIP (Tailored

Immunization Program), and electronic immunization registries in European countries. Finally,

the presenter remind the attendees about recommendations on implementing EVAP in the national

immunization plan and strengthening accountability by progressing on regional goals.

Table 1. EVAP Goals and Objectives, WHO-Euro

Dr. Lia Jabidze, EPI manager, first spoke about the history and role of immunization; she then

highlighted the national policies and strategies that apply to Georgia’s immunization system, and

described the goals and achievements of the NIP. Dr. Jabidze noted that the NIP goals were set in

cMYP of 2012-2016 and mainly correspond to the regional vaccine action plan (2014-2020). This

includes goals such as targeting coverage and drop-out rates, surveillance strengthening, and new

vaccine introduction. She reviewed the immunization calendar and recent changes in it due to

introducing Rota (2013), Pneumo (2014) and hexa-valent (2015) vaccines. The latest healthcare

system reforms are influencing performance of the national immunization program, as seen in

these examples:

Healthcare has become a high priority in the country and since 2012, the government

nearly doubled its financing

A universal healthcare system has been introduced and the government became the main

purchaser of healthcare services, increasing guarantees for accessing immunization

services

Primary health care system has been restructured

School doctors institute has been established

Immunization coverage remains high at the national level

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Dr. Jabidze used the results of the graduation mission re-assessment to list strengths of Georgia’s

NIP:

prioritization of immunization and high political commitment; separate immunization

budget line and MTEF projections for 4 years; immunization program and services are

continuous and fully financed by the government (only 4% use private services);

established NITAG and active ICC;

centralized vaccine procurement and usage of UNICEF Supply Chain mechanisms;

complex and integrated immunization information system; increased funds for cold chain

and effective vaccine distribution mechanisms;

developed graduation action plan with GAVI technical support of about 600,000 USD

The EPI manager concluded that recent trends in healthcare system and the NIP match global and

regional goals, but there remains many ways to improve NIP performance.

Theme 2: Financial Sustainability of the National Immunization Program Dr. Paatashvili gave an overview of immunization program financing in Georgia, including the

trends of funding sources, co-financing and projections of immunization costs based on the

information from the National Center of Disease Control and the Ministry of Finance. She gave a

fiscal space analysis, comparison of regional and country financing trends, immunization budget

flow analysis and SWOT analysis through GAVI suggested dimensions of resource mobilization,

budget reliability and efficiency.

The graphs showed a 14-fold increase of routine immunization funds by 2018 (the time of total

self-financing). Due to new vaccine introduction and the progressing rate of co-financing, the

routine immunization state budget increased 4.4-fold from 2012 to 2015; for the same period,

government funding for routine immunization as a percent of total healthcare program budget

increased from 0.49% to 1.09% and achieved the suggested minimum threshold of 1%. By 2018,

it is expected that an additional 1.5-fold increase in funds will lead to immunization expenditures

equaling 1.32% of total healthcare program budget (Table 2).

Table 2. Fiscal Space Analysis

Government Expenditure

2012 2013 2014 2015 2016 2017 2018 2019

Immunization State Program budget (budget line), million GEL

3.2 6.0 4.4 10.4 12.3 13.0 14.0 14.0

Immunization budget line - % /Total health care program budget line

0.96% 1.4% 0.76% 1.58% 1.54% 1.62% 1.71% 1.67%

Government expenditure on routine vaccines, million GEL

1.65 2.950 1.474 7.22

10.29 10.8 10.8 10.8

Routine vaccines- %/Total health care program budget

0.49% 0.89% 0.28% 1.09% 1.29% 1.35% 1.32% 1.28%

Total health care budget, million GEL

332.8 435.5 577.5

658.5 799.5 800.5 820.5 840.5

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Health care program budget- %/ GDP

1.3% 1.6% 2.0% 2.1% 2.4% 2.2% 2.0% 1.9%

Nominal GDP (million GEL) 26,167.3 26,847.4 29,352.0 30,663.8 33,909.8 37,205.8 40,625.9 44,360.5

Ministry of Health and Social Affairs (budget line), million GEL

1,793.9 2,126.5 2,632.6 2,785.0 3,070.9 3,100.9 3,151.0 3,201.0

Projections for the next several years show a moderate increase in both healthcare and routine

immunization funds; however, the percentage of healthcare program funds as a percentage of GDP

is not expected to grow. Phasing out core donors such as GAVI and the Global Fund, together with

high demands of the universal healthcare budget, create a significant burden on the public budget

and generate concerns about further expanding the immunization calendar. High depreciation of

local currency is another constraint. Competing priorities make strong advocacy for immunization

resource mobilization essential.

Georgia’s JRF reporting shows increased immunization funding and prioritization of routine

immunization in the country: government expenditure on routine immunization per surviving

infant increased from USD$13 in 2006 to $61 in 2014. Georgia ranks second among four SIF EU

countries, after Armenia ($84). This JRF indicator is expected to be much higher for 2015 due to

hexa-valent vaccine introduction. However, it is still behind the average for WHO European

countries.

Table 3. Government Expenditure on Routine Immunization per Surviving Infant

The budget flow analysis introduced a positive image of PEFA indicators for 2013 and 2014,

underlying highly positive results in budget credibility, absorptive capacity, cash hoarding and

misclassification. However, there are gaps in report accuracy. In addition, cMYP calculations for

proposed years (2013-2014) are higher than the projected and approved funds for vaccines. In fact,

the cMYP costing tool is not integrated into budget calculations for routine immunization cost.

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The comparison of vaccine prices procured by the Georgia government (within the national

immunization calendar) to the WHO V3P median and average prices for the same vaccines shows

the considerable efficiency of Georgia’s procurement mechanisms, mostly using UNICEF supply

schemes (Table 4). In addition, Georgia has effective national procurement mechanisms; the

country succeeded in procuring hexa-valent vaccine much more cheaply than the V3P WHO

median and average.

Table 4. Comparison of Vaccine Prices

Dr. Paatashvili focused on the areas for improvement regarding resource mobilization, budget

reliability and efficiency. There are insufficient national allocations for training, communication,

and monitoring. After graduation, the underfunding of those activities could highly affect the NIP.

Shared NIP operational costs are integrated into different health care programs and NCDC

administrative expenditures. In 2012, a service fee for routine immunization was removed from

the immunization program and was integrated into the capitation fee of the primary health care

state program. Consequently, tracking routine immunization resources individually became more

difficult.

Dr. Paatashvili then proposed immunization financing discussion questions. How would the NIP

perform well if immunization personnel are not educated in immunization safety, vaccine storage,

and cannot/do not properly communicate with parents? How can Georgia ensure firm political

support for future budget increases?

Dr. Eka Kavtaradze, Deputy Head of NCDC, commented about the urgent issue on f the 2016

immunization budget. During the first hearing, the Ministry of Finance introduced the national

budget law with 2 million GEL less for immunization budget line than was proposed by the

Ministry of Health. Dr. Kavtaradze called on the Ministry of Finance to take immediate action to

fully fund the program and avoid failing in its governmental responsibilities.

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The floor was then given to Mr. Vladimer Getia, of the National Center for Disease Control and

the Head of State Program Department, who presented an analysis of recent immunization program

expenditures. The immunization budget line contains routine (70% of full program cost) and non-

routine vaccine components. Introduction of Rota and Pneumo vaccines and transition to GAVI-

graduation requires 1 million GEL annually from the state budget in addition to 2,5 million GEL

for hexa-valent vaccine (since 2015). After graduation, Georgia will need additional 6.35 million

GEL for vaccines (routine and non-routine).

High quality vaccines are procured from prominent European companies or have been WHO pre-

qualified. In 2014, the immunization state program financed 40% of cold chain equipment. No

disruptions in vaccine supply occurred from 2012-2015. Vaccines and vaccine materials for

routine immunization are purchased through UNICEF and for non-routine vaccines the country

uses transparent and effective electronic tender procedures. However, depreciation of local

currency and increasing vaccine prices as well as problems at the vaccine market and lack of

country influence on UNICEF procurement mechanisms cause instability in resource projections

and vaccine supply.

Mr. Getia suggested changes in procurement approaches: 1. Contracting in USD instead of local

currency for more sustainability; and 2. Making preliminary orders and increasing critical storage

of deficit vaccines to ensure continuity of supply. Finally, he asked the representative from the

Ministry of Finance to consider the risk of a vaccine shortage if the reduced immunization fund

were approved.

Dr. Khundadze commented that, at the next budget hearing, the parliamentary committee would

strongly advocacy that the Ministry of Finance increase the immunization budget line to the

amount proposed by MOH.

Ms. Ekaterine Guntsadze, Head of Ministry of Finance Budgetary Department, explained the

immunization budget reduction was related to the lack of total healthcare funds caused by the huge

demand from the Universal Health Care (UHC) Program; the MOF had to cut budget projections

from nearly all healthcare programs for 2016. She explained that 2 Million GEL for immunization

is not too large of an amount compared with the MOH request of about 90 million GEL for the

UHC program.

Ms. Guntsadze clarified the state budgeting procedures and noted that, during the third hearing at

the parliament on November 30, the MOH would have the chance to present its priorities, convince

stakeholders, and change allocations among the programs within its ceiling.

A root problem is poor state budget planning by the spending agencies (MOH performs better than

others are). Agencies provide inaccurate calculations and weak arguments for public expenses

during MTEF cycle. Budget projections are often ignored or exaggerated; priorities do not contain

strong arguments often due to miscommunication between ministry policy and finance

departments. When the budgets are wrongly planned, the MOF struggles in allocating resources

and has to split budgets. During the third budget hearing, as stakeholders discuss arguments on

priorities presented by ministries, the MOF can rectify the budget, release additional resources,

and reallocate funds.

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Although the program budgeting principle focused on results-based funding has been introduced

in several years, it still remains on the paper; the approach of “how to spend” should be replaced

with thinking through indicators and results. This year new methodology of baseline indicators

was introduced, and supports using indicators for actual measurement of changes and results.

Active Parliamentary involvement is crucial to implementing this mechanism effectively as the

parliament it monitors how the executive agencies would improve their performance with more

resources, as well as considering the associated risks. Performance-based audits are another way

of supporting this approach.

Australia is a successful example of implementing results-based budgeting. However, it took

decades. Program-based budgeting works when programs use a performance-based payment

approach. The format of the Immunization State Program provides clear indicators and can serve

as a best case scenario for implementing results-based budgeting. Finally, Ms. Guntsadze

highlighted ways to balance state budget needs and commented on the trends in fiscal resources.

She explained that social expenditures were rising but not taking special social guarantees. The

government faces a dilemma between social and capital expenditure.

Conclusions from discussion on immunization financing:

Prioritization of immunization and trends of increasing state immunization budget should

be maintained; continuous advocacy and collective effort of stakeholders are essential.

Elaboration of detailed country action plan with clear linkage to updated cMYP document

and its further monitoring at all levels of decision-making is essential.

Georgia introduced 3 new vaccines in 2013-2015 and investing in strengthening the system

would be more reasonable than introducing the HPV vaccine.

Sufficient vaccine expenditure is not enough for effective program performance.

Graduation period should be used by the government to prepare for full country ownership

and to allocate resources for underfunded/Gavi funded activities.

Develop innovative approaches and make incentives for using existing resources

effectively (in immunization service provision, training and education, communication and

monitoring).

Vaccine procurement remains challenging. More flexibility in national contracting

mechanisms and better consideration of country preferences by UNICEF would be useful.

Availability of GAVI prices for 5 years after graduation is extremely valuable.

Program budgeting with result-based approach is an area for innovation in effective

program planning and performance; it supports active collaboration of MOH, MOF and the

parliament. Immunization State Program can become a precedent of successful

implementation. It perfectly applies to the primary health care component of the UHC

program where immunization service provisions is incorporated.

Budget flow analysis of the immunization program can be used regularly by NCDC. This

practice would be in compliance with Open Budget principles. Deviation in “reporting

accuracy” is interesting to clarify as is checking definitions of JRF form indicators.

Theme 3: Legislative Framework for Immunization

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The participants learnt about immunization-related legislation. Georgia’s legislative provisions

were analyzed in terms of the international practices and were compared to the similar

immunization-related legislative documents in the other SIF countries in the European region.

Dr. Marina Darakhvelidze, Head of the MOH Healthcare Department, presented a list of

immunization-related regulatory documents and highlighted government responsibilities in

immunization.

The laws on Public Health and Health Care state that prevention of communicable diseases,

including routine vaccination, is among key government functions in Georgia. The MOH ensures

access to routine vaccinates in accordance with National Immunization Calendar; maximum

coverage with vaccination; provision quality; effective and safe routine vaccines to medical

institutions; safety of their storage, and conducting immunization surveillance. The Law on Public

Health also clarifies the obligations of medical facilities in routine immunization and requires that

they provide comprehensive information on vaccines and vaccination, report on immunization

process and refusals, and collect statistics. Since 2015, immunization services have been regulated

medical activates and violation of norms has been subject to penalties.

Dr. Darakhvelidze presented ideas about how to improve documenting of vaccination process and

status information. She also introduced the draft of the vaccine refusal form, which considers

recommendations of the American Pediatric Academy. Dr. Darakhvelidze mentioned that several

regulatory norms, required by the Public Health Law, still were being drafted.

Dr. Paatashvili touched on the one of the main recommendations from GVAP, developing

comprehensive regulations for immunization program sustainability. She distinguished

declarative, financial, and operational provisions, citing Vaccination Legislation in Latin

American and the Caribbean (Trumbo et al 2012). Immunization regulations tend to contain

declarative and financial provisions, she reasoned.

She found the following operational gaps:

1. No incentives exist for immunization providers to increase coverage.

2. The Public Health Law stipulates that routine immunization is mandatory but doesn’t

account for unimmunized citizens.

3. Vaccine safety regulations must be improved to meet WHO standards (Annex F)

Dr. Paatashvili went on to brief the delegation on the legislative of the SIF EURO countries. She

explained that Georgia appears to be the most advanced, boasting both an immunization-related

Public Health Law and a recently updated MOH regulatory decree. See Table 5 below.

Immunization Legislation Processes in SIF Euro-Region (X.15)

Country Legislative Project

Phase I Phase II Phase III Phase IV Phase V Phase VI Phase VII

National Counterparts

Devise Legislative Strategy

Drafting Workshops/Expert

Consultations [#† of Both]

Public Vets Bill

Government Submits Bill

to Parliament

Parliament Registers Bill for

Vote

Parliament Passes Bill

Immunization-Related Provisions

Implemented

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Table 5. SIF/EURO Legislative Status

Discussion

The participants considered how the existing legislation supports NIP and what improvements

should be made. Any change should be thoughtful and informed by international experience. The

delegates expressed their interest in advancing these legislative projects. They debated the

following modifications to the existing legislation:

1. Obligatory vs. voluntary immunization

2. Cheap incentives for immunization officials to increase coverage

3. Collaboration with a wider set of immunization stakeholders

4. Institution of international vaccine quality control mechanisms at the local level

Theme 4: Performance of the National Immunization Program: Recent Trends and Plans The delegates then surveyed performance of the NIP at multiple levels.

Dr. Lia Jabidze, NIP Manager, outlined the Program’s planning and reporting practices and

coverage challenges. Coverage against most antigens (excluding rotavirus and PCV) remains

above 90%; this still falls below the WHO/EURO target of 95%. DTP3, OPV3, and Penta3

coverage for 2013-2015 decreased considerably at the national level. In 2014, 30% of districts

notched under 90% coverage, and 6% of districts fell below 80%. High population centers

exhibited low coverage and high drop-out. Following the measles outbreak of 2012-2013,

campaign have since improved MMR coverage.

Georgia

Public Health Law (with

separate article on

immunization)

In 2007

Immunization legal acts

MOH decree #183/n of 2010 on immunization regulation, last update -November, 2015

Armenia

Public Health Law (with

separate article on

immunization)

In process

National Immunization

Program (2016-2020)

Government order, last updated in 2015

Sanitarian-hygienic

norms (series of MOH

decrees)

Key regulatory acts, implemented

Moldova

Public Health Law (with

separate article on

immunization)

in 2012

National Immunization

Program (2016-2020)

Includes regulatory norms; Government order, last update in 2015

Law on Sanitary Welfare

of the Population (with a

short statement on

immunization)

August, 2015

Uzbekistan MOH decree on

Immuno-prophylaxis

Last update – August, 2015

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She suggested the following interventions to reduce child drop-out and improve coverage:

1. Improved monitoring, communication, and reporting system among public health

institutions through staff trainings.

2. Further digitization of information.

3. Implementation of performance-based approaches in NIP planning and financing

4. Enforcement of existing legislation.

5. Equipping schools with a list of mandatory and recommended vaccines, concomitant with

school entrance limitations.

6. Investing in educational institutions as immunization centers.

Dr. Zurab Teneishvili, Adjara Autonomous Republic Minister of Health, and Dr. Koba

Nakaidze, Adjara Public Health Director, then took the floor. They communicated the various

achievements and challenges commonly met at the local level in immunization coverage and

program management. They are similar to those at the national level, including:

1. Migration, marginalized demographics, difficulties in identifying and monitoring the target

population

2. Demotivated and under-educated healthcare personnel, communication gaps between

doctors and the general population

3. Vaccine hesitancy, especially to new vaccines

More specifically, the program is affected by geographic obstacles, late vaccinations, and

electronic reporting issues. Dr. Tenishvili emphasized recent changes in local primary health care

financing issues, including financial incentives and special transportation for doctors and nurses

in mountainous areas. Utility charges, medication fees, and fuel & driver expenses are difficult to

track.

Theme 5: Discussion on Institutional Linkages for a Sustainable Immunization Program

During the discussion, participants from parliament, MOH, NCDC, Adjara MOH and the

Municipality of Tbilisi ventilated upon their institutions’ planning, executing, and reporting

procedures. The participants agreed that there are gaps and inconsistences to address:

According to the Public Health Law of Georgia, public health workers, responsible for

disease surveillance and immunization at the local level, work for local municipalities.

Their multiple functions, designated by law, usually exceed their capacity; they are highly

underfunded and hardly linked with other healthcare institutions.

Better linkage and collaboration is needed between primary health care facilities and public

health authorities; this should be considered during the current primary health system

reform.

The parliament should use its authority to improve coordination between MOH and MOF

and oversee planning, budgeting and supervision of the NIP.

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A national immunization action plan for implementing the cMYP strategic approaches and

regional objectives should be developed which defines the roles and responsibilities of all

key stakeholders

The capacity and resources of medical educational institutions in developing immunization

trainings and guidelines as well as establishing continuous education system should be

harnessed for a sustainable and effective NIP.

Day 2

Theme 6: Best Practices for NIP Performance and Sustainability Work began with Hon. Dr. Khundadze re-capping the discussions of Day 1. The delegation then

entered to the sixth workshop theme on best practices for NIP performance and sustainability.

Dr. Beka Ioseliani, Director of Family Medicine Professionals’ Union and Deputy Director of

Family Medicine Education Center, introduced the best practice of the PHC facility, achieving the

highest immunization coverage in Tbilisi. Dr. Ioseliani highlighted the following management

approaches enacted by his center:

Clearly defined responsibilities: the deputy director (supervisor) oversees and monitors

immunization process; a team of doctors and nurses responsible for creating an

immunization registry contingent on age groups, monthly planning and monitoring of

immunization activities per catchment area; the deputy director ensures monthly

monitoring (mostly randomized) and performance analysis, including monitoring of

refusals, contradictions and “postponed cases”.

Routine and ad-hoc monitoring and analysis of immunization service delivery.

Immunization plans prepared by the immunization teams are reviewed and compared with

coverage results per catchment area on a monthly basis;

Management uses performance-based remunerations whereby an immunization team must

hit 95% coverage, and then receives a salary bonus for every additional percent. Any less

than 95% warrants a reduced salary.

Implementation of an electronic immunization module and a quality reporting system is

monitored and rewarded.

Dr. Ioseliani mentioned that today, no legislative nor contractual provisions incentivize better

performance. However, family doctors and nurses are motivated by an immunization service fee

that is included in the per capita payment. Immunization is considered a public good, and private

providers have little incentive to invest in better coverage, social marketing, and quality assurance.

He argued that no performance-based management system is sustainable without proper

regulations and a sound payment system. He suggested several quick fixes to his fellow

participants:

1. Instituting a published rating system for immunization service providers.

2. Enable providers to analyze data electronically.

3. Make coverage plans more flexible so that the providers may update them in real time.

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Dr. Ivdit Chikovani and Dr. Ketevan Goguadze from Curatio International Foundation then

examined the importance of evidence-based decision-making and the role of national research.

They are eager to invest in Results-Based Financing (RBF) research for the Georgian NIP, which

would introduce strategic remunerative mechanisms which base wages on qualitative and

quantitative indicators. Dr. Ioseliani committed to collaborate closely in this research.

Group work: Solutions for Country Ownership and Sustianability The participants were randomly assigned to two small groups and given 60 minutes to discuss

country ownership and NIP sustainability, and to brainstorm institutional innovations – new ways

of working and new practices and to identify the changes needed in immunization financing,

legislation and advocacy. They were expected to come up with the three main barriers and enablers

to ensure sustainable NIP. The work groups were facilitated by the public health experts from

Curatio Foundation: Ivdit Chikovani (Group I) and Ketevan Goguadze (Group II).

Each group had 15 minutes to present its work and 30 minutes were allocated for final discussion.

The groups consisted of representatives from different stakeholders who helped the delegation

reach consensus on the barriers and enablers.

Group I: Results

Dr. Ekaterine Kavtaradze, Deputy Director of NCDC, presented the group work results:

Group I identified 3 main levels to consider the barriers and enablers:

I. Policy level – maintaining NIP prioritization; improving NIP coordination; HR

development;

II. Supply level – vaccines, services, information system

III. Demand – educating population about immunization

1. HR focus:

- Insufficient education of medical personnel

- Low motivation of service providers

- Low qualification and incentives of public health specialists

- Gaps in pre, post, and continuous medical education and professional development

2. Vaccines/cold chain

- Gaps in cold chain system

- Ignorance of immunization responsibilities from the local municipality authorities

- Poor quality assurance system regarding vaccines (central level)

- Ignorance of cold chain requirements at the primary health care (PHC) level

3. Services

- System is not responsive to the performance of immunization service providers at the PHC

level; no quality assurance and performance measurement process

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- Lack of facility-based monitoring and assessment system

- Immunization is a low priority for PHC management

4. Health Information System

- Gaps in internet and computer availability (especially in rural regions)

- Low immunization skills of family doctors and nurses, especially in rural regions

- No communication strategy and absence of relevant budget

Group II: Results

Dr. Beka Ioseliani presented 17 activities, developed by the group II, necessary in Georgia reality

for the sustainable NIP:

1. Development of National action plan of immunization

2. Improvement of coordination within NIP, define clear roles and responsibilities for each

stakeholder

3. Develop effective mechanisms for NIP management at central and local levels

4. Strengthen the national pharmacovigilance system

5. Further activities for vaccine safety and cold chain replacement

6. Elaborating national standard for safe immunization

7. Develop standards for education and qualification of medical personnel as well as

standards for provision and assessment of immunization activities

8. Make the standard forms on vaccination and vaccine refusals obligatory to use for all the

immunization service providers

9. Ensure effective mechanisms for vaccine procurement and supply

10. Support multi-year procurement system for vaccines

11. Introduce obligatory vaccination

12. Solve the gaps regarding vaccination of non-resident people

13. Review the immunization state program budget and consider funds for monitoring and

other supportive services

14. Ensure geographic accessibility of immunization services

15. Inform population about immunization benefits

16. Develop criteria to assess education, qualification, and awareness and performance in

immunization for medical personnel and provide incentive system

17. Improve and finalize the immunization electronic system.

Conclusions Dr. Eka Paatashvili summarized the key messages of policy dialogue:

• Increase awareness

– Sufficient vaccine storage cannot be enough;

– Monitoring, trainings, communication, cold chain – less considered and under-

budgeted

– Additional funds are necessary; after graduation, even more funds will be needed

– Important regulatory aspects and those that needs improvements – discussed

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– Best practices at local government and PHC facility level, existing resources can

be well-managed and influence program results

– Stakeholders better understood each other

• Increase roles and involvement

– Parliament Health Care Committee took the leadership in coordinating the

legislative changes and support program budget; collaborate with partners in

advocacy

– MoF – develop pilot of performance-based program budgeting on immunization

program

– Local government – dedicate local resources, improve linkage between PHC and

PH

– PHC association – share good practice, support public-private-partnership

– Curatio - Results-based financing research, bring international experience

Finally, Dr. Paatashvili encouraged the delegation to evaluate the workshop and where they saw

the most promising areas for collaboration with Sabin. The participants viewed the workshop as

highly important. It gave them the opportunity to communicate openly and easily on key

immunization-related policy issues, challenges, and potential next steps at all levels of governance.

Dr. Irakli Pavlenishvili noted, “It is a good start for a very useful process”. The attendees

acknowledged that the participation of the MOF was essential for effectively advocating for the

2016 budget. Sabin’s involvement would be valuable in resource mobilization, motivating inter-

institutional collaboration, and strengthening regulatory mechanisms.

Dr. Khundadze viewed the workshop quite positively and recognized the active participation of

the delegates. “I see, besides our achievements in immunization, there still exist many pending

issues, and we mustn’t relent in our communication and joint efforts to meet our graduation

challenges and to sustain our progress.” He invited the delegates to speak at the upcoming

Parliamentary Committee session, to continue the conversation and induce real progress at the

policy level. Dr. Khundadze and other parliamentary representatives expressed their willingness

to collaborate closely with the Sabin Vaccine Institute. The Curatio Foundation reiterated its

readiness to develop a collaborative plan with the Sabin Vaccine Institute in research and advocacy

for immunization.

Follow-Up The report on the Policy Dialogue will be circulated among the participants and other key

officials and its annotation will be send to ICC. In the coming months, national counterparts

concurred that Sabin could convene a series of similar briefings with the same objectives.

Sabin Vaccine Institute will collaborate with the parliament to use the arguments provided

during the workshop and advocate for sustainable immunization financing and program

performance. Sabin Vaccine Institute together with Curatio International will conduct the

next meeting with stakeholders in March to discuss progress in immunization-related

legislation and compare national (e.g. Curatio RBF research) and international practices.

National counterparts will be invited to participate in EURO regional conference on

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immunization-related legislation as well as in peer exchanges with other SIF countries with

the aim of exchanging best practices in the areas of financing, budgeting and resource

tracking, legislation and domestic advocacy for immunization program sustainability.

ANNEXES

Annex A: list of participants

List of Particpnats Position Parliamnet

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1 Diitri Khundadze MP, Head of the Committee on Health and Social Affairs

2 Darejan Chkhetiani MP, Member of the Committee on Health and Social Affairs

3 Zaza Avaliani Member of the Public Health Panel at the Committee on Health and Social Affairs

4 Shalva Brachuli Member of the Public Health Panel at the Committee on Health and Social Affairs

5 Irina Khasaia Head of the Office of the Committee on Health and Social Affairs

6 Eka Zhorzholadze the Committee on Health and Social Affairs

7 Ketevan Mchedlishvili the Committee on Health and Social Affairs

8 Neli Giutashvili the Committee on Health and Social Affairs

9 Maia Esebua the Committee on Health and Social Affairs

10 Lela Asatiani the Committee on Health and Social Affairs Ministry of Health of Georgia

11 Marina Darakhvelidze Head of the Health Care Department

12 Ekaterine Adamia Head of the State Program Division

13 Marine Baidauri Head Speciaist of Regulatory Division

14 Mzia Jokhidze Head Speciaist of Regulatory Division 15 Natia Khmaladze Head of Legal Department

16 Irma Kitiashvili Head of Division at Legal Department 17 Maia Gotiashvili Head of budgetary Division

18 Tea Zhorzholadze Head Specialist, Universal Health Care Department

Ministry of Finance

19 Ekaterine Guntsadze Head of Budgetary Department Ministry of Health of Adjara Autonomous Republic

20 Zurab Teneishvili Deputy Minister of Health Care

21 Koba nakaidze Head of Public Health Center of Adjara Autonomous Republic

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National Center for Disease Control and Publlic Health

22 Ekaterine Kavtaradze Deputy Director of the National Center for Disease Control and Publlic Health

23 Paata Imnadze

Deputy Director of the National Center for Disease Control and Publlic Health; Head of Public Health Faculty at the Tbilisi State University

24 Khatuna Zakhashvili Head of Infectious Control Department

25 Lia Jabidze EPI manager, Head of Immunoprophylactics Division

26 Vladimer Getia Head of the State Program Department

27 Gia Kobalia Deputy Head of Financing Department

28 Nona Beradze Head Specialist of the Division of Immunoprophilaxis

29 Tamta Komakhidze Head Specialist of the Division of Immunoprophilaxis

30 Teona Kashibadze Head Specialist of the Division of Immunoprophilaxis; Secretary of NITAG

NITAG 31 Ivane Chkhaidze Chairman of NITAG

Curatio International Foundation

32 Ketevan Goguadze Head of Public Health Department

33 Ivdit Chikovani Head of Public Health Science Unit Family Medicine Professionals' Union

34 Beka Ioseliani Director of Union Tbilisi Family Medicine Study Center

35 Varlam Kvantaliani Head of Preventive Medicine Department Local Government

36 Irakli Pavlenishvili Member of Tbilisi Municipality; Head of Pediatric Association

WHO 37 Giorgi Kurtsikashvili WHO country office

UNICEF 38 Tamar Ugulava UNICEF country office

39 Ana Chvamania Technical Assistant

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Annex B: Agenda

Friday, November 06, 2015

19:00 – 21:00 Rixos Borjomi, Registration at the hotel

Dinner

Saturday, November 07, 2015

7:00 – 10:00

Breakfast

10:00 – 10:30

Greeting

Dimitri Khundadze, Head of the Committee of Health and Social

Affairs, Parliament of Georgia

Davit Sergeenko, Minister of Labour, Health and Social Affairs of

Georgia

Introduction

Part I

10:30 – 10:45

Immunization as a public good

Eka Paatashvili, Sabin Vaccine Institute

10:45 – 11:15

Global and European Immunization Action Plans (GVAP & EVAP)

Giorgi Kurtsikashvili, WHO Office in Georgia

TBA, UNICEF/Georgia

11:15 – 11:45

National Immunization Program: Policy basis and public health

importance –

Amiran Gamkrelidze, Director of National Center for Disease Control

and Public Health (?)

11:45 – 12:00

12:00 – 12:30

Q/A

Coffee Break

12:30 – 13:00 13:00 – 13:30

Financial Sustainability and EPI program

Sabin Vaccine Institute

Financing and Budgeting of the National Immunization Program

Ekaterine Guntsadze (?), Head of Budgetary Department, Ministry of

Finance of Georgia

13:30 – 14:00 Legislative Framework for Immunization

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Immunization-related legislation in Georgia - Overview

Minimum set of legislation provisions

TBA. Ministry of Labour, Health and Social Affairs

Sabin Vaccine Institute

14:00 – 15:00

15:00 – 15:40

Lunch

Panel Discussion: Institutional linkages for a sustainable immunization

program

Parliament of Georgia

Ministry of Labour, Health and Social Affairs

Ministry of Finance

Local Government

Part II

15:40 – 16:20

16:20 – 16:30

16:30 – 17:00

17:00 – 17:30

Panel Discussion: NIP performance – Recent trends and plans

Immunization coverage and demand

Immunization delivery and the NCDC research results

Contracting immunization providers

Implementation of immunization module

Immunization planning and monitoring

Center for Disease Control and Public Health

Ministry of Labour, Health and Social Affairs

Coffee Break

NIP management at the local level – Case of Adjara region

Immunization as a part of the healthcare system

Strategies to achieve equity (high mountain area)

Ministry of Adjara Autonomous Republic

Discussion and Summary of Day I

19:00 - Dinner

Sunday, November 08, 2015

Part 3

Briefing on Day I.

22

10:00 – 10:10

10:10 - 10:50

10:50 -10:15

Panel on country ownership and EPI sustainability: Trends, challenges

and best practices

UNICEF

NITAG

Curatio

Association of Family Medicine

Sabin Vaccine Institute

Others

Discussion

10:15 – 11:15 Way forward: Action steps for country ownership and sustainability

11:15 – 11:45

Three interdisciplinary working groups (Partners moderate)

Coffee break

11:45 – 12:45

Working group reports

Three group rapporteurs

12:45 – 13:30

Discussion and wrap up

Dimitri Khundadze

Eka Paatashvili

13:30 – 15:00

15:00

Lunch

Departure

Annex C: Discussion Questions

Part I

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Immunization is a public good the state must provide but isn’t there another side to the

story? What about the public, the citizens themselves? Don’t they have to also co-produce

the public good? If demand for immunization (ie, vaccine coverage) is low in a particular

area, doesn’t that mean we are failing to deliver the public good there? How should that

problem be addressed?

Country ownership is a term in both GVAP and EVAP. What does it really mean? How would

we know, in Georgia, whether or not we have achieved it?

At the policy level, the Government of Georgia strongly supports immunization. Can

support to immunization also support the rest of the health services?

Do we know how much the government spends to immunize a child these days in Georgia?

How can we be sure the government will always set aside the amount of funds the

immunization program needs each year?

What are the main functions linking the key public institutions engaged in the

immunization program- - Parliament, Ministry of Labour, Health and Social Affairs, Ministry

of Finance, Local Government? Are current practices sufficient to keep all of them

connected and up to date regarding the financing and execution of the program or are new

practices needed? What kind of new practices would help make the program more

sustainable?

Part II

Georgia’s immunization program is delivered by both public and private sector providers.

What has been the experience so far? Do the two sectors closely collaborate? Do vaccines

and information flow freely between the two? What new practices could improve this

inter-sectoral collaboration?

How effective is the EPI surveillance system? How many outbreaks of vaccine-preventable

diseases were carried out this year so far? How are the outbreaks detected and how are

the investigations carried out?

Do we have an annual work plan for the immunization program? How is it prepared and

monitored?

Do the regions of Georgia have sufficient resources to keep their populations immunized?

Do the regions regularly report their activities and receive feedback from central level on

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their work? What new practices might be developed to better link regional and federal

level managers?

Part III

How does immunization program performance in Georgia compare to that of other

emerging middle income countries? What specific practices (say in the areas of vaccine

delivery, demand creation, surveillance, finance and budgeting, legislation) can be found in

Georgia that are not found elsewhere? What specific practices have other countries

developed which might benefit Georgia?

Annex D: Workshop evaluation At the end of the Policy Dialogue, the participants filled workshop evaluation forms. The results are found below:

# question 5 – perfect 4 - good 3 - satisfactory 2 - bad 1 – very bad

1 Importance of topics discussed 100%

2 Relevance, involvement and interaction of participants

100%

3 Meeting format and organization

91% 9%

4 Achievement of results 86% 14%

5 Willingness to participate in next meetings

100%

Priority topics for further meetings and discussions:

1. Legislative changes and/or practical steps to increase immunization coverage

2. Monitoring and assessment framework for NIP

3. NIP financing and legislation provisions for developing immunization incentives, result-

based and quality-based approaches

4. Population awareness on immunization

5. Tainting and education of PHC personnel

6. Linkage of the central level, local government and PHC service providers; delegated

functions and effective communication system

7. Sharing international experience in NIP management and regulations

8. Quality regulations of vaccines, pharmacovigilance

9. Cold chain control

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10. Regulation enforcements in immunization coverage for PHC facilities

11. National Action Plan – to start development

12. Start immediate action regarding the issues discussed at the conference

Links on the Facebook of the parliament health and social affairs committee: https://www.facebook.com/media/set/?set=a.775194105943388.1073742050.427303587399110&type=3 https://www.facebook.com/427303587399110/videos/765089006953898/