anglophone africa peer review workshop on sustainable ... · were ranked in terms of perceived...

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Anglophone Africa Peer Review Workshop

on Sustainable Immunization Financing

Nairobi, Kenya | 26-28 October 2015

Prepared by Diana Kizza Mugenzi, Dana Silver, and Andrew Carlson

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Table of Contents Introduction .................................................................................................................................................. 3

Proceedings ................................................................................................................................................... 3

Day 1 ......................................................................................................................................................... 4

Theme I: Domestic Financing Arrangements ........................................................................................ 6

Theme II: Budget and Resource Tracking ........................................................................................... 10

Day 2 ....................................................................................................................................................... 15

Theme III: Legislation and Legislative Process .................................................................................... 15

Theme IV: Advocacy Strategies ........................................................................................................... 19

Day 3 ....................................................................................................................................................... 22

Peer Review ........................................................................................................................................ 22

Results ................................................................................................................................................. 23

Discussion ............................................................................................................................................ 27

Remaining Challenges and Next Steps ................................................................................................ 28

ANNEXES ..................................................................................................................................................... 30

Annex A: List of participants ................................................................................................................... 30

Annex B: Agenda ..................................................................................................................................... 31

Annex C: Nigeria Legislation Process Case Study .................................................................................... 33

Annex D: Small Group Results................................................................................................................. 35

Annex E: Peer Review Guide ................................................................................................................... 41

Annex F: Country action points ............................................................................................................... 45

Annex G: Workshop Evaluation .............................................................................................................. 46

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Introduction

Lower and lower-middle income countries are gradually becoming owners of their national

immunization programs. Ownership is directly measured by the adequacy of financing, budget

execution and the technical integrity of the programs. With the arrival of new vaccines,

immunization program costs have increased. Growing populations are another factor pressuring

governments to increase their annual immunization budgets. Gavi-eligible countries increasingly

face these financial challenges as they must co-finance progressively more of their new vaccine

costs. Current investments by countries are insufficient, creating ever-widening funding gaps.

Development partners have so far been filling these gaps. The result, in many countries, is growing

dependency.

Since 2008, the Sabin Vaccine Institute’s Sustainable Immunization Financing (SIF) Program has

collaborated with 22 countries, five of which are in Anglophone Africa: Sierra Leone, Liberia,

Nigeria, Uganda, and Kenya. Experience shows that sustainable financing for national

immunization programs can be secured through collective action by key national institutions. SIF

supports this kind of collective action in countries through a range of advocacy activities. These

activities include briefings on immunization financing and legislation, peer exchanges between

countries and support to the key public institutions as they develop particular innovations that are

leading to increased domestic immunization financing and more efficient immunization programs.

Peers from seventeen Sabin/SIF countries scrutinized each other’s institutional innovations in the

Second Colloquium on Sustainable Immunization Financing in Dakar, Senegal in August 2013.

Using a standard guide, participants scored each project. Results were analyzed and the countries

were ranked in terms of perceived innovativeness. Follow-up peer review workshops were held

for six Asian SIF countries (Phnom Penh, Cambodia, July 2014) and six Francophone African

countries (Kribi, Cameroon, December 2014), using the same methods. This workshop is the next

in the series, and precedes the Third Colloquium on Sustainable Immunization Financing, to take

place in summer 2016.

The workshop gathered 24 participants (Annex A). This report: (a) conveys the workshop

objectives, (b) unpacks the workshop proceedings, (c) analyses institutionalized, implemented, or

aspirational key innovations, (d) determines the role of technical partners within these processes,

and (e) closes with next steps.

Proceedings

The workshop agenda can be found in Annex B. Delegations presented their results in four

domains, including: (a) domestic financing arrangements, (b) budgeting and resource tracking,

(c) legislation and legislative process, and (d) advocacy strategies. These cycles were paired with

three rounds of small group work. The workshop ended with a formal peer review, in which each

delegate scored the other countries on the innovativeness of their work. Finally, the peers

produced a series of main action points which they have challenged each other to implement.

The delegates engaged intensely in small working groups, plenary discussions, and the formal

http://www.sabin.org/updates/pressreleases/dakar-conference-countries-showcase-increased-efforts-fund-their-own

http://www.sabin.org/updates/blog/following-regional-workshop-asian-countries-accelerate-progress-towards-sustainable

http://www.sabin.org/search/content/kribi

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peer review. Partner agency representatives, from Sabin, USAID, Bill & Melinda Gates

Foundation and the Clinton Health Access Initiative (CHAI), served as moderators.

Day 1

Welcome Address

The day kicked off with a welcome address delivered by Sabin Sustainable Immunization

Financing (SIF) Program Director Dr. Mike McQuestion. Since 2008, the SIF Program has

been working with 15 lower and lower middle income countries in the areas of immunization

financing and advocacy. The number of SIF countries has since expanded to 22 across Africa,

Asia, and Eastern Europe. The Program encourages key stakeholders from national ministries,

parliaments, the domestic private sector, key civil society groups, and external partners to work

together to identify sustainable, country-specific financing mechanisms for immunization.

AFRO Region Trends over Time:

AFRO Region Trends over GNI:

20

40

60

80

Per

cap e

xpend U

S$

6 8 10 12 14year

AFR non-AFR

GGHE

Fig 1. Govt NHA spending by year

10

20

30

40

50

US

$/infa

nt

10 11 12 13 14year

AFR non-AFR

JRF Indicator 6730

Fig 2. Govt RI spending by yearGavi-eligibles

0

100

200

300

400

Per

cap e

xpend U

S$

0 2000 4000 6000 8000gni

AFR non-AFR

GGHE

Fig 3. Govt NHA spending by gni

010

20

30

US

$/infa

nt

0 500 1000 1500gni

AFR non-AFR

JRF Indicator 6730

Fig 4. Govt RI spending by gni

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Reflecting on Figures 1-4, Dr. McQuestion explained that the African Gavi-eligible countries

have not been increasing their routine immunization spending as have the Gavi countries in other

regions. In all regions, investments by countries in the US$500-1200 GNI range tend to flatten.

Countries below and above that range spend more on immunization as their incomes rise. The

results capture the dependency problem which most markedly affects African countries. While

the countries are reaching and immunizing around 80% of their children, the programs rest on

fragile underpinnings. Dr. McQuestion challenged the delegates to think of ways their countries

can move out of the current dependent situation and move toward the country ownership goal.

Progress is best measured by the amount of public spending for routine immunization. In order to

increase investment functions, innovations must occur within key public institutions and at

various levels, including ministries of health, ministries of finance, parliaments and sub-national

governments. Champions within those institutions must use targeted advocacy efforts to

convince their colleagues to pull together to make the necessary institutional changes.

It is the institutional champions who must do the necessary institutional work. They explain their

case in rational terms using different techniques including mimicry, theory-based arguments, and

educating others about the new practices needed (Lawrence and Suddaby 2006). The workshop

delegates are themselves institutional champions. The workshop will have succeeded if they

leave with an expanded understanding of their roles as change agents and a better idea of the

methods and successes achieved to date across the thematic areas of financing arrangements,

budget and resource tracking, legislation and local advocacy.

Workshop Objectives

The main objectives of this workshop were to: (1) identify, share, and cross-evaluate financing,

budget and expenditure tracking, local advocacy, and legislative practices for immunization

financing; and, (2) develop a set of short-term action points for each Anglophone African SIF

country to pursue to secure sustainable immunization financing.

More specifically, the workshop allowed for:

a. Discussion and development of innovative financing arrangements;

b. Documentation and evaluation of immunization resource tracking mechanisms in place or

under development;

c. Review and improvement of draft laws and regulations on immunization that exist or are

under preparation in the five participating countries;

d. Documentation of country legislative narratives (case studies); and

e. Sharing of local advocacy practices for sustainable immunization financing.

Additional Introductory Remarks

Partner agency counterparts introduced themselves and offered remarks on immunization

financing.

Ms. Antonia Pannell, Gavi Senior Country Manager, discussed co-financing arrangements and

upcoming Gavi transitions for certain African nations.

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Mr. Samburu Wa-Shiko, Senior Advisor for the Bill & Melinda Gates Foundation, spoke about

the Decade of Vaccines, polio eradication and the importance of strategic relationships among

partner agencies and countries.

Mr. Mike Bryson, Senior Associate at the Clinton Health Access Initiative, spoke about new

vaccine introductions, bottom-up management approaches, and the importance of financial data

for decision making.

The group then took up the workshop’s first technical theme.

Theme I: Domestic Financing Arrangements

SIF Director Mike McQuestion began with an overview of concepts and applications relevant to

domestic immunization financing arrangements.

An important concept is the growing cost of immunization. In 2001, the set of six WHO-

recommended vaccines cost $0.57 per child. By 2011, the eight recommended antigens cost

$11.34. By 2014, the eleven WHO-recommended antigens cost $21.31. As the earlier presented

WHO/UNICEF Joint Review Form statistics show, countries on the whole are increasing their

immunization investments but not at a rate fast enough to keep up with fast-growing vaccine

costs.

Domestic sources of immunization financing include public revenues, royalties, private sector

donations, and out-of-pocket expenditures. External sources include foreign aid and loans, gifts,

and remittances. Other funding sources include public-private financing arrangements such as

public ring-fenced funds and private trust funds, which have been proposed in several SIF

countries (Kenya, Nepal, Nigeria, Senegal, Uganda). The arrangements can include national

immunization funds, which already exist in Mongolia and Senegal, and, in larger countries,

shared federal and provincial financing (DRC, Kenya, Senegal).

The floor was then opened to the delegates to present their current domestic immunization

financing arrangements. All five countries presented.

Liberia

Ms. Alice O. Peters, representing Liberia’s MOH/EPI, described her nation’s existing financing

mechanisms. The Ministry of Finance and Development Planning allocates EPI funds through

the MOH to the counties, which then disburse the finds. Some external partners allocate

extrabudgetary funds through the Office of Financial Management at the MOH, while others

channel them through the MOF. Polio campaigns have been entirely externally supported.

Information dissemination is strong. The EPI team regularly briefs Parliamentarians on

immunization financing issues, especially during period of budget preparation, which they

actively oversee.

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There is no legislation clearly providing for immunization financing by the government. Existing

internal mechanisms do not adequately finance the program, but the funding gap has been

reduced in recent years as funding has increased. There are plans to establish an Immunization

Financing Trust Fund with revenues earmarked from “sin taxes” and a mobile phone tax, as well

as private sector contributions.

Sierra Leone

Mr. Mustapha Alpha of Sierra Leone’s Ministry of Health and Sanitation presented his nation’s

financing processes and aspirational financing mechanisms. EPI Programme financing comes

from two sources: Public funds covering both national and district level immunization delivery

and external partner funds covering other program needs. There is currently no legislation on

immunization financing, and current domestic arrangements are not adequate to fully finance the

national immunization program. Additional health budget line items are needed to increase

financial support. Government and parliament are jointly discussing developing innovative

financing arrangements, including an immunization trust fund and effective expenditure tracking

tools. Anticipated new revenue sources include “minute taxes” on communication, new taxes on

petroleum companies, and new “sin taxes” on tobacco & alcohol.

Lack of awareness hurts the nation’s ability to develop new financing solutions. Neither the

public nor health workers know the immunization cost per child or the sources of immunization

funding. Financial information is mainly reported only to the external funding sources or shared

with auditing authorities. The Parliamentary Health and Sanitation Committee provides oversight

and support, and MPs are quickly becoming aware of the immunization financing challenges

through periodic advocacy meetings.

Identified areas for improvement include: more dissemination of financial and programmatic

information across Ministries, Departments and Agencies; increased analysis and annual

accounting of the human resource component of total government immunization expenditures;

new structures for reporting immunization finances, and training of personnel in tracking

immunization expenditures.

Nigeria

Speaking next, Ms. Damaris Onwuka of Nigeria’s National Primary Health Care Development

Agency (NPHCDA) enumerated her country’s existing and aspirational financial arrangements.

The cost of a fully immunized child (FIC) under Nigeria’s National Immunization Programme is

$38. The government currently pays about 23% of the cost while Gavi pays around 60%. The

high cost per FIC is due to low economies of scale. (As recently as 2010, only 21% of children

were fully immunized.) Nigeria recently introduced several new vaccines and is planning to

introduce another three.

Nigeria’s 2014 National Health Act includes a legal mandate for public health financing, and

government policy is that vaccines should be free for all women and children. However, the law

is not yet implemented. This year, the government used World Bank funds to finance some

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vaccines. Private donors in some states are supporting immunization delivery. Other sources of

immunization funding include government budgets and other external partners. Government

funding sources include annual federal and state health appropriations, which are managed

through state/local government joint accounts. There are budget line items at both the federal and

subnational level for immunization service delivery. The immunization budget is overseen by

Parliamentary committees, CSOs, and the Ministries of Planning, Health and Finance.

Immunization financing, however, is insufficient. Nigeria spends just 5-7% of the national

budget on health, falling short of the Abuja Declaration goal of 15%. There are funding gaps for

procurement of vaccines. CSOs are actively advocating for an increased immunization budget.

Key bottlenecks stem from delayed release of appropriated funds and low private sector

participation.

Nigeria’s plans for sustainable immunization service delivery include increased mobilization of

private sector resources through public-private partnerships. A national immunization financing

trust fund is under consideration, to be created in conjunction with the National Health Act. The

NPHCDA has commissioned an Immunization Financing Task Force to plan new funding

arrangements, explore the public-private partnership options and consider local vaccine

production.

Nigerian delegate Dr. Ben Anyene commented that Nigeria is really eight countries joined

together. In some of the 37 states, health spending is near the 15% Abuja-recommended level.

The federal government finds it hard to know the “value chain”- the amount of health funding

actually reaching children- because budget information is generally not shared by the states.

Recent drops in oil prices have diminished the public funding envelope, further aggravating the

situation. In order to address the looming financing gaps, the various levels of government must

be brought on board through proper knowledge management. The Nigerian Immunization

Financing Task Force will play a large part in this.

Kenya

Representing the Kenyan Ministry of Health, Dr. Dominic Mutie described his country’s

financing mechanisms. Kenya’s Constitution guarantees every Kenyan the right to a high

standard of health, and there is a regular federal health budget line for vaccines. However,

government funds for immunization have been decreasing despite the county’s continued robust

economic growth. Kenya has recently been re-categorized by the World Bank as a lower-middle

income country based on its rising GNI. This growth is already making the country ineligible for

certain foreign aid flows. The immunization program is especially affected by reduced Gavi

support.

Since 2010, Kenya has struggled with the devolution of formerly centralized health services. The

47 counties now oversee most aspects of the immunization services. Program performance has

deteriorated in some but not all counties.

Vaccine procurement is a bone of contention. Kenya currently procures its vaccines through

UNICEF’s Supply Division, however, the counties are clamoring to procure and distribute their

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own vaccines and vaccination supplies. Parliament and government are attempting to legislate a

pooled procurement solution.

Clarifying the national and county roles with regard to immunization remains a key challenge.

The Ministry of Health currently communicates directly with the country governors. The First

Lady is involved. Counties are providing little feedback on the status of their devolved health

systems. In all of the confusion, immunization has lost its pride of place. Additional challenges

include lack of timely release of funds, lack of innovative funding mechanisms, lack of

operational funding for implementing immunization services, and inadequate cold chain capacity

at lower levels. Kenya needs to increase outreach services and stakeholder involvement in order

to generate greater support for immunization activities.

Another challenge is the low level of public financing. Gavi currently finances 90% of routine

immunization services. Counties are underspending. In the 40 counties that receive and

distribute public funds, interest is focused on visible development projects such as infrastructure,

water, and energy, at the expense of less visible public goods like immunization. Under the new

constitution, the federal government cannot force the governors to finance immunization.

Recent sub-national briefings in Naivasha and Nairobi (October 2015) helped to clarify the

respective roles of national and county stakeholders. However, continued and increased

engagement and communication is needed.

There is presently no legal framework allowing the Kenyan treasury to leave a portion of funds

for management at national level. Proposed future steps include advocating for increased

budgetary allocation for immunization at the national level, and ring fencing immunization funds

rather than pooling them with other MOH funds. Additional advocacy efforts should be

undertaken at county level, added Dr. Mutie. The logical conduit is the Council of Governors.

The key message: prioritize immunization services, allocate increased immunization funds.

Devolution should be seen as an opportunity to improve on coverage and equity rather than

impede it.

Uganda

Ugandan delegate Ishmael Magona of the Ministry of Finance, Planning and Economic

Development (MOFPED) wrapped up the Theme I presentations with a discussion of his

nation’s immunization financing arrangements. Uganda’s National Immunization Programme is

implemented at both national and local levels. The federal government is responsible for policy

formulation, resource mobilization and budgeting, coordination, setting standards, and quality

assurance. Local governments are responsible for outreach and implementation.

Mr. Magona displayed data indicating that total immunization funding has increased from 2009-

2014. The Government of Uganda has consistently financed just above half of routine

immunization costs. Government spending rose from US$30.3m in 2009-10 to $51.3m in 2013-

14. The increase is mainly due to consecutive new vaccine grants from Gavi, which more than

doubled the government’s co-financing obligations over the period. Operations, equipment, and

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infrastructural costs have also increased. As a result, the government’s share of total financing

actually decreased, from a high of 63.4% in 2011-12 to 53.4% in 2013-14.

Financing bottlenecks are chronic, arising from the multiplicity of budget line items contributing

to immunization. Each year, Parliament votes on separate budget line items for immunization

delivery (facility-level accounts), vaccines and supplies (through National Medical Stores) and

central program operations. Other bottleneck causes include poor external partner coordination,

uncontrolled financial flows from central to operational levels and a general lack of skilled

subnational managers and health workers. The FY 2015/16 anticipated routine immunization

budget shortfall is about US$400,000. (Only US$2.2m of the $2.6m needed for the 2015 Gavi

co-financing payment is currently in hand.)

Parliament actively oversees the immunization budget and the MPs are aware of immunization

financing issues. The Parliamentary Health Committee keeps the MPs informed. There is a draft

Immunization Bill currently in Parliament but it is on hold until after the upcoming election

cycle is complete (February, 2016). According to the Public Finance Management Act of 2015, a

separate immunization fund cannot be created. Immunization financing currently comes from a

ring-fenced PHC budget. Given the financial structures and the chronic system-level deficits, the

best immunization financing advocacy strategy is to push for increased primary health care

funding.

Summarizing, Mr. Magona identified a set of specific areas for improvement, including:

Pass the national immunization bill in 2016

Increased partner coordination

Single vote function for increased immunization budget, tracking, and monitoring

Increased vaccine storage facilities

Increased funding at the local level, with goals of facilitating staff placements in

convenient areas to aid retention

Strengthened monitoring of central and local government budgets to better track

immunization provisions and expenditures

Small Groups: Theme I

After the plenary session, delegates were randomly assigned to three small groups of 5-8 people.

External partner counterparts facilitated the group work using the nominal group technique. The

theme for this first round of group work was domestic immunization financing. The small group

findings were reported in plenary, with one spokesperson representing each group. The

presentations were followed by a question and answer session. Small group members and results

are shown in Annex D.

Theme II: Budget and Resource Tracking

The budget and resource tracking theme was introduced in plenary with a presentation by

Sabin/SIF Senior Program Officer Dr. Clifford Kamara. Many countries, stated Kamara, are

paying more of their immunization program costs than their reported numbers show, since they

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are not properly capturing and reporting expenditures. The countries are therefore closer to the

goal of country ownership than they realize.

Kamara explained the importance of financial data collection, focusing on how a budget is

implemented and accounted for once it has been approved. He described the importance of good

financial data and indicators to monitor progress towards country ownership. Six World Bank

Public Expenditure and Financial Accountability (PEFA) standards offer a systematic,

comprehensive approach to chart budget performance. They are: credibility, transparency,

policy-based budgeting, predictability, accounting and reporting, and external scrutiny. They

become increasingly important as immunization budgets grow. Immunization managers must

increasingly demonstrate transparency, accountability and budget efficiency. Value for money

can be shown by linking outputs and impacts to investments. Thirdly, managers need to do

empirical budgeting, creating budgets based on actual expenditures. Achieving this level of fiscal

discipline and effective budget management are crucial to successfully advocating for increased

immunization investments.

Dr. Kamara discussed the SIF budget flow analysis tool, which a little more than half of SIF

countries have used to date. It incorporates the above-mentioned PEFA indicators. Kamara

provided a recent example from DRC, where Ministry of Health counterparts have tracked

central level immunization budget performance for four consecutive years. The DRC example

shows how consecutive budget flow analyses allow an accurate analysis of trends in approved,

disbursed and executed budget amounts and reported expenditures over time. Dr. Kamara

encouraged delegates to capture all their sources of immunization funding and to transparently

use the information (example: the gap between amounts budgeted and amounts actually

disbursed) for advocacy purposes. In three SIF countries, immunization managers secured the

budget they sought simply by presenting EPI expenditure data over the previous several years as

part of their “investment case.” In several SIF countries, resource tracking has led to other

immunization financing advances, such as improved provincial expenditure reporting and

increased disbursement of the immunization budget.

Following lunch, the delegates presented their national budget and resource tracking systems,

highlighting associated institutional innovations. Four countries presented.

Nigeria

Dr. Lekan Olubajo of Nigeria began by describing Nigeria’s expenditure tracking processes

and budget mechanisms. The annual budget cycle follows five steps, beginning with preparation

and approval of medium-term expenditure frameworks and strategies. Ministries use these to

prepare their budget proposals, which then are defended and approved by the ministries and

presented to the Legislature. The budget is announced and appropriated, and follow-up

evaluations measure the release of funds.

The aggregate expenditure data are analyzed using specialized software and expenditure reports

are published annually in the form of statutory financial statements. Because immunization is a

separate line item in the annual Appropriation Act, immunization expenditures are

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distinguishable from other appropriations. However, the formal financial management machinery

acts as a barrier and leads to manifold bottlenecks.

Private immunization provisions are important in the country. However, current systems do not

capture private provider expenditures, and government systems do not capture external partner

expenditures. Funds are separated from public funds, but no shared costing protocol exists.

The annual JRF financial reports are Nigeria’s only direct measure of country immunization

investments. The Interagency Coordinating Committee (ICC) Finance Committee is responsible

for completing the financial section of the JRF. Identification and compilation of public routine

immunization expenditures are accomplished by collating expenditure returns from the national,

level. (The federal government does not currently track health expenditures at subnational [LGA,

ward] levels, which is a major reason government expenditures are systematically

underreported.) The existing expenditure tracking sources include data collected from paid

vouchers, adjustment vouchers, cashbooks, journals, ledgers and trial balances.

Underreporting is a problem in the current tracking system. The system also fails to capture

shared costs such as personnel. Dr. Olubajo recommends resolving this by estimating costs using

ratios of time spent on immunization activities multiplied by the numbers of relevant personnel

at each level.

Other areas for improvement include the timeliness of the budget cycle. Delays in passing

appropriations bills are common. Cumbersome procurement procedures also cause delays in

program execution. A third area for improvement is sub-national expenditure tracking.

Dr. Olubajo proposed expanding a public expenditure tracking survey, currently being piloted in

Ekiti and Niger States. He stated that Nigerian ministries would be switching to zero-based

budgeting as opposed to the current incremental budgeting method in 2016.

New bottom-up approaches to planning, budgeting and tracking expenditures are also needed.

The nation needs to institute a transparent, replicable accounting system which operates at all

levels. It will require regular internal and external supervision, moving from a paper-based to an

electronic accounting system and instituting cash backing policies.

Finally, Dr. Olubajo suggested that states should be able to compare themselves to each other in

terms of routine immunization financing and performance, just as they have learned to do for

polio eradication. This would help bolster stakeholder involvement and sidestep the formal

constraints on resource tracking at subnational levels. The current iteration of this, implemented

three years ago, is a primary health care score card being used for peer review across states.

Sierra Leone

Ms. Isha Kamara explained that resource tracking has been operational in Sierra Leone since

2012 when the EPI team developed an expenditure tracking tool. In 2013-2014, government

officials from the MOFED worked with EPI accountants to illustrate the nation’s top-down

approach to immunization spending, including district-level health expenditures. MOFED

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counterparts are using the Chart of Accounts in this resource tracking work. The SIF budget flow

analysis tool was an inspiration, she remarked.

At the district level, expenditure tracking is not working well, but it is improving under the

responsibility of District Health Management Teams. Financial and immunization data are stored

electronically, with a mixture of software used for financial tracking including MS Excel &

Integrated Financial Management System. Expenditures are disaggregated according to public or

private sources. Shared costs are included as separate budget lines, and include areas such as

program management, vehicle maintenance, service delivery, monitoring & surveillance, and

human resources. Public expenditures are reported quarterly. Since 2008, district funding has

been channeled through Local Development Councils. Immunization expenditure data is not

readily available. The MOFED allocates the approved budget on a quarterly basis to the

EPI/MOHS, which is responsible for planning and implementing routine immunization activities.

Routine immunization data are reported to partners on a monthly basis, and annually through the

WHO/UNICEF Joint Reporting Form. The current central-level expenditure tracking process has

been in existence since 2006. Public routine immunization expenditures are reported in the JRF

as percentage of total expenditure on vaccines and percentage of total expenditure on routine

immunization financed by government funds. Ms. Kamara cited the underreporting of human

resource expenditures as a major data gap, as well as underreporting of immunizations funds

from local partners, poor accountability for the cost of wasted vaccines and low capacity of

personnel in tracking immunization expenditures. She also cited difficulty in extracting required

information from other ministries, departments, and agencies.

Kamara next described the annual budget cycle. Sierra Leone’s EPI team plans its expected

annual activity costs in the final quarter of the preceding year. The EPI Manager submits the

budget for consolidation into the total MOHS budget. The budget is then submitted to the

MOFED, which consolidates all ministries’ budgets for parliamentary approval. In the first

quarter of the new year, the Minister of Finance receives parliamentary notification of approved

funds, which are then disbursed to ministries in quarterly installments.

Potential solutions to the problems presented include: an annual estimation of human resource

components of total immunization expenditures; establishing a system for tracking the cost of

wasted vaccines; setting up structures specifically for immunization finance tracking in all

relevant agencies; and, training personnel to track immunization expenditures. The EPI

Programme will present a plan to implement these steps to the ICC for its approval.

Parliamentarians will take up the legal aspects of immunization financing.

Uganda

In Uganda, there are no government resource tracking systems in place for immunization.

Resource tracking for health is done through National Health Accounts.

A recent Gavi-funded study used the System of Health Accounts framework (2011) to estimate

the total resource envelope for immunization in two different scenarios during 2013-14.

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Scenario 1 includes Government of Uganda (GoU) salaries at Health Facilities (HF) and District

Health Office (DHO) levels

Total envelope = Donor funds + GoU (contribution at national level) + GoU (Salaries and

PHC proportion for immunization)

Scenario 2 excludes Government of Uganda salary expendituresat HFs and DHO level

Total envelope = Donor funds + GoU (contribution at national level)

Scenario one shows the GoU as the greatest contributor to routine immunization (42.8% vs

23.8% from Gavi), while Scenario 2 shows Gavi to be the greater contributor (23.8% vs 13%

from Government of Uganda). In Scenario 1, 64.6% of funds are spent on facility-based routine

immunization services; in Scenario 2, the facility delivery proportion drops to 34.7%.

As mentioned earlier, Uganda’s EPI budget increased between 2009/2010 and 2013/2014 but the

share of total expenditures attributable to the government has not risen. Dr. Henry Luzze,

deputy national immunization program manager, explained an important change in financial

management practices. Beginning in 2014/15, sub-national funds are now sent directly from the

MOFPED to District Health Officers and to health facilities instead of through district offices.

He reported that this practice was adopted in response to chronic delays in 2013/14 fund

disbursements to districts and facilities.

Other major budget tracking limitations include the fact that most external partner funds are off-

budget, unplanned, and earmarked for specific activities. Another major bottleneck results from

external partners requiring different formats for reporting and expenditure tracking. Dr. Luzze

also mentioned budget shortfalls and insufficient funds, as well as continuing issues with timely

release of funds.

As Deputy EPI manager, Dr. Luzze is familiar with the WHO/UNICEF JRF system. Uganda has

difficulty completing the annual JRF expenditure reports for several reasons. One problem is

that the JRF works by calendar year, which is at odds with Uganda’s financial year. This makes

disaggregating data for the JRF reports difficult. Secondly, Uganda does not distinguish vaccine

procurement and immunization delivery expenditures, which poses another challenge. Dr. Luzze

believes that new financial management practices could ameliorate many of the budget and

resource tracking problems he identified.

Liberia

Ms. Alice O. Peters, of Liberia’s EPI/MOH, finished out the plenary session by describing her

nation’s immunization budget and resource tracking processes. The Office of Financial

Management (OFM) in the MOH Health Financing Unit is responsible for expenditure tracking.

The OFM uses data collection instruments derived from the National Health Accounts format.

These tools cannot generate immunization-specific expenditure reports. Yet the OFM generates

the annual JRF expenditure reports, bypassing the EPI team.

The budget process begins in February or March each year with the Minister of Health

submitting his prepared budget to the Minister of Finance and Development Planning. From

P a g e | 15

there it is submitted to the Legislature for review, in April or May. Upon Legislative approval

(June or July), the MOFED is authorized to disburse funds to the MOH for EPI. The EPI

Manager receives and records the funds in the 3rd Quarter. The EPI team allocates the funds

according to their annual work plan. The counties receive and disburse funds to local health

facilities.

The public financial management system was decentralized in 2007, with more financial

oversight responsibilities given to counties. County health teams (an administrator and an

accountant) do not submit regular reports on routine immunization expenditures, nor do their

reports capture shared health system costs. Counties submit financial reports to the OFM only if

they receive special funds for outreach services or outbreak responses. Some health facilities

receive direct budgetary support for immunization activities from partner agencies. The latter

generally require the submission of expenditure reports but externally funded immunization

expenditures are not reported to the government at any level.

A major problem precluding accurate expenditure tracking process is that the health facility and

county level teams report irregularly. Capacity building, commented Ms. Peters, is badly needed

along with intensified, supportive supervision/monitoring by the MOH/EPI team. With these

inputs, standard immunization budget tracking tools and procedures might be put into place.

Small Groups: Theme II

Delegates were again randomly assigned to three small groups to further discuss Theme II. The

results of the small group work are found in Annex D.

Day 2

Work began with Kenyan delegate Ms. Sharon Wanyeki re-capping the discussions of Day 1.

The agenda then shifted to the third workshop theme: Immunization legislation.

Theme III: Legislation and Legislative Process

The Sabin team offered two brief presentations to set the legislative theme. SIF Program Officer

Dana Silver described the range of legal provisions observed in existing vaccine-related laws,

drawing from the framework put forth in Trumbo et al (2012). The existence of vaccine-related

legislation is one of the sustainability indicators in the Global Vaccine Action Plan (2010-2020)

and developing such legislation is a key recommendation in the African Regional Strategic Plan

for Immunization. Provisions fall under three categories: Declarative, financial and operational.

Silver compared examples of provisions from both SIF and non-SIF countries, demonstrating

varying levels of detail and precision.

SIF Director Mike McQuestion then summarized the SIF countries’ progress to date in the

immunization legislation arena. He described case studies to demonstrate different formal

P a g e | 16

processes through which these documents were produced, which institutions participated and the

steps they followed.

In all successful cases, governments and parliaments ultimately came together to craft the

legislation. In the majority of cases, political resistance, or the failure of the key institutions to

come together, leads to the legislative project never being completed. This is universal, and not

just for immunization. After a particular legislative strategy is blocked, commented McQuestion,

another can be tried. A new approach would incorporate structural or political shift, depending

on the nature of the blockage.

The following chart depicts the current status of legislative projects in the SIF Anglophone

African countries:

The countries then presented their legislative projects in plenary. Three countries presented.

Nigeria

Hon. Dr. Chukwuemeka Ujam, member of Nigeria’s House of Representatives, gave an

overview of his nation’s legislative progress. Nigeria revised its National Health Policy in 2004,

in the process identifying the need for formal legislation defining government and institution

roles and functions. After studying scores of other nations’ legislative frameworks, the first draft

of the National Health Bill was produced. At that time, recalled Hon. Ujam, the Bill was

propelled forward by the 2000 World Health Report, which ranked Nigeria’s health system near

the bottom.

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The first draft of the bill was approved in 2005 following a continuous advocacy campaign

involving a range of stakeholders. Following hearings by the Federal Executive Council and the

Senate and House Health Committees in 2006, the House passed the Bill in 2007. However, the

Senate Health Committee did not take it up. The draft bill was reviewed in 2008, and both

houses passed it in 2009. Amendments were subsequently made and a harmonized, final bill was

passed by both houses in 2011. The bill was then sent to the president, who did not sign it.

The Senate resurrected the bill, organizing another round of meetings and public hearings. In

2014, both Houses again passed the bill. Following intense advocacy efforts, the President signed

it into law in October 2014. Advocacy efforts continue as supporters work on implementation of

the Bill’s provisions. An implementation working group was inaugurated in April 2015.

Gazetting of the law is expected in November 2015, and a basic health care provision fund is

expected to be incorporated in the 2016 federal budget.

Hon. Ujam reiterated the important advocacy roles faith-based organizations and CSOs played in

ensuring the bill became reality. He also mentioned the important role played by a committed

critical mass of change agents, the importance of extensive stakeholder consultations, and the

support provided by media covering the story.

Hon. Ujam then introduced Dr. Ben Anyene, Chairman of Nigeria’s National Vaccine Financing

Task Team, who gave an insider’s account of the twelve-year legislative project. Dr. Anyene led

the effort to pass the National Health Bill from beginning to end. His remarks are summarized in

Annex C.

Liberia

Next, Hon. Daniel F. Naatehn Sr. described how Liberia’s many current childhood

immunization policies are rooted in a 1956 Public Health Law. Although it contains several

relevant provisions, there is no immunization financing clause. A draft immunization bill was

prepared in 2013. Parliament has led the legislative work with health committees in both houses

coordinating their efforts. The Ministry of Health has already prepared draft administrative

regulations for the bill. A few amendments were made following an initial (first reading) public

vetting process. The bill was approved by the Senate in 2014. It currently rests with the House of

Representatives. Senate supporters, however, are considering withdrawing and amending the bill

to include financial provisions, at which point it would be re-submitted to both houses anew.

Parliament can hold the bill for as long as it chooses. If it approves the bill, the President would

then have 20 days to act, otherwise the bill becomes law.

As currently written, the bill ensures universal availability of vaccines, compulsory

immunization of all children under one and full childhood immunization as a criterion for school

enrollment. There have been some negative responses to penalties proposed in the bill. Others

have expressed concerns about the government’s ability to make vaccines universally available.

Hon. Naatehn described the challenge posed by the numerous delays at each stage of the project.

He suggested remedial steps, including intensifying advocacy efforts focused on the legislature

P a g e | 18

and following up on revising the implementation clauses of the bill. Since 2017 is an election

year, all efforts must be made to ensure the bill’s passage before then.

Sierra Leone

Parliamentarian Hon. A.B.D. Sesay of Sierra Leone presented his nation’s immunization

legislation project. Among the key institutions, the Ministry of Health and Sanitation is

responsible for ensuring vaccine access, while the Ministry of Finance and Economic

Development is primarily responsible for funding the National Immunization Program (with

government and external partner funding). The Parliamentary Health and Sanitation Committee

provides oversight and support (although without government financing for its work).

There is no current legislation on immunization. The National EPI Policy stipulates that all

vaccines should be provided for free and procured through the MOHS and its designated

agencies, from WHO/UNICEF-approved sources. Legislation is being developed based on the

National Immunization Policy. This legislation will affect which vaccines the country uses and

how they are to be procured. Other provisions cover regulation of vaccine safety, that

vaccinations are mandatory and that vaccines will be targeted to certain groups. There are

currently no financing provisions in the draft bill.

Sierra Leone is using a three-pronged approach to develop its immunization legislation. First, the

Law Officer’s Department (LOD) and MOHS are producing a Cabinet Paper as a precursor to a

draft law. Second, immunization-related clauses will be inserted into an amended version of the

1960 Public Health Act, which is currently under revision. The Chairman of the Parliamentary

Health and Sanitation Committee will then submit the amended Public Health Act to Parliament

as a Private Member’s Bill.

A key handicap has been high turnover of key counterparts. There is a lack of continuity and

institutional memory as EPI team members and MPs on the Parliamentary Health Committee

come and go. Identifying and mentoring a handful of permanent Parliament staff members,

allowed Hon. Sesay, would assuage the problem. The staff would maintain the institutional

memory and help sustain the bill’s momentum toward passage by briefing new parliamentary

committee members. Additional resources for the legislative work may become available from

government. The EPI team plans to insert a new advocacy activity area into its annual work plan.

Small Groups

Delegates were then assigned randomly to a third set of small groups to analyze their legislative

documents and propose strategies to advance their immunization legislation projects. The small

group findings were reported out in plenary by a panel consisting of one spokesperson for each

group. The results of this third round of small group work are found in Annex D.

P a g e | 19

Theme IV: Advocacy Strategies

Sabin’s Mike McQuestion introduced the final theme: Advocacy. The art of advocacy is

knowing how to formulate messages that fit into each particular institution’s logic and deliver

them effectively. Examples of institutional logics include welfare (provide for all), medicine (do

all one can to save a life), economics (rationally allocate), public finance (accountability,

efficiency, value for money) and politics (get re-elected).

Dr. McQuestion described the social contract concept wherein citizens are linked to the leaders

they elect into power, and how this involves agreement to follow laws, participate in governance

and hold government and parliament accountable. The greater the participation, the richer the

social contract.

After citing a few case studies, McQuestion opened the plenary session to delegates to present

their domestic advocacy strategies for sustainable immunization financing. Three countries

presented.

Sierra Leone

Mr. Mustapha Alpha, the EPI Data Manager for Sierra Leone’s Ministry of Health and

Sanitation, began by explaining his nation’s budget advocacy strategy. There is a domestic

advocacy network for sustainable immunization financing in the country. It is a multi-

institutional immunization network, which was established by the MOHS, MOFED and

Parliament in 2013 and became operational the following year.

Advocacy activities have been carried out at high levels and fall into several categories. Network

members have advocated for increased immunization budgets in concert with the annual Budget

Acts which Parliament must approve. Key messages have been to allocate a greater portion of

the national budget to routine immunization and requesting that the government finance all

traditional vaccines and gradually increase its Gavi co-financing efforts in order to reach

sustainability. This year, the network has begun to focus on legislation. Network members

helped draft a concept paper on immunization legislation.

At central level, the SIF advocacy network targets CSOs, development partners and senior

government officials. The network now wishes to extend advocacy for better immunization

budgetary performance to the district council level. Local governments need to regularly

disburse funds to District Health Management Teams if immunization program implementation

is to improve.

Mr. Alpha also discussed how regular changes in parliamentarians and EPI Managers complicate

the advocacy work. He suggested recruiting a focal point and establishing an immunization

financing advocacy committee in Parliament to compensate for the lack of cohesiveness.

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Liberia

Hon. Shah Joseph, Co-Chair of Liberia’s Health Parliamentary Committee, stated that his

committee receives quarterly updates from the EPI team and regular briefings on health

expenditures from the Ministry of Finance & Development Planning. The Parliamentary Forum

for Immunization serves as an intra-parliamentary advocacy group. It works to increase

immunization budgetary support and achieve sustainable immunization financing. Advocacy

happens during annual budget negotiations. Advocates also engage the media as a means of

persuading government policymakers to more strongly support immunization. Advocacy relating

to vaccine purchasing focuses on the need for complete and timely co-payments to Gavi. There

are also advocacy efforts targeting county health officers, superintendents, private companies,

and community leaders.

The advocacy work is paying off. The government share of total routine immunization

expenditures increased from 3% in 2006 to 28% in 2013, indicating progress towards country

ownership. The government is now conducting immunization budget tracking analyses. This

involves scrutinizing performance reports and organizing field visits by lawmakers active in the

Forum.

Hon. Joseph also suggested that immunization advocates join advocates concerned with other

health causes so as to synergize their efforts.

Nigeria

Representing Nigeria was Dr. Ben Anyene Chairman of the Health Reform Foundation of

Nigeria (HERFON) and Nigeria Immunization Financing Task Team (NIFTT), a newly created

advocacy advisory group to the National Primary Health Care Development Agency

(NPHCDA). NIFT membership includes government officials, external partners and

representatives from CSOs and the domestic private sector.

Dr. Anyene gestured to some of Nigeria’s advocacy challenges. Immunization program costs are

rapidly rising. According to the cMYP 2016-2020, vaccine costs will jump from US$215 million

in 2016 to US$280 million in 2020. Costs are rising in the context of declining federal

appropriations for vaccines, a weakening economy, and a political transition.

The government is responsible for all traditional vaccine costs, and co-finances new and

underutilized vaccines. It has never defaulted on Gavi payments, but while the government

committed US$47 million towards immunization in 2014, it only released $25 million.

The NIFTT follows a multi-step theory of change which focuses on powerful actors. The full

dynamics and inputs are outlined in the following figure:

P a g e | 21

The plan is to create platforms for states, local governments and political wards. The overall

advocacy strategy involves mobilizing support amongst stakeholders, leveraging influential

individuals and using the media to build popular support. The major objectives of sustainable

immunization financing and ensuring every child is vaccinated are being pursued through the

smaller goals of increasing the federal government immunization budget and establishing an

immunization trust fund with public and private contributors.

Advocates are also targeting smaller groups to take up the cause, including women’s groups and

groups focused on other health issues. Advocates are working to consolidate a diverse advocacy

coalition, and are encouraging states and local governments to develop innovative financing

strategies within their jurisdictions.

While currently focused on creating an Immunization Financing Trust Fund, the NIFT intends to

eventually advocate for specific legislation to attract tax revenue and levies to finance

immunization activities. Their second main track of advocacy work is to draft a national policy

for local vaccine production. HERFON has financed its own advocacy work to date with

extrabudgetary funds. The government (NPHCDA) is expected to add a budget line item to

support NIFT’s work beginning in 2016.

In a Q&A session, Kenyan delegate Dr. Ephantus Maree compared Kenya’s counties to

Nigeria’s states and asked the Nigerians how they are advocating with them for sustainable

immunization financing. Both countries have councils of governors and the governors demand

full control over all devolved public finances. The Nigerians developed a plan to advocate for

immunization financing with their state governors in 2013 but it has yet to be implemented. In

Kenya, reflected Dr. Maree, the 2013 devolution created deep mistrust and open acrimony. The

best strategy, commented Dr. Anyene, is to find ways to establish trust between federal and

subnational counterparts. Two recent workshops in Kenya (which Sabin assisted along with

UNICEF and other partners) seem to have started this trust-building process, remarked Dr.

Maree. The MoH is contemplating more subnational advocacy activities in 2016. Exactly how to

P a g e | 22

make the federal- county co-financing arrangements is a bedeviling task, added Dr. Maree. Can

we form a community of practice, he asked, so that the countries can learn from one another how

best to do this?

Uganda

Dr. Henry Luzze described the Ministry of Health’s most recent advocacy strategy for

immunization. The plan was to involve religious leaders to advocate for immunization with their

parishioners. The effort initially failed because the MoH did not engage the leaders through their

existing structures and communication channels. Eventually the MoH got it right and now works

with the leaders through an existing ecumenical council.

In a Q&A follow-up, Dr. Anyene commented that government officials have limited advocacy

potential. In Nigeria, HERFON acts as an intermediary between government and the people.

Most smaller African CSOs, he continued, are not effective advocates.

Country Delegation Meetings

At the conclusion of Day 2, delegations met to prepare their country presentations for the

following day’s Peer Review.

Day 3

Summary of Thematic Discussions

Dr. McQuestion gave a summary of the different innovative methods of achieving sustainable

financing that had been shared the past two days, referencing Nigeria’s story of its 12-year road

to an immunization law, and acknowledging that most countries currently have draft laws. Not

all drafted laws have financing components, which is an area for improvement. Dr. McQuestion

described the delegates’ general consensus that JRF expenditure data are often incomplete, and

countries may therefore need to develop the own budget tracking tools and find ways to

encourage sub-national budget tracking. Numerous advocacy practices were shared and

discussed, including Parliamentary fora, county stakeholder meetings and reaching out to

existing networks.

Peer Review

Day 3 began with a peer assessment of each country’s institutional innovations. Delegates used a

standard peer review guide to score each country (Annex E). Sixteen delegates from the five

countries participated in the peer review session.

Raters used a standard guide to examine the innovative practices that governments and

parliaments are developing, or have developed, to move their countries closer to the sustainable

P a g e | 23

immunization financing goal. New practices were classified in terms of functional area (finance,

budget, legislation, advocacy), developmental mechanism (top-down, bottom-up, third party),

duration (less than one year, 1-2 years, 3 years or more), level (regional, national, subnational),

the institutions involved (elected body, ministry, non-governmental) and current level of

development (aspirational, being tried, becoming institutionalized, fully institutionalized, being

blocked).The guide included several open-ended and multiple choice questions and a list of ten

items scored on a Likert scale.

The peer review activity was divided into two consecutive sessions. In the first session,

reviewers interviewed their peers from Nigeria, Sierra Leone, and Liberia. In the second round,

reviewers interviewed their peers from Uganda and Kenya. In addition, raters jotted down

comments and recommendations for the presenters. Fifty-eight completed forms were collected.

Scores were tabulated by Sabin staff. Results are summarized below.

Results

All but two workshop participants participated in the peer review exercise, with 15 raters

completing 58 total surveys. Seven of the 15 raters (46.6%) represented ministries of health.

Four (26.7%) were Parliamentarians, three (20%) represented ministries of finance, and one rater

(6.7%) represented another institution. Of the 15 raters, 14 completed all four assessments

assigned to them.

Raters classified the practices they assessed as resource tracking (14%), legislation (36%),

domestic advocacy (40%), legislation and advocacy (7%), or some combination of these areas

and finance (3%). Ninety percent of the practices were occurring at national level, 3% at the

regional level, and 5% at the subnational or national and subnational levels, with 2% of values

missing.

Eighty-eight percent of the assessments identified more than one public institution involved in

the new practice. Ministries of health were involved in every instance, excluding the 3% of

missing values. After that, most frequent were parliaments (78%) and ministries of finance

(64%). Other institutions were involved in 8 out of 58 (14%) of cases, with community service

organizations (CSOs) most commonly mentioned (53%).

The practices tended to originate in top-down fashion (76%); just 8 out of 58 (14%) emerged

from the bottom-up. Six innovations (10%) originated through outside organizations or

institutions. Eleven out of 58 (19%) of the practices began within the past 1-2 years with 47 out

of 48 (81%) ongoing for three years or more.

The raters determined that 20 out of 58 (34%) of the new practices were already fully

institutionalized, i.e., they were no longer innovations. Some 34 out of the 58 innovations (59%)

were still in pilot phase or in the process of becoming institutionalized. Four cases (7%) were

still in the talking stage, and no innovations had been blocked.

The ten subjective Likert-scaled items are described in Table 2. Raters assigned each item a

score of 1-5, with 1 being “No chance”, 2 “Not likely”, 3 “Unsure”, 4 “Likely” and 5 “Almost

P a g e | 24

certain.” Inter-rater reliability is a concern for data such as these. Different numbers of raters

rated each case. Raters likely differed in systematic ways in how they assessed a given country’s

innovation. The intra-class correlations (ICCs) shown in Table 1 indicate how similarly

(reliably) the raters rated each item for each country. Four ICCs are statistically significant,

however, they are relatively low, ranging from 0.46 (my_ctry) to 0.20 (resist). The four reliably

measured variables are further described below.

resist: In 23 out of 58 assessments (42%), raters perceived that resistance to the innovation

was likely to certain. Resistance was least evident in Nigeria (1/9) and Kenya (2/11).

mix_inst. In 47 out of 58 assessments (81%), raters concluded the right mix of institutions

was likely or almost certainly involved in the innovative practice. Scoring highest on this

variable were Nigeria (10/10) and Uganda (11/13).

no_costs. The raters were mixed on whether they concluded that the innovations they

assessed would entail additional costs: 16 out of 58 said likely or very likely (28%) versus

27 out of 58 unlikely (47%). Additional costs were judged least likely in Liberia, Sierra

Leone, and Nigeria.

my_ctry. In 32 out of 58 assessments (55%), raters felt the innovation would likely or

almost certainly succeed in their own country. Scores on this variable were highest for

Nigeria (8/10) and Sierra Leone (7/8).

Table 1. Scoring results per subjective item on Likert Scale | Anglophone Africa Peer Review Workshop, Nairobi, Kenya, 2015

Item Description of Item Obs. (n)

Mean Std. Dev.

Min Max Intra-Class Correlation

(rho)

Sig.(f-value) of ICC

95% C.I.

Concept The innovation is well conceptualized. The proposed solution matches the problem or opportunity it addresses.

58 4.09 0.80 1 5 0.07 0.25 (0.00, 0.32)

Approach Another approach would have been more suitable for solving the problem/improving the sustainability of the immunization.

57 3.53 1.07 2 5 0.16 0.09 (0.00, 0.43)

mix_inst The right mix of institutions is or was involved in developing the innovation.

57 4.12 0.92 1 5 0.23 0.03* (0.00, 0.52)

Resist There is or was a lot of resistance to this innovation.

55 2.96 1.36 1 5 0.20 0.05* (0.00, 0.49)

no_costs This innovation is or was carried out without incurring significant new costs.

58 3.24 1.13 1 5 0.21 0.04* (0.00, 0.48)

Sustain This innovation will help the country reach sustainable immunization financing sooner.

56 3.89 1.00 1 5 0.03 0.37 (0.00, 0.27)

inst_nation The innovation will ultimately be institutionalized nationwide.

57 4.30 0.76 1 5 0.13 0.21 (0.00, 0.35)

Ownership If successful, the innovation will increase country ownership of immunization program.

57 4.09 0.83 1 5 0.00 0.70 (0.00, 0.22)

Likely Considering all the factors, how likely is the innovation to succeed, to become institutionalized?

58 4.03 0.90 1 5 0.07 0.27 (0.00, 0.31)

my_ctry This innovation would likely succeed in your own country.

54 3.59 1.21 1 5 0.46 0.00* (0.18, 0.75)

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The four items were then rescaled to the (-2,2) interval and the scores were summed for each

country. The next step was to find the best combination of items to make an overall

innovativeness index. Factor analysis revealed that three items made the best index (resist, no

cost, my ctry, Cronbach’s alpha=0.57). Mean scores and ranks for each index item and for the

overall innovativeness index are shown in Table 2. The country raters found most innovative

was Nigeria, followed by Kenya and Liberia.

Table 2. Countries Ranked by Average Scores on Three Innovativeness Variables | Anglophone Africa Peer Review Workshop on Sustainable Immunization Financing, Nairobi, Kenya. 2015.

International Adaptability Resistance to Innovation Minimal Added Costs

Rank Country Average Rank Country Average Rank Country Average

1 Nigeria 1.10 1 Nigeria -1.33 1 Kenya 0.50

2 Sierra Leone 0.88 2 Kenya -0.73 2 Nigeria 0.30

3 Liberia 0.67 3 Uganda 0.54 3 Liberia 0.25

4 Uganda 0.38 4 Liberia 0.67 4 Sierra Leone 0.09

5 Kenya 0.09 5 Sierra Leone 0.70 4 Uganda 0.08

Average Innovativeness

Rank Country Average

1 Nigeria 0.85

2 Kenya 0.40

3 Liberia 0.08

4 Sierra Leone 0.04

5 Uganda -0.03

In Figures 1 and 2, the countries’ innovativeness indexes are plotted against their 2014 gross

national incomes (GNI) per capita. Countries in the top half of both graphs boast the best

innovativeness scores; those toward the right have the highest incomes.

Figure 1 provides the broad strokes of where the countries fell in terms of rank. The peers

considered Nigeria and Kenya the most innovative. Liberia has the lowest income, yet bested the

wealthier Uganda and Sierra Leone in innovativeness.

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When actual innovativeness scores (scaled on the -2 to 2 interval used previously) are compared

with actual GNI per capita, as shown in Figure 2, there are a few important considerations. First,

countries in the low-income stratum1 (Liberia, Sierra Leone, Uganda) received mediocre scores

on the three selected items (-0.03<mean innovativeness<0.08). From there, innovativeness

increased with wealth. Kenya won the second highest innovativeness score. Nigeria’s score was

more than twice Kenya’s score. The pattern suggests that a strong positive association exists

between innovativeness and wealth.

The raters provided insights and recommendations on the innovations presented:

Sierra Leone shared its intentions to draft an immunization bill and develop an

immunization trust fund. The majority of raters suggested that the peers employ a

bottom-up approach to improve the legislative process. Many raters agreed that the

country still has much work to do in developing these projects. The law must guarantee

adequate financing for the immunization program, a handful wrote. Moving forward, one

peer recommended that the drafters “look at good practice from other countries to help

push [the legislative project] forward.”

The eleven delegates who reviewed Liberia elected to analyze an innovation in

legislation. The innovations in this domain met positive reception across raters. Still, an

alternative approach—“a presidential proclamation based on a constitutional

provision”—was offered to replace the draft immunization bill. A peer observed that the

Liberians seemed to learn from Nigeria’s legislative experience presented in the

workshop. The peer urged the delegation to take these lessons home with them.

Nigeria was also evaluated for its legislative innovations. Two reviewers recorded the

“involvement of community members in pushing forward this act [who] marched to

parliament in demand for this act” as an innovation. A second one, that “the initiative

started in academia, identifying the role legislation can play”, was recognized by another

1 Using the 2014 World Bank Atlas Method; GNI/capita>$1,045.

P a g e | 27

reviewer. This is “the most viable and practical innovative strategy towards sustainable

immunization financing,” enthused one peer. Other evaluators echoed this sentiment.

The thirteen delegates who reviewed Uganda evaluated it based on its budget allocation

and resource tracking innovations. Raters wrote positively about the innovation, with one

peer stating that it ensures that “only activities that have value for money are

implemented,” and another noting that, “there is need to pass strategies onto other

countries for adaptation.” Several raters indicated that Uganda should push legislative

innovations in addition to budget and resource tracking in order to achieve wider results.

Kenya was evaluated on its “Beyond Zero” advocacy campaign initiated by the first lady,

which aims in part to improve vaccine coverage. The majority of raters suggested that

legislation would increase the strength and sustainability of the innovation. One peer

formulated this sentiment by stating, “With devolution of powers, a new problem has

arisen, so centralized laws need to be strengthened.” Another rater voiced concern on the

impact of devolution on vaccine procurement responsibilities. While some raters praised

the inclusion of CSOs in the innovative processes, others felt that Kenya needed to

increase harmonization with government institutions to create lasting impact.

Discussion

A rapid peer review exercise was organized during a workshop on sustainable immunization

financing for five Anglophone African countries in Nairobi, Kenya. Fifteen peers participated,

both as raters and presenters of their respective country innovations.

Results show the peers generally understand the concept of institutional innovations. Most of the

innovations they examined had been underway for three or more years, at the national level, with

both government and parliament involved.

The raters decided that wealthier countries are more apt to innovate to improve immunization

financing than poorer ones. This finding is in contrast with a similar workshop held among

Francophone African countries in Kribi, Cameroon, December 2014. In Kribi, peers observed

that countries’ innovativeness was independent of wealth; the two poorest countries received the

highest innovativeness scores. In Nairobi, it was the two most affluent countries that scored

highest. Further research will be necessary to analyze the reasons behind this contrast.

Some caveats may threaten the validity of these findings. Actual and aspirational innovations

were bundled into the same analysis, which may have resulted in higher scores for a country with

impressive planned innovations than one with satisfactory existing ones. There were relatively

few observations to analyze. Only fifteen raters participated, each of whom carries their own

biases and misconceptions. Many presenters were not necessarily personally involved in the

legislative, financing, or advocacy innovations they depicted. Some evaluators clearly

misunderstood some of the concepts they were measuring.

The mean innovativeness scores raise further considerations. The Likert items used in the

innovativeness index had to satisfy two statistical criteria: intra-class correlation (ICC) and

statistical significance. While the items were correlated (significant), the ICC values were quite

low (0.2<ICC<0.47), indicating internal consistency could not be assured. In addition, the term

http://www.sabin.org/updates/events/francophone-africa-peer-review-workshop-sustainable-immunization-financing

P a g e | 28

“innovativeness” may be less applicable for the Nairobi workshop results than for earlier

workshops. It is not clear what concepts the three significant index items—Resistance to

Innovation, Minimal Added Costs, International Adaptability— are tapping. The assumption is

that the items measure how popular (or threatening), cost-effective and transferable the

innovative practice is.

Remaining Challenges and Next Steps

In their final activity, delegates worked by country to develop action points they would pursue

following the workshop. Each delegation nominated a spokesperson who presented the points in

plenary. The action points are outlined below:

Sierra Leone (Hon. ABD Sesay. Mr. Mustapha Alpha, Ms. Isha Kamara):

Convene stakeholder meetings (MPs, MOF, MOH, partners) to discuss issues and how

the ownership process will continue

Multiple agencies will work to draft the immunization bill

Resource tracking capacity building

The Sierra Leonean delegates’ main concern is improving resource tracking. This will entail

capacity building among all levels of health workers.

Uganda (Dr. Henry Luzze, Mr. Ishmael Magona):

Meetings bringing together representatives from MOH, MOF to establish an

immunization resource utilization and reporting community of practice

Updated communication strategy to include financing and legislation messages to the

public

Improved budget allocation tools to capture: a) finance and expenditure data at sub-

national levels, b) off-budget immunization resources, thereby improving MOF

transparency

Develop alternative communications modalities between government and parliament

regarding the National Immunization Bill

The Ugandan delegates also agreed that resource tracking is their weakest point and resolved to

bring together both government and external partners to improve practices.

Nigeria (Hon. Chukwuemeka Ujam, Dr. Ben Anyene, Dr. Lekan Olubajo, Ms. Damaris Onwuka,

Mr. Oluremi Onabajo):

Improve JRF reporting, correct past reporting errors

Develop an accountability framework to be used in immunization service delivery

Step up implementation (gazetting) of the National Health Act through a proposed MOH

technical working group

Explore local vaccine production

Explore setting up a public-private immunization trust fund

The most feasible first step, felt the Nigerians, is to repair the JRF expenditure data.

P a g e | 29

Liberia (Hon. Saah Joseph, Ms. Alice O. Peters, Hon. Daniel Naatehn):

Organize a joint executive- legislative retreat to discuss immunization financing,

legislation

o Establish and maintain direct communication between both houses of Congress

and the (MoH) immunization program

o Revise the pending Immunization Bill to include financing provision(s) (Ideally

do this this before July 2016, since elections are the following year.)

Carry out immunization advocacy in all counties through media, MOH public relations

training

Provide immunization expenditure reports to counties

Highest priority, stated the Liberians, is completing their immunization legislative project.

Kenya (Mr. Chris Malala, Dr. Dominic Mutie, Ms. Sharon Wanyeki, Dr. Ephantus Maree):

Communicate with the Council of Governors on immunization financing issues (strong

advocacy strategy)

Stabilize vaccine procurement and distribution between federal and county levels

Push legislation to secure immunization financing within the devolution process

Identify a new cadre of MPs to champion sustainable immunization financing

Continue identifying county-level immunization champions; engage county level

planners to translate national-level immunization budgeting, planning and reporting

methods to county level

Advocate more aggressively to ensure government allocates sufficient funds to meet Gavi

co-financing requirements

Commenting “you can’t track resources you don’t control,” the Kenyans felt that deepening their

stakeholder advocacy strategy with the counties is the most pressing next step. Further noting the

absence of any Kenyan MPs in the workshop, the delegate resolved to recruit a new cadre of MP

immunization financing champions.

Annex F summarizes the main points by country across the four functional areas.

Workshop Evaluations The workshop concluded with votes of thanks from each delegation. Delegates were asked to

complete a short workshop evaluation form. Thirteen completed forms were collected. Results

are summarized in Annex G.

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ANNEXES

Annex A: List of participants

Delegate Title/Institution Country

Dr. Henry Luzze Deputy EPI Manager, MOH Uganda

Mr. Ishmael Magona Budget Policy Commissioner, MOF Uganda

Dr. Ephantus Maree EPI Manager, MOH Kenya

Ms. Sharon Wanyeki Information, Communications, & Technology Officer, MOF Kenya

Mr. Christopher Malala Senior Accountant, MOF Kenya

Dr. Dominic Mutie Deputy UVIS Manager, MOH Kenya

Hon. A.B.D. Sesay MP, Health Committee Chairman, Parliament Sierra Leone

Ms. Isha Kamara Assistant Secretary, MOF Sierra Leone

Mr. Mustapha Alpha EPI Program Assistant, MOH Sierra Leone

Hon. Saah Joseph MP, House Health Committee Co-Chairman, House of

Representatives

Liberia

Hon. Daniel Naatehn MP, Senate Health Committee Member, Senate Liberia

Mrs. Alice O. Peters Assistant Supplementary Immunization Activities Officer, MOH Liberia

Hon. Dr. Chukwuemeka

Ujam

Member, Federal House of Representatives Nigeria

Dr. Ben Anyene Chairman of National Immunization Financing Task Team Nigeria

Dr. Damaris Onwuka Director, Disease Control and Immunization, NPHCDA Nigeria

Dr. Lekan Olubajo Head, Health Financing, NPHCDA Nigeria

Mr. Oluremi Onabajo Assistant Director International Economic Relations, MOF Nigeria

External Partners Title/Institution Country

Mr. Jack Ndegwa Head, Policy & Advocacy, Kenya AIDS NGOs Consortium Kenya

Mr. Mike Brison Senior Associate, Clinton Health Access Initiative Uganda

Mr. Samburu Wa-Shiko Senior Advisor, Bill & Melinda Gates Foundation Kenya

Dr. Subroto Mukhrjee East Africa Regional Mission, USAID Kenya

Dr. Mike McQuestion SIF Program Director, Sabin United States

Dr. Clifford Kamara Senior Program Officer, Sabin/SIF Sierra Leone

Ms. Dana Silver Program Officer, Sabin/SIF United States

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Annex B: Agenda

Time Presentation Presenters Location/Notes

8:00-8:10 Registration

Plenary 8:10-8:20 Welcome & Workshop Objectives Sabin

8:20-8:50 Introductory Presentations WHO/UNICEF/Gavi/BMGF

Theme I: Domestic Financing Arrangements

8:50-9:05 Overview of public and private immunization financing arrangements

Sabin

Plenary 9:05-9:35 Domestic financing arrangements in Anglophone

African subregion National delegations

9:35-10:25 Discussion and small group work instructions (first round)

Sabin

10:25-11:55 First Round Small Groups: Developing & evaluating public immunization financing arrangements

Three small groups Separate rooms

11:15-11:30 Coffee Break

11:55-13:15 Panel Presentations: Financing arrangements Country delegates Plenary

13:15-14:15 Lunch Break


14:15-14:50 Immunization budgeting and expenditure tracking: concepts and practices in SIF countries Sabin

Plenary

14:50-15:30 Budget and expenditure tracking approaches in the Anglophone African subregion

National delegations


15:40-16:40 Second Round Small Groups: Developing & evaluating budgeting and expenditure tracking approaches

Three small groups Separate rooms

16:40-17:15 Panel presentations: Budgeting and expenditure tracking practices

Country delegates Plenary

17:15 End of Day One

Day Two:

Time Presentations Presenters Location/Notes

Theme III : Legislative Process and Text Analysis

8:15-8:30 Summary of Day One Rapporteur Plenary

8:30-8:45 Overview of generic immunization-related legal provisions

Sabin

Plenary 8 :45-9:00 Overview of legislative processes Sabin

9:00-10:30 Legislative processes and provisions in the Anglophone African subregion

Country Delegates


10:45-12:00 Third Round Small Groups: Developing & evaluating legislative strategies

Three Small Groups Separate rooms

12:00-13:15 Panel presentations: Best legal provisions for the SIF/Anglophone African region


P a g e | 32

13:15-14:15 Lunch Break

Theme IV.: Financing and Budget Advocacy

14:15-14:40 Overview of financing and budget advocacy strategies in SIF program countries

Sabin

Plenary 14:40-15:30

Financing and budget advocacy approaches in the Anglophone African subregion

National delegations

15:30-16:00 Discussion All delegates


16:15-17:00 Country delegation meetings to prepare for peer review presentations


17:00 End of Day Two

Day Three:

Time Presentation Presenters Location/Notes

Peer Review: Innovations in Sustainable Immunization Financing

8:30-8:50 Peer review instructions and demonstration Sabin Plenary (note: use Peer Reviewer Packet)

8:50-9:35 Peer review, part I: (Group A) Country delegates

9:35-10:10 Peer review, part II: (Group B) Country delegates

Way Forward


10:25-10:45 Country action plan Panel 1: Financing strategies Country delegates

Plenary 10:45-11:05

Country action plan Panel 2: Resource tracking strategies

Country delegates

11:05-11:25 Country action plan Panel 3: Local advocacy strategies Country delegates

11:25-11:45 Country action plan Panel 4: Legislative strategies Country delegates


11:45-12:00 Workshop evaluations Country delegates Plenary

12:00-12:30 Closing words Sabin, country delegates

12:30 End of workshop

P a g e | 33

Annex C: Nigeria Legislation Process Case Study

Dr. Ben Anyene’s Presentation on Nigerian Legislation Enactment Process

Dr. Anyene explained that bringing Nigeria’s new health law required bringing together a critical mass of

change agents from both the public and private sectors. When Dr. Anyene was asked to chair the

technical committee, he chose 30 people to form that critical mass. Among these were not only health

professionals but also lawyers and others engaged and informed about public health matters. They began

their work in 2002, spending three weeks together in Abuja where they analyzed problems faced by the

health sector and reviewed laws that dated back to the 1920s (colonial period).

The group soon realized that when Nigeria became a republic in 1999, its new Constitution contained no

health care provisions. Starting from scratch, Dr. Anyene brought in expert consultants and divided the

team into separate groups focusing on policy and service delivery. The teams traveled outside Nigeria to

examine more comprehensive systems. The policy group went to Ghana and the service delivery group to

South Africa. The policy group found that Ghana’s policy and planning processes start at the facility-level

rather than operating top-down. Ghana disburses funds quarterly, and all levels of workers understand the

ministry’s budgetary policies and regulations.

Dr. Anyene asked the team to develop a plan that would align with Nigeria’s four-year electoral cycle.

They began by revising Nigeria’s National Health Policy. They undertook large-scale consultations and

stakeholder analyses, recognizing that any significant changes would need to be widely supported and

owned all citizens. This led to the formation of a National Health Council in 2004. The team then focused

its work on drafting the National Health Bill.

A three-person committee was put together to provide a constitutional basis for the law. After a study tour

of Brazil and Malaysia, the basis was worked out and the team produced the first draft of the Bill in 2004.

With the agreement of with the Health Minister and National Health Council, 400 copies of the bill were

printed and given to team members to be distributed to the states for state authorities to review and

provide their input. That plan was blocked, however, by the Ministry of Health directors, who had not yet

seen the Bill. The 400 copies were brought back to Abuja. The team also realized that Parliament also had

to buy in. Eventually these steps were followed. The Bill was reviewed by the MOH directors and

circulated to the states for their input. The team incorporated the subsequent revisions and returned the

revised Bill to the National Health Council, which sent the provisional draft it on to the government for

further action.

Nigeria’s two parliamentary houses must agree in order to pass any law, so the team organized a 2005

retreat for MPs to analyze the Bill. While there was initial enthusiasm, the MPs directed the team to

further revise the Bill to add more state-focused provisions. The work continued. Following the 2007

elections, Dr. Anyene and his team reviewed their advocacy plan. The team was expanded to a health

sector reform coalition. There was some opposition. In 2010, the team organized meetings of health

professionals and religious leaders in order to garner further support for the Bill. Influential outside

figures, including Hillary Clinton, Bill Gates, and British Prime Minister Gordon Brown relayed their

support for the Bill to the President.

The National Assembly ultimately passed the Bill and the President eventually signed it. The Bill

guarantees public health funding through a system of national health accounts. The team is now working

on its implementation. Since some clauses are difficult to implement, a technical working group is

identifying the “low-hanging fruit”—the provisions to be implemented first, which include quality

assurance and financing of basic health services. However, the Bill has yet to be gazetted. While the MoH

P a g e | 34

is not concerned with this step, some CSO groups are. Gazetting was expected to occur in November

2015. It is a necessary step before the Bill can be implemented.

Reflecting on the Nigerian experience, Dr. Anyene commented that successful advocacy encompasses

deep knowledge, willingness to speak to powerful groups and constant and continuous stakeholder

engagement. The environment is constantly changing so adjustments to the advocacy plan must often be

made. Advocacy does not end when the objective is achieved. Now that the Bill has been passed,

Nigerians must be brought together to see it is properly implemented. There must be more money in the

2016 health budget to implement it. For other countries attempting to pass immunization legislation, Dr.

Anyene advised first creating a reform environment within the health sector. To do this, his team had to

invest effort at the lowest levels of the health system; it was insufficient just to work at the national level.

P a g e | 35

Annex D: Small Group Results

Theme I: Domestic financing arrangements

Group B (Rapporteur: Hon. Chukwuemeka Ujam)

Group Members: Hon. Joseph, Hon. Sesay, Ms. Onwuka, Hon. Ujam, Dr. Olubajo

The group decided that the most important action for immunization financing needs to be taken

by the executive branch of government. Governments can immediately act by:

Pushing parliaments to provide more active oversight

Finding ways to increase fiscal space

Reducing cash hoarding (ie, disburse approved budgets in timely fashion)

Ensure immunization budget line items are visible to MPs, others

The group also identified a need for domestic private sectors to participate in immunization

financing. This includes creating new public-private partnerships and engaging philanthropists,

foundations and NGOs.

PPP example from Nigeria: Local vaccine production

Thirdly, the group called for up-to-date vaccine legislation. MPs are particularly poised to act in

the legislative sphere as doing so increases their visibility, ergo their electability.

A brief Q&A followed the plenary discussion.

Regarding legislation, “You can’t give what you don’t have”, commented one delegate.

New revenue sources are needed. The case of Sierra Leone was described where the

government levies a tax of 500,000 Leones (US$0.50) on every barrel of oil imported and

uses it for the national road maintenance fund. An analogous tax and ring-fenced fund is

needed for immunization.

Countries are generally failing to make strong immunization investment cases, delegates

agreed. More advocacy is needed, across the sociopolitical spectrum.

Group A (Rapporteur: Dominic Mutie)

Group Members: Ms. Peters, Mr. Magona, Hon. Haatehn, Mr. Alpha, Ms. Wanyeki, Dr. Mutie

This group generated five points they considered most salient for sustainable immunization

financing:

Stepped up advocacy efforts are sorely needed

Budget line items for immunization need to be made clear to stakeholders and decision

makers

P a g e | 36

Country ownership is so far not in sight for most countries

Governments must be held accountable for immunization financing; government

commitment to cost sharing and matching funds is crucial for long-term strategy

Political decision makers are not now motivated to act

Group A members also called for measuring and communicating the cost effectiveness of

vaccines to high-level decision makers.

In the Q&A that followed, delegates returned to the need for legislation assuring sustainable

(public) financing for immunization. Delegates urged each country to develop specific new tax

proposals (including “sin” taxes on tobacco and liquor), following the road maintenance models

described earlier in Sierra Leone and Kenya. A third theme was information. Without accurate

financial data, advocacy often falls flat.

Group C (Rapporteur: Isha Kamara, Chris Malala)

Group Members: Dr. Luzze, Dr. Anyene, Mr. Malala, Mr. Onabajo, Ms. Kamara

The topics selected as highest priority by this group included:

Need to know immunization costs, county by county

Immunization trust funds

Government budget line items for immunization

Resource mapping, county by county

Need to increase both government and private domestic sector financing

How to engage the private sector

Delegates considered the above topics to be interrelated. The example of Nigeria was discussed.

A sequential approach to country ownership in Nigeria would be to first map domestic resources,

then develop a local vaccine production scheme, then develop and carry out suitable advocacy

strategies aimed at increasing the overall national immunization investment.

Reflecting on Kenya, delegates agreed the strategy should first be to get each county to establish

an immunization budget line item. Other financing objectives can follow. The two recent

stakeholder forum meetings revealed how far the country is from that point. The most important

thing accomplished in those workshops, commented Dr. Mutie, was to begin establishing trust

between federal and county counterparts.

All countries are interested in exploring immunization trust funds. Delegates are aware of their

complexity and chequered history- many have failed (including two recently in Kenya).

Engaging the private sector will increase financial accountability and therefore the probability of

success.

What if the external partners were to leave tomorrow, asked one delegate. What would we do?

Nigeria was considered fortunate in this regard because the National Health Act clearly spells out

the government’s public financing responsibilities. Kenyan delegates said they would keep

P a g e | 37

bringing together federal and county counterparts and try to develop "air tight" governance

structures which would assure proper immunization financing.


Group C (Rapporteur: Mustapha Alpha)

Group Members: Mr. Malala, Mr. Alpha, Ms. Kamara, Ms. Peters

Five key budget and resource tracking problems were identified by this group:

Adequate tools are unavailable

Data are missing; performance and financial data are not cross analyzed

Human resources, other shared costs are missed

Delayed budget disbursements

Little or delayed feedback on immunization expenditures to those who report

Two root causes of these problems were identified: various external partners operating

independently in the countries, and generally low levels of financial management expertise.

This group compared and contrasted budget and resource tracking issues country by country. The

case of Kenya, where sudden devolution has totally disrupted previous budget and financial

management systems, is particularly dramatic. Counties are now essentially doing their own

thing- not accounting for expenditures in a standard way and not reporting them to the national

level. Counties receive pooled federal transfers determined by a formula developed by

Parliament. They do what they wish with these unrestricted funds. Misspending is frequently

uncovered. Only the governors and county assemblies have the power to remedy the situation.

Liberian delegates reported a similar result.

Kenya is currently using Gavi HSS funds to sensitize county authorities to immunization issues

and to strengthen their technical capacities. There have been some improvements noted since

2013. County-level advocacy has led to better accountability overall. Lowest performing

counties and districts are being targeted. Health workers are being trained to do advocacy work

with CSOs,. Religious and elected leaders.

No countries report feeding back expenditure reports to subnational counterparts. Kenya and

Liberia feed back just vaccine coverage reports.

In Sierra Leone, budget and resource tracking suffer because no one is assigned at department

level to do these tasks. Until 2008, Sierra Leone had a bottom-up planning system which

incorporated resource tracking. Provinces, for example, regularly reported external partner inputs

for immunization and other phc services. This capacity was lost when the health sector was

devolved. All funds and financial reporting now go through the Ministry of Local Government to

district development committees. Like Kenya, advocacy capacity building is underway in lowest

performing districts. One strategy is to enlist local CSOs and NGOs as monitoring agents who

P a g e | 38

can manage public funds and document where they are going. If no such monitoring agent can be

found in a given area, the health system does not operate there.

The group also talked about the human resource needs, which are often underestimated and

therefore improperly budgeted. The needs should be identified and evaluated so that full capacity

needs can be met.

Group C felt that peer-to-peer learning would be helpful in approaching these various problems.

Group B (Rapporteur: Sharon Wanyeki)

Group Members: Hon. Ujam, Hon. Haatehn, Mr. Magona, Ms. Wanyeki, Dr. Anyene

This group identified three overarching budget and resource tracking problems:

Off-budget resources

Poor financial data collection and reporting

Inadequate tools and techniques at operational levels

Members called for remedial action in three key areas:

Improving financial data quality

Innovative resource mobilization efforts at subnational levels

Joint expenditure and service delivery tracking at facility level

Group A (Rapporteur: Olalekan Olubajo)

Group Members: Hon. Joseph, Dr. Luzze, Hon. Sesay, Dr. Olubajo, Mr. Onabajo

Members of this group considered the SIF budget flow analysis tool. All stated they did not to

understand it and that they had never used it.

The group recommended inter-country peer reviews as a capacity building method in this area of

budgeting and resource tracking. The aim would be to set into motion bottom-up learning

processes. The group also suggested Parliamentarians take field visits to assess immunization

situations, and subsequently increase their understanding of appropriations.

A tool is needed to monitor budget disbursements, members generally agreed. It would be used

to keep parliaments informed and by MPs to pressure the government to eliminate disbursement

delays for immunization. Such a system assumes immunization expenditures can be tracked in

unitary fashion. A single immunization accounting system is ultimately needed.

A fourth topic discussed was how to control external partner expenditures for immunization. The

partner areas of operation can be mapped. Particular partners can be assigned to work in specific

geographic areas. They should be obliged to report their expenditures regularly to the

government.

P a g e | 39

Theme III: Legislation

Group A (Rapporteur: Hon. Saah Joseph)

Group Members: Hon. Joseph, Mr. Magona, Mr. Alpha, Dr. Anyene, Mr. Malala

This group elaborated five topics:

Ensuring stakeholder buy-in

Legislative specificity

Contending with high turnover, especially in Parliament and EPI

Keeping MPs informed

Developing strategic, non-state champions

The group considered the case of Liberia where, with parliamentary support, the EPI team saw

its annual budget grow from US$50k to over $500k. The investment case was effectively made

all around. Developing new immunization legislation appears to be more complex.

In a follow-up Q&A, one delegate stated that finding the domestic financial resources is the root

problem. Poor countries won’t pass laws obliging themselves to finance immunization or

anything else unless the revenues are visible.

Given Nigeria’s experience, perhaps the legislative projects need support from the outside,

ventured another. One idea would be to create a new NGO and staff it with experienced,

motivated former MPs and government officials who want to see the law passed.

The group further discussed the importance of finding the right champions and providing the

institutional support and outside network to sustain their involvement and ensure their success.

Group B (Rapporteur: Olalekan Olubajo)

Group Members: Ms. Onwuka, Hon. Naatehn, Ms. Wanyeki, Ms. Kamara, Dr. Olubajo, Dr.

Maree

The group saw legislative projects beginning with a champion who can clearly conceptualize the

final intended result and build a critical mass to support it. Stakeholders need to be mapped out

and brought into the process, with the draft legislation circulated among the various groups to

ensure their support. Thirdly, the group agreed, a rigorous immunization bill must have a

financial provision. A specific legislation drafting team is helpful in speeding up processes.

Group C (Rapporteur: Hon. Chukwuemeka Ujam)

Group Members: Hon. Sesay, Hon. Ujam, Mr. Onabajo, Dr. Mutie, Ms. Peters, Dr. Luzze

The group discussed the importance of a bottom-up approach where the people affected by the

legislation are involved in its creation. The ministry of health, felt Group C, must lead the

legislative project, rather than a political group. The crucial step comes when the minister of

P a g e | 40

health has to convince the cabinet of ministers that the legislation will be beneficial. It is helpful

if CSOs and faith based organizations back the legislation at this point.

On the political side, the ruling party stands to gain electorally by supporting the bill. Some in

the group posed a different, people-power scenario. Again the case of Nigeria was invoked,

where an organization of market women emerged as a powerful supporter of the National Health

Act.

P a g e | 41

Annex E: Peer Review Guide

Description

Since 2009, the Sabin Sustainable Immunization Financing (SIF) Program has been working with African

and Asian countries to develop and refine institutional innovations-new ways of working, new practices-

that contribute to financially sustainable immunization programs. In today’s peer review session,

delegates will present their practices (case studies) in three broad areas:

finance, budget and resource tracking

immunization-related legislative projects

local advocacy strategies

This checklist was prepared to help you perform this peer review.

The focus is on state institutions, i.e., government agencies and elected bodies, whose responsibilities

include the financing, budget execution, legislation and oversight of public immunization services. The

institutions may operate at national level, sub-national level or both.

We wish to understand how the innovative activity or strategy began. Was it proposed by an individual in

a particular institution? Was it proposed by a group of champions, perhaps representing two or more

institutions?

A successful innovation is one that has passed from being new to having been institutionalized- it has

become routine. Perhaps the innovation you evaluate is still developing. Many, perhaps most, innovations

ultimately fail. The ideas behind it may not have been well adapted to the local context or not thought

through well enough. There could have been resistance to it. Perhaps key people changed positions and

support for the innovation was lost. Other background factors might have changed such that the

innovation lost relevance. It is important to assess these innovations and whether or not they succeeded.

Methods

The peer review will take place in two consecutive 30-minute sessions. In the first session, reviewers will

assess the countries in “Group A”. In the second session “Group B” countries will be assessed.

Group A includes: Sierra Leone, Liberia, Nigeria.

Group B includes: Kenya, Uganda.

Each peer reviewer is asked to prepare up to four assessments- one per country excepting his or her own.

The goal is to generate as many individual assessments per country as possible.

All assessments will be anonymous.

Information for the peer assessments will be obtained through discussion with the country delegates. Each

reviewer should interview two or three delegates from each country being reviewed.

Conversations must be kept short. Ten minutes have been allotted for each assessment.

P a g e | 42

SABIN SUSTAINABLE IMMUNIZATION FINANCING PEER REVIEW GUIDE

******************************************************************************

Reviewer’s country: _______________________________________________

Reviewer’s home institution (check one):

___Min health ___Min finance ___parliament ___other (specify:

___________________)

___Partner agency counterpart

Country studied: ___________________________________________

******************************************************************************

Classify the innovative activity or strategy by functional area (check one or more):

____ financing ___ budget, resource tracking ___ legislation ___advocacy activity

___other (specify: ________________________________________________________)

Is the activity/strategy already happening or still aspirational (check one)

___existing ___aspirational ___unclear (specify why:

________________________________)

Describe the innovative activity/strategy. What problem or opportunity does it address?

Do you think a different practice or approach would have better addressed the issue at hand? If

so, please describe it.

When- how long ago- did the innovation begin (check one)?

___three or more years ago ___past 1-2 years ___this year

How did the innovation begin (check one)?

___ Top -> down ___ Bottom -> up ___ Outside third party introduced it

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On which level of governance did the innovation originate (check one)?

_____ regional or sub-regional multiple countries)

___ national ___sub-national ___ both levels together

Which institutions are or were involved in developing the innovation (check one or more)?

Government

___ ministry of health ___ ministry of finance ___ elected body

___ other government ministry or agency (identify:

___________________________________)

Non-government

___ community service organization (identify:

____________________________________)

___ domestic business sector (identify: ______________________________________)

___ other (identify: ______________________________________)

At this point, how advanced is the innovation (check one)?

___ aspirational: people are just talking about it

___ the new practice(s) is (are) now being tried

___the new practice(s) is (are) becoming institutionalized

___the new practice(s) is (are) fully institutionalized

___ the innovation is being blocked

What feedback and recommendations do you wish to convey to these delegates about this

particular innovation? (continue writing on back of page if needed)

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On a scale of one to five, with 1 being no chance and 5 being almost certain, please answer the

following questions. Circle one response per item.

Item

1 2 3 4 5 No chance Not likely Unsure Likely Almost certain

The innovation is well conceptualized. The proposed solution matches the problem or opportunity it addresses.

1 2 3 4 5

Another approach would have been more suitable for solving the problem/improving the sustainability of the immunization program.

1 2 3 4 5

The right mix of institutions is or was involved in developing the innovation.

1 2 3 4 5

There is or was a lot of resistance to this innovation.

1 2 3 4 5

This innovation is or was carried out without incurring significant new costs.

1 2 3 4 5

The innovation will help the country reach sustainable immunization financing sooner.

1 2 3 4 5

The innovation will ultimately be institutionalized nationwide.

1 2 3 4 5

If successful, the innovation will increase country ownership of the immunization program.

1 2 3 4 5

Considering all the factors, how likely is the innovation to succeed, to become institutionalized?

1 2 3 4 5

This innovation would likely succeed in your own country.

1 2 3 4 5

List below and briefly describe any other innovations you observed in this country.

THANK YOU FOR YOUR CONTRIBUTIONS! THE SABIN SIF TEAM WILL ANALYZE

AND DISTRIBUTE THESE RESULTS TO ALL PARTICIPANTS.

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Annex F: Country action points

Functional Area Kenya Liberia Nigeria Sierra Leone Uganda

Financing arrangements

*Joint

executive-

legislative

retreat

*Public-

private

immunization

trust fund

Budget/Resource tracking

*Translate

immunization

budgeting,

planning,

reporting

methods to

county level

*Provide

immunization

expenditure

reports to

counties

*Correct past,

improve future

JRF financial

reporting

*accountability

framework at

delivery level

*Resource

tracking

capacity

building

*Immunization

resource

utilization and

reporting

community of

practice

*improved

budget

allocation tools

Legislation

*Push

legislation to

secure

immunization

financing

within

devolution

process

*Revise

pending bill by

July 2016

*Step up

gazetting of

National

Health Act

*Multiple

agencies draft

bill

*Alternative

communication

modalities

between

government,

parliament

Local advocacy

*Communicate

with Council

of Governors

on

immunization

financing

issues

*Identify new

cadre of MP

champions

*Meet Gavi

co-financing

requirements

*Multi-media

county-level

advocacy

*MoH public

relations

training

*Convene

stakeholder

meetings

*Update public

communication

strategy

Other

*Stabilize

vaccine

procurement,

distribution at

federal, county

levels

*Establish,

maintain direct

communication,

both Houses of

Congress, MoH

EPI team

*Explore local

vaccine

production

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Annex G: Workshop Evaluation

Thirteen delegates completed an anonymous workshop evaluation form. The form asked the

respondents to indicate which objectives motivated their participation, and whether the workshop

satisfied these objectives. On a scale from 1-5, the peers specified to what extent they agree or

disagree with the following statements:

(a) the workshop accomplished its objectives

(b) the event was well organized and planned

(c) the material and discussions will promote sustainable immunization financing among the

countries

(d) the material was clear and pertinent

(e) the respondent would recommend such a workshop to others

(f) the workshop will help the respondent with his/her own work

The respondents then had the opportunity to elaborate upon each of these answers in the

comments section that followed. Finally, the delegates issued their recommendations for

improvement for future workshops.

In 91% of answered statements, the respondents agreed or strongly agreed with the above six

statements. Out of the seventy-eight possible statements, one was skipped (1/78; 1%). Seven

received a “3/uncertain” or “2/disagree” (7/77; 9%). The remaining seventy statements received

a “4/agree” or “5/strongly agree” (70/77; 91%).

The peers’ comments were informative.

Many delegates agreed that it was the exposure to other countries’ practices that would help

them reach sustainable immunization financing in their respective countries.

Following the workshop, all respondents voiced their commitment to advance legislative,

advocacy, resource tracking, and financing projects forward in their countries.

The respondents unanimously divulged that they would present the lessons learned from the

workshop to their home institutions.

Finally, the peers issued the following recommendations to the SIF team:

1. Invite more parliamentarians and stakeholders from all government ministries.

2. Accommodate even more host country participants.

3. Invite more participants. Clerks of parliamentary health committees will be helpful in

preparing and compiling the report. Also, they will maintain the institutional memory.

4. Increase the duration of the workshop to five days.

P a g e | 47

5. I think Sabin is doing well, and pray & hope that more and more of such workshops

occur.

6. Please allow more legislative representatives to attend, especially from countries that

have not passed a[n immunization-related] bill. Please organize work between legislators

and EPI.

7. Great facilitation; more time for parliamentarian mobilization in future.

8. Similar workshops among peer groups should be held to allow for exchanges of learnt

lessons.

9. Consider one or two more participants, resources permitting, for successful country

participation.

10. Track activities and outcomes in the various countries. Ensure more MPs participate in

subsequent workshops.

11. Generally this workshop has been successful: there was the right number of participants

& participatory approaches, and nice accommodation & meals. Keep it up.

anglophone africa peer review workshop on sustainable ... · were ranked in terms of perceived...

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