assessment of immunization systems in select gavi...

ASSESSMENT OF IMMUNIZATION SYSTEMS IN SELECT GAVI COUNTRIES

UNIVER SITY O F WASHI N GT ON GLOBAL HEALTH S T ART PROGR AM REPORT TO THE B ILL A ND MEL INDA G ATE S FOU NDAT ION

MAY 31 2012

PRODUCE D BY : M ATHE SON, A, COLL IER , K , M ANHART, LE , WA L SO N, JL , LEV INE, G , H AWE S, S

Produced by UW GH START Program, May 2012 1

PURPOSE

This document is in response to the work order “Assessment of Immunization Systems in select GAVI

countries”, received by the University of Washington’s Strategic Analysis, Research, and Training (START)

team in the week of March 17.

The information below is the final compilation of relevant material located about the state of routine

immunization in Uganda, the Democratic Republic of the Congo, and Mozambique. Supporting figures

are located in three accompanying spreadsheets.

UGANDA Produced by UW GH START Program, May 2012 2

UGANDA

A. POLITICAL COMMITMENT

i. Timeline of vaccine introductions since 1990 and current vaccination schedule

TABLE 1: UGANDA VACCINE SCHEDULE AND TIMELINE OF INTRODUCTION

Vaccine Vaccine in schedule (as of 31 Dec 2010)

Year of introduction in entire country

Year of introduction in part of the country

HepB birth dose (in 2010)

Birth Dose offered to all children

Year of introduction of birth dose

BCG Yes <1990*

DTP** Yes <1990*

HepB** Yes 2002 No n/a n/a

Hib** Yes 2002

HPV Yes(P) n/a 2008

MCV Yes <1990*

OPV Yes <1990*

PCV No 2013

TT (pab) Yes <1990*

Vitamin A Yes ? * Date obtained from earliest reported coverage estimates

** Vaccine included in the DTwPHibHep pentavalent vaccine that was introduced in 2002

In addition to the 2013 introduction of PCV, Uganda is expected to introduce the rotavirus vaccine in

2015. (HPV Information Center)

Sources Vaccine schedule: WHO Vaccine Preventable Diseases Monitoring System

(http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileselect.cfm)

Vaccine introduction: WHO (http://www.who.int/entity/immunization_monitoring/data/year_vaccine_introduction.xls) (unless

noted)

HPV Information Center: WHO (http://apps.who.int/hpvcentre/statistics/dynamic/ico/SummaryReportsSelect.cfm)

ii. Percent of districts that have <50% coverage, 50-79% coverage and ≥80% coverage

Data not available for 2010 from WHO summary. However, 2009 data for DTP3 are below. (UNICEF

2012)

TABLE 2: UGANDA DPT3 COVERAGE BY DISTRICTS

Coverage level Proportion districts

< 50% 4%

50–79% 38%

≥ 80% 59%

Not reported 0%

http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileselect.cfm

http://www.who.int/entity/immunization_monitoring/data/year_vaccine_introduction.xls

http://apps.who.int/hpvcentre/statistics/dynamic/ico/SummaryReportsSelect.cfm


The 2006 DHS also reported sub-national coverage information for several vaccines. Data on DTP3 are

presented below. (Uganda Bureau of Statistics 2007)

FIGURE 1: UGANDA DTP3 COVERAGE BY AREA

Sources UNICEF. (2012). Immunization Summary. Geneva: WHO/UNICEF. Accessed April 3, 2012 from

http://www.childinfo.org/files/immunization_summary_en.pdf

Uganda Bureau of Statistics (2007). Uganda Demographic and Health Survey 2006. Kampala: Uganda Bureau of Statistics



iii. Summary of major immunization-related legislation

In late 2010, Sabin commissioned a study of Uganda’s existing health legislation with a focus on

immunization. Among the findings were these:

The Constitution of Uganda lacks a substantive provision on the right to health generally but

makes mention of the right under directive principles of government policy. Parliament has the

mandate to make laws to operationalize that constitutional right.

The Public Health Act 1935 (Ch 281) identifies notifiable diseases, outlines the government’s

epidemic control responsibilities, empowers the government to require certain vaccinations and

identifies vaccination as a requirement for school entry.

The Local Government Act (Ch 243) gives powers to the local governments to carry out

immunization and other public health functions and to pass laws, bylaws and local ordinances

on immunization provided they are compatible with federal laws.

There are no bills specific to immunization approved by or introduced to Parliament.

Sources Sabin Institute. (2011). Sustainable Immunization Financing — Uganda Country Summary. Accessed April 3, 2012

from http://www.sabin.org/files/Uganda_mm.pdf

iv. Summary of multi-year plan for immunization and annual work plan for immunization activities for recent years

The plan aims to address the stagnation in performance that occurred between 2007 and 2009. Priority

areas are as follows:

Focus on the district level to improve routine immunization and surveillance performance

Strengthen logistics at all levels

Introduce pneumococcal and rotavirus vaccines

Strengthen capacity of mid-level managers, operational level health workers and pre service

trainees to deliver quality EPI services

Advocate for sustainable financing of the program; achieve and maintain polio free status,

neonatal tetanus elimination and pre-elimination measles targets

Sources Republic of Uganda. (Revised April 2011). Uganda National Expanded Programme on Immunization Multi Year Plan

2010–2014

v. Definition of routine immunization

There does not appear to be a consistently used, formal definition of routine immunization in Uganda.

However, the cMYP draws a distinction between routine immunization and supplemental activities for

polio, tetanus, and measles.

http://www.sabin.org/files/Uganda_mm.pdf


vi. Budget making and other political considerations

Uganda operates under a parliamentary system with a unicameral legislature. A 19-year ban on multi-

party politics was rescinded in 2005 by national referendum. Presidential and legislative elections are

held every five years (the last being 2011). The current president, Yoweri Museveni, has been in power

since 1986 and his political party, the National Resistance Movement, gained majorities in the previous

two elections. We were able to identify three recent ministers of health:

Dr. Christine Ondoa (May 27, 2011–present)

Dr. Stephen Malinga (2006–May 27,2011)

Dr. Jim Muhwezi (2001–2006)

Jim Muhwezi was the minister when the Global Fund suspended disbursements in 2005 due to

misappropriation of funds and was also implicated in mismanagement of GAVI funds. (Njoroge, 2010)

During late 2007 and into 2008, Dr. Malinga was reported to be at odds with his deputy, state minister

for primary healthcare Dr. Emmanuel Otaala. This led to internal conflict within the Ministry of Health,

which had a flow on effect on the immunization program (though it was not clear how). (Sources:

Obore, n.d.; Obore, 2007)

The Ugandan budgeting process takes place at the national, sectorial and local levels. Each level

prepares what is termed a Budget Framework Paper (BFP), which lays out expected expenditure for the

next three years (they are updated annually on a rolling basis). The BFPs forms the basis for consultation

and coordination between each level. Ultimately, the BFPs are compiled into a national document that is

approved by the cabinet. (The Global Mechanism, 2008)

Sources Njoroge, J. (2010, June 6). Uganda: Muhwezi, Mukula And Group Face Anti-Corruption Court. The Independent (Kampala).

Accessed May 15, 2012 from http://allafrica.com/stories/201006090795.html

Obore, C. (n.d.) Uganda Ministry of Health Scandals, UNICEF Withdraws $$ [Web log comment]. Accessed May 14, 2012 from

http://protectafrica.wordpress.com/about/ug-ministry-of-health-scandals-unicef-withdraws-money/

Obore, C. (2007, November 3). Ministers fight at meeting. Sunday Monitor. Accessed May 15, 2012 from

http://www.connectuganda.com/forum/broken-news/4369-ministers-fight-at-meeting

The Global Mechanism of the UNCCD. (2008). Budget processes and financing instruments in Uganda. The Global Mechanism:

Rome. Accessed May 15, 2012 from http://www.global-mechanism.org/en/GM-Publications/GM-Publications/Budget-

processes-and-financing-instruments-in-Uganda/Download

http://allafrica.com/stories/201006090795.html

http://protectafrica.wordpress.com/about/ug-ministry-of-health-scandals-unicef-withdraws-money/

http://www.connectuganda.com/forum/broken-news/4369-ministers-fight-at-meeting

http://www.global-mechanism.org/en/GM-Publications/GM-Publications/Budget-processes-and-financing-instruments-in-Uganda/Download

http://www.global-mechanism.org/en/GM-Publications/GM-Publications/Budget-processes-and-financing-instruments-in-Uganda/Download


B. FINANCING AND PRICING

i. Country health expenditure, by source from 1990-2010

Total Health Expenditure data:

Uganda allocated 10 percent of total recurrent government expenditure to health in 2007

In 2011 the level of funding for health was US$10.40 per capita (government and donor funds

pooled together)

▫ This translates to about $340,184,000 in total health funding, given the WHO 2009

population estimate of 32,710,000

▫ Total health expenditure of $10.40 per capita is below the $34 per capita WHO

recommends for developing countries

Government funding for immunization was inconsistent and trended downward over past decade:

Immunization spending by government has been inconsistent over the past decade, increasing

dramatically from 2001 to 2004 and then dropping again in 2007-2009 due to interruptions in

federal government funding disbursement (figure 2)

Uganda government funded 13 percent of Routine Immunization in 2009, down from 17 percent

in 2008

FIGURE 2: IMMUNIZATION SPENDING FINANCED BY GOVERNMENT OF UGANDA

*No same source data available on 2003, 2005, 2006


FIGURE 3: ROUTINE IMMUNIZATION SPENDING IN UGANDA BY SOURCE COMPARED AGAINST BIRTH COHORT AND

FUNDING PROJECTIONS




Republic of Uganda. (Revised April 2011). Uganda National Expanded Programme on Immunization Multi Year Plan 2010–2014

Republic of Uganda. (Revised August 2006). Uganda National Expanded Programme on Immunization Multi Year Plan 2006-

2010

Sabin Institute. (2011). Sustainable Immunization Financing Uganda Country Summary. Accessed April 3, 2012 from


ii. Percent of government health expenditure allocated to vaccines, portion of that allocated to RI

In 2008, vaccines represented 65 percent of EPI program costs (new and underused vaccines)

Overall budget expenditures for immunization increased 74 percent (all sources combined) from

2012 to 2013

▫ Major spending increases in personnel, new vaccines

▫ Increase likely due to introduction of PCV in 2013

TABLE 3: OVERALL BUDGETED EXPENDITURES FOR IMMUNISATION IN UGANDA FROM ALL SOURCES (GOVT &

DONORS) IN US$

*Traditional Vaccines: BCG, DTP, OPV (or IPV), Measles 1st dose (or the combined MR, MMR), TT. HepB and Hib vaccines also in

this row if these vaccines were introduced without GAVI support

Expenditure by CategoryBudgeted Year

2012

Budgeted Year

2013

Traditional Vaccines* 2,888,601$ 3,247,478$

New Vaccines 30,597,694$

Injection supplies with AD

syringes1,183,393$ 1,868,630$

Injection supply with syringes

other than Ads

Cold Chain equipment 60,780$ 111,918$

Personnel 6,276,248$

Other operational costs 15,873,295$ 11,890,327$

Supplemental Immunisation

Activities5,377,309$

Under used vaccines 17,271,533$ 20,065,307$

Total Expenditures for

Immunisation42,654,911$ 74,057,602$




Sources Government of Uganda. (Submitted June 2011). GAVI Alliance Annual Progress Report 2010. GAVI Alliance. Accessed April 13,

2012 from http://www.gavialliance.org/results/gavi-progress-reports/

iii. Spending focus, by donor in country

Spending by donor source:

Government: vaccines, injection supplies, personnel, transport, other recurrent costs

Donors: vaccines, injection supplies, training, monitoring and surveillance, all capital equipment

(vehicles, cold chain)

Districts (via federal PHC Grant and external partner grants): finance immunization operations

Government of Uganda (GOU):

Pays 100% for BCG, OPV, Measles, TT vaccines and injection safety materials

Co-finances DPT-HepB+Hib vaccine and will co-finance Pneumococcal and rotavirus vaccine

Funds secured (based on historical funding patterns) for 2010-2014 for the following cost

categories related to polio, measles, BCG, TT: injection supplies, personnel, transport,

maintenance for vehicles, gas for the cold chain, overhead

District Level Governments:

Use Primary Health Care (PHC) conditional grants to implement EPI activities and operations

Funding for EPI Program in the baseline year and expected for 2010-2014:

64 percent of funding from GAVI for the DPT-HepB+Hib vaccine

JICA expected to fund capital costs (cold chain expansion and rehabilitation, and vehicles)

Donors include UNICEF, WHO, USAID

Sources Republic of Uganda. (Revised April 2011). Uganda National Expanded Programme on Immunization Multi Year Plan

2010–2014



iv. Current funding gaps in health system (funds available vs. budget)

Uganda EPI Multiyear Plan requires budget of US$256,913,788 over five years, 2010-2014

Expected funding gap of US$73,615,260 summed over years 2010-2014

GAVI and the Government of Uganda may provide funding for Pneumococcal vaccines which

would reduce the total gap to US$4,480,772

The majority of the funding gap is for new vaccines and injection materials, and for

supplemental immunization activities

http://www.gavialliance.org/results/gavi-progress-reports/



TABLE 4: COMPOSITION OF FUNDING GAP (IMMUNIZATION SPECIFIC ONLY) FOR UGANDA

TABLE 5: IMMUNIZATION FINANCING GAPS PER INFANT IN UGANDA

Inadequate funds for EPI routine operations:

The Government of Uganda contribution to EPI routine operations is inadequate

District level Primary Health Care (PHC) funds available for implementing EPI activities are

frequently delayed, causing delays in implementation

Few partners currently supporting EPI

Much government funding is not secured:

67 percent classified as “secure”(based on historical funding patterns)

31 percent classified as “probable”

2 percent classified as unsecured

Sources Republic of Uganda. (Revised April 2011). Uganda National Expanded Programme on Immunization Multi Year Plan 2010–2014

Country Profile: WHO Immunization Financing Uganda cMYP

(http://www.who.int/immunization_financing/countries/cmyp/uganda/en/index.html)

v. Qualitative summary of key barriers in financing and pricing at national and sub-national level

Macroeconomic challenges contribute to the shortage of funding:

38 percent of the population lives below the poverty line (down from 52 percent in 1992/93, 44

percent in 1997/98, but up from 35 percent in 2000)

The government has had difficulty mobilizing partners to contribute to health services

Compositition of the funding

gap2010 2011 2012 2013 2014

Vaccines and injection

equipment30,597,694$ 28,723,342$

Personnel 1,595,891$ 1,543,182$ 2,607,156$

Activities and other recurrent

costs674,948$ 211,270$ 2,180,704$ 1,748,936$ 1,408,305$

Logistics (Vehicles, cold chain

and other equipment)452,698$ 170,595$ 810,585$ 889,956$

Total Funding Gap 1,127,646$ 211,270$ 3,947,190$ 34,700,397$ 33,628,759$

*Shared costs not included

2007 2008 2009 2010 2011

Resource Needs per Infant $19.40 $30.00 $27.60 $13.80 $14.40

Financing per Infant $17.30 $27.80 $24.40 $10.40 $10.60

Gaps per Infant $2.10 $2.20 $3.20 $3.30 $3.80

Infants (Millions) 2.88 2.97 3.06 3.06 0.00

http://www.who.int/immunization_financing/countries/cmyp/uganda/en/index.html


Potential for additional vaccination funding if government and the health sector receive additional

resources:

Health and agriculture are priorities among unfunded priorities

Vaccines among the health sector unfunded priorities

In addition to gaps, irregular funding for immunization (EPI) is a major challenge:

Routine Immunization 2001-2002:

▫ Prior to GAVI support, in 2001, Uganda government spent US$3.0 million for routine

immunization, US$2.1 million for supplementary immunization services

▫ In 2002, government expenditures increased to $4.9 million for routine immunization, in

part because a new immunization was introduced

EPI 2004-forward

▫ 2004 (cMYP): $22 million in 2004 for routine EPI program, plus $3.6 million for shared

health services expenditures

Government covered $7.5 million of the $22 million specifically for routine EPI

▫ 2007-2009 (WHO/UNICEF Joint Reporting Form): Government spending on routine

immunization program dropped to US$2.9 million, and then $617,077 in 2008, and $3.6

million in 2009

▫ 2010-2014 (cMYP): total expenditure on routine EPI was $16.8 million in 2009 (21%

from government)


Government of Uganda. (Submitted June 2011). GAVI Alliance Annual Progress Report 2010. GAVI Alliance. Accessed April 13,

2012 from http://www.gavialliance.org/results/gavi-progress-reports/

C. SUPPLY CHAIN AND LOGISTICS

In August 2009 USAID released a logistics assessment of the Uganda National EPI. The report authors

identified several areas for improvement, but a recurring theme was inadequate reporting between

different levels of the immunization system.

Sources USAID | DELIVER PROJECT, Task Order 1. 2009. Logistics Assessment of the Uganda National Expanded Programme

on Immunization. Kampala, Uganda. USAID | DELIVER PROJECT, Task Order 1

D. HUMAN CAPACITY

i. Total est. number of providers that immunize, by provider type

Immunization services are available in 81 percent of private facilities, while 90 percent of government

facilities provide childhood immunizations. More than 70 percent of facilities in all regions provide

immunization. (SPA 2007)

During the implementation of the HSSP II the number of static service delivery points for immunization

increased from 1950 to 2100. (Uganda MoH HSSP III)



TABLE 6: PROPORTION OF FACILITIES IN UGANDA PROVIDING IMMUZIAITON

Facility type (N=491) Prop. providing

immunization*

Number of facilities

nationwide

Estimated no. providing

immunization

Hospital 98% 108 106

Health center-IV 100% 160 160

Health center-III 96% 873 838

Health center-II 82% 1,593 1,306

Total 88% 2,734 2,410

* Defined as offering child immunization services and storing vaccines

Sources Ministry of Health [Uganda], Uganda Bureau of Statistics, and Macro International Inc. (2007). Uganda Service Provision

Assessment Survey 2007: Key Findings on Family Planning, Maternal and Child Health, and Malaria. Kampala, Uganda:

Ministry of Health [Uganda] and Macro International, Inc.

Ministry of Health [Uganda]. (2010). Health Sector Strategic Plan III 2010/11–2014/15. Kampala, Uganda: Ministry of Health

[Uganda]. Accessed April 12, 2012 from

http://www.kampala.cooperazione.esteri.it/utlkampala/Download/HSSIP%20Final.pdf

Unknown author. (2005). Health System Profile for Uganda. Accessed April 10, 2012 from

http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2835&ei=dAWHT7TAM-

rjiAKykaDfDw&usg=AFQjCNFFP8HT_nk97BWpJLNuHypX1hIh9Q&cad=rja

ii. Profiles of providers who immunize people

No data identified.

E. PERFORMANCE MANAGEMENT AND TRAINING

i. Immunization responsibilities at the federal, state, district, village levels and ratios (number of HCWs per supervisor)

Ministry of Health/UNEPI is responsible for policy, standards and priority setting, capacity building,

coordinating with other stakeholders and partners, resource mobilization, procurement of inputs such

as vaccines and injection safety materials, monitoring and technical support supervision to the districts.

The districts and health sub-districts are responsible for planning, management and delivery of EPI

services through the implementation of the overall district health plan.

There were 20 EPI mid-level managers trained by 2010 and plans were in place to train 450 more by

2014. The cMYP reports that staffing norms were “available with skilled manpower at the

implementation levels (HSD)” but “not attained at national, district, and health facility levels”.

Around 84,000 people have been trained as village health team (VHT) members since the program’s

inception in 2002. However, there are no firm data on the number of current VHT members. There are

18 (23%) districts with no VHTs, but these districts have other community health workers.



http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2835&ei=dAWHT7TAM-rjiAKykaDfDw&usg=AFQjCNFFP8HT_nk97BWpJLNuHypX1hIh9Q&cad=rja



Ministry of Health [Uganda]. (2010). Health Sector Strategic Plan III 2010/11–2014/15. Kampala, Uganda: Ministry of Health

[Uganda]. Accessed April 12, 2012 from


Unknown author. (2005). Health System Profile for Uganda. Accessed April 10, 2012 from

http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2835&ei=dAWHT7TAM-

rjiAKykaDfDw&usg=AFQjCNFFP8HT_nk97BWpJLNuHypX1hIh9Q&cad=rja

Taylor, H. (2009). Situation Analysis: Village Health Teams Uganda 2009. Kampala: Ministry of Health Uganda





FIGURE 4: IMMUNIZATION SYSTEM STRUCTURE IN UGANDA WITH RATIOS OF FACILITIES TO POPULATION

TARGET RATIO: 1:1,000 /

1:25 H/holds

Actual ratio: unknown

TARGET RATIO: 1:5,000

Actual ratio: 1:14,490








ii. Percent ‘missed opportunities’ (children eligible for vaccines that come to health center but do not receive them)

No data identified.

iii. Summary of any other performance metrics captured by the MoH or other organization (e.g., no. of supervisory visits)

The 2006 DHS found a vaccination card retention rate of 63%.

TABLE 7: DPT DROPOUT RATES IN UGANDA BY YEAR

Indicator 2006 2007 2008

National DPT1-3 dropout rate 10% 10% 11.6%

Proportion of districts with DPT1-3 dropout rate ≤ 10% 33/69 (47.8%) 39/80 (48.8%) 36/80 (45.0%)

TABLE 8: VACCINE WASTAGE (%) IN UGANDA BY VACCINE AND YEAR

Vaccine 2011 2010 2009 2008 2007 2006

BCG 72 70 73

DTP 11 7 6

HepB 11 7 6

Hib 11 7 6 9 9 10

Polio 29 20 31

MCV 40 51 44 44

Tetanus 23 10

Sources Uganda Bureau of Statistics (2007). Uganda Demographic and Health Survey 2006. Kampala: Uganda Bureau of Statistics


Vaccine schedule: WHO Vaccine Preventable Diseases Monitoring System




F. COMMUNITY ENGAGEMENT

i. Distribution of health posts/health centers compared to population density

FIGURE 5: AREAS OF UGANDA WHERE THE POPULATION IS WITHIN 5KM OF A HEALTH FACILITY


FIGURE 6: AREAS OF UGANDA WITH >1,500 POPULATION THAT ARE MORE THAN 10KM FROM A HEALTHCARE

FACILITY


The figures above come from a paper that used spatial methods to assess access to healthcare facilities

in Uganda. The authors used 5x5km grids to build a picture of population density and compared that

with healthcare facility locations. Figure 5 shows areas where the entire population lives within 5km of a

healthcare facility. Figure 6 shows areas where the population of the grid square is greater than 1,500

and more than 10km from a healthcare facility (marked in yellow), overlaid on a population density

choropleth (legend not displayed, but darker = greater population density). There were no higher

resolution images available.

Sources Lwasa, S (2007). Geospatial analysis and decision support for health services planning in Uganda. Geospatial Health, 2(1):29–40.

ii. Data on demand-side reasons for un- or undervaccination

Social influences, particularly from male partners and older generations, and level of trust in

immunizations are two key sources of influence on a mother’s decision to immunize her children.

(Babirye)

One study in eastern Uganda found that infants whose mothers have a secondary education are at least

50% less likely to miss scheduled vaccinations compared to those whose mothers only had primary

education. (Nankabirwa)

A series of focus groups in Kampala and Mbarara that only included caregivers who expressed concern

about the safety of childhood vaccines found the following: (Asiimwe)

Concern about the quality of the vaccines stemmed from the memory of a series of adverse

events in the early 1990s and from the perception that an erratic power supply would

compromise vaccine quality.

There is a perception among some parents that the tetanus vaccine was intended to make

women sterile (because it was only targeted at adolescent girls).

Caretakers had suspicion about mass vaccination efforts and preferred routine immunizations.

Concerns about mass vaccinations included the following:

o Unnecessary exposure to vaccines when the child is already fully immunized

o Low skill levels of vaccinators used in mass campaigns

o The inconvenience of having a fixed time or day for vaccinations

o Caregivers do not receive immunization cards during mass vaccinations whereas they do

for routine immunizations, which causes distrust (this last concern came from the

Nuwaha paper).

Sources Babirye, J et al. (2011). More support for mothers: a qualitative study on factors affecting immunisation behaviour in Kampala,

Uganda. BMC Public Health, 11:723

Nankabirwa et al. (2010). Maternal education is associated with vaccination status of infants less than 6 months in Eastern

Uganda: a cohort study. BMC Pediatrics, 10:92

Asiimwe et al. (2006). Vaccine Safety Perceptions among Parents in Developing Countries and Influence of Adverse Events

Following Immunization (AEFI) on their Decisions to Vaccinate Children. Kampala: Uganda Ministry of Health. Accessed April

10, 2012 from http://dspace.mak.ac.ug/bitstream/123456789/710/1/Kibombo_misr_article.pdf

Nuwaha, F. et al. (2000). Causes of low attendance at National Immunization Days for polio eradication in Bushenyi District,

Uganda. Trop Med & Int. Health, 5(5): 363–9

http://dspace.mak.ac.ug/bitstream/123456789/710/1/Kibombo_misr_article.pdf


iii. Data on level of public trust

No data identified.

G. MONITORING AND USE OF DATA

i. DHS, any national surveys and WUENIC coverage levels for all available dates (DTP3, MCV, and others), with potential explanations for any changes in trends

FIGURE 7: DISPARITY IN REPORTED VACCINE COVERAGE RATES IN UGANDA, BY REPORTING AGENCY

FIGURE 8: VACCINE COVERAGE RATES IN UGANDA BY WEALTH QUINTILE

84 83

60 55 55

90.5 89.8

63.9 68.1

59.3

79 77 79

0

10

20

30

40

50

60

70

80

90

100

BCG DTP1 DTP3 MCV Pol3

Vac

cin

e co

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%)

WHO/UNICEF 2010 DHS 2006 MoH HMIS 2008

0

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20

30

40

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60

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Lowest Second Middle Fourth Highest

Vac

cin

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vera

ge (

%)

Wealth quintile

BCG

DPT3

Pol3

MCV


FIGURE 9: UGANDA DPT3 COVERAGE OVER TIME, COMPARED TO AFRICAN REGION



Uganda Bureau of Statistics (2007). Uganda Demographic and Health Survey 2006. Kampala: Uganda Bureau of Statistics


0

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20

30

40

50

60

70

80

1980 1985 1990 1995 2000 2005 2010

DTP

3 v

acci

ne

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rage

(%

)

Uganda AFR

EPI revitalization plan developed

Pentavalent vaccine introduced (with GAVI support)

Period of decentralization

GAVI funding suspended



ii. Reported measles cases compared to MCV coverage 1980-2010, with note if SIA’s occurred

FIGURE 10: REPORTED MEASLES CASES COMPARED TO MCV COVERAGE OVER TIME IN UGANDA



WHO. (2011). Reported Incidence Time Series. Geneva: WHO. Accessed April 12, 2012 from

http://www.who.int/entity/immunization_monitoring/data/incidence_series.xls

0

20

40

60

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100

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10000

20000

30000

40000

50000

600001

98

1

19

82

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Mea

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es

Measles cases MCV coverage

SIAs (year and pop. reached) 2000: 2.1M 2006: 5.2M 2001: 614K 2009: 4.9M 2003: 13.5M

Irregular and varying estimates of measles

cases



DEMOCRATIC REPUBLIC OF CONGO Produced by UW GH START Program, May 2012 22

DEMOCRATIC REPUBLIC OF CONGO (DRC)



TABLE 9: DRC VACCINE SCHEDULE AND TIMELINE OF INTRODUCTION







BCG Yes <1990*

DTP** Yes <1990*


Hib** Yes 2009

MCV Yes <1990*

OPV Yes <1990*

PCV No n/a 2011

Rotavirus No 2013

TT (pab) Yes <1990*

Vitamin A Yes ?

YF Yes 2004 2003 * Date obtained from earliest reported coverage estimates


There are currently no plans to introduce the HPV vaccine, though the quadrivalent vaccine (Gardasil) is

licensed in the DRC.




noted)

HPV information center: WHO (http://apps.who.int/hpvcentre/statistics/dynamic/ico/SummaryReportsSelect.cfm)


TABLE 10: DTP3 COVERAGE DATA IN THE DRC FROM 2010


< 50% 9%

50–79% 42%

≥ 80% 49%

Not reported 0%





The 2007 DHS also reported sub-national coverage information for several vaccines. Data on DTP3 are

presented below.

FIGURE 11: DRC DPT3 COVERAGE LEVELS BY AREA



Ministry of Planning [DRC]. (2008). DRC Demographic and Health Survey 2007. Kinshasa: Ministry of Planning [DRC]


The Sabin Institute identified the following pieces of legislation as being pertinent to immunization:



Section I, Articles 42 and 47 of the Constitution (2006) obliges the State to guarantee the health

of every Congolais child

Section VII, Article 204 of the Constitution empowers provinces to organize basic health

services, including immunization campaigns

In 2010 the MoF began drafting a law to create a national immunization trust fund.

Sources Sabin Institute. (2010). Sustainable Immunization Financing — DRC Country Summary. Accessed April 12, 2012 from

http://www.sabin.org/files/DR%20Congo_mm.pdf


The current MYP identifies several priority areas: service delivery, procurement and quality of vaccines,

logistics, surveillance and the fight against disease and communication for EPI.

Key challenges include inconsistent availability of vaccines at the operational level, absence of a national

regulatory authority, the lack of transportation at the intermediate and operational levels, the internal

transmission of poliovirus, and the absence of national policy for the integration of vaccine interventions

Sources Ministry of Health [DRC]. (2008). Plan Pluriannuel Complet du PEV de la République Démocratique du Congo, 2008-2012

[Complete Multi-Year Plan for EPI in the Democratic Republic of Congo, 2008-2012]. Kinshasa: Ministry of Health [DRC]


The DRC’s cMYP describes the routine EPI as consisting of the seven vaccines currently listed on the

schedule. A distinction is drawn between routine EPI and supplemental activities for polio, tetanus, and

measles.

vii. Budget making and other political considerations

The DRC uses a bicameral legislature, with the two houses being the National Assembly and the Senate.

The first elections in over 40 years were held in July 2006 and again in 2011. Despite criticisms in the

integrity of the poll, Joseph Kabila continues as president, a position which he has held since 2001. We

were able to identify the following recent ministers of health:

New minister (we were unable to find any details about the new minister) (? 2012–present)

Victor Makwenge Kaput (February 2010– ? 2012)

Augustin Mopipi (Mupipi?) Mulumania(October 2008–February 2010)

Victor Makwenge Kaput (February 2007–October 2008)

Zacharie Kashogwe (? 2006–February 2007)

Professor Emile Bongeli (? 2005–February 2007)

We did not locate any additional information about how the ministers impacted routine immunization.



The DRC’s budgeting process is opaque, receiving a score of 6 out of 100 in the International Budget

Partnership’s Open Budget Index 2010. We were unable to locate any documents that detail the budget

making process using English search terms, though it is likely that budgets are managed in a

decentralized manner.

Sources International Budget Partnership. (2010). Open Budget Index 2010—Democratic Republic of Congo. Accessed May 17, 2012

from http://internationalbudget.org/wp-content/uploads/2011/04/OBI2010-DemRepCongo.pdf



DRC allocated 6 percent of total recurrent government expenditure to health in 2007.

The government contributes very little to immunization and health in general

Government funded 5.5 percent of routine immunization in 2004, up from 1.3 percent in

2002

Government funded less than 2 percent of immunization in 2010 (according to the most

recent GAVI Alliance Progress Report)

WHO/UNICEF are the major contributors according to two GAVI reports

UNICEF provided 40 to 45 percent of total immunization finance from 2002 to 2004

WHO and UNICEF contributed 89 percent of immunization funding in 2010 (according to the

most recent GAVI Alliance Progress Report)

FIGURE 12: DRC IMMUNIZATION FINANCE BY SOURCE (RELATIVE SHARE IN %)

http://internationalbudget.org/wp-content/uploads/2011/04/OBI2010-DemRepCongo.pdf


FIGURE 13: IMMUNIZATION CONTRIBUTION BY SOURCE FOR DRC




GAVI cMYP costing & financing tool http://www.who.int/immunization_financing/tools/en/

The Government of Democratic Republic of the Congo. (Submitted October 2011). GAVI Alliance Annual Progress Report

2010. GAVI Alliance. Accessed April 17, 2012 from http://www.gavialliance.org/results/gavi-progress-reports/




Health is largely underfunded by government:

70 percent total health sector costs paid out-of-pocket

Interim Poverty Reduction Strategy Paper committed DRC to increasing percent of national

budget dedicated to health services:

▫ In 2001, less than 1 percent of national government budget went to health services

▫ Increased to 7 percent in 2004

Discrepancy between budget for health sector and actual spending:

In 2004, US$80 million budgeted, only US$25 million actually spent

In 2008, 58 percent of total immunization spending was allocated to routine immunization


http://www.who.int/immunization_financing/tools/en/




TABLE 11: OVERALL BUDGETED EXPENDITURES FOR IMMUNISATION IN THE DRC FROM ALL SOURCES (GOVT &

DONORS) IN US$



The Government of Democratic Republic of the Congo. (Submitted October 2011). GAVI Alliance Annual Progress Report 2010.

GAVI Alliance. Accessed April 17, 2012 from http://www.gavialliance.org/results/gavi-progress-reports/


No data identified.


Funding gap is growing year-on-year. The gap is 4-5 times larger than Uganda on a per infant in 2010-

2011


2012

Budgeted

Year 2013


New Vaccines 29,426,190$ 34,238,757$

Injection supplies with AD

syringes2,242,611$ 2,310,441$

Injection supply with syringes

other than Ads

Cold Chain equipment 548,988$ 624,227$

Personnel

Other operational costs

Supplemental Immunisation

Activities43,627,479$ 46,813,827$

Total Expenditures for

Immunisation79,594,397$ 87,902,784$



TABLE 12: IMMUNIZATION FINANCING GAPS PER INFANT IN THE DRC

Sources Country Profile: WHO Immunization Financing Democratic Republic of the Congo cMYP

(http://www.who.int/immunization_financing/countries/cmyp/cod/en/index.html)


Unreliable funding institutions:

In 2010, the Congolese Bank liquidated and failed to release funds in a timely manner

Slow process for release of funds from central government, Ministries of Budget and Finance

The State is highly dependent on external partners for purchase of vaccines, equipment and finance of

immunization operations

2008-2012 cMYP advised increased advocacy to central government to create a specific budget for

purchase of vaccines, equipment and vaccine operations; advocacy in Ministry of Health to increase

the proportion of the health budget allocated for vaccination




No data identified.

D. HUMAN CAPACITY

i. Total est. number of providers that immunize, by provider type

The WHO does not have any data on the number of community health workers in the DRC. In 2009

there were an estimated 52,329 nurses (0.79 per 1,000 population), but it is not clear how many provide

immunizations. (African Health Worker Observatory)

Sources African Health Worker Observatory. (2010). HRH Fact Sheet—DRC. Accessed May 17, 2012 (http://www.hrh-

observatory.afro.who.int/en/component/content/article/6-country-monitoring/57-drc-monitoring.html)

2007 2008 2009 2010 2011



Gaps per Infant $2.10 $2.20 $3.20 $3.30 $3.80


http://www.who.int/immunization_financing/countries/cmyp/cod/en/index.html



No data identified.



“The HZ integrates primary health care services and a first reference hospital. Each health zone is

managed by a Medical Inspector of the Health Zone (“Médecin Chef de Zone de Santé”) who is in charge

of the HZ Office, which houses a team of MCZ, an administrator, one/two nurse supervisors and a

pharmacist. HZ’s are divided in to areas that service between 5,000 and 10,000 persons in rural areas

and 15,000 to 30,000 in urban areas. Each area is served by a Health Center, staffed by a head nurse and

assistant and one midwife; and a number of health posts and community health workers.” (Mock 2006)

“At the organizational level, the EPI has a national headquarters, 11 provincial coordination units and 36

antennas each serving an average of 15 health areas. The central level plays a strategic and normative

role. The coordination units and antennas provide technical and logistical support to the health areas in

terms of training, supervision and the supply of vaccines and vaccination equipment. And immunization

activities are organized at the health center level.” (MoH Financial Sustainability Plan)

Three key strategies of vaccination applied to achieve the program's target populations are as follows:

Fixed strategy: these are the vaccinations performed in fixed centers to reach the target

population within a radius of less than 5 km around the clinic. This strategy covers almost 40%

of the target population, mainly in urban areas.

Outreach strategy: these are vaccinations carried out from fixed center to cover the target

population within a radius of 5 to 15 km around the clinic. It covers nearly 40% of the target and

applies in all health zones (HZs) according to the realities on the ground.

Decentralized mobile strategy: this is used to serve the target population located in areas of

difficult access, which represents nearly 20% of the overall target. The HZs rarely use them due

to lack of adequate transport.

(Translated from DRC cMYP)

In reality, the DRC’s healthcare system is decentralized and fragmented. Many health zones and facilities

are autonomous and charge patients fees to fund their operations. Due to a lack of funding from central

government, a large portion of health facilities are funded through non-governmental organizations or

international organizations such as the World Bank.

Sources Mock, N. et al. (May 2006). Public Health Training in the Democratic Republic of Congo: A Case Study of the Kinshasa School of

Public Health. Accessed May 17, 2012 from http://www.jhsph.edu/gra/Congo.pdf

Ministry of Health [DRC]. (2005). Financial Sustainability Plan of the Expanded Programme on Immunization. Kinshasa: Ministry

of Health [DRC]

Ministry of Health [DRC]. (2008). Plan Pluriannuel Complet du PEV de la République Démocratique du Congo, 2008-2012


http://www.jhsph.edu/gra/Congo.pdf


Waldman, Ron. 2006. Health in Fragile States, Country Case Study: Democratic Republic of the Congo. Arlington, Virginia, USA:

Basic Support for Institutionalizing Child Survival (BASICS) for the United States Agency for International Development

(USAID).

Sabin Institute. (2010). Sustainable Immunization Financing — DRC Country Summary. Accessed April 12, 2012 from



No data identified.


TABLE 13: DPT DROPOUT RATES, 2002-2007 FOR DRC

Year DTP1–DTP3 dropout rate

2002 18.2%

2003 19.0%

2004 15.8%

2005 13.0%

2006 11.5%

2007 8.5%

TABLE 14: VACCINE WASTAGE (%) IN THE DRC BY VACCINE AND YEAR

Vaccine 2011 2010 2009 2008 2007 2006

BCG 29 34 35 39

DTP 5 7

HepB 5 7 9 18

Hib 5 7 9 NA

PCV 5

Polio 12 14 14 21

MCV 15 24 25 33 32 33

YF 16 22 25 27

Tetanus 16 20 21 28










“The DRC currently has some 401 hospitals, of which 176 belong to the State, 179 to religious groupings,

and 46 to public and private sector enterprises. There are a total of [7,725]* other healthcare

establishments in the form of referral health centers, health centers, maternity units, clinics and

polyclinics belonging to the State, enterprises, religious groupings, NGOs and private individuals or

entities. However, the hospitals and other State healthcare establishments are for the most part in a

state of advanced disrepair.” (MoH Financial Sustainability Plan)

*Note: Updated this figure based on more recent reports

“The DRC has over 500** hospitals and more than 5,000 health facilities that are in varying states of

functioning. Of these facilities, private institutions, churches, and NGOs operate more than half…. A

2004 survey in Equateur Province found that 42.7 percent of households had to walk over eight hours to

reach a health facility (World Bank 2005a)

**Government documents note the existence of 510 hospitals; a recent MSF report noted only about

400 hospitals and 5,000 health facilities.” (Waldman)

Sources Ministry of Health [DRC]. (2005). Financial Sustainability Plan of the Expanded Programme on Immunization. Kinshasa: Ministry

of Health [DRC]

Waldman, Ron. 2006. Health in Fragile States, Country Case Study: Democratic Republic of the Congo. Arlington, Virginia, USA:


(USAID).


Cost is a major barrier to accessing healthcare, followed by non-availability of medicines and long

distances to healthcare. (Kassa 2005) There is some evidence of community resistance to vaccines in

some parts of the country, though we were not able to quantify it. (Seay 2011)

Sources Kassa, A. et al. (2005). Access to healthcare, mortality and violence in Democratic Republic of the Congo. Brussels: Médecins

Sans Frontières. Accessed April 12, 2012 from

www.doctorswithoutborders.org/publications/reports/2005/drc_healthcare_11-2005.pdf

Seay, L. (2011, August 31). A Vaccination Triumph in Congo Offers Strategic Lessons. The Interdependent. Accessed May 17,

2012 from http://www.theinterdependent.com/110831/a-vaccination-triumph-in-congo-offers-strategic-lessons


Though not quantified, a USAID report alluded to low levels of public trust in government-run

institutions.

Sources Waldman, Ron. 2006. Health in Fragile States, Country Case Study: Democratic Republic of the Congo. Arlington, Virginia, USA:


(USAID).

http://www.doctorswithoutborders.org/publications/reports/2005/drc_healthcare_11-2005.pdf

http://www.theinterdependent.com/110831/a-vaccination-triumph-in-congo-offers-strategic-lessons




FIGURE 14: DISPARITIES IN REPORTED VACCINE COVERAGE RATES IN THE DRC, BY REPORTING AGENCY

FIGURE 15: VACCINE COVERAGE RATES IN THE DRC BY WEALTH QUINTILE

85

67 63

68 72

62

71.7 70.6

44.4

62.9

45.7 49.6

85 82

62

72

59

70

0

10

20

30

40

50

60

70

80

90

BCG DTP1 DTP3 MCV Pol3 YF

Vac

cin

e co

vera

ge (

%)

WHO/UNICEF 2010 DHS 2007 MICS 2010

0

10

20

30

40

50

60

70

80

90

100


Vac

cin

e co

vera

ge (

%)

Wealth quintile

BCG

DPT3

Pol3

MCV

YF


FIGURE 16: DRC VACCINATION RATES COMPARED TO AFRICA REGION VACCINATION RATES




Ministry of Planning [DRC], National Institute of Statistics [DRC], UNICEF. (2011). DRC Multiple Indicator Cluster Survey 2010.

Kinshasa: Ministry of Planning [DRC]


0

10

20

30

40

50

60

70

80

1980 1985 1990 1995 2000 2005 2010

DTP

3 v

acci

ne

cove

rage

(%

)

DRC AFR

Number of health zones increased / health system restructured

GAVI immunization services support initiated

Politcal, economic and health crises



FIGURE 17: REPORTED MEASLES CASES COMPARED TO MCV COVERAGE IN THE DRC





0

20

40

60

80

100

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

200000

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Vac

cin

e co

vera

ge (

%)

Mea

sles

cas

es


SIAs Epidemic in

Kinshasa

These are the WHO figures, but, though we found some references to an outbreak in 2005/20006, there was little

detailed information



MOZAMBIQUE Produced by UW GH START Program, May 2012 35

MOZAMBIQUE



TABLE 15: MOZAMBIQUE VACCINE SCHEDULE AND TIMELINE OF INTRODUCTION







BCG Yes <1990*

DTP** Yes <1990*


Hib** Yes 2009

MCV Yes <1990*

OPV Yes <1990*

PCV No 2012

TT (pab) Yes <1990*

Vitamin A Yes ? * Date obtained from earliest reported coverage estimates


There are currently no plans to introduce the HPV vaccine, and neither vaccine is licensed in

Mozambique. The estimated date of introduction of the rotavirus vaccine is 2014.




noted)

HPV information center: WHO (http://apps.who.int/hpvcentre/statistics/dynamic/ico/SummaryReportsSelect.cfm)


TABLE 16: DTP3 DATA FOR MOZAMBIQUE FROM 2010


< 50% 9%

50–79% 6%

≥ 80% 30%

Not reported 56%





The 2008 MICS also reported sub-national coverage information for several vaccines. Data on DTP3 are

presented below.

FIGURE 18: MOZAMBIQUE DTP3 COVERAGE BY AREA



Instituto Nacional de Estatísticas [National Statistics Institute, Mozambique]. (2009). Final Report of the Multiple Indicator

Cluster Survey, 2008. Maputo: Instituto Nacional de Estatísticas [Mozambqiue]




A 2004 WHO report summarized legislation relating to primary care. The following is particularly related

to immunization:

Order of July 30, 1975—“Establishes that all (nationalized health facilities shall be supplied with

medicines, laboratory material, and so forth, by the Central de Medicamentos or Depositos

Provinciais”.

Law number 2/77 de 27 de Setembro—“The law establishes that all preventive care is free.”

Preventive care is defined under Order of October 12, 1977 to include immunizations.

Subsequent legislation modified allowable fees for healthcare services (including outpatient

care) but it is not clear if this altered the requirement for free immunizations.

The 1990 Mozambican Constitution—“Establishes the right of every citizen to health care…the

state is responsible for organizing the National Health System (NHS) to guarantee citizens’

rights.”

Sources Lindelow, M. et al. (2004). Primary Health Care in Mozambique—Service Delivery in a Complex Hierarchy. Washington, DC:

World Bank


The cMYP identified several specific priorities within each area of the EPI. The prominent priorities are

listed below:

Service delivery: address the high geographic variation in coverage and dropout rates

Logistics: implement a vaccine management system in all districts and improve transportation

Advocacy and communication: develop and implement a global communication strategy

Surveillance: improve surveillance of polio, measles, tetanus, and Hib

Program management: establish a data quality and management system, enhance district

planning by limiting central government involvement, an establish a vaccine wastage monitoring

system

Sources Republic of Mozambique Ministry of Health. (n.d.) Expanded Programme on Immunization Comprehensive Multi-year Plan

(2009–2013). Maputo: Ministry of Health [Mozambique]


The Mozambique cMYP appears to treat routine immunization as all activities conducted as part of the

EPI but excluding supplemental activities.

vi. Budget making and other political considerations

Mozambique uses a presidential democratic republic system where the president is both head of state

and head of government. The government exercises both executive power and legislative power in the

unicameral Assembly of the Republic. Mozambique has been led by the Liberation Front of Mozambique

(FRELIMO) since independence in 1975. Elections take place every five years and the current president


(Armando Guebuza) has been in place since February 2005. We were able to identify two recent

ministers of health:

Dr. Alexandre Lourenço Jaime Manguele (October 2010–present)

Dr. Paulo Ivo Garrido (January? 2005–October 2010)

There was little information found from English search terms about the impact of the ministers on

routine immunization. Dr. Garrido was removed from office in October 2010 despite being reappointed

to a second term earlier that year but the reasons for his dismissal were not clear. One article did posit

that there had been tensions between Garrido and staff within the Ministry and that the resulting

resignations have disrupted the medicines distribution system. (Omondi 2010)

Mozambique’s budget process does not appear to be rigorous or transparent. Reviews of the process

noted that budgets are primarily a result of negotiations between the executive branch and donors, with

a legislative rubber stamp of approval. (Pereira 2011) Other challenges include a lack of linkages

between policy priorities and resource allocation and direct funding of ministries or projects by donors.

(Suleman 2007)

Sources Omondi, P. (2010, October 12). Mozambique: Economic Ministers Sent Packing. News from Africa. Accessed May 22, 2012 from

http://www.newsfromafrica.org/newsfromafrica/articles/art_12027.html

Pereira, J. (2011) Slow Progress towards Democratic Ownership in Mozambique. Accessed May 22, 2012 from

http://www.alliance2015.org/fileadmin/Texte__Pdfs/Text_Documents/Alliance2015_Democratic_Ownership_Mozambique

_2011.pdf

Suleman, J (2007). Mozambique: Better Budget Machinery – First Focus of Reforms. OECD Journal on Budgeting, 6(2). Accessed

May 22, 2012 from http://www.oecd.org/dataoecd/24/62/43470116.pdf



Total health Expenditure Data:

In 2010, the level of funding for health was US$21 per capita (government and donor funds pooled

together), up from US$12 per capita in 2003

This translates to $432,600,000 total, given the WHO 2007 population estimate of 20.6 million

Total Health Expenditure of US$21 per capita is lower than the $34 WHO-recommended for

developing countries

Government and other health funding grew significantly in late 2000s

State budget for health sector grew significantly in real terms 2004-2009 (Table 17)

Government funding projections in cMYP 2009-2012 showed continued growth trend, but actual

expenditure lagged, as made apparent in the cMYP 2012-2016 (Figure 18)

Government funded 25 percent of routine immunization in 2010, down from 46 percent in 2008

(Figure 18)

http://www.newsfromafrica.org/newsfromafrica/articles/art_12027.html

http://www.alliance2015.org/fileadmin/Texte__Pdfs/Text_Documents/Alliance2015_Democratic_Ownership_Mozambique_2011.pdf

http://www.alliance2015.org/fileadmin/Texte__Pdfs/Text_Documents/Alliance2015_Democratic_Ownership_Mozambique_2011.pdf

http://www.oecd.org/dataoecd/24/62/43470116.pdf


TABLE 17: HEALTH EXPENDITURE (IN MILLIONS OF US$) FOR MOZAMBIQUE

FIGURE 19: ROUTINE IMMUNIZATION SPENDING IN MOZAMBIQUE BY SOURCE COMPARED AGAINST BIRTH

COHORT AND FUNDING PROJECTIONS

Source 2004 2005 2006 2007 2008

State Budget 4$ 104$ 108$ 127$ 138$

Common Fund 63$ 106$ 99$ 125$ 74$

Vertical Fund 85$ 130$ 141$ 150$ 300$

Total Expenditures 152$ 340$ 348$ 402$ 512$

2008 2009 2010 2011 2012 2013 2014 2015 2016

Infants (Millions): 0.79 0.80 0.81 0.82 0.83 0.84 0.85 0.86 0.87

RI Funding: 10,524,083$ 27,211,123$ 15,414,459$ 62,534,300$ 24,511,136$ 27,688,170$ 44,896,489$ 49,095,256$ 47,764,783$

Funding per Infant: 13.38$ 34.18$ 19.12$ 76.64$ 29.67$ 33.16$ 53.13$ 57.42$ 55.09$

*Uses average growth rate of 1.22% from 2012-2016 to estimate births in 2008-2011**RI Funding based on available projections from cMYPs. Funding for 2008 and 2010 reflect actual Expenditure

46%

25%

13%

7%

28%

45%

10%

2%

3%3%

10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

JICA

Government GAVI Co-Financing

Prosaude

FDC

WHO

GAVI

UNICEF

Government

7%


TABLE 18: CMYP COST PROJECTIONS FOR MOZAMBIQUE, YEARS 2008-2012 AND 2012-2016

Public Health financing structure:

Internal Funds (increasing in recent years)

External Funds (increasing in recent years)

o Common Fund called “Prosuade” – Pooled funding mechanism for 14 development partners

o Projects managed by individual agencies

o Sector Wide Approach (SWAp) About 26 bilateral and multilateral cooperation agencies (14

coordinated through Prosuade

Revenues from health sector

o Moving toward gratuitous system where children, pregnant women, and chronic patients do

not pay for consultation and admission

Sources The Government of Mozambique. (Submitted October 2010). GAVI Alliance Annual Progress Report 2010. GAVI Alliance.

Accessed May 10, 2012 from http://www.gavialliance.org/results/gavi-progress-reports/.

Republic of Mozambique Ministry of Health. (2009). Expanded Programme on Immunization Comprehensive Multi-Year Plan

2009-2013.


2012-2016.

Country Profile: WHO Immunization Financing Mozambique cMYP

(http://www.who.int/immunization_financing/countries/cmyp/mozambique/en/index.html)

Actual

Expenditure

2008 (Baseline

Year)2009 2010 2011 2012 2013

Total 2009-2013

Cost Category

Routine Recurrent Costs 6,219,296$ 23,176,117$ 35,351,657$ 47,421,123$ 72,049,414$ 79,597,469$ 257,595,780$

Routine Capital Costs 250,344$ 695,485$ 1,775,783$ 1,846,461$ 1,732,683$ 1,095,269$ 7,145,681$

Campaign Costs 3,502,003$ 4,015,911$ 4,015,911$

Shared Health Systems Costs (personnel, transportation, new buildings)552,440$ 3,339,521$ 6,237,864$ 9,250,805$ 12,381,768$ 15,634,270$ 46,844,228$

Grand Total 10,524,083$ 27,211,123$ 43,365,304$ 62,534,300$ 86,163,865$ 96,327,008$ 315,601,600$

Routine Immunization 7,022,080$ 27,211,123$ 43,365,304$ 58,518,389$ 86,163,865$ 96,327,008$ 311,585,689$

Supplemental Immunization Activities3,502,003$ -$ -$ 4,015,911$ -$ -$ 4,015,911$

Note: cold chain infrastructure investments primarily made prior to 2012 introduction of pneumococcus vaccine

Actual

Expenditure

2010 (Baseline

Year)2012 2013 2014 2015 2016

Total 2012-2016

Cost Category

Routine Recurrent Costs 13,613,591$ 22,478,889$ 22,914,266$ 42,752,657$ 42,867,220$ 45,637,984$ 176,651,015$

Routine Capital Costs 861,400$ 1,029,226$ 1,621,861$ 1,010,056$ 852,207$ 947,218$ 5,460,567$

Campaign Costs -$ -$ 2,083,303$ -$ 4,219,377$ -$ 6,302,680$

Shared Health Systems Costs (personnel, transportation, new buildings)939,468$ 1,003,021$ 1,068,740$ 1,133,776$ 1,156,452$ 1,179,581$ 5,541,571$

Grand Total 15,414,459$ 24,511,136$ 27,688,170$ 44,896,489$ 49,095,256$ 47,764,783$ 193,955,834$

Routine Immunization 15,414,459$ 24,511,136$ 25,604,867$ 44,896,489$ 44,875,879$ 47,764,783$ 187,653,153$

Supplemental Immunization Activities -$ -$ 2,083,303$ -$ 4,219,377$ -$ 6,302,681$

Future Projections

Future Projections



In 2012, between 2 and 5 percent of total health expenditure was allocated to routine and campaign

immunization

Between 10-12 percent of government health expenditure was allocated to routine and campaign

immunization

In 2012, 97 percent of total EPI was allocated to routine immunization (the rest is for Supplementary

Immunization Activities like polio and measles)

Routine immunization is budgeted at $36.4 million per annum (average of five year projection,

2012-2016). Total resource requirements per annum over 2012-2016 for EPI is estimated at $37.7

million per annum

Projections take into account population growth of 2.14 percent, introduction of Pneumococcal

vaccine (PCV) from 2012, introduction of Rotavirus from 2014, increased coverage target for

traditional vaccines

EPI is among highest priorities for MoH, but lacks local partners to support implementation

Lack of implementation infrastructure and human resources may account for failure to spend

allocated budget

Total EPI future projected spending decreased from $315 million in the 2009 cMYP to $194 million in

2012 cMYP


TABLE 19: OVERALL BUDGETED EXPENDITURES FOR IMMUNISATION IN MOZAMBIQUE FROM ALL SOURCES (GOVT

& DONORS) IN US$

*Traditional Vaccines: BCG, DTP, OPV (or IPV), Measles 1st dose (or the combined MR, MMR), TT. HepB and Hib vaccines also in

this row if these vaccines were introduced without GAVI support

Sources The Government of Mozambique. (Submitted October 2010). GAVI Alliance Annual Progress Report 2010. GAVI Alliance.

Accessed May 10, 2012 from http://www.gavialliance.org/results/gavi-progress-reports/.


2009-2013.


2012-2016.


Spending by donor source:

Government of Mozambique, Pharmaceutical Purchasing Department purchases most vaccines

UNICEF Supply Division purchases new vaccines like Pentavalent

International agencies provide 87 percent of total immunization cost and 89 percent of total vaccine

injection safety supplies cost

GAVI covers the bulk of vaccine and associated costs for adding pneumococcal vaccine


2012

Budgeted Year

2013


New Vaccines 14,450,714$ 14,175,983$

Injection supplies with AD syringes 623,245$ 667,694$

Injection supply with syringes other than

Ads

Cold Chain equipment 491,380$ 1,021,367$

Personnel 2,994,216$ 3,294,318$

Other operational costs 3,285,810$ 3,566,329$

Supplemental Immunisation Activities 2,083,303$

Under used vaccines 537,846$ 600,494$

Total Expenditures for Immunisation 23,508,115$ 26,619,430$


Sources Republic of Mozambique Ministry of Health. (2009). Expanded Programme on Immunization Comprehensive Multi-Year Plan

2009-2013.


2012-2016.


Mozambique EPI Multiyear Plan requires budget of US$187,653,153 over five years 2012-2016.

Resource requirements have a high likelihood of being met as long as probable funding becomes secure

funding

Faces potential funding gap of US$136,986,801 by 2016 (summed over years 2012-2016)

Given probable funds, gap reduces substantially to US$5,629,595

Probable funding includes $109.5 million from GAVI mostly for PCV13 and rotavirus

Majority of funding gap is the high costs of new vaccine introduction (PCV13 from 2012 and rotavirus

from 2014). Funds are not yet guaranteed – pending GAVI approval

Other major cost drivers include Reach Every District (RED) strategy, and follow up measles

campaign in 2015

Average funding gap as a percentage of total resources required is 73 percent from 2012-2016 (without

probable funds)

Gap is 50 percent in 2012

Peaks at 84 percent in 2015

Falls to 82 percent in 2016

TABLE 20: COMPOSITION OF FUNDING GAP (IMMUNIZATION ONLY) FOR MOZAMBIQUE WHO COUNTRY PROFILE

2010

Composition of the funding

gap2012 2013 2014 2015 2016

Vaccines and injection

equipment$9,305,855 $8,741,204 $26,823,538 $31,266,449 $33,333,885

Personnel $540,000 $550,000 $737,363 $665,869 $688,157

Transport $0 $503,148 $1 $480,601

Activities and other

recurrent costs$1,780,057 $2,375,158 $2,462,507 $3,127,663 $3,023,212

Logistics (Vehicles, cold

chain and other equipment)

$290,032 $1,558,070 $860,056 $752,207 $947,218

Campaigns $0 $2,083,303 $0 $4,219,377 $0

Total Funding Gap* $11,915,944 $15,307,735 $31,386,612 $40,031,565 $38,473,073


TABLE 21: RESOURCE REQUIREMENTS, FINANCING AND GAPS IN MILLIONS OF US$ FOR MOZAMBIQUE

(CONSTRUCTED FROM 2009 CMYP AND 2012 CMYP)

Table 22: IMMUNIZATION FINANCING GAPS PER INFANT IN MOZAMBIQUE


2009-2013.


2012-2016.

Country Profile: WHO Immunization Financing Mozambique cMYP

(http://www.who.int/immunization_financing/countries/cmyp/mozambique/en/index.html)


State is highly dependent on donors for future financing and sustainability of current EPI activities

Combined donor contribution accounts for 72 percent of routine immunization program cost

Funding difficulties include:

Late disbursements

Unpredictability of funding and lack of sustained long term financing agreements

Agency specific reporting mechanisms

Resistance of agencies to coordinate

Threats to financing identified in cMYP 2012:

Insufficient financial resources to implement EPI Plan of Action

Donors prefer to channel funds through Global Health Initiatives that target specific interventions

outside of immunization

Compositition of the funding gap (cMYP 2009) 2009 2010 2011 2012 2013 2014 2015 2016

Total Resource Requirements 23,871,602$ 37,127,440$ 53,283,494$ 73,782,097$ 80,692,738$

Total Resource Requirements (Routine only) 23,871,602$ 37,127,440$ 49,267,584$ 73,782,097$ 80,692,738$

per capita 1$ 2$ 3$ 3$ 4$

Total Secured Funding 22,680,893$ 34,387,449$ 40,809,708$ 54,839,770$ 62,134,814$

Funding Gap (Secured Funds Only) 1,190,709$ 2,739,991$ 12,473,786$ 18,942,327$ 18,557,924$

Total Probable Financing 1,540,710$ 2,739,992$ 12,473,789$ 18,942,327$ 18,557,925$

Funding Gap (Secured Funds & Probable Funds) (350,001)$ (1)$ (3)$ -$ (1)$

Compositition of the funding gap (cMYP 2012)

Total Resource Requirements 23,508,115$ 26,619,430$ 43,762,712$ 47,938,803$ 46,585,202$

Total Resource Requirements (Routine only) 23,508,115$ 24,536,127$ 43,762,712$ 43,719,426$ 46,585,202$

per capita 1$ 1$ 2$ 2$ 2$

Total Secured Funding 11,592,171$ 11,311,695$ 12,376,100$ 7,907,239$ 8,112,129$

Funding Gap (Secured Funds Only) 11,915,944$ 15,307,735$ 31,386,612$ 40,031,564$ 38,473,073$

Total Probable Financing 11,205,188$ 14,349,486$ 30,742,092$ 39,248,654$ 36,839,692$

Funding Gap (Secured Funds & Probable Funds) 710,756$ 958,249$ 644,520$ 782,910$ 1,633,381$

2012 2013 2014 2015 2016



Gaps per Infant $14.27 $18.34 $37.16 $46.80 $44.39



Cost-effective health and other social interventions compete for government resource: Malaria,

treatment of diarrhea with ORS and Zinc, Vitamin A supplementation

Problems reaching harmony between partners and donors (aligning priorities, reliability and timing

of fund disbursements and financing agreements)

Threats to financing identified by Ministry of Health 2006:

High transaction costs due to the number of development partners

Low accountability among donor groups

High competition for funds from other health categories


2009-2013.

Ministry of Health for Mozambique. (2008). International Health Partnership Taking Stock Report Mozambique.


TABLE 23: AVAILABILITY OF VACCINES (%) AT PRIMARY HEALTHCARE FACILITIES THAT OFFERED CHILD

VACCINATION SERVICES IN MOZAMIQUE, 2003

Vaccine Urban Rural Health post Health center Overall

BCG 93.6 83.5 86.9 82.2 84.6

DTP 93.6 92.0 90.9 93.5 92.2

Polio 93.6 79.8 90.9 71.8 81.4

Measles 93.6 94.5 95.4 93.5 94.4

Tetanus 93.6 84.0 80.6 89.6 85.1

All EPI vaccines 93.6 70.7 77.9 68.6 73.3

Sources Lindelow, M. et al. (2004). Primary Health Care in Mozambique—Service Delivery in a Complex Hierarchy.

Washington, DC: World Bank

D. HUMAN CAPACITY

i. Total est. number of providers that immunize, by provider type “In 2010, immunization services were offered in approximately 1160 health centres, which

represents 90% of health unities in the existing health network with fixed vaccination sites.

However, less than 50% of the country population is served by the existing health network.”

(cMYP2011)

Sources Republic of Mozambique Ministry of Health. (2011) National Immunization Program Comprehensive Multi-year Plan (2012–

2016). Maputo: Ministry of Health [Mozambique]



“In each facility one health worker is responsible for the EPI. It is usually the mid-wife who also holds

multiple health care program responsibilities, for example, maternal health care.” (Mavimbe 2005)

“Generally the cadre responsible [for immunization] are “agentes preventivas”—which are just below

nurses in seniority in the Mozambican system. Nurses or “tecnicos preventivas” may also give

immunizations, but less often. Most health facilities outside of district and provincial hospitals have

VERY few staff (2-3), so people wear many hats.” (S. Gimbell, personal communication, May 2, 2012)

Sources Mavimbe J. et al. (2005). Assessing immunization data quality from routine reports in Mozambique. BMC Public Health, 5:108



Central level

Set policies, standards, and priorities

Build capacity (not further defined)

Coordinate with partners

Mobilize resources

Procure inputs such as vaccines

Monitor and provide technical support to the provincial level

Provincial level

Build capacity (not further defined)

Monitor, supervise and provide technical support to the district level

District level

Plan, manage and deliver EPI services

Community level

Mobilize and bring children in for immunization


TABLE 24: POPULATION SERVED AND STAFFING RATIOS AT EACH LEVEL OF CARE IN MOZAMIQUE

Level of activity Type of facility Population

served

Typical staffing

Community-based Rural health post 500 1 community health worker

(CHW)

“Estratégia avançada”

(translated as ‘forward

strategy’, i.e. outreach)

“Supported by

health center”

7,500–

25,000

1 orderly/general worker

1 technician with basic training

(in vaccination, oral health,

nutrition etc.)*

First contact with the national

health system

Health center 16,000–

100,000

3–5 orderlies/general workers

1 administrator

9–10 technicians and medical

practitioners (of varying levels of

training)**

First referral level District hospital 50,000–

250,000

8–10 orderlies/general workers

2–3 administrators

22–29 technicians and medical

practitioners (of varying levels of

training)**

Rural and

general hospitals

150,000–

900,000

39 administrators

137 technicians and medical

practitioners (including 9

doctors)***

* The Portuguese term used here is “técnicos básicos das carreiras especificas”.

** The Portuguese term used here is “técnicos das carreiras especificas” and indicates that the person may have a higher level

of training than at the outreach level (and may be a nurse or doctor).

*** The Portuguese term used here is “técnicos das carreiras específicas de saúde”, but this is not instrumentally different from

the previous designation.

Sources Republic of Mozambique Ministry of Health. (n.d.) Expanded Programme on Immunization Comprehensive Multi-year Plan

(2009–2013). Maputo: Ministry of Health [Mozambique]

Ministry of Health [Mozambqiue]. (2008). Plano Nacional de Desenvolvimento dos Recursos Humanos da Saúde (PNDRHS)

2008–2015 [National Development Plan for Human Resources in Health 2008–2015]. Maputo: Ministry of Health

[Mozambique]. Accessed May 3, 2012 from

http://www.misau.gov.mz/pt/content/download/9918/66557/file/Plano%20Nacional%20de%20Desenvolvimento%20dos%

20Recursos%20Humanos%20da%20Sa%C3%BAde.pdf


A 2001 study of Magude District (Maputo Province) found that 25.7% of children had at least one missed

opportunity for vaccination, with a mean of 1.73 opportunities. (Jani 2008)

http://www.misau.gov.mz/pt/content/download/9918/66557/file/Plano%20Nacional%20de%20Desenvolvimento%20dos%20Recursos%20Humanos%20da%20Sa%C3%BAde.pdf



Household surveys conducted in Niassa and Cabo Delgado in 2010 found that approximately 40% of

respondents reported not receiving a vaccine for their child while visiting a health center. The two most

common reasons cited were a lack of vaccines in the health center and vaccines not being offered that

day. (VillageReach 2010—Niassa and Cabo Delgado)

A 2002/3 study in three provinces found that 15.7% of children who received their first polio or DPT-

HepB vaccine did not receive the other vaccine on the same day. Among children who had been

weighed five times, 18.1% had not received one or more of the BCG, polio (x3) or DPT-HepB (x3)

vaccines (there was substantial provincial variation, with 10.7% missing one or more vaccines in Gaza,

20.9% in Zambezia, and 27.2% in Nampula). (Sheldon 2003)

Sources Jani, J. et al. (2008). Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique.

BMC Public Health, 8:161

VillageReach. (2010). Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study—Niassa. Accessed May 1, 2012

from http://villagereach.org/vrsite/wp-content/uploads/2011/05/Vaccine-CovrageReport-Niassa-Final.pdf

VillageReach. (2010). Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study—Cabo Delgado. Accessed May 1,

2012 from http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-

Delgado_FINAL.pdf

Sheldon, S. and Alons, C. (2003). A Study to Describe Barriers to Childhood Vaccination in Mozambique. Accessed on May 10,

2012 from http://pdf.usaid.gov/pdf_docs/PNACW518.pdf


A small 2005 study (Mavimbe) from one district in Niassa Province found inconsistencies between tally

sheets, facility reports, and district reports in terms of the counts of vaccinated children. Typically,

facility reports were higher than the individual tally sheets from within that facility. However, the facility

that performed the bulk of the vaccinations produced facility reports that were concordant with the

tally sheets, so numbers in the district reports were not substantially inflated.

Another data quality study of 9 facilities in three districts in Sofala Province found 85% concordance

over a 6-month period between facility clinical registers and monthly facility reports for DTP3. Most

discordance occurred in urban facilities. The same study compared DTP3 coverage with the DHS and

MICS surveys. There was generally good agreement between the sources, but the health information

system indicated a higher coverage level than the MICS estimates for 2006 and 2007, the most recent

years for which data were available. (Gimbel 2011)

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Vaccine-CovrageReport-Niassa-Final.pdf

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-Delgado_FINAL.pdf

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-Delgado_FINAL.pdf

http://pdf.usaid.gov/pdf_docs/PNACW518.pdf


TABLE 25: VACCINE WASTAGE (%) IN MOZAMQIUE BY VACCINE AND YEAR

Vaccine 2011 2010 2009 2008 2007 2006

BCG 51

DTP 18

HepB 18

Hib 18

Polio 14

MCV 33

Tetanus

Sources Mavimbe J. et al. (2005). Assessing immunization data quality from routine reports in Mozambique. BMC Public Health, 5:108

Gimbel, S. et al. (2011) An assessment of routine primary care health information system data quality in Sofala Province,

Mozambique. Population Health Metrics, 9:12





TABLE 26: NUMBER AND DENSITY OF HEALTH FACILITIES IN EACH PROVINCE OF MOZAMBIQUE, BY TYPE

(NATIONAL INVENTORY OF INFRASTRUCTURE, HEALTH RESOURCES AND SERVICES 2007)

Province Population Health level No. health units I II III IV

No. Pop. /facility

No. Pop. /facility

No. No.

Niassa 1,178,117 135 8,727 1 1,178,117 1 137

Cabo Delgado 1,632,809 95 17,187 4 408,202 1 100

Nampula 4,076,642 183 22,277 8 509,580 2 193

Zambézia 3,892,854 172 22,633 6 648,809 1 179

Tete 1,832,339 98 18,697 3 610,780 1 102

Manica 1,418,927 78 18,428 4 354,732 1 83

Sofala 1,654,163 134 12,345 4 413,541 1 139

Inhambane 1,267,035 101 12,545 2 633,518 1 104

Gaza 1,219,013 123 9,911 4 304,753 1 128

Maputo Province

1,259,713 78 17,496 2 629,857 80

Maputo City 1,099,102 27 40,707 3 366,367 2 32

Total 20,530,714 1,224 16,773 41 500,749 7 5 1,277



TABLE 27: NUMBER OF INHABITANTS PER PUBLIC HEALTH/PREVENTIVE MEDICINE WORKER, BY PROVINCE IN

MOZAMIQUE (JUNE 2007) (HUMAN RESOURCES DEVELOPMENT PLAN 2008)

Province Pop. per worker

Niassa 21,989.20

Cabo Delgado 17,911.50

Nampula 32,448.30

Zambézia 35,274.40

Tete 28,968.30

Manica 24,145.10

Sofala 21,179.70

Inhambane 23,676.80

Gaza 23,485.80

Maputo Province 13,400.60

Maputo City 17,660.70

National 23,820.80

Sources Ministry of Health [Mozambique]. (2007). Inventário Nacional de Infraestruturas de Saúde, Serviços e Recursos, Moçambique

2007 [National Inventory of Infrastructure, Health Resources and Services]. Maputo: Ministry of Health [Mozambique].

Accessed May 3, 2012 from

http://www.misau.gov.mz/pt/misau/dpc_direccao_de_nacional_planificacao_e_cooperacao/departamento_de_informaca

o_para_a_saude_e_monitoria_e_avaliacao/documentos_chave_do_sistema_de_informacao_para_a_saude/sam_inventari

o_nacional_de_infra_estruturas_de_saude_2007

Ministry of Health [Mozambqiue]. (2008). Plano Nacional de Desenvolvimento dos Recursos Humanos da Saúde (PNDRHS)

2008–2015 [National Development Plan for Human Resources in Health 2008–2015]. Maputo: Ministry of Health

[Mozambique]. Accessed May 3, 2012 from

http://www.misau.gov.mz/pt/content/download/9918/66557/file/Plano%20Nacional%20de%20Desenvolvimento%20dos%

20Recursos%20Humanos%20da%20Sa%C3%BAde.pdf


A cross-sectional survey in Magude District (Maputo Province) from 2001 found that a mother having a

low level of schooling, not having knowledge of the EPI program, having negative attitudes towards

vaccination, the child being born outside of Mozambique, and receiving vaccinations at home rather

than in a facility were all associated with incomplete vaccinations. (Jani 2008)

A household survey in Niassa found that only 33% of interviewees (mostly mothers) were aware of the

reasons for vaccination. Perhaps related to this, 57% of those with unvaccinated children (not defined in

the report) cited a lack of information about vaccines as a reason for failing to vaccinate the child,

followed by a lack of motivation (25%) and other obstacles (18%), including distance from the health

center. (VillageReach 2010—Niassa)

In contrast, a household survey in Cabo Delgado found that distance from home to the health center

was the reason given for not vaccinating the child in 61% of cases, followed by family problems (e.g.,

http://www.misau.gov.mz/pt/misau/dpc_direccao_de_nacional_planificacao_e_cooperacao/departamento_de_informacao_para_a_saude_e_monitoria_e_avaliacao/documentos_chave_do_sistema_de_informacao_para_a_saude/sam_inventario_nacional_de_infra_estruturas_de_saude_2007






illness in the family) in 13% of cases. A lack of information about vaccines was mentioned by 4% of

respondents. (VillageReach 2010—Cabo Delgado)

A study of four districts in three provinces (selected to represent a range of vaccination coverage levels)

found that among mothers whose child had never received a vaccine, over half cited distance to the

vaccination site as a reason for not immunizing their child (the figure in the report was 51.5% but

multiple responses were allowed so this actual proportion may be higher). Negative perceptions of the

vaccine (e.g., that it is ineffective or even causes disease), were not mentioned often as causes. (Sheldon

2003)

Sources Jani, J. et al. (2008). Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique.

BMC Public Health, 8:161

VillageReach. (2010). Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study—Niassa. Accessed May 1, 2012

from http://villagereach.org/vrsite/wp-content/uploads/2011/05/Vaccine-CovrageReport-Niassa-Final.pdf

VillageReach. (2010). Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study—Cabo Delgado. Accessed May 1,

2012 from http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-

Delgado_FINAL.pdf

Sheldon, S. and Alons, C. (2003). A Study to Describe Barriers to Childhood Vaccination in Mozambique. Accessed on May 10,

2012 from http://pdf.usaid.gov/pdf_docs/PNACW518.pdf


Though no studies were found that focused specifically on public trust, the studies mentioned in the

preceding section indicate generally high levels of support for vaccination among caregivers. This is

reinforced by the opinions of START’s contacts who work in Mozambique. It appears that structural

weaknesses in healthcare infrastructure are largely responsible for low vaccination rates.

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Vaccine-CovrageReport-Niassa-Final.pdf

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-Delgado_FINAL.pdfd

http://villagereach.org/vrsite/wp-content/uploads/2011/05/Final-Vaccine-CovrageReport-Cabo-Delgado_FINAL.pdfd

http://pdf.usaid.gov/pdf_docs/PNACW518.pdf




FIGURE 20: DISPARITY IN REPORTED VACCINE COVERAGE RATES IN MOZAMBIQUE, BY REPORTING AGENCY

FIGURE 21: VACCINE COVERAGE RATES IN MOZAMBIQUE BY WEALTH QUINTILE

90

77 74

70 73

87 88

72 77

70

88 88

74 74 73

0

10

20

30

40

50

60

70

80

90

100

BCG DTP1 DTP3 MCV Pol3

Vac

cin

e co

vera

ge (

%)

WHO/UNICEF 2010 DHS 2003 MICS 2008

0

20

40

60

80

100

120


Vac

cin

e co

vera

ge (

%)

Wealth quintile

BCG

DPT3

Pol3

MCV


FIGURE 22: MOZAMBIQUE VACCINATION RATES COMPARED TO AFRICA REGION VACCINATION RATES



Instituto Nacional de Estatísticas [National Statistics Institute, Mozambique]. (2005). Inquérito Demográfico e de Saúde 2003

[Demographich and Health Survey 2003]. Maputo: Instituto Nacional de Estatísticas [Mozambqiue]

Instituto Nacional de Estatísticas [National Statistics Institute, Mozambique]. (2009). Final Report of the Multiple Indicator

Cluster Survey, 2008. Maputo: Instituto Nacional de Estatísticas [Mozambqiue]

0

10

20

30

40

50

60

70

80

1980 1985 1990 1995 2000 2005 2010

DTP

3 v

acci

ne

cove

rage

(%

)

Mozambique AFR




FIGURE 21: REPORTED MEASLES CASES COMPARED TO MCV COVERAGE IN MOZAMBIQUE, OVER TIME

Sources Mandomando, I. et al. (2011). Assessment of the epidemiology and burden of measles in Southern Mozambique. Am J Trop

Med Hyg, 85(1):146–51

UNICEF. (2012). Immunization Summary. Geneva: WHO/UNICEF. Accessed April 23, 2012 from




0

20

40

60

80

100

0

5000

10000

15000

20000

25000

30000

35000

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

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97

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98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

Vac

cin

e co

vera

ge (

%)

Mea

sles

cas

es


SIAs (year and pop. reached) 2005: 8.2M 2010: 3.6M 2008: 3.3M

Measles outbreak with case fatality of 8/1,000

